Inspection·April 13, 2023

F 0583 R306's walker. The therapy staff walked past R72 multiple times and did nothing to provide R72 privacy. Level of Harm - Minimal harm or potential for actual harm At 10:43 Social Service Director notified V6 (LPN/Licensed Practical Nurse) that R72 was half undressed and uncovered in his bed. V6 went and asked V5 (CNA/Certified Nurse Assistant) to help her. Residents Affected - Some At 10:48 AM, V6 and V5 entered R72's room to provide care. 3. R307's EMR showed she was admitted to the facility on [DATE], was sent to the hospital on March 23, 2023, and returned to the facility on April 3, 2023. R307's diagnoses included neoplasm of uncertain behavior and other specified sites, chronic diastolic (congestive) heart failure, pneumonitis due to inhalation of food and vomit, ascites, acute respiratory failure, altered mental status, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and weakness. R307's MDS dated [DATE], showed R307 had severe cognitive impairment and required extensive two staff assistance for personal hygiene. R307's care plan dated March 27, 2023, showed R307 had an ADL self-care performance deficit related to weakness, loss of vision, and incontinence. On April 10, 2023, at 1:36 PM surveyor asked V5 (CNA) to come check R307's incontinence brief. R307 is in the bed next to the window. V5 started to pull blankets down to provide care and surveyor stopped V5 and asked her if she wanted to close the blinds. V5 said yes, and then went and closed the blinds. 4. R309's EMR showed R309 was admitted to the facility on [DATE], with diagnoses that included unspecified fracture of left pelvis, dementia, need for assistance with personal care, long term and current use of insulin, diabetes mellitus with hyperglycemia, and anxiety. R309's MAR (Medication Administration Record) showed Insulin lispro, 100 units per ml (milliliter). amount to administer 10 units, subcutaneous before meals and at bedtime. On April 12, 2023, at 10:32 AM, observed V11 administering insulin to resident. After checking R309's blood sugar and preparing the insulin, V11 went into R309's room and lifted up R309's shirt with the door wide open and the window blinds open. There was a confused resident in next room who kept trying to push the nurse's medication cart out of the way so she could get to into the room. Insulin was injected into the abdomen. On April 12, 2023, at 9:21 AM, V2 (DON/Director of Nursing) said when providing care, the staff need to pull the curtain between beds, close the room door, and close the window blinds. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145761 If continuation sheet Page 2 of 26 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 145761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewood Nrsg & Rehab Center 14716 S Eastern Avenue Plainfield, IL 60544 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R30 has multiple diagnoses which includes fracture of lower end of the left humerus, weakness, macular degeneration and need for assistance with personal care, based on the face sheet. Residents Affected - Some R30's admission MDS dated [DATE] shows that the resident is cognitively intact and required extensive assistance from the staff with most of her ADLs including personal hygiene. On April 10, 2023 at 12:20 PM, R30 was sitting in her wheelchair inside her room. R30 was alert, oriented and verbally responsive. R30 had accumulation of long and curling chin hair. R30's fingernails were long, jagged with black substances underneath. R30 stated that she wants the staff to remove her facial hair and to clean and trim her fingernails. V7 (Director of customer experience) was informed of R30's request to have her facial hair removed, and fingernails trimmed and cleaned. R30 has an active care plan initiated on February 10, 2023 that shows that the resident has impaired ADLs related to decreased mobility related to left humerus fracture. The same care plan showed that the goal is for R30 to complete ADLs with the assistance of staff. 3. R82 has multiple diagnoses which includes right hand contracture and weakness, based on the face sheet. R82's quarterly MDS dated [DATE] shows that the resident is moderately impaired with cognition and required extensive assistance from the staff with most of her ADLs including personal hygiene. On April 10, 2023 at 12:31 PM, R82 was sitting in her wheelchair inside her room. R82 was alert, oriented and verbally responsive. R82 had right hand contracture. R82's fingernails were long and jagged. When R82 attempted to open her right hand with the help of her left hand, indentations caused by the long fingernails were observed on her right palm. V8 (Nurse) was made aware of R82's fingernails. R82 has an active care plan initiated on April 11, 2023 that shows that the resident has ADL self-care performance deficit related to decreased mobility, weakness and contracture of the right hand. On April 12, 2023 at 9:50 AM, V2 (Director of Nursing) stated that the nursing staff are expected to assist all residents that needs assistance with trimming and cleaning of fingernails because it is part of the nursing care. V2 stated that the nursing staff are also expected to assist all residents, male or female that needs assistance or wants to be assisted with shaving or removal of facial hair, because it is part of the nursing care. 4. R41's diagnoses in EMR included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unspecified osteoarthritis, unspecified site, need for assistance with personal care, encounter for palliative care. R41's Quarterly MDS dated [DATE] included that R41 is moderately impaired in cognition and requires extensive assistance of one person for personal hygiene. On 04/10/23 at 01:30 PM, R41 was seen lying in bed and had very long (about 1 inch) fingernails with some nails jagged and multiple long (greater than 1 inch) chin hairs. R41's appeared very thin with hands contracted with arthritis. R41 stated that she needs help from staff and would like to have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145761 If continuation sheet Page 3 of 26 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 145761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewood Nrsg & Rehab Center 14716 S Eastern Avenue Plainfield, IL 60544 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm nails trimmed and facial hairs removed. R41's roommate R94 remarked, Everyone who comes in here says that her nails need to be cut but no one does it. On 04/11/23 at 9:44 AM, the above observation was relayed to V13 (Certified Nursing Assistant) who stated that she is aware that R41 needs her nails trimmed and facial hairs removed. Residents Affected - Some 5. R89's diagnoses in EMR included presence of artificial hip joint, bilateral, need for assistance with personal care, weakness, iron deficiency anemia secondary to blood loss. R89's Annual MDS dated [DATE] included that R89 was cognitively intact and required extensive assistance of one person for personal hygiene. 04/11/23 09:30 AM, R89's had very long (about one inch) fingernails with some of them jagged and with blackish substance underneath most of the nails. R89 stated that she doesn't want them cut, but the jagged ones filed down and nails cleaned. R89 remarked, They need to be soaked. This information was relayed to V13. 8. R72's EMR (Electronic Medical Record) showed R72 was admitted to the facility on [DATE] with diagnoses that included unspecified intracranial injury without loss of consciousness encephalopathy, weakness, traumatic subdural hemorrhage without loss of consciousness fracture of unspecified phalanx of right thumb, need for personal care, and history of falling. R72's MDS (Minimum Data Set) dated March 17, 2023 showed R72 had severe cognitive impairment and required one staff extensive assistance for personal hygiene. R72's care plan dated March 20, 2023 showed R72 had an ADL (Activity of Daily Living) self-care performance deficit related to weakness, decreased mobility, pain, incontinence, and fracture of right thumb. On April 10, 2023 at 11:46 AM, R72 had a thick brown substance between several of his upper teeth that was visible when talking. R72 was asked if gets help brushing his teeth and he said no but that would be nice. Staff had just finished incontinence care. In addition to R72's teeth, hair is standing up all over his head, and he has facial whiskers. On April 11, 2023 at 10:47 AM, R72 still had a thick brown substance between his teeth, hair uncombed, and whiskers. On April 11, 2023 at 10:48 AM, R72 continues to have thick brown stuff in between his teeth. 9. R306's EMR showed R306 was admitted to the facility on [DATE] with diagnoses that included weakness, unspecified abnormalities of gait and mobility, localized edema- chronic (swelling) to bilateral lower extremities, unspecified dementia, morbid obesity due to excess calories, and peripheral vascular disease. R306's MDS dated [DATE] showed R306 was cognitively intact and required one staff extensive assistance for personal hygiene. R306's care plan dated April 12, 2023 showed R306 had an ADL (Activity of Daily Living) self-care performance deficit and staff were to provide supervision, set-up and assistance as needed for hygienic care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145761 If continuation sheet Page 4 of 26 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 145761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewood Nrsg & Rehab Center 14716 S Eastern Avenue Plainfield, IL 60544 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm On April 10, 2023 at 12:00 PM, R306 said he has been here 11 days and has not had a bath or shower, has not brushed his teeth. R306's family was present and they pulled out the supplies provided by the facility to R306 on admission. The tooth brush and tooth paste provided by the facility have not been opened. R306 said one day he had to ask for a wash cloth because he could no longer stand the smell of himself. Incontinence care has been the only care provided by the staff. Residents Affected - Some 10. R307's EMR showed she was admitted to the facility on [DATE], was sent to the hospital on March 23, 2023 and returned to the facility on April 3, 2023. R307's diagnoses included neoplasm of uncertain behavior and other specified sites, chronic diastolic (congestive) heart failure, pneumonitis due to inhalation of food and vomit, ascites, acute respiratory failure, altered mental status, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and weakness. R307's MDS dated [DATE], showed R307 had severe cognitive impairment and required extensive two staff assistance for personal hygiene. R307's care plan dated March 27, 2023 showed R307 had an ADL self-care performance deficit related to weakness, loss of vision, and incontinence. On April 10, 2023 at 11:57 AM R307 is in bed, yelling out, there is a foul odor noticed when close to R307 in bed. R307's hair is greasy, stringy, and matted to her head. R307's gown had several stains on it. On April 10, 2023 at 1:21 PM, V24 (R307's family member) was in the room with R307, she was combing R307's hair. V24 said she comes every day after 11:00 AM and [R307] has not been given a shower, bed bath., or had her hair washed since she came here. R24 said [R307] is always in a stained hospital gown, with foul odor noted, and resident is always restless. On April 11, 2023 at 1:36 PM, surveyor asked V5 (CNA/Certified Nursing Assistant) to come check on R307. V5 unfastened and opened R307's incontinence brief, it was wet and soiled. Stool was dried onto her buttocks. V5 wiped several times to clean the stool off of R307's skin. There was an outer ring where stool was dried onto her skin, and V5 had to wipe the area several times before stool coming off of her skin. On April 12, 2023 at 9:21 AM, V2 (DON/Director of Nursing) ADL (Activity of Daily Living) and grooming care is done every day. Showers are twice a week and on non-shower days the staff are still expected to assist the resident as needed with washing face, hands, armpits, and groin area. The staff are to help the resident get dressed if needed, assist with oral care, nail care, and shaving if needed. 6. The EMR (Electronic Medical Record) showed R10 was admitted to the facility on [DATE], with multiple diagnoses including heart failure, breast cancer, colon cancer, and diabetes. The MDS (Minimum Data Set) dated January 18, 2023, showed R10 had severe cognitive impairment. The MDS continued to show R10 required extensive assistance of facility staff for personal hygiene. R10's care plan dated January 25, 2023, showed, Resident has ADL (Activity of Daily Living) self-care performance deficit related to decreased cognition, decreased safety awareness, weakness, and requires assistance for ADL's to be met. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145761 If continuation sheet Page 5 of 26 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 145761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewood Nrsg & Rehab Center 14716 S Eastern Avenue Plainfield, IL 60544 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm On April 10, 2023, at 12:22 PM, R10 was eating lunch in the dining room. R10 had multiple curling chin and upper lip hairs. On April 10, 2023, at 1:08 PM, R10 was in her wheelchair, sitting in her room. R10 had multiple curling chin and upper lip hairs. Residents Affected - Some On April 11, 2023, at 1:32 PM, R10 was in her wheelchair, sitting in her room. R10 had multiple curling chin and upper lip hairs. On April 11, 2023, at 4:34 PM, R10 was in her wheelchair, sitting in her room. R10 had multiple curling chin and upper lip hairs. On April 12, 2023, at 1:28 PM, R10 was in her wheelchair, sitting in her room. R10 had multiple curling chin and upper lip hairs. Facility documentation for R10's April showers showed R10 was not shaved during showers on April 4, April 8, or April 11. 7. The EMR showed R67 was admitted to the facility on [DATE], with multiple diagnoses including dementia, weakness, delirium, and stroke. R67's MDS dated [DATE], showed R67 had severe cognitive impairment. The MDS continued to show R67 required extensive assistance of facility staff for personal hygiene and was totally dependent on facility staff for bathing. R67's care plan dated April 12, 2023, showed, ADL: [R67] has ADL self-care performance deficit related to decreased mobility, weakness, unsteadiness on feet, need for assistance with personal care, unspecified dementia, unspecified severity, with other behavioral disturbance, and other disease process. She requires assists for all ADLs. On April 10, 2023, at 1:06 PM, R67 was in her wheelchair, sitting in her room. R67's hair had appeared to have a greasy texture. On April 11, 2023, at 1:39 PM, R67 was in her wheelchair, sitting in her room. R67's hair had appeared to have a greasy texture. On April 12, 2023, at 9:40 AM, R67 was in her wheelchair, sitting in her room. R67's hair had appeared to have a greasy texture. Based on observation, interview and record review the facility failed to assist residents identified as needing assistance with oral care, bathing/shower and personal hygiene. This applies to 10 of 11 residents (R10, R30, R41, R57, R67, R72, R82, R89, R306, R307) reviewed for ADL (activities of daily living) in the sample of 27. Findings include: 1. R57 has multiple diagnosis which includes, dementia with agitation, weakness, and need for assistance with personal care, based on the face sheet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145761 If continuation sheet Page 6 of 26 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 145761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewood Nrsg & Rehab Center 14716 S Eastern Avenue Plainfield, IL 60544 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R57's annual MDS (minimum data set) dated February 22, 2023, indicates the resident is cognitively impaired and requires extensive assistance from the staff with most of her ADLs including personal hygiene. On April 10, 2023 at 10:55 AM, R57 was observed sitting in her wheelchair in the 400 hallways, propelling the wheelchair with her feet. R57 was observed with patches of long, curly chin hair. V8, (Nurse) was present and made aware of the chin hair. R57 has an active care plan initiated on April 11, 2023, which shows that the resident has ADL self- care performance deficit and requires extensive staff assistance for all ADLs, including hygienic care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145761 If continuation sheet Page 7 of 26 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 145761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewood Nrsg & Rehab Center 14716 S Eastern Avenue Plainfield, IL 60544 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to assess and provide adaptive equipment and services to residents, to prevent further reduction in mobility and ROM (range of motion). This applies to 2 of 3 residents (R36 and R82) reviewed for mobility and range of motion in the sample of 27. The findings include: 1. R36 has multiple diagnoses which includes hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and dementia without behavioral disturbance, based on the face sheet. R36's quarterly MDS (minimum data set) dated March 16, 2023 shows that the resident is modified independence (some difficulty in new situations only) with cognitive skills for daily decision making and required extensive assistance from the staff with most of her ADLs (activities of daily living.) The same MDS shows that R36 has functional limitations in range of motion on both sides of her upper and lower extremities. On April 10, 2023 at 1:19 PM, R36 was sitting in her wheelchair inside her room. R36 was alert, oriented and verbally responsive. R36 had weakness on her right arm and right hand. R36's right hand was contracted and was not able to open her right hand without the help of her left hand. No adaptive device was observed on R36's right hand. According to R36, she never had any device applied on her right arm and right hand for the weakness. On April 11, 2023 at 8:49 AM, R36 was sitting in her wheelchair inside her room. R36 was alert, oriented and verbally responsive. R36 had weakness on her right arm and right hand. R36's right hand was contracted, and the resident was having difficulty opening her right hand, even with the help of her left hand. No adaptive device was observed on R36's right hand. V2 (Director of Nursing) was present during the observation and was prompted to have the OT (occupational therapist) screen R36 for the need for an adaptive equipment/device. On April 11, 2023 at 3:01 PM, V17 (Occupational Therapist) stated that she had screened R36 per nursing request and based on her screening she is recommending for the resident to use a right resting hand splint to prevent further contracture. R36's occupational therapy screening dated April 11, 2023 created by V17 shows, Provided resident with resting hand splint [right] to prevent further contracture. 2. R82 has multiple diagnoses which includes right hand contracture and weakness, based on the face sheet. R82's quarterly MDS dated [DATE] shows that the resident is moderately impaired with cognition and required extensive assistance from the staff with most of her ADLs. The same MDS shows that R82 has functional limitations in range of motion on both sides of her upper and lower extremities. On April 10, 2023 at 12:31 PM, R82 was sitting in her wheelchair inside her room. R82 was alert, oriented and verbally responsive. R82 had right hand contracture. R82 cannot fully open her right hand (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145761 If continuation sheet Page 8 of 26 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 145761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewood Nrsg & Rehab Center 14716 S Eastern Avenue Plainfield, IL 60544 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few even with the help of her left hand. R82 cannot open/extend her 3rd, 4th and 5th right fingers. No adaptive device was observed on R82's right hand. During the same observation, when R82 attempted to open her right hand, indentations caused by her long fingernails were observed on her right palm. On April 11, 2023 at 8:46 AM, R82 was sitting in her wheelchair inside her room. R82 was alert, oriented and verbally responsive. R82's right hand was contracture. The resident cannot fully open her right hand even with the help of her left hand. R82 cannot open/extend her 3rd, 4th and 5th right fingers. No adaptive device was observed on the resident's right hand. On April 11, 2023 at 9:00 AM, R82 was being wheeled to the beauty shop by a staff. During that time, V2 (Director of Nursing) was informed about the right hand contracture. V2 saw the condition of the R82's right hand. V2 was prompted to have the OT (occupational therapist) screen R82 for the need for an adaptive equipment/device. On April 11, 2023 at 3:03 PM, V17 (Occupational Therapist) stated that she had screened R82 per nursing request and based on her screening she is recommending for the resident to use a right hand palm protector to prevent further finger contracture. R82's occupational therapy screening dated April 11, 2023 created by V17 shows, Resident could benefit from [right] palm protector to prevent further contracture. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145761 If continuation sheet Page 9 of 26 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 145761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewood Nrsg & Rehab Center 14716 S Eastern Avenue Plainfield, IL 60544 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their policy on using a gait belt when transferring a resident. This applies to 1 of 2 residents (F306) reviewed for transfers. The findings include: R306's EMR (Electronic Medical Record) showed R306 was admitted to the facility on [DATE] with diagnoses that included weakness, unspecified abnormalities of gait and mobility, localized edema- chronic (swelling) to bilateral lower extremities, unspecified dementia, morbid obesity due to excess calories, and peripheral vascular disease. R306's MDS (Minimum Data Set) dated April 5, 2023 showed R306 was cognitively intact and required two staff extensive assistance for transfers from bed to wheelchair. R306's care plan dated April 12, 2023 showed R306 had an ADL (Activity of Daily Living) self-care performance deficit and staff were to provide supervision, set-up and assistance as needed for transfers. On April 12, 2023 at 10:52 AM, V20 (PT/Physical Therapist), said staff always need to use a gait belt when transferring a resident. [R306] is going home today per the family's request, but I think he could have benefited from more rehab but they wanted him to go back to the facility he came from. On April 12, 2023 at 9:21 AM V2 (DON/Director of Nursing) said when transferring a resident, the use of a gait belt depends on the resident and their transfer status. Surveyor asked V2 about [R306] whose MDS showed he was a 2 staff extensive assistance for transfers. V2 said maybe the MDS assessment has not caught up with resident current status. On April 11, 2023 at 9:20 AM, V23 (CNA/Certified Nurse Assistant) had finished assisting R306 with personal hygiene. R306 was sitting on the side of his bed. V23 did not apply a gait belt or ask for any staff assistance. V23 placed R306's walker in front of him and stood next to R306 as he stood and pivoted into his wheelchair. Facility provided undated policy titled Safe Patient Lifting Policy showed, Gait belt usage is mandatory for all resident handling. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145761 If continuation sheet Page 10 of 26 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 145761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewood Nrsg & Rehab Center 14716 S Eastern Avenue Plainfield, IL 60544 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide incontinence care in a manner that would prevent urinary tract infection. In addition, the facility failed to ensure that an indwelling urinary catheter is secured or anchored to the resident to prevent from potential pulling. This applies to 3 of 7 residents (R72, R96, R307) observed for incontinence and catheter care in the sample of 27. The findings include: 1. On 4/11/23 at 12:56 PM, V26 (Certified Nursing Assistant/CNA) rendered catheter care to R96. R96's catheter had no anchor to secure the catheter tube in place as R96 was being given peri-care and catheter care, and while being repositioned. The tube was hanging loosely and without security. On 04/12/23 at 2:20 PM, V2 (Director of Nursing/DON) stated that the indwelling urinary catheter should have an anchor to prevent from pulling. R96's urinary catheter care plan shows that R96 requires an indwelling urinary catheter related to neuromuscular dysfunction of the bladder. The goal is to provide urinary catheter care managed appropriately as evidenced by not exhibiting signs of infection and urethral trauma. Facility's Policy and Procedure for Urinary Catheter indicates: 15. Ensure that the catheter remains secured with a leg strap to reduced friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh). 2. R72's EMR (Electronic Medical Record) showed R72 was admitted to the facility on [DATE] with diagnoses that included unspecified intracranial injury without loss of consciousness encephalopathy, weakness, traumatic subdural hemorrhage without loss of consciousness fracture of unspecified phalanx of right thumb, need for personal care, and history of falling. R72's MDS (Minimum Data Set) dated March 17, 2023 showed R72 had severe cognitive impairment and required one staff extensive assistance for personal hygiene. R72's care plan dated March 20, 2023 showed R72 had an ADL (Activity of Daily Living) self-care performance deficit related to weakness, decreased mobility, pain, incontinence, and fracture of right thumb. Staff are to check R72 every two hours and as needed for incontinence. On April 12, at 10:48 AM V6 (LPN/Licensed Practical Nurse) and V6 (CNA/Certified Nursing Assistant) both put on gloves to provide incontinence care for R72. V5 used a disposable wipe and cleaned from front to back the left side of groin, and right side of groin, R27's penis was in between legs, V5 lifted it up so it rested more on top of his legs. The side of penis on top was wiped down but the underside or the meatus (tip of penis) did not get cleaned. 3. R307's EMR showed she was admitted to the facility on [DATE], was sent to the hospital on March 23, 2023 and returned to the facility on April 3, 2023. R307's diagnoses included neoplasm of uncertain behavior and other specified sites, chronic diastolic (congestive) heart failure, pneumonitis due to inhalation of food and vomit, ascites, acute respiratory failure, altered mental status, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and weakness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145761 If continuation sheet Page 11 of 26 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 145761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewood Nrsg & Rehab Center 14716 S Eastern Avenue Plainfield, IL 60544 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R307's MDS dated [DATE] showed R307 had severe cognitive impairment and required extensive two staff assistance for personal hygiene. R307's care plan dated March 27, 2023 showed R307 had an ADL self-care performance deficit related to weakness, loss of vision, and incontinence. On April 10, 2023 at 1:36 PM surveyor asked V5 (CNA) to come check R307's incontinence brief. V5 (CNA) pulled down the covers and opened her incontinence brief. V5 used a wipe to the outside of the labia, cleaning from front to back, when she was at the bottom or closest to the incontinence brief, there was stool on the wipe. V5 did not spread the labia and clean in between or make sure there was no stool in between the labia. V5 used a new wipe to clean in the right side of groin and then left side of groin. V5 turned R307 onto her left side and there was blood and stool in the incontinence brief. Stool was dried on her buttocks. V5 wiped stool off and then there was an outer ring where stool was dried onto her skin, and was not coming off. V5 wiped the area several times before the stool came off. On April 12, 2023 at 9:21 AM, V2 (DON/Director of Nursing) said when staff are providing incontinence care to a female resident, the staff need to clean the female from front to back, spread the labia and clean from front to back before turning to clean the back side. When providing incontinence care to a male resident, the staff need to clean the penis from top to bottom, if uncircumcised, they need to pull the foreskin back and clean the meatus, and then pull the foreskin forward, if circumcised start at the top and clean down the shaft. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145761 If continuation sheet Page 12 of 26 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 145761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewood Nrsg & Rehab Center 14716 S Eastern Avenue Plainfield, IL 60544 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that a resident receives the intravenous medication as ordered by the physician. This applies to 1 of 1 resident (R156) reviewed for intravenous medication in the sample of 27. Residents Affected - Few The findings include: R156 was admitted to the facility on [DATE] from the hospital. R156 has multiple diagnoses which includes orthopedic aftercare following surgical amputation-4th metatarsal head resection, acute osteomyelitis of the left ankle and left foot metatarsal, type 2 diabetes mellitus with diabetic chronic kidney disease and hyperglycemia and dependence on renal dialysis. R156's social service progress notes dated April 10, 2023 showed that the resident is cognitively intact. On April 10, 2023 at 11:30 AM, R156 was in bed, alert, oriented and verbally responsive. R156 stated that he is new to the facility and over the weekend (no specific date given) his ordered IV (intravenous) antibiotic which was to run for 4 hours was administered by the nurse only within 1 hour. On April 11, 2023 at 8:57 AM, R156 was in bed, alert, oriented and verbally responsive. V2 (Director of Nursing) was in the room to start R156's IV antibiotic. V2 stated that when R156 was admitted , she was the nurse on duty who verified and received the order to administer/run the reconstituted piperacillin-tazobactam IV antibiotic over four hours. V2 stated that the IV antibiotic order was based on the hospital medication list for R156 to continue taking. According to V2 on April 8, 2023 at around 12:00 AM, she administered R156's reconstituted piperacillin-tazobactam IV antibiotic within an hour, because the pharmacy had labeled the IV antibiotic to run for one hour, instead of four hours. Review of R156's hospital medication list dated April 7, 2023 showed that the resident should take multiple medications including, piperacillin-tazobactam 4.5 [grams]. Next dose due: [April 7] tonight at midnight. The same medication list indicated instructions to administer the piperacillin-tazobactam 4.5 grams every 12 hours for 22 days. Administer over 4 hours. R156's physician prescription order received, created and verified by V2 on April 7, 2023 at 4:17 PM showed an order for, Piperacillin-Tazobactam [reconstituted solution]: 4.5 grams, intravenous, every 12 hours [12:00 AM and 12:00 PM]. The same prescription order showed the special instruction to, Administer over 4 hours. Review of the event report dated April 8, 2023 (12:00 AM) created by V2 showed that the IV antibiotic piperacillin-tazobactam was administered to R156 over one hour. The event report documented that it was an incorrect medication rate. The event report showed that the IV antibiotic was supposed to be administered over four hours. The same event report showed that the physician was notified, the pharmacy was contacted and correct label for the IV antibiotic medication was provided by the pharmacy for future doses. R156's progress notes dated April 8, 2023 (12:59 AM) recorded as a late entry by V2 showed in-part, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145761 If continuation sheet Page 13 of 26 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 145761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewood Nrsg & Rehab Center 14716 S Eastern Avenue Plainfield, IL 60544 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 0694 Level of Harm - Minimal harm or potential for actual harm Resident IV administered over 1 hour, MD (Medical Doctor) notified. Resident in no distress. Vitals WNL (within normal limits). On April 12, 2023 at 10:58 AM, V19 (Physician) stated that the facility should always follow the physician's orders for medication administration. Residents Affected - Few The facility's medication administration policy and procedure dated October 25, 2014 shows in-part under policy, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. The same policy and procedure shows in-part, 4) Five rights - Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. A triple check of these 5 rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container and finally (3) just after the dose is prepared and the medication put away. a. Check #1: Select the medication- label, container and contents are checked for integrity, and compared against the medication administration record (MAR) by reviewing the 5 rights. b. Check #2: Prepare the dose - the dose is removed from the container and verified against the label and the MAR by reviewing the 5 rights. c. Check #3: Complete the preparation of the dose and re-verify the label against the MAR by reviewing the 5 rights. 5) Prior to administration, the medication and dosage schedule on the resident's medication administration record (MAR) are compared with the medical label. If the label and MAR are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, The physician's orders are checked for the correct dosage schedule. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145761 If continuation sheet Page 14 of 26 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 145761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewood Nrsg & Rehab Center 14716 S Eastern Avenue Plainfield, IL 60544 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 observation, interview and record review the facility failed to follow the plan of care for behavior monitoring for a resident receiving psychotropic medication. This applies to 1 of 5 residents (R61) reviewed for psychotropic's in the sample of 27. The findings include: R61's EMR (Electronic Medical Records) included diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, restlessness and agitation, major depressive disorder, single episode. R61's Quarterly MDS (Minimum Data Set) dated 1/19/23 showed that R61 is moderately impaired in cognition. R61's POS (Physician Order Sheet) included Seroquel 25 mg, 12.5 mg/milligram twice a day (start date 01/05/23) for Restlessness and Agitation. R61's care plan initiated 01/26/23 showed that R61 is at risk for adverse side effects related to routine use of antipsychotic medication utilized to assist in managing diagnoses of anxiety, depression, and dementia. The same care plan included that diagnosis for restlessness/agitation added on 01/05/23. Goal with target Date 04/26/2023 for the same care plan included that resident will not have adverse side effects related to antipsychotic medication use through next review date. Interventions with approach start date 1/26/23 included as follows: Assess if the residents behavioral symptoms present a danger to the resident and/or others. Intervene as needed. Assess/record effectiveness of drug treatment. Monitor and report signs of sedation, anticholinergic and/or extrapyramidal symptoms. On 04/10/23 at 9:24 AM, R61 was sitting quietly in a wheel chair in his room. R61 stated that his only concern is that staff are more engrossed in their own work and do not heed his personal wishes. When asked to clarify, V61 stated, They ignore me when I want to be moved around and want to go out of my room. V28 (Licensed Practical Nurse) who was in the area was notified of the same. V28 stated that R61 prefers to be outside his room. V28 added that R61 likes to go outdoors and family does so when they visit and sometimes the staff take him out when they are available. On 04/12/23 at 10:14 AM, V22 (Restorative Nurse) stated that she oversees the use of Psychotropic's. V22 continued He [R61] was admitted on [DATE] and around June-July 2022, he had a lot of behaviors and his wife requested for him to start a medication that would calm him down. At first, we tried other measures. He likes to go outside and be near people, so we made accommodations for the same. Activity staff take him out when its nice outside and take him to activities and we moved him closer to nursing station to be around people. Psych [Psychiatry and Psychology services] started seeing him on 6/11/22. He came [admitted ] with escitalopram oxalate [Lexapro] 10 mg 1 tablet which was increased to 2 tablets in 11/30/22. Seroquel was added on 1/05/23 by Psychotropic Nurse Practitioner for restlessness and agitation and he has calmed down and only has had a few moments of anger and lashing out. V22 added that she was able to verify who ordered Seroquel by checking the order date. V22 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145761 If continuation sheet Page 15 of 26 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 145761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewood Nrsg & Rehab Center 14716 S Eastern Avenue Plainfield, IL 60544 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 also stated that Psychotropic Nurse Practitioner rounds weekly and sees patients as needed and that Psychiatric Medical Doctor sees residents every quarter. Psychiatric Progress notes of Psychotropic Nurse Practitioner with service dates on 01/31/2023 and 02/28/2023 (edited 03/09/2023) listed current Psychotropic Medications: Lexapro 20mg daily. Residents Affected - Few Facility reported that behavior monitoring was recorded by CNA's (Certified Nursing Assistants) in Point of Care History. Review of the same showed that behaviors were not recorded to current date since the addition of Seroquel on 01/05/23. Facility Psychotropic Medication Policy (effective date February 2014) included as follows: Policy: To establish the process for monitoring the use of and the reduction of doses of psychotropic medications without compromising the resident's health and safety, ability to function appropriately, or the safety of others. Definitions: Psychotropic medication: medication that is used for or listed as used for antipsychotic, antidepressant, anti-maniac, or anti-anxiety behavior modification for behavior management purposes. Psychopharmacologic drug use procedure: Procedure: To assure that appropriate monitoring is provided to residents receiving psychopharmacologic drugs, that the lowest possible dose necessary for the benefit of the resident to improve or control mood, mental status and/or behavior is utilized, and to reduce or eliminate the usage of these medications. 5. Documentation of behaviors and conditions requiring the use of these medications must be done on a routine basis including resident response to the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145761 If continuation sheet Page 16 of 26 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 145761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewood Nrsg & Rehab Center 14716 S Eastern Avenue Plainfield, IL 60544 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review, the facility failed to follow recipe for pureed breaded fish and cheese sandwich and failed to use scoop sizes as shown on menu spread for pureed and mechanical soft diets. This applies to 9 of 9 residents (R16, R24, R36, R40, R57, R72, R96, R256, R308) observed for dining in the sample of 27. 1. On 04/10/23 at 11:55 AM, V14 (Dietary Manager) was at the steam table during lunch meal service in the facility kitchen platting foods for the pureed diets. V14 used a #8 scoop to serve pureed Beef Stroganoff to R57, R72, R96, R256). R57 was served pureed diet in bowls and ate in dining room. R256, R96, and R72 received room trays. Facility Menu Daily Spreadsheet for week 1, Monday showed to use #6 scoop of pureed Beef Stroganoff for pureed diets. On 04/10/23 at 2:17 PM, V14 stated that she did not notice that the pureed diet serving portions on the menu spreadsheets and that the above residents should have received #6 scoop of the same. Facility Portion Control Chart showed that #8 scoop is = 4 ounces/scoop and that #6 scoop = 6 ounces/scoop. 2. On 04/11/23 09:47 AM, during the pureed meal prep in the facility kitchen, V15 (Cook) stated that he is preparing total of 7 servings. V15 pureed 7 pieces of already cooked breaded fish along with 1 cup broth in a blender and transferred the mixture into a pan to reheat in a steamer. V15 was not following a recipe. Recipe for Pureed Breaded Fish and Cheese Sandwich for one serving showed ingredients of 1 each with 2 slices cheese (2 oz protein) and 2 tablespoons of broth. The same recipe included to place fish and cheese portion and hot broth in a food processor and blend until a smooth consistency. On 04/11/23 at 11:38 AM, V15 was platting the lunch meal in the facility kitchen. V15 used #8 (gray) scoop to serve pureed fish (without cheese) to R72, R96, and R308. V15 used #12 (green) scoop to serve mechanical soft breaded fish with 1 slice cheese inside a bun and R16, R24, R36 and R40 received the same. Facility Menu Daily Spreadsheet for Week 1, Tuesday showed to use 2 #8 scoops of ground breaded fish and cheese for mechanical soft diets. The same spread sheet showed to use 2 #10 scoops of pureed fish with cheese for pureed diets. Facility Portion Control Chart showed that #12 scoop = 2.5 oz/ounce, #10 scoop = 3.25 oz and #8 scoop = 4 oz. On 04/11/23 at 12:15 PM, V14 (Dietary Manager) stated that the above scoop sizes were used for the lunch meal service as she felt that the portion sizes were too large when using the scoop sizes as shown on the menu spread sheet. On 04/11/23 at 1:11 PM, V16 (Dietitian Consultant) stated that the facility should follow the menu spreadsheets that are written by a contracted menu company based on regulations established by the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145761 If continuation sheet Page 17 of 26 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 145761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewood Nrsg & Rehab Center 14716 S Eastern Avenue Plainfield, IL 60544 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm State of Illinois to meet the protein needs. V16 stated that when it's a breaded item like the breaded fish, larger portions are served to meet the estimated protein needs. Facility Client List Type report printed on 4/10/23 included that R16, R24, R36 and R40 were on Mechanical Soft diets and R57, R72, R96, R256, R308 were on Pureed diets. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145761 If continuation sheet Page 18 of 26 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 145761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewood Nrsg & Rehab Center 14716 S Eastern Avenue Plainfield, IL 60544 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview and record review, the facility failed to serve mechanical soft consistency fruit for the lunch meal. This applies to 5 of 5 residents (R14, R25, R39, R41, R81) observed for dining in the sample of 27. The findings include: On 04/10/23 starting at 11:55 AM, during the lunch meal service in the facility main dining room, R14, R25, R39, R41 and R81 who were on mechanical soft diets, received pineapple tidbits for dessert. These residents were seated on an area that needed assistance by staff and noted to have poor dentition and/or were edentulous and did not eat the pineapple tidbits. Facility menu spreadsheet for week 1 Monday included 1/2 cup (#8 scoop) of soft canned fruit for mechanical soft diets. On 04/10/23 at 2:17 PM, Dietary Manager stated mechanical soft diets should have received diced peaches. On 04/11/23 at 1:11 PM, V16 (Dietitian Consultant) stated that the facility policies and guidelines for diets are listed in a book provided by the menu service providers. V16 added that the facility should follow the policy which shows that for mechanical soft diets, pineapple should not be served. Facility Menu Hand Book (revised September 2021) for Mechanical Soft -Dysphagia Level -3 diets included as follows: Stringy high pulp fruits such as mango, pineapple and papaya will be avoided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145761 If continuation sheet Page 19 of 26 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 145761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewood Nrsg & Rehab Center 14716 S Eastern Avenue Plainfield, IL 60544 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to serve milk prior to the expiration date and ensure that the milk provided was not spoiled. This applies to 2 of 2 residents (R30, R51) observed during dining experience in the sample of 27. The findings include: 1. On 4/11/23 at 12:20 PM, lunch observation was conducted. R51 was eating lunch in his room. R51 held out a carton of milk (Vitamin A & D 2% reduced fat milk) to surveyor and stated, I think this is spoiled, I drank it, and it was sour. They just gave it to me a few minutes ago. The milk was curdled and appeared to be like cottage cheese floating in a whitish colored fluid. The carton of milk showed an expiration date of 4/8/23. On 4/11/23 at 1:20 PM, V27 (Certified Nursing Assistant/CNA is the staff who passed the tray to R51) stated that the milk was already on the tray when she served it to R51. The milk came from the kitchen. 2. On 4/11/23 at 1:28 PM, there was a carton of milk (Vitamin A &D 2% reduced fat milk) in R30's lunch tray which was opened and was full. It showed curdled milk. The carton showed an expiration date of 4/8/23. On 4/12/23 at 2:40 PM, V14 (Food Service Director) stated that the staff must check the dates of the expiration of the milk prior to serving to residents. Expired milk should be discarded or thrown away. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145761 If continuation sheet Page 20 of 26 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 145761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewood Nrsg & Rehab Center 14716 S Eastern Avenue Plainfield, IL 60544 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow infection control process related to hand hygiene and gloving during provisions of care. This applies to 5 of the 7 residents (R51, R72, R96, R307, R308) observed for infection control during provisions of care in the sample of 27. Residents Affected - Some The findings include: 1. 04/11/23 09:16 AM, V26 (Certified Nursing Assistant/CNA) rendered incontinence care to R51 who was wet with urine and a small bowel movement. V26 cleaned R51 from front to back, applied incontinence brief, and V26 touched the beddings while wearing same soiled gloves. On 4/11/23 09:30 AM, after the incontinence care was completed, V29 (Nurse) came to the room to apply Zinc ointment to R51's buttocks. V29 opened the incontinence brief, applied, the ointment, then she closed the brief, removed her gloves, and left the room without hand hygiene. 2. On 4/11/23 at 12:56 PM, V26 rendered catheter and incontinence care to R96 who had a bowel movement. V26 then adjusted the clean blanket without changing gloves. V26 then positioned R96 to left side and clean his back peri-area. R96 had a bowel movement she cleaned it up. Repositioned R96, adjusted his pillow while wearing same soiled gloves. On 4/12/23 at 2:17 PM, V2 (Director of Nursing/DON) stated that hand hygiene and change of gloves should be performed anytime the hands are soiled, before and after care, and in between care if you're going from dirty to clean task or when you're going to touch a different part of the body. this is to prevent spread of infection and prevent contamination. 3. R72's EMR (Electronic Medical Record) showed R72 was admitted to the facility on [DATE], with diagnoses that included unspecified intracranial injury without loss of consciousness encephalopathy, weakness, traumatic subdural hemorrhage without loss of consciousness fracture of unspecified phalanx of right thumb, need for personal care, and history of falling. R72's MDS (Minimum Data Set) dated March 17, 2023, showed R72 had severe cognitive impairment and required one staff extensive assistance for personal hygiene. R72's care plan dated March 20, 2023, showed R72 had an ADL (Activity of Daily Living) self-care performance deficit related to weakness, decreased mobility, pain, incontinence, and fracture of right thumb. Staff are to check R72 every two hours and as needed for incontinence. On April 12, at 10:48 AM V6 (LPN/Licensed Practical Nurse) and V5 (CNA/Certified Nursing Assistant) both entered R72's room and put on gloves without doing hand hygiene. V5 gathered supplies to provide incontinence care for R72. V5 used a disposable wipe and cleaned the left groin from front to back and then the right side of groin from front to back. R27's penis was tucked in between is legs. V5 lifted it up so it rested more on top of his legs. V5 used a new wipe and wiped only the side of penis on top. V5 did not lift the penis to clean the underside and did not clean the meatus (tip of penis). V6 and V5 rolled R72 onto his to left side. V5 did not remove her gloves, do hand hygiene, or put on new gloves before cleaning R72's back side. R72 was rolled to the other side to adjust the new incontinence brief that was placed under him and remove the old incontinence brief. V6 removed her gloves and left the room without doing hand hygiene. 4. R307's EMR showed she was admitted to the facility on [DATE], was sent to the hospital on March (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145761 If continuation sheet Page 21 of 26 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 145761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewood Nrsg & Rehab Center 14716 S Eastern Avenue Plainfield, IL 60544 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 23, 2023, and returned to the facility on April 3, 2023. R307's diagnoses included neoplasm of uncertain behavior and other specified sites, chronic diastolic (congestive) heart failure, pneumonitis due to inhalation of food and vomit, ascites, acute respiratory failure, altered mental status, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and weakness. R307's MDS dated [DATE], showed R307 had severe cognitive impairment and required extensive two staff assistance for personal hygiene. R307's care plan dated March 27, 2023, showed R307 had an ADL self-care performance deficit related to weakness, loss of vision, and incontinence. On April 10, 2023, at 1:36 PM surveyor asked V5 (CNA) to come check R307's incontinence brief. V5 (CNA) pulled down the covers and opened her incontinence brief. V5 used a wipe to the outside of the labia, cleaning from front to back, when she was at the bottom or closest to the incontinence brief, there was stool on the wipe. V5 did not spread the labia and clean in between or make sure there was no stool in between the labia. V5 used a new wipe to clean in the right side of groin and then left side of groin. V5 turned R307 onto her left side without removing gloves, doing hand hygiene, and putting on new gloves. Stool was dried on her buttocks. V5 wiped stool off and then there was an outer ring where stool was dried onto her skin, and it is not coming off. V5 wiped the area, several times before coming off. V5 removed her gloves and left the room without doing hand hygiene. 5. R308's EMR showed R308 was admitted to the facility on [DATE], with diagnoses that included chronic respiratory failure, tracheostomy status-capped, gastrostomy, neuromuscular dysfunction of bladder, type 2 diabetes, and chronic systolic (congestive) heart failure. R308's MDS was requested from the facility. The facility said R308 did not have an MDS due to recent admission. R308 was alert and oriented and able to answer all questions appropriately. R308's care plan dated April 10, 2023, showed R308 is at risk for adverse consequences related to tracheostomy. R308's POS (Physician Order Set) dated April 2, 2023, showed tracheostomy care every shift and as needed. On April 11, 2023, at 2:17 PM, V21 (Regional Nurse Consultant) was providing tracheostomy care to R308. 1. cleaned table with disinfectant wipe, watched for area to dry and continued to wipe for 3 minutes, placed paper towels on over the bed tray table. 2. hand sanitizer - new gloves 3. lungs auscultated anteriorly, asked if resident could sit forward, she said if you help me, V21 asked surveyor if could help, told him no, he told resident I cannot lift you. When auscultated anteriorly V21 said he heard, just a little bit gurgle coming from upper, nothing swimming in there. 4. removed gloves, hand hygiene, new gloves 5. laid out of supplies: hydrogen peroxide packet with water, new tracheostomy cannula, gauze dressing 6. removed gloves, hand hygiene, new gloves 7. removed old dressing, small amount of yellowish green discharge. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145761 If continuation sheet Page 22 of 26 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 145761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewood Nrsg & Rehab Center 14716 S Eastern Avenue Plainfield, IL 60544 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 8. removed old tracheostomy cannula Level of Harm - Minimal harm or potential for actual harm 9. removed gloves, hand sanitizer, new gloves 10 open new bottle of saline and filled small square tray, checked suction functioning, Residents Affected - Some 11. opened sterile glove packet and placed on tray table 12. removed old gloves, hand sanitizer, new gloves, opened new tracheostomy cannula 13. removed old gloves, put on new gloves (non-sterile) and put the sterile gloves on over the non-sterile gloves. 14, suctioned resident 15 removed gloves, hand sanitizer, new gloves 16, hydrogen peroxide poured on to gauze, cleaned around right side of tracheostomy stoma 17, removed gloves, hand sanitizer, new gloves 18. poured hydrogen peroxide on gauze, cleaned around left side of tracheostomy stoma 19. removed gloves, hand sanitizer, new gloves, 20. auscultated lungs anteriorly- said expiratory junk upper respiratory system 21. removed gloves, hand sanitizer, new gloves 22. opened new tracheostomy cannula, open new suction kit and removed sterile gloves and placed on tray table 23. removed old tracheostomy cannula 24. put on sterile gloves over the non-sterile gloves. 25. inserted new tracheostomy cannula correctly 26, removed sterile gloves, non-sterile glove broke 27. removed hand sanitizer, new gloves 28. new sponge dressing put on, and tracheostomy ties in place. On April 12, 2023, at 9:21 AM, V2 (DON/Director of Nursing) said during tracheostomy care, before putting on sterile gloves, you have to remove the old gloves, do hand hygiene, and using sterile technique you put one sterile glove on at a time. You should not put sterile gloves over regular gloves. When staff are providing incontinence care, they need to remove old gloves, use hand hygiene, and put on new gloves after cleaning a soiled area and before moving to another area or anytime when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145761 If continuation sheet Page 23 of 26 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 145761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewood Nrsg & Rehab Center 14716 S Eastern Avenue Plainfield, IL 60544 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 moving from soiled to clean area. Level of Harm - Minimal harm or potential for actual harm Facility provided undated policy titled Tracheostomy Care showed under Miscellaneous 3 .Sterile gloves must be used during aseptic procedures. Residents Affected - Some Facility provided policy with revision date of June 2005, titled Protective Equipment- Using Gloves showed under Procedure Putting on gloves 1. wash hands .3. open package and do not touch gloves. 4. grab one glove on the inside of the cuff. Insert opposite hand into the glove, leave the cuff turned down. 5. Pick up the remaining glove with the gloved hand. Insert ungloved hand into the second glove Facility provided policy titled, Handwashing/Hand Hygiene Policy Effective date of March 2020 showed, It is the policy of this facility to assure staff practice recognized hand-washing/hand hygiene procedures as a primary means to prevent the spread of infection among residents, personnel and visitors. Alcohol based hand rubs (ABHR) can be used when hands are not visibly soiled with blood or bodily fluids. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145761 If continuation sheet Page 24 of 26 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 145761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewood Nrsg & Rehab Center 14716 S Eastern Avenue Plainfield, IL 60544 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to offer residents the influenza and pneumococcal vaccine. This applies to 5 of 5 residents (R10, R5, R17, R45, and R78) reviewed for immunizations in the sample of 27. Residents Affected - Some The findings include: 1. The EMR (Electronic Medical Record) showed R10 was admitted to the facility on [DATE], with multiple diagnoses including heart failure, breast cancer, colon cancer, and diabetes. The facility documentation titled, Informed Consent for Vaccinations, dated September 2015, showed R10 consented to the pneumococcal vaccine on October 1, 2020. The facility does not have documentation to show R10 had received the pneumococcal vaccine. On April 12, 2023, at 10:33 AM, V2 (DON/Director of Nursing) said the expectation is R10 should have received the pneumococcal vaccine when she consented to receiving the vaccine. 2. The EMR showed R5 was admitted to the facility on [DATE], with multiple diagnose including urinary tract infection, bilateral lung granulomas, and pulmonary embolism. On April 12, 2023, at 10:33 AM, V2 said the expectation of staff is to offer the pneumococcal vaccine within 48 hours of a resident's admission to the facility. The facility does not have documentation to show R5 had received or was offered the pneumococcal vaccine prior to February 12, 2023. 3. The EMR showed R17 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, atrial fibrillation, morbid obesity, pulmonary embolism, and heart disease. On April 12, 2023, at 10:33 AM, V2 said the facility follows CDC (Centers for Disease Control and Prevention) guidelines for pneumococcal vaccination timing. The facility does not have documentation to show R17 was offered the pneumococcal vaccine within 48 hours of admission. The facility does not have documentation to show R17 had received or was offered a second pneumococcal vaccine. 4. The EMR showed R45 was admitted to the facility on [DATE], with multiple diagnoses including type 2 diabetes, chronic kidney disease, and morbid obesity. The facility does not have documentation to show R45 had received or was offered the influenza or pneumococcal vaccine within 48 hours of admission. 5. The EMR showed R78 was admitted to the facility on [DATE], with multiple diagnoses including stroke, heart failure, pulmonary embolism, chronic obstructive pulmonary disease, and end stage renal disease. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145761 If continuation sheet Page 25 of 26 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 145761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewood Nrsg & Rehab Center 14716 S Eastern Avenue Plainfield, IL 60544 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 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On April 12, 2023, at 10:33 AM, V2 said if a resident refuses the pneumococcal vaccine because they do not want the vaccine, the facility will offer the pneumococcal vaccine monthly. The facility does not have documentation to show R45 had received or was offered the pneumococcal vaccine within 48 hours of admission to the facility. The facility does not have documentation to show R45 was offered a second pneumococcal vaccine after October 2021. The facility policy titled Influenza and Pneumococcal Immunizations, dated November 2016, showed, Policy: To assure that each resident receives education regarding the benefits and potential side effects before being offered influenza and pneumococcal immunizations and securing their informed consent for administration of these immunizations. Policy Specifications: 1. Each resident, or when appropriate their resident representative, will be educated regarding the benefits and potential side effects of both influenza and pneumococcal immunizations and will be provided the opportunity to accept or refuse them . 5. The facility will assure that an on-going process exists to educate and provide new residents or their representative with the opportunity to accept or refuse both the pneumococcal and influenza immunizations, the latter of which will be offered during the annual influenza season. The Pneumococcal Vaccine Timing for Adults on the cdc.gov website, dated April 1, 2022, showed CDC recommends pneumococcal vaccination for adults [AGE] years old and older. For those who previously received PPSV23 (23-valent pneumococcal but who have not received any pneumococcal conjugate vaccine, you may administer one dose of PCV15 (15-valent Pneumococcal conjugate vaccine) or PCV20 (20-valent Pneumococcal Conjugate Vaccine). Regardless of which vaccine is used (PCV15 or PCV20): the minimum interval is at least one year. Pneumococcal vaccine timing for adults who previously received PCV13: CDC recommends one dose of PPSV23 at age [AGE] years or older. Administer a single dose of PPSV23 at least one year after PCV13 was received. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145761 If continuation sheet Page 26 of 26