Health inspection·April 4, 2024

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated that it would be nice to have a regular shower, he needs help when he goes to the shower. R60 also said that he has been asking for a shower, but he is told that they don't have enough staff. The last time he had shower was 2 weeks ago. 4. R72's Face sheet shows that R72 is 74 years-old who has multiple medical diagnoses which include Parkinson's disease without dyskinesia and Neurogenic disorder with Lewy bodies. R74's MDS dated [DATE], shows that R72 requires substantial to maximal assistance for grooming and hygiene care. On April 2, 2024, at 11:11 AM, R72 was sitting in the dining room. R72 had long dirty fingernails with black and brown substance underneath nails, and thick, overgrown nasal hair which was sticking out of his nostrils. On April 3, 2024, at 12:00 PM, R72 was sitting in his wheelchair remained unkempt and disheveled with long dirty fingernails and long nasal hairs. V29 (CNA) stated today she would give a shower to R72. V29 also stated R72 is usually cooperative and has no behaviors during ADL care. On April 3, 2024, at 1:25 PM, V29 (CNA) stated she doesn't know how she could trim R72's nasal hair. On April 3, 2024, at 1:30 PM, V32 (CNA) stated that they don't have a nasal hair trimmer. They will call R72's caregiver to provide a nasal hair trimmer. On April 3, 2024, at 4:00 PM, V2 (Director of Nursing/DON) stated that showers are scheduled 2 times a week or more often if the resident requests. If the resident refuses the first scheduled shower for the week that is scheduled, they ask the family to assist with encouraging the resident to get a shower. Shaving is to be done with the shower or if there is facial hair visible and in need of being shaved, men may need shaving done daily. Nail care should be provided immediately when noted that the nails are dirty or in need of being clipped or with the weekly shower. On April 2, 2024, at 2:39 PM, V27 (CNA) stated that residents are scheduled to be given a bed bath or shower twice a week and they document it when they provided it. On April 2, 2024, around 2:30 PM, V5 (Medical Record Staff) presented a copy of their most recent Bath and Skin Report Sheet (shower/bed bath) sheets which was only for the month of March 2024. V5 stated that she could not find any shower sheet for the month of April for R58, R60, R72, R100. The March 2024 Bath and Skin Report Sheet shows that the last time the following residents were showered or received bed bath was on 3/17/24 for R100 and 3/18/24 for R58, R60 and R72. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 2 of 24 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 145901 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lemont Nursing & Rehab Center 12450 Walker Road Lemont, IL 60439 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 1. R65's Face sheet stated R65 was readmitted from the hospital on March 01, 2024, with diagnoses including encounter for other orthopedic aftercare, local infection of the skin and subcutaneous tissue, unspecified, acquired absence of left foot, encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, non-pressure chronic ulcer of left ankle with unspecified severity, peripheral vascular disease. Residents Affected - Few R65's 5-day MDS (minimum data set) dated March 7, 2024, showed that R65 was cognitively intact. R65's POS (Physician Order Sheet) included hydrocodone-acetaminophen 10-325 mg/milligrams [Norco]1 tablet every 4 Hours as needed (start date March 01, 2024). Physician progress note dated March 28, 2024 (Recorded as Late Entry on April 01, 2024) included as follows: Patient having a lot of pain in his foot as well as bilateral shoulders though bilateral shoulder pain is chronic. Pain management - Reviewed pain relief and side effects of current medications. Recommend continue (gabapentin, hydrocodone-acetaminophen). On April 01, 2024, at 2:32 PM, R65 was in his room with meal untouched. R65 stated that he is unable to eat as he in a lot of pain. R65 stated I have been asking for pain medications since 8:00 AM this morning. I went to therapy and came back, and my pain is worse. I asked the nurse again a few minutes ago [for pain medications]. She said it hasn't been filled through the normal channels. It happened before. Two weeks ago, when I first got here from the hospital, it took two weeks for them to start giving me medications. When asked what his pain score was on a scale of 1-10, R65 replied 9 and a 1/2 (half). On April 01, 2024, at 2:42 PM the above information was reported to V6 (Registered Nurse) who was at the nurse's station. V6 stated He's asking for Norco, and he does not have a refill order for it (from Practitioner). I asked V2 (Director of Nursing) for it right away and she said that he needs a script for it and the NP (Nurse Practitioner) is not here. He (R65) says that a few days ago he asked for it and they haven't put the order in yet. This morning before therapy he told me his pain was around 7 and that he needed the pain medications before therapy. He has an order for Tylenol, and I just can't give him that. On April 01, 2024, at 02:46 PM, V19 (Certified Nursing Assistant) came to the nurse's station and reported to V6 that R65 told her that he is in a lot of pain around his foot and going up his spine and unable to eat his lunch meal. R65's MAR (Medication Administration Record) showed that R65 started receiving prn (as needed) Norco from March 20, 2024, until March 26, 2024, between 1-2 times daily. The same MAR showed that R65 did not receive Norco from March 26, 2024, until current date (April 2, 2024). The same MAR also had a foot note (by V6) that showed that at on April 1, 2024, at 10:37 AM, the prn order was not administered as drug/item unavailable in cart. On April 02, 2024, at 9:12 AM, R65 was in his room and stated My pain is still 9 and a 1/2. They still haven't done anything about it. The Tylenol does not help. On April 02, 2024, at 9:14 AM, the concern about R65's pain was reported to V7 (Licensed Practical Nurse) who was outside R65's door, getting R65's medications ready. V7 searched in the medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 3 of 24 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 145901 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lemont Nursing & Rehab Center 12450 Walker Road Lemont, IL 60439 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cart and stated there is no Norco in here. He R65 told me that his pain was about 9 around 9:00 [AM]. The Pharmacy says that they need a new script. On April 02, 2024, at 3:32 PM, V2 (Director of Nursing) stated that she learned about R65's pain only that morning and she talked to V14 (Nurse Practitioner) and got a script from her and faxed it to the pharmacy. V2 stated that she can now get the Norco from the electronic medication dispenser to administer to R65. V2 added that prior to getting the script the pharmacy would not give her access to the emergency dispenser. On April 02, 2024, at 4:02 AM, V14 stated that she wasn't made aware that R65's pain was 9 and a half. V14 stated that if she had known, she would have prescribed something for break through pain. V14 stated that she was only told today that R65 needed a refill for his Norco. Facility policy titled Pain-Clinical Protocol (Revised August 2008) included as follows: Monitoring: 1. The staff will reassess the individual's pain and consequences of pain at regular intervals. a. For example, review frequency and intensity of pain, ability to perform activities of daily living (ADLs), sleep pattern, mood, behavior, and participation in activities. 3. The staff will discuss significant changes in levels of comfort with the Attending Physician who will adjust interventions accordingly. a. This may include adjustments of regular and PRN analgesic doses to find the best combination of effectiveness and tolerable side effects, or possible addition of non-pharmacological interventions. Notification: 7. Resident's Physician and resident's family/ responsible party should be notified of significant changes pertaining to resident's pain level. Based on observation, interview, and record review, the facility failed to notify the physician of a resident's pain and provide medication as ordered by the physician. This applies to 1 of 2 residents (R65) reviewed for pain management in a sample of 24. The findings include: FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 4 of 24 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 145901 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lemont Nursing & Rehab Center 12450 Walker Road Lemont, IL 60439 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 monitor clinical condition of a resident upon returning from dialysis. The facility also failed to provide clinical documentation of resident's condition during dialysis treatment. Residents Affected - Few This applies to 1 of 2 residents (R66) reviewed for dialysis in the sample of 24. The findings include: R66 is a [AGE] year-old male with medical diagnoses that include acute and chronic congestive heart failure, end stage renal disease, dependence on renal dialysis, morbid obesity, and type 2 diabetes mellitus according to the face sheet. Review of R66's physician orders showed there was no order for dialysis or for monitoring R66's dialysis access shunt site upon return from dialysis. On April 3, 2024, at 12:42 PM, V2 (Director of Nurses, DON) stated that R66's order for dialysis was not reactivated. V2 stated she would reactivate them now. On April 3, 2024, at 3:02 PM, V2 stated the facility does not have any reports from the dialysis company post dialysis sessions and no weights, labs, or communication from the dialysis company. V2 stated that the dialysis company does not send them any reports. On April 3, 2024, at 3:54 PM, V2 stated the facility does not get any written communication from the dialysis provider. V2 stated she does not get any clinical communication after dialysis from the dialysis company. On April 3, 2024, at 4:02 PM, V2 handed the surveyor a blank Dialysis Log Profile that she stated she sends with the resident each time. V2 stated, when the dialysis log profile forms don't come back after dialysis, she does not follow up with the dialysis company to find out what occurred during dialysis. On April 3, 2024, at 4:13 PM, V2 stated that each time R66 comes from dialysis they should be checking, the resident's access site, and the dressing on it. V2 stated she does not know if the assessments are documented because she just reactivated all of the resident's dialysis orders. On April 3, 2024, at 3:35 PM, V39 (Dialysis RN) stated that she is familiar with R66. V39 stated they do not provide a form to document pre/post dialysis. V39 stated that each facility usually sends the form, and the dialysis company will document on the form. V39 stated she has never received a form from the facility for R66. V39 stated that the facility only sends R66's face sheet and medication list with him. V39 stated their Dietician and the Dietician at the nursing facility follow up with each other regarding the resident's nutrition. There was no documentation noted in R66's medical record of any assessment after dialysis from March 12, 2024, until April 3, 2023. This documentation was requested, but by the end of the survey, no documentation regarding R66's pre and post dialysis condition was provided. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 5 of 24 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 145901 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lemont Nursing & Rehab Center 12450 Walker Road Lemont, IL 60439 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete R66's Dialysis care plan dated April 12, 2023, shows: monitor and report signs of localized infection. Monitor circulation, motion, sensation of extremity with access device every shift. Palpate shunt for thrill site every shift. The facility did not provide a policy for dialysis care and treatment after being requested. V1 (Administrator) stated on April 3, 2024, at 4:30 PM the facility does not have a policy regarding dialysis care. Event ID: Facility ID: 145901 If continuation sheet Page 6 of 24 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 145901 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lemont Nursing & Rehab Center 12450 Walker Road Lemont, IL 60439 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. Based on observation, interview, and record review, the facility failed to identify the diagnosis and specific behavior for residents who are prescribed antipsychotic medication. This applies to 3 of 5 residents (R32, R72, R99) reviewed for psychotropic medications in the sample of 24. The findings include: 1. R72's Face sheet shows that R72 is a 74 years-old who has multiple medical diagnoses which include parkinson's disease without dyskinesia and neurogenic disorder with lewy bodies, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Physician Order Summary (POS) shows multiple medications which include Quetiapine (antipsychotic medication) tablet 25 milligrams (mg) at bedtime. From April 2, 2024, through April 3, 2024, random observations were conducted on R72 between 9:35 AM through 3:00 PM. R72 was observed in the dining room either sleeping or sitting quietly. There was no behavior noted during observation. R72 was pleasantly confused when surveyor talked to him. On April 2, 2024, at 2:34 PM, V27 (Certified Nursing Assistant/CNA) stated that R72 displays no behavior except for attempting to stand up occasionally. R72 mumbles to himself, very confused. R72 does not display paranoia, and he has no aggressive behavior. On April 3, 2024, at 1:40 PM, V29 (CNA) stated that R72 is usually quiet and cooperative. On April 3, 2024, at 2:09 PM, V40 (Social Service Director) stated that R72 is pleasantly confused, he has no behavior. On April 4, 2024, at 2:39 PM, V2 (Director of Nursing/DON) stated that R72 has no psychiatric evaluation. The behavioral monitoring is done by the staff, and they record it. R72's active care which was started on 12/13/2023 with reviewed/revised date of 3/20/2024 shows that R72 receives antipsychotic medication. This same care plan shows multiple approaches which include monitoring R72's behavior and response to medication. However, there was no documented targeted behavior which addressed why R72 needs to use anti-psychotic medication. R72's Point of Care Mood Category Report dated February to April 2024 does not have observation of any behavior. 2. R99's Face sheet shows R99 is a 82 years-old who has multiple medical diagnoses which include unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. From April 1 through April 4, 2024, multiple random observations were conducted between 9:20 AM though 12:30 PM, R99 was observed sleeping in bed majority of the time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 7 of 24 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 145901 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lemont Nursing & Rehab Center 12450 Walker Road Lemont, IL 60439 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 Physician Order Summary (POS) shows multiple medications which include Quetiapine (antipsychotic medication) 25 mg every morning and 75 mg at bedtime. Psychiatric evaluation dated 12/13/23 does not have documentation of behavior pertaining to the use of Quetiapine. Residents Affected - Few On April 3, 2024, at 1:59 PM, V40 (Social Service Director) stated that R99 currently has no behavior but before the use of Quetiapine medication, he was very impulsive, he would try to get out of bed. V40 stated there was no other behavior assessment. R99 was confused, he was unable to participate in the PHQ9 (Patient Health Questionnaire-9) assessment which determines depression and the information for PHQ9 came from the staff. R99 sleeps a lot and had difficulty concentrating. R99's active care which was started on 4/19/2023 with reviewed/revised date of 1/23/2024 shows that R99 is at risk for adverse side effects related to use of psychotropic medications. R99 utilizes antipsychotic medications to assist in managing diagnoses of depression. This same care plan shows multiple approaches which include assessing if R99's behavioral symptoms present a danger to the resident and/or others, intervene as needed, quantitatively and objectively document the resident's behavior. However, there was no documented targeted behavior which addressed why R99 needs to use anti-psychotic medication. R99's Point of Care Mood Category Report dated February to March, 2024 does not have observation of any behavior. 3. R32 was admitted to the facility October 12, 2023, with diagnoses including but not limited to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; and other diagnoses that do not include any psychiatric diagnoses. According to the discharge report from the hospital where R32 was treated immediately prior to admission to the facility, R32 was not given any antipsychotic medication and had no psychiatric diagnosis. The POS (physician's order sheet) shows R32 was prescribed quetiapine (antipsychotic medication) 50mg at bedtime, on October 26, 2023. The POS shows as well that quetiapine 25mg TID (three times each day) was added for R32 on February 21, 2024. The facility Point of Care documentation for the month of October 2023 shows R32 had psychiatric behaviors or changes of mood during that month or any month thereafter including the month of February 2024. On April 2, 2024, at 4:42pm, V36 (medical Director) stated he was familiar with R32 and did not know why R32 was prescribed quetiapine. V36 stated he would not prescribe quetiapine 50mg for any patient new to the medication and there needs to be a rationale for the use of quetiapine. The care plan for R32 shows no behavior or diagnosis to be targeted by an antipsychotic medication. The facility provided a Psychotropic Medication Policy dated February 2014 which shows: Policy: To establish the process for monitoring the use of and the reduction of doses of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 8 of 24 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 145901 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lemont Nursing & Rehab Center 12450 Walker Road Lemont, IL 60439 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 psychotropic medications without compromising the resident's health and safety, ability to function appropriately, or the safety of others. Policy Specifications: 2. Residents shall not be given antipsychotic drugs unless antipsychotic drug therapy is necessary to treat a specific or suspected condition as diagnosed and documented in the clinical record or to rule out the possibility of one of the conditions listed in the guidelines of the recognized external review agencies. G. Use of Antipsychotic Drugs: Antipsychotic drugs should not be used unless the clinical record documents that the resident has on of the following specific conditions: Conditions Other Than Dementia 1. Schizophrenia 2. Schizo-affective disorder; 3. Delusional disorder 4. Mood Disorders (e.g. Bipolar disorder, severe depression refractory to other therapies and/or with psychotic features); 5. Schizophreniform disorder; 6. Tourette's disorder 7. Nausea and vomiting associated with cancer or chemotherapy; 8. Hiccups (not induced by other medications) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 9 of 24 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 145901 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lemont Nursing & Rehab Center 12450 Walker Road Lemont, IL 60439 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 9. Level of Harm - Minimal harm or potential for actual harm Medical illnesses with psychotic symptoms (e.g. neoplastic disease or delirium) and /or treatment related top psychosis or mania (e.g. high dose steroids) Residents Affected - Few Behavioral or Psychological Symptoms of Dementia (BPSD) 1. Antipsychotic medication may be considered for elderly residents with dementia but only after medical, physical, functional, psychiatric, social and environmental causes have been identified and addressed. 2. Antipsychotic medications must be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. Antipsychotic medication in persons with dementia should not be used if one or more of the following is/are the only indication: 1. Wandering, 2. Poor self care 3. Restlessness, 4. Impaired memory, 5. Mild anxiety 6. Sadness or crying alone that is not related to depression or other psychiatric disorders, 7. Insomnia (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 10 of 24 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 145901 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lemont Nursing & Rehab Center 12450 Walker Road Lemont, IL 60439 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 8. Level of Harm - Minimal harm or potential for actual harm Inattention or indifference to surroundings, 9. Residents Affected - Few Fidgeting, 10. Nervousness 11. Uncooperativeness (e.g. refusal of or difficulty receiving care) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 11 of 24 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 145901 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lemont Nursing & Rehab Center 12450 Walker Road Lemont, IL 60439 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that a resident was not given Insulin belonging to another resident and failed to follow the facility's policy regarding medication administration. Residents Affected - Few This applies to 1 of 1 resident (R115) reviewed for medication errors in the sample of 24. The findings include: On April 2, 2024, at 1:26 PM with V7 (Agency Nurse) outside of R115 room in the doorway, V7 asked R115 what his blood sugar was. R115 stated his blood sugar was 256. V7 stated R115 has an implanted monitor that shows his blood sugar. R115 stated he had lunch about 30 minutes ago. V7 apologized for being late. V7 stated, R115 blood sugar is high, I have to give him insulin. V7 stated she is going to give R115 five (5) units of Insulin Aspart. V7 (agency) looked for insulin in her cart and did not find any insulin and then said the insulin is in another cart. V7 then walked to another cart by the nurses' station and grabbed a box that had R65 name on it and showed it was Aspart Protamine 70/30. Inside the box there was a used multi-dose vial of Insulin Aspart with R380's name on it. On April 2, 2024, at 1:34 PM, V7 withdrew 5 units of insulin from a used multi-dose vial of insulin Aspart that had R380's name on it and showed it to the surveyor. V7 did not recap the insulin needle and she turned and said she was going to give the insulin to R115. Surveyor asked V7 if she was about to give that now to the R115. V7 stated, Yes. Surveyor asked if V7 should give that insulin that she drew from R380's name on it. Surveyor pointed to the vial that V7 had just drew from that had R380 name on it. V7 stated she should not give insulin she just drew. R380 was discharged on 1/16/2024 according to her face sheet. On April 3, 2024, at 12:42 PM, V2 (Director of Nurses, DON) stated that insulins expire 28 days after they are opened. On April 4, 2024, at 10:57 AM, V2 stated they do not share insulins between patients. On April 4, 2024, at 11:06 AM, V2 stated they don't share insulins between residents because it is an infection control issue. V2 stated insulins are good for 28 days after first use. On April 4, 2024, at 11:21 AM, V37 (Pharmacist) stated we do not recommend sharing insulins between residents for safety reasons. V37 stated there is always some infection control concern also. The facility's Expiration dates for certain drugs, biologicals, and records policy show that insulins expire 28 or 42 days after use. The facility's Medication Administration policy dated 10/25/2014 shows the following: Preparation 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 is put away. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 12 of 24 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 145901 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lemont Nursing & Rehab Center 12450 Walker Road Lemont, IL 60439 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 0760 Level of Harm - Minimal harm or potential for actual harm 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. Residents Affected - Few c. Check #3: Complete the preparation of the dose and re-verify the label against the MAR by reviewing the 5 Rights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 13 of 24 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 145901 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lemont Nursing & Rehab Center 12450 Walker Road Lemont, IL 60439 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 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 serve portions for mechanical soft fish as shown on menu spreadsheet. Residents Affected - Some This applies to 5 of 5 residents (R16, R72, R100, R103, and R175) observed for dining in the sample of 24. The findings include: Menu spreadsheet for Fall Winter Menus (cycle day 23) for the mechanical soft diet showed to serve #6 scoop of ground baked fish with 2 oz/ounce gravy. On April 1, 2024, at 1:03 PM, during tray line service, the residents on mechanical soft diet received two scoops of ground fish served with a red handled spoodle and R16, R 72, R100, R103, R175 received the same. The same residents also did not receive gravy with the flaked fish. No menu spread sheet was seen in the meal service area. When asked, V8 (Cook) who was on the tray line serving the food, stated that the scoop yields 1 + 1/3rd oz/scoop. This showed that each resident on mechanical soft diet received 2 +2/3 oz/serving of mechanical soft fish. When V8 was shown the menu spreadsheet, he went looking for a #6 scoop and came back and stated that there are none available on hand. V8 also added that he was not aware of the spreadsheet as he usually works on the side of the main cook and just watch, look and see during meal service. V8 also stated that the main cook called off that day. On April 3, 2024, at 12:33 PM, V20 (Vice President of Culinary) stated that the facility should follow the menu spreadsheet in order to receive the required amount of protein for the meal. Facility scoop equivalent chart showed that #6=5+1/3 oz. Facility diet order listing showed that R16, R 72, R100, R103, R175 were on mechanical soft diets. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 14 of 24 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 145901 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lemont Nursing & Rehab Center 12450 Walker Road Lemont, IL 60439 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 0806 Level of Harm - Minimal harm or potential for actual harm Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, interview and record review, the facility failed to provide substitute meals with the same nutrient content. Residents Affected - Few This applies to 3 of 3 residents (R35, R86, R102) reviewed for dining in the sample of 24. The findings include: Facility Fall /Winter menus (week 4) for Monday showed Lemon Baked Fish as the main entree. Production recipe for the same showed to serve 1 filet of fish with a yield of minimum 2 oz (ounce) of protein. On April 1, 2024, at 12:50 PM, during lunch meal prep in the facility kitchen, V24 (Cook) was seen making grilled cheese sandwiches. V24 placed 2 slices of cheese in between two slices of bread and grilled it. R35, R86 and R102 were served the same on tray line. These residents' meal tickets showed written orders for grilled cheese and V24 stated they had ordered the same as a meal substitute for lemon baked fish. Facility Production recipe for Sandwich Cheese Grilled included to assemble sandwiches with 2.25 oz of cheese (3 slices of .75 ounces slices of cheese). On April 03, 2024, at 12:26 PM, V20 (Vice President of Culinary) stated that you need to use 3 slices of cheese to obtain 2 oz protein. V20 added that the meal replacement should have the same equivalent of protein servings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 15 of 24 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 145901 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lemont Nursing & Rehab Center 12450 Walker Road Lemont, IL 60439 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 0809 Level of Harm - Minimal harm or potential for actual harm Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on observation, interview, and record review, the facility failed to serve meal at the scheduled times. Residents Affected - Many This applies to all 129 residents that receive food prepared in the facility kitchen. The findings include: 1. During entrance conference on April 1, 2024, the facility provided information that the census was 129 residents with no residents in house on NPO (nothing by mouth) status. On April 1, 2024, lunch service began after 1:45pm. On April 2, 2024, at 1:30pm, residents who are active in the Resident Council, including R51, R7, R26, R45, R50, R93, R95, and R108 met with this writer. During the meeting, R51 stated meals have been served as late as 2 hours after the scheduled time; all the other residents in the meeting affirmed R51's statement. R51 stated it gets quite late in the evening for dinner, as late as 8:00pm. 2. Facility Mealtimes schedule showed that the variable units would receive breakfast and lunch meals between 8:00-8:30 AM, and 12:00-12:30 PM respectively. On April 1, 2024, at 12:55 PM, the meal service was noted to start at the facility kitchen. When asked why the meal service was started late, V8 (Cook) stated that it's taking him more time to prepare the meals as I usually work on the side. I am not used to being the lead cook. On April 1, 2024, at 1:45 PM, V22 (Physical Therapy Assistant) was seen coming to the kitchen and enquiring why the trays are so late. V22 added that she needs to take residents to therapy after lunch and its past the meal schedule time. V9 (Dietary aide) responded to V22 that the 5:00 AM cook called off and a dietary aide also did not show up. V9 stated that she was off and was called to come in and assist. On April 1, 2024, at 2:15 PM, the last cart was seen taken to the floor. On April 2, 2024, at 9:06 AM, R276 was in his room starting to eat his breakfast. R276 stated Look at the time? Breakfast should be served between 7-7:30 [AM]. Yesterday I received lunch after 1:00 PM. On April 2, 2024, at 9:10 AM, R65 was in his room eating his breakfast. R65 stated They just brought my tray a little while ago. I am a diabetic. If they bring it earlier, I will have a chance to digest my food before I go to therapy at 10:00 AM. Yesterday they brought my lunch tray after 2:00 PM. They call it lunch because it's supposed to be served at noon. On April 2, 2024, around 4:30 PM, V1 (Administrator) stated that he was aware of the late meal times since last week as he had received complaints from staff about it. Facility policy titled Mealtimes and Frequency included as follows: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 16 of 24 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 145901 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lemont Nursing & Rehab Center 12450 Walker Road Lemont, IL 60439 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 0809 Level of Harm - Minimal harm or potential for actual harm The facility will provide at least three meals at regular times comparable to standard mealtimes in the community or in accordance with the patient'/residents' needs, preferences, requests , and plan of care. Meals will be served in a timely manner to maintain food quality and safe and palatable food temperatures. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 17 of 24 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 145901 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lemont Nursing & Rehab Center 12450 Walker Road Lemont, IL 60439 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm Based on observations, interview and record review, the facility failed to serve foods in a sanitary manner. Residents Affected - Many This applies to all 129 residents that receive food prepared in the facility kitchen. The findings include: During entrance conference on April 1, 2024, the facility provided information that the census was 129 residents with no residents in house on NPO (nothing by mouth) status. 1. On April 1, 2024, starting at 9:53 AM, during initial tour of facility kitchen, V5 (Medical Records Director) was in the dietary office and stated that she is helping out with the meal tickets as the Dietary Manager is out on medical leave. V5 stated that she does not oversee the other functions in the kitchen. At the hand washing sink, there was a dirty rag inside the sink. Near the hand washing sink, the clean side of the dish machine area had extensive grime, and unknown debris. Two tray racks with washed glasses were stored over this same soiled area. V12 (Dietary Aide) was seen coming from outside the kitchen and stated that she went to collect the dirty dishes stored in the cart. V12 (not wearing gloves) proceeded to put away the rack with the cleaned glasses which were to be stacked one on top of the other in another area. V12 was notified of contamination risk from going from dirty to clean without washing his hands and also notified of the soiled dish machine area where clean dishes were stored. V12 stated that the night shift staff left it like that. Near the dish machine, there were multiple washed bowls stored on a free-standing rack with some bowls that were not inverted containing free standing water in them. V13 (Dishwasher) stated that these bowls are used for salad and should have been stored inverted. Above the dish machine, the ceiling tiles were stained with grayish/brown patches and had one of the tiles come off and tilted in a slant with the area beyond exposed. The walk-in cooler had extensive debris on the floor under the storage racks. The items on the racks were disorganized with various items randomly placed on the shelves. In the food prep area, multiple used and dirty rags were seen strewn all over the kitchen counters. Soiled sanitizer buckets were seen in the dish room area. A free-standing milk refrigerated storage unit had extensive congealed grayish colored spills at the bottom of the refrigerator and had a putrid smell. V8 (Cook) stated that he has only been at the facility for two weeks and does not know what these spills are. The dry storage area had multiple loafs of bread, rolls and buns stored in tray racks which V8 stated were just delivered that day and would be put away on the bread storage rack. The bread storage rack already had remaining items of bread, rolls and buns stored on them. When asked, how the staff would know which items to use first, cook stated that the manager does not use the first in, first out system and the items that were delivered will just be added on to the shelf based on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 18 of 24 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 145901 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lemont Nursing & Rehab Center 12450 Walker Road Lemont, IL 60439 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 differentiation of wheat, white bread or rolls and/or buns. Level of Harm - Minimal harm or potential for actual harm The spoodle and scoop storage units near the tray line serving area contained blackish grime and other dirt like particles. V8 was notified that these serving items are contaminated with the unknown debris and will have to be washed before using them. During tray line service (around 12:55 PM) V8 was seen taking a scoop out of the same storage unit that remained as seen earlier with the unknown contaminants and was again reminded of the earlier notification. Residents Affected - Many 2. On April 2, 2024, at 11:28 AM, V12 was washing pots and pans in the 3 compartment sink. V12 was washing the dishes in the wash sink and rinsing the dishes off in the second sink under running water. Multiple soiled dishes were seen placed in the 3rd sink used for sanitizing. When asked why the 3rd sink with sanitizing solution was not used, V12 stated that the sanitizing sink does not hold water and does not work. V12 then proceeded to fill the 2nd rinse sink with sanitizing solution and put the washed dishes with soap suds and food particles into the sanitizer in the 2nd sink. V13 who was in the area stated that they were supposed to use the 3 sinks to wash, rinse and sanitize respectively. 3. On April 2, 2024, at 11:31 AM, the pureed meal prep of Teriyaki Chicken by V11 (Cook) was observed in the facility kitchen. V11 did not have a recipe in front of her during the pureed preparation. V11 stated that she is preparing for total 10 serving portions. V11 washed hands and put on new gloves and was seen going from one area of the kitchen to the other touching multiple surfaces with gloved hands while getting items ready. V11 pureed an unmeasured amount of cooked chicken and broth in a blender and added a tablespoon of thickener and pureed the mixture. V11 was seen dipping a gloved fingers into the blended product and stirred it and then test the product by rubbing it between her gloved forefinger and thumb. V11 then transferred the product into a container and stated that it is ready for service. V11 covered the pureed mixture with cling wrap and stated that she is going to place it directly on tray line. V11 was also seen touching multiple surfaces including a garbage can prior to applying a cling wrap over the container. When asked if she was going to reheat the pureed item, V11 stated that she is going to put it on the steam table for tray line service. V11 was notified that the pureed product was not safe to serve as she had touched multiple surfaces and touched the pureed mixture with the same gloves. On request, V11 presented the recipe that was placed in a binder. Recipe for Chicken Teriyaki Pureed Thick included as follows: 1. Measure portions required from the regular prepared recipe. 4. Scrape down sides of food processor with a rubber spatula and process for 30 seconds. Reheat to 165 degrees Fahrenheit. CCP [Critical Control Point]: Final internal cooking temperature must reach minimum of 165 degrees Fahrenheit, held for a minimum of 15 seconds. Facility diet order listing showed that R9, R34, R56, R96, R99, R104 and R277 were on pureed diet. On April 3, 2024, at 12:26 PM and 1:00 PM, V20 (Vice President of Culinary) stated that the facility should follow the 3 steps of the 3 compartment sink: soak and rinse pots and pans in the wash sink, rinse off in the 2nd rinse sink and sanitize in the 3rd sink with sanitizer for 60 seconds. V20 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 19 of 24 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 145901 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lemont Nursing & Rehab Center 12450 Walker Road Lemont, IL 60439 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 added that the pureed food should be reheated to 165 degrees Fahrenheit as additional products like thickener and other additives are added to the mixture and the temperature of product tends to be lowered during pureeing process. Facility Policy titled Sanitation and Infection Control included as follows: Residents Affected - Many Purpose: The purpose of this policy is to ensure that the culinary experience team members prepare, process, handle, package, transport, display, serve and store foods in a sanitary manner protected from contamination and spoilage; to ensure proper maintenance, disinfecting and sanitizing techniques are followed throughout the department: and to ensure all team members understand and follow infection prevention. Facility Policy titled Dishwashing and Sanitation included as follows: Purpose: To properly wash and sanitize is necessary to prevent food-borne diseases. Dishware, pots, pans, or utensils should be thoroughly cleaned and sanitized before use in food preparation or food serving to prevent the spread of food-borne diseases. Mechanical Dishwashing: 2. Clean dishware and utensils should be kept separate from dirty dishware and utensils. Manual Dishwashing: 3. Items should be pre-soaked (if necessary) and then scraped free of food debris before placing in wash sink. 5. Items should be washed thoroughly in clean water with detergent solution. Dirty water should be cleaned frequently. 6. Items should be rinsed thoroughly in clean water to remove any remaining food particles or detergent. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 20 of 24 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 145901 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lemont Nursing & Rehab Center 12450 Walker Road Lemont, IL 60439 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 observation, interview, and record review, the facility failed to follow standard infection control practices with regards to hand hygiene and gloving during provisions of incontinence care. In addition, the facility failed to ensure staff donned full PPE (Personal Protective Equipment) when entering isolation rooms. Residents Affected - Some This applies to 6 of the 24 residents (R26, R53, R58, R59, R100, R104) reviewed for infection control in the sample of 24. The findings include: 1. On April 1, 2024, at 2:57 PM, V33 and V34 (Both Certified Nursing Assistants/CNAs) rendered incontinence care to R58 who was wet with urine and had a bowel movement. V34 cleaned R58's peri-area from front to back then she (V34) opened the bathroom door with her soiled gloved hands to wash her gloved hands. After washing her gloved hands and without changing her gloves, V34 continued to clean R58. V33 on the other hand helped to clean the left side of R58's peri-area. After wiping R58, V33 changed her fecal stained gloves and did not perform hand hygiene. Both CNAs then repositioned R58 to the right side. V33 did another round of cleaning/wiping of R58's buttocks area, while wearing the same soiled gloves, then V33 applied barrier cream and incontinence brief to R58. 2. On April 2, 2024, at 11:36 AM, V35 (CNA) rendered incontinence care to R59 who was wet with urine. V35 cleaned R59's perineum from front to back, she (V35) removed the soiled brief and applied a new one and repositioned R59 while wearing the same soiled gloves. 3. On April 2, 2024, at 12:23 PM, V29 and V35 (Both CNAs) rendered peri-care and catheter care to R100. V29 cleaned R100's perineum from front to back including her catheter tube. V29 changed her soiled gloves and did not perform hand hygiene, she then continued to apply a clean incontinence brief and repositioned R100. The electronic medical record (EMR) shows that R100 is on isolation for MRSA (Methicillin-resistant Staphylococcus-aureus) in the wound. On April 4, 2024, at 12:16 PM, V2 (Director of Nursing/DON) stated that when staff renders incontinence care, they should perform hand hygiene before and after care, and in between care from dirty to clean tasks. The staff should not wash their soiled gloves. The staff should remove the soiled gloves and perform hand hygiene then wear another set of clean gloves. This should be done to prevent infection. The Facility's Handwashing/Hand Hygiene Policy with effective date of March 2020 shows: Policy: It is the policy of the facility to assure staff practice recognized handwashing/hand hygiene procedures as a primary means to prevent the spread of infections among residents, personnel, and visitors. Policy Specifications: 4. When hands are not visibly soiled, employees may use an alcoholic-based hand rub (foam, gel, liquid) containing at least 60% alcohol in all the following situations: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 21 of 24 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 145901 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lemont Nursing & Rehab Center 12450 Walker Road Lemont, IL 60439 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 g. before moving from a contaminated body site to a clean body site during resident care. Level of Harm - Minimal harm or potential for actual harm h. before and after putting on and upon removal of PPE, including gloves. m. after removing gloves. Residents Affected - Some 4. R104's face sheet included diagnoses of urinary tract infection, site not specified, other specified bacterial agents as the cause of diseases classified elsewhere, enterocolitis due to clostridium difficile, not specified as recurrent. R104's POS (Physician Order Sheet) showed Contact Isolation for Organism ESBL (extended -spectrum beta-lactamase) in urine. On April 1, 2024, at around 10:48 AM, R104's room door showed signage for Contact Precautions. The signage included Stop. Contact Precautions. Providers and staff must also put on gown before room entry. Discard gown before room exit. A plastic container with PPE was stored outside the room. V21 (Housekeeper) was seen going into the room with gloves and cleaned the room and bathroom without wearing disposable gown. R104 was sleeping in her bed. 5. R53's face sheet included diagnoses of urinary tract infection, site not specified, MRSA (methicillin resistant staphylococcus aureus) infection, unspecified site, resistance to vancomycin, resistance to multiple antibiotics. R53's POS showed Contact Isolation for Organism: VRE (vancomycin-resistant enterococcus) in urine. On April 1, 2024, at 10:48 PM, R53's room door showed signage for Contact Precautions. A plastic container with PPE was stored outside the room. V21 was seen going into the room with gloves and cleaned the room without wearing disposable gown. R53 was in his room. 6. R26's face sheet included diagnoses of local infection of the skin and subcutaneous tissue, unspecified, Parkinson's disease without dyskinesia, without mention of fluctuations. R26's POS showed Contact Isolation for Organism MRSA. On April 1, 2024, at 10:51, R26 room door showed a signage for Contact Precautions. A plastic container with PPE was stored outside the room. V21 was seen going into the room wearing only gloves and without wearing disposable gown to clean the room. R26 was in the bathroom. When asked why she did not don a gown as shown on the signage on doors of the rooms she cleaned, V21 responded that she is not a CNA (Certified Nurse's Assistant) and has not been told about wearing any additional PPE. On April 1, 2024, at 10:52 PM, V2 (Director of Nursing) stated that V21 should have worn gown and gloves when she cleaned the rooms as organisms from the urine or wound could be anywhere in the room. V2 added that although R26 is on isolation related to MRSA in wound and its contained, a gown and gloves should always be worn on entrance to the room as the signage shows. V2 stated that she will notify the House Keeping Director with the directives. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 22 of 24 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 145901 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lemont Nursing & Rehab Center 12450 Walker Road Lemont, IL 60439 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 provide documentation that influenza and pneumococcal vaccines had been offered. Residents Affected - Some This applies to 5 of 5 residents (R26, R49, R53, R86, R104) reviewed for immunizations in the sample of 24. The findings include: 1. R86's EMR (Electronic Medical Record) showed R86, age [AGE], admitted to the facility on [DATE], with multiple diagnoses including cerebral infarction, dysphagia, atrial fibrillation, artificial opening of the urinary tract and urinary tract infection. On April 3, 2024, at 11:20 AM, V4 (IP Nurse) and V2 (DON) stated they were unable to provide documentation of influenza vaccine and pneumococcal vaccines were offered or declined, since admission for R86. V4 stated R86's family requested the vaccines be administered but was unable to provide documentation that the vaccines were administered. 2. R53's EMR showed R53, age [AGE], was admitted to the facility on [DATE], with multiple diagnoses including pneumonia, paroxysmal atrial fibrillation, chronic obstructive pulmonary disease, psoriatic arthritis and history of resistance to multiple antibiotics. R53's immunization records showed R53 received the PCV 13 (Pneumococcal vaccine 13) vaccine on June 23, 2016. According to the CDC (Center for Disease Control) Pneumonia Vaccine Timing for Adults, adults who received the PCV 13 at any age should receive the PPSV 23 (Pneumococcal Polysaccharide vaccine) if it has been more than one year since last administered. On April 3, 2024, at 11:20 AM, V4 and V2 stated there was no documentation that R53 had been offered or declined the pneumococcal vaccine. 3. R104's EMR showed R104, age [AGE], was admitted to the facility on [DATE], with multiple diagnoses including metabolic encephalopathy, chronic obstructive pulmonary disease, type 2 diabetes, unspecified dementia and heart failure. R104's immunization record showed there was no documentation the influenza or pneumococcal vaccines had been administered since admission. On April 3, 2024, at 11:20 AM, V4 and V2 stated there was no documentation that the influenza and pneumococcal vaccines had been offered or declined since admission. 4. R26's EMR showed R26, age [AGE], was admitted to the facility on [DATE], with multiple diagnoses including Parkinson's disease, heart failure, polyosteoarthritis, polyneuropathy and atrial fibrillation. R26's immunization record showed R26 had received the pneumococcal vaccine PPSV 23 on January 31, 2023. According to the CDC's Pneumococcal Vaccine Timing for Adults, adults greater than age [AGE], who have already received the PPSV 23 vaccine should be offered the PCV20 vaccine. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 23 of 24 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 145901 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lemont Nursing & Rehab Center 12450 Walker Road Lemont, IL 60439 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 3, 2024, at 11:20 AM, V4 and V2 stated there was no documentation that R26 had been offered or declined the pneumococcal vaccine. 5. R49's EMR showed R49, age [AGE], was admitted to the facility on [DATE], with multiple diagnoses including acute diastolic congestive heart failure, epilepsy, obstructive and reflux uropathy, and moderate protein-calorie malnutrition. R49's immunization record showed R49 last received the influenza vaccine on October 12, 2022, but did not receive the vaccine for the 2023-2024 Flu season. There is no record that the pneumococcal vaccine has been administered. On April 3, 2024, at 11:20 AM V4 and V2 stated there was no documentation that R49 had been offered the influenza vaccine for the 2023-2024 Flu season, nor that the pneumococcal vaccine had been offered or declined. The facility's policy titled Influenza Vaccine dated December 2006, showed 2 residents admitted between October 1st and March 31st shall be offered the vaccine within 5 days of the resident's admission to the facility, and .6. A resident's refusal of the vaccine shall be documented in the resident's medical record. The facility's policy titled Pneumococcal Vaccine dated December 2006, showed 2. Assessments of pneumococcal vaccination status will be conducted within 5 working days of the resident's admission, if not conducted prior to admission and . 7. Administration of the pneumococcal vaccination or revaccination will be made in accordance with current CDC recommendations at the time of the vaccination and .5 .If refused, appropriate entries will be documented in each resident's medical record indicating the date of the refusal of the pneumococcal vaccine. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 24 of 24