Inspection·April 7, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm 1. R39 is a 90 year male admitted [DATE] with a diagnosis not limited to unsteady gait, primary hypertension, and need for assistance with personal care. On 04/05/2023 at 10:35 AM, V3 (Registered Nurse/RN) entered R39's room without knocking or gaining permission before entering R39's room. Residents Affected - Some On 04/05/2023 at 10:37 AM, V3 said she should have knocked on the door and gained permission before entering R39's room. On 04/06/2023 at 10:10 AM, V2 (Director of Nursing) said she expects staff to knock on residents' door and gain permission before entering the residents' room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145827 If continuation sheet Page 2 of 9 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 145827 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE British Home, The 8700 West 31st Street Brookfield, IL 60513 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 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to protect the resident from misappropriation of personal property for one of one resident (R200) reviewed for abuse in a sample of 12. Residents Affected - Few Findings include: On 04/06/2023 at 3:19PM, R200 said her credit card is kept in a wallet in her purse. She said she cannot remember when, but she was going for therapy that day, but since this facility is nice, she trusted everybody in the facility and left her purse in the drawer. She stated her daughter called her that day and asked her if her credit card was with her. When she checked, it was not where she left it, and she said she knows where she kept it, so she knows where to look. She said her daughter visited the next day and they found her credit card in her purse, but not where it was supposed to be. She said it was like it was just dropped in there. On 04/07/2023 at 8:00AM, V21 (R200's family member) said on 1/25/23 at 4:52PM, she received a fraud notification from the credit card bank, stating that her mother's credit card was used at a retail store amounting $879.00, but was declined. When she checked the transactions, it was noted that there were two transactions prior to this at a fast-food chain that were approved. She stated she visited her mother on 1/24/23, and knew the credit card was in her wallet because she was looking for her mother's vaccination card. She said she visited her mother on 1/26/23, and they found the credit card loosely in her purse. She said they notified the facility, and they called the police, who took over the investigation. She said the police determined who used the card, and the facility identified who it was. On 04/07/23 at 10:33AM, V13 (Scheduler) stated she was in the facility when the police came in to ask to identify the person on the camera footage who used the credit card at the time fraud notification was received by V21, and they identified the person in the footage as V25 (Certified Nursing Assistant). R200's Inventory Sheet did not indicate a credit card. R200's final reportable for the allegation of theft, dated 1/28/2023, indicated the allegation was confirmed. V25's two employment verification & reference request form, authorized by V25 on 10/21/22, did not indicate any communication with previous employers about the character and reliability of V25. Facility Policies: Title: Elder Abuse and Neglect Revision Date: 10/31/22 II. Purpose: (Facility) is committed to observing high standards of ethical and business conduct. (Facility) expects its employees to exercise honesty and integrity in fulfilling facility's responsibilities and complying with all laws and regulations. It is the policy of the facility, in order to ensure the safety and well-being of our clients, and to thoroughly investigate EVERY allegation of physical abuse/neglect. The purpose of this policy is to assure that Cantata is doing all that is within its control to prevent occurrences of abuse or neglect. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145827 If continuation sheet Page 3 of 9 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 145827 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE British Home, The 8700 West 31st Street Brookfield, IL 60513 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 0602 i. Definitions of Elder Abuse and Neglect Level of Harm - Minimal harm or potential for actual harm 1. Abuse is defined as willful, purposeful or intentional act against another that can cause harm or emotional ill being. Residents Affected - Few iv. Financial: misuse of a client's funds, asking an individual for money, taking either money, charge cards or personal items of value, forcing an individual to write a check to you. ii. Employees 1. Screening a. Prior to hiring an employee, (Facility) obtains information from previous and current employers (with applicant's permission) for a history of abuse, neglect, or mistreatment of residents. Title: Personal Property Reviewed Date; 1/27/2022 Policy Statement: Residents are permitted to retain and use personal possessions and appropriate clothing, as space permits. Policy Interpretation and Implementation 5. The resident's personal belongings and clothing shall be inventoried and documented upon admission and as such items are replenished. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145827 If continuation sheet Page 4 of 9 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 145827 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE British Home, The 8700 West 31st Street Brookfield, IL 60513 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to collaborate with hospice for the development and implementation of the coordinated plan of care for two of four residents (R2, R11) reviewed for hospice care in a sample of 12. Residents Affected - Few Findings include: On 04/04/2023 at 11:40AM, R2's hospice binder was noted with no coordinated plan of care on file, and R11's hospice binder was noted with coordinated plan of care, dated 01/20/23 to 03/20/23. On 04/05/2023 at 12:40PM,R2's hospice binder was again noted with no coordinated plan of care on file, and R11's hospice binder was again noted with coordinated plan of care, dated 01/20/23 to 03/20/23. V2 stated there should be coordinated plan of care on R2's hospice binder, and an updated coordinated plan of care should be on R11's hospice binder. R2's Profile Face Sheet indicated admit date of 03/07/2023 and diagnosis of dementia. Physician's orders for 04/06/2023 indicated order for hospice, with order date of 03/07/23. R11's Profile Face Sheet indicated admit date of 05/17/2019 and diagnosis of dementia. Physician's orders for 04/06/2023 indicated order for hospice, with order date of 11/21/22. Facility policy: Title: Coordination of Hospice Services Date Reviewed/Revised: 1/1/23 Policy: When a resident chooses to receive hospice care and services, the facility will coordinate and provide care in cooperation with hospice staff in order to promote the resident's highest practicable physical, mental and psychosocial well-being. Policy Explanation and Compliance Guidelines: 2. The facility and hospice provider will coordinate a plan of care and will implement interventions in accordance with the resident's needs, goals, and recognized standards of practice in consultation with the resident's attending physician/practitioner and resident's representative, to the extent possible. Hospice-Skilled Nursing Facility Agreement 2.5 Hospice Services (a) Coordination of Services (ii) Hospice shall provide Nursing Home with the following information: (a) the most recent individualized Hospice Plan of Care for each Hospice Patient; FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145827 If continuation sheet Page 5 of 9 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 145827 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE British Home, The 8700 West 31st Street Brookfield, IL 60513 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow standard practice and the resident's preference in treating one resident's (R150) pain of 3 residents reviewed for pain in a sample of 12. This failure resulted in R150 experiencing pain of 9/10 and not receiving a stronger medication for pain that she preferred. Residents Affected - Few Findings include: On 4/5/2023 at 8:10 AM, while preparing medications for R150, V15 (Nurse Practitioner) came out of R150's room and told V3 (Registered Nurse/RN) that the resident is in pain. V3 prepares R150's medications including Acetaminophen. On 4/5/2023 at 8:15 AM, V3 went into R150's room. V3 stated she has R150's medication, and R150 stated she is in pain. V3 asked R150 what is her pain level on 1-10 scale, and R150 stated her pain is a 9/10, as she moaned while adjusting herself in the bed. V3 says oh and then hands R150 the pills, and said, There is pain medication in there. On 04/05/23 11:09 AM, V3 stated she usually gives acetaminophen first for pain. V3 stated she gave R150 acetaminophen for pain, because that is what she knew the resident had. R150 stated her pain is now 5/10. On 4/5/2023 at 11:11 AM, after V3 said she would get R150 something more for pain, V3 stated, I have Hydrocodone I can give you and a knee cream. V3 then left the room. R150 then stated normally they give her Hydrocodone when her pain is as high as it was earlier, at a 9/10. R150 stated she would have preferred Hydrocodone earlier if given the choice. R150 stated she has cancer and wants something to take the pain away immediately. R150 stated she prefers being given an option. On 4/6/2023 at 3:07 PM, V2 (Director of Nursing/DON) stated they use a pain scale to determine pain; above five would be considered moderate pain. V2 stated pain lower than 5 is considered low pain. V2 stated 9/10 would be considered high pain. V2 stated she would give Hydrocodone over acetaminophen to a resident with a pain level of 9/10, because the pain is so high. V2 stated, I know [brand name Hydrocodone] would probably work better, but I would always ask which the resident prefers. Review of R150's physician orders documents the following: Acetaminophen 500 mg (1,000 mg) by mouth every 6 hours as needed for mild pain. Hydrocodone 5 mg - acetaminophen 325 mg, tablet 1 tablet by mouth every 4 hours as needed for pain. The facility's Pain assessment and Management policy, dated 2001, documents the following: General guidelines 1) The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145827 If continuation sheet Page 6 of 9 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 145827 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE British Home, The 8700 West 31st Street Brookfield, IL 60513 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. Based on observation, interview, and record review, the facility failed to store two medication in a secure location for 1 resident (R147) of 6 residents reviewed for medication storage in a sample of 12. This failure led to one resident's medication being left on top of the medication cart unsecured while nurse was in another patient's room passing medications. This failure had the potential to affect all residents on the second floor. Findings include: On 4/5/2023 at 8:24 AM, V3 (Registered Nurse/RN) pulled new medications for R147 from the medication cart, and put the metoprolol and torsemide (still in the open packaging) partially under a spray bottle on top of the medication cart and went back into R147's room to pass medication. On 4/5/2023 at 9:00 AM, R147's medications (that were left in its white small open packaging under a spray bottle) are still there on top of the medication cart. On 4/5/2023 at 9:06 AM, surveyor points out R147's medication that V3 (RN) left on top of the medication cart, and asked V3 (RN) where are the medications normally stored. V3 stated the medication should be stored in the drawer and stated, Sometimes I forget, and stated she is not supposed to leave the medication there. V3 stated she has to fax those containers to the pharmacy to replace the medication because the second ones she used were for tomorrow. On 4/6/2023 at 3:07 PM, V2 (Director of Nursing/DON) stated medication should be properly stored in the medication cart. V2 stated they secure it in the medication cart to prevent unauthorized persons from getting the medications. The facility's Storage of Medications policy, dated 2001, documents the following: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and implementation. 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only Persons authorized to prepare and administer medications have access to locked medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145827 If continuation sheet Page 7 of 9 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 145827 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE British Home, The 8700 West 31st Street Brookfield, IL 60513 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 Based on interview and record review, the facility failed to follow their risk management plan for Legionella Control by not flushing unused pipes weekly. This failure has potential to effect all 36 residents who depend of the water system in the facility. Residents Affected - Many Findings include: On 04/06/23 12:13 PM, V7 (Maintenance Director) stated the north wing of the facility is not being used. Therefore, water is not circulating. V7 stated they are flushing the water pipes in the north wing of the property monthly. V7 stated the last time they tested for Legionella was in 2018. Review of the facilities Monthly (north wing) Water flushing documents monthly flushing of water pipes were done. The facility's Hazard identification and risk assessment table, including examples documents the following: Page 8 System component: Pipework Hazard and hazardous event: low flow in several areas (allows adherence and proliferation of Legionella and other opportunistic pathogens). Risk score: High Possible control measures: Weekly flushing of water in areas of low use. Page 9 Control procedures: All control measures and monitoring activities; whether they are regular maintenance, operational practices or corrective actions, require written procedures detailing how to undertake the required task. Complete the table below with control measures identified in the hazard identification and risk assessment table and operational procedure Table 6: Risk management plan procedures: System component: Pipework Control measure: Regular (weekly) flushing of low use areas Procedure: Flushing of pipes in vacated Laurels. The facilities water management program, dated 2022, documents the following: The water management team shall regularly verify that the water management program is being implemented as designed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145827 If continuation sheet Page 8 of 9 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 145827 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE British Home, The 8700 West 31st Street Brookfield, IL 60513 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 Based on interview and record review, the facility failed to ensure that one resident (R27) was offered the Pneumococcal Vaccination, and one resident (R147) was offered the Influenza vaccination of 5 residents reviewed for vaccinations in a sample of 12. Residents Affected - Some Findings include: Review of R27's immunization record did not show any Pneumococcal vaccine or refusal of the vaccination. Review of R147's immunization record does not show any Influenza vaccine or refusal of the vaccination. On 4/7/2023 at 10:42 AM, V5 (Assistant Director of Nursing/ADON/Infection Preventionist/IP) stated during flu season, they have a house stock and offer the influenza vaccine on admission. If the resident agrees to having the vaccine, they put in order and document on TB/immunization tab in the resident's electronic record. They should document in the same immunization tab if not given. V5 stated they screen for the pneumonia vaccination on admission if the resident wants the pneumonia vaccine, the facility will have a clinic to administer it . V5 stated they document it in the immunization tab when given or if the vaccine was refused. V5 stated she is not aware of any requirement or regulation to document refusal of influenza or pneumonia vaccine. V5 stated the previous staff did no such documentation. The facility's Pneumococcal vaccine program, dated 10/30/2021, documents the following: Purpose: to reduce the incidence of Pneumococcal disease and the morbidity and mortality attributed to this infection. Pneumococcal Vaccine program procedure: 2. Upon admission, resident Pneumococcal vaccination history is assessed. 3. Immunization record is updated and documented in the resident's care profile. The facility's influenza Vaccine Program, dated 2/16/22, documents the following: Purpose: To reduce the incidence of influenza and the morbidity and mortality attributed to this infection. Procedure: All new admissions will be screened and given the influenza vaccine unless specifically ordered otherwise by the primary physician on admission orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145827 If continuation sheet Page 9 of 9