Health inspection·January 10, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 01/07/25 at 04:05 PM, V17 (Hospice CNA) was providing bathing assistance to R32 with the room door opened and no curtain closed around the bed to protect R32 from view. R32, who has severe cognitive impairment, did not verbalize concern with the curtain not being pulled to protect her privacy, but a reasonable person would want their naked body protected from the view of passersby. On 01/09/25 at 02:22 PM, V2 DON (Director of Nursing) stated curtains should be closed during cares to block the residents from view; urine collections bags should be covered from view; blinds should be closed when care is being provided to residents; and when staff walk away from residents, they should cover them and not leave their genitals exposed. The facility Resident Rights Guideline states residents have the right to be treated with respect and dignity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 2 of 21 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 01/10/2025 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide resident and/or their family/power of attorney (POA) in writing the reason residents were transferred to the hospital, and the facility failed to notify the ombudsman of resident hospital transfers. This applies to 3 of 3 residents (R25, R108 and R136) reviewed for hospitalization in a sample of 29. The findings include: 1. R108's Emergency Department (ED) hospital record of 11/21/24 shows that R108 was seen at the hospital for Altered Mental Status and Leukocytosis. R108's progress notes of 11/21/24 at 6:12 PM states that resident was confused and unable to acknowledge nursing staff. Resident's POA was notified and requested for resident to be sent to the hospital. Nurse informed the provider and the Director of Nursing (DON), orders received to send to the ED. 2. R25's ED hospital record of 1/3/25 shows that R1 was seen at the hospital for abdominal pain, ascites, and pneumonia. R25's progress notes of 12/31/24 at 4:45 PM states that R25 was complaining of severe abdominal and chest pain; R25's abdomen was distended and firm. The physician was notified and ordered to send R25 to the ED. R25' wife was notified of the transfer. On 1/9/25 at 9:10 AM, V2 (DON) said resident's family are notified of the transfers to hospital, however, there is no written documentation of reason of transfer and that the bed hold policy was provided to the residents and/or their POAs. V2 said that they do not notify the ombudsman of residents' transfers to the hospital. V2 stated the facility does not have a bed hold policy; they have an assessment that is done in the EMR and that is presented to the resident when they leave the facility. The facility's ECC Bed Hold Policy (undated) states that this form serves as a written information and notice to the resident or legal representative at the time of admission, and in advance of any transfer, and at the time of transfer that specified the duration of the bed hold policy under the Medicare and Medicaid state plan of the facility. The facility permits private pay residents, Medicare-eligible residents and Medicaid-eligible residents whose leaves have exceeded the Medicaid-reimbursed 10 day bed hold period who wish to pay from their own income to hold the bed. 3. R136's Face sheet shows she was admitted to the facility on [DATE]. R136's Change in Condition Evaluation documented on 11/1/24 at 13:33 shows R136 was transferred to the hospital after an unwitnessed fall. On 1/9/25 at 2:13 PM, V2 (DON) said the facility does not have documentation showing R136 or her family were notified in writing of the reason for R136's transfer to the hospital. V2 said the facility did not notify the Ombudsman of R136's transfer to the hospital because V2 stated she did not know the facility was supposed to notify the Ombudsman. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 3 of 21 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 01/10/2025 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide resident and/or their family/power of attorney (POA) written documentation of bed hold policy when residents were transferred to the hospital. The facility also failed to notify the ombudsman of resident transfer to the hospital. This applies to 3 of 3 residents (R25, R108 and R136) reviewed for hospitalization in a sample of 29. The findings include: 1. R108's Emergency Department (ED) hospital record of 11/21/24 shows that R108 was seen at the hospital for Altered Mental Status and Leukocytosis. R108's progress notes of 11/21/24 at 6:12 PM states that R108 was confused and unable to acknowledge nursing staff. Resident's POA was notified and requested for resident to be sent to the hospital. Nurse informed the provider and the Director of Nursing (DON), orders received to send to the ED. The facility was unable to provide documentation that the bed hold policy/assessment form was given to the resident and/or the POA upon transfer to the hospital. 2. R25's ED hospital record of 1/3/25 shows that R25 was seen at the hospital for abdominal pain, ascites and pneumonia. R25's progress notes of 12/31/24 at 4:45 PM states that R25 was complaining of severe abdominal and chest pain; R25's abdomen was distended and firm. The physician was notified and ordered to send R25 to the ED. R25' wife was notified of the transfer. The facility was unable to provide documentation that the bed hold policy/assessment form was given to the resident and/or the POA upon transfer to the hospital. On 1/9/25 at 9:10 AM, V2 (DON) said resident's family are notified of the transfers to hospital, however, there is no written documentation that the bed hold policy was provided to the residents and/or their POAs. V2 stated the facility does not have a bed hold policy; they have an assessment that is done in the EMR and that is presented to the resident when they leave the facility. The facility's ECC Bed Hold Policy (undated) states that this form serves as a written information and notice to the resident or legal representative at the time of admission and in advance of any transfer and at the time of transfer that specified the duration of the bed hold policy under the Medicare and Medicaid state plan of the facility. The facility permits private pay residents, Medicare-eligible residents and Medicaid-eligible residents whose leaves have exceeded the Medicaid-reimbursed 10 day bed hold period who wish to pay from their own income to hold the bed. 3. R136's Face sheet shows she was admitted to the facility on [DATE]. R136's Change in Condition Evaluation documented on 11/1/24 at 13:33 shows R136 was transferred to the hospital after an unwitnessed fall. On 1/9/25 at 2:13 PM, V2 (DON) said the facility does have a Bed Hold Policy Form, but it was not documented for R136's transfer to hospital. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 4 of 21 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 01/10/2025 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to have an accurate MDS (Minimum Data Set) assessment to document the functional limitation in range of motion (ROM). Residents Affected - Few This applies to two of the two residents (R66 and R64) reviewed for assessment accuracy in a sample of 29. The Findings include: 1. R66 is a [AGE] year-old male admitted with an admitting diagnosis, including cerebral infraction and hemiplegia affecting the right dominant side. On 01/07/25 at 12:03 PM, R66 was observed with his contracted right hand, third and fourth fingers curled and touching his palm. A review of R66's MDS dated [DATE] documented no impairment with functional limitation in range of motion. 2. On 01/07/25 at 10:18 AM, R64 was observed in her bed with contracted hands, fingers curled and touching her palm. A review of R64's MDS dated [DATE] documented no impairment with functional limitation in range of motion. On 01/08/25 at 9:59 AM, V8 (MDS Coordinator) stated, The hand contracture is coded in the functional limitation in ROM. The restorative is the one coding this section and should have been coded accurately to reflect resident status. On 01/08/25 at 10:40 PM, V2 (Director of Nursing/DON) stated, The MDS assessment should reflect resident status. An inaccurate MDS code can cause a lack of care with residents. The restorative is the one document of the functional limitation in ROM and should have been documented accurately for R64 and R66. A review of the facility presented Resident Assessment Instrument (RAI) Guidelines document: Ensure timely and accurate submission to avoid penalties and maintain compliance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 5 of 21 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 01/10/2025 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 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** Based on observations, interviews, and record reviews, the facility failed to provide grooming and hygeine cares for residents who require staff assistance. Residents Affected - Some This applies to 5 of 7 residents (R64, R66, R76, R114, and R125) reviewed for activities of daily living (ADL) in a sample of 29. The Findings include: 1. R64 is an [AGE] year-old female admitted with severe cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. The MDS also documents that R1 is dependent for eating, toileting hygiene, oral hygiene, and personal hygiene. On 01/07/25 at 10:18 AM, R64 was observed in her bed with contracted hands, fingers curled, and nails about 7 millimeters (mm) past the fingertip, that were dirty with a brownish deposit underneath the nails, which were touching her palm. R64 stated that she wanted to trim her nails, but she couldn't do it alone, and nobody was helping her. On 1/8/25 at 9:37 AM, R64 was in her bed with a dry, crusty lip peeling off, and the resident was observed licking her dry lips. 2. R66 is a [AGE] year-old male admitted with an admitting diagnosis, including cerebral infraction and hemiplegia affecting the right dominant side. A review of the MDS dated [DATE] documents that R66 has cognition intact. The MDS also documents that R1 requires set-up assistance with eating, partial/moderate assistance with toileting hygiene, and supervision or touching assistance with personal hygiene. On 01/07/25 at 12:03 PM, R66 was observed with the contracted right hand, having a dirty long nail about 6-8 millimeters past the fingertip with a blackish deposit underneath the nails on the third and fourth fingers. R66 stated that nobody was helping him to cut his fingernails. On 1/8/25 at 10:40 AM, V2 (Director of Nursing/DON) stated, Certified Nursing Assistants (CNAs) should be doing nail trimming and grooming at least on shower days and as needed. The long nails with contracted hands can cause ulcers. CNAs are also supposed to provide oral care. A review of the ADL policy (effective 02/2023) document: Guideline: In accordance with the comprehensive assessment, together with respect for individual resident needs and choices, our facility provides care and services for the following activities: Hygiene: Bathing, dressing, grooming, and oral care. The facility presented the Nail Care Guidelines (effective 02/23) document: Nail care includes routine cleaning and regular trimming. Proper nail care can help prevent skin problems around the nail bed. 3. On 1/7/24 at 11:10 AM, R114 was observed with long jagged fingernails. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 6 of 21 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 01/10/2025 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 0677 Level of Harm - Minimal harm or potential for actual harm R114's 12/26/24 MDS showed that R114 needs substantial/maximal assistance from staff for personal hygiene and that R114's cognition is severely impaired. On 01/09/25 at 09:42, AM V2 (DON) said that the staff should be clipping residents nails every day and the residents' nails should be short for infection control and safety, so they don't scratch themselves or others. Residents Affected - Some 4. On 01/07/25 at 01:29 PM R76's nails were observed long, up to 1 inch in length, jagged, nails curling under tips of fingers, and with a brown substance under the nails. R76's 11/6/24 MDS showed R76 needs substantial/maximal assistance from staff for personal hygiene. On 01/09/25 at 09:43 AM V2 said that residents should receive nail care as needed. The facility's Activities of Daily Living (ADL) policy dated 2/2023 showed that the facility provides necessary care and services to ensure that the residents abilities in activities of daily living (ADL) do not diminish . The policy showed that in accordance with the residents' comprehensive assessment the facility provides care and services for: hygiene, mobility, elimination The facility's professional team will implement interventions in accordance with the resident's evaluated needs . 5. On 1/7/25 at 11:34 AM, R125 was in bed watching TV. R125 was noted with several white hair on her chin and her fingernails were long and dirty with black/brownish substance. On 1/9/25 at 11:38 AM, R125 was resting in bed, fingernails still long with black/brownish substance in nail bed. R125 said she would need assistance with getting her nails trimmed. Review of R125's Electronic Medical Record (EMR) shows the following diagnoses of cerebral infarction, cognitive communication deficit, and lack of coordination. R125's MDS of 12/24/24 shows that R125's cognition is moderately impaired and needs substantial/maximal assistance with personal hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 7 of 21 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 01/10/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement a physician's order for 1 of 1 residents (R239) reviewed for quality of care in a sample of 29. Residents Affected - Few The findings include: R239 is a [AGE] year old female admitted to the facility on [DATE]th, 2024, with diagnoses including mechanical complications of nephrostomy catheter, calculus of kidney, hydronephrosis with ureteral stricture, urinary tract infection, and urge incontinence. On 1/7/25 at 2:11 PM, V9 (R239's daughter) said that she had concerns with the staff not changing the dressing to R239's nephrostomy every day. V9 turned R239 on her side and exposed R239's dressing to her nephrostomy. The date on the adhesive dressing showed 1/2/25 (five days earlier). V9 said, See, they are not changing it every day. On 1/8/25 at 12:04 PM, V6 (Wound Nurse) was preparing to provide wound care for R239. V6 turned R239 on her side, pulled down R239's pants, and opened her brief. Two adhesive dressings were present, one on the coccyx area and one on the right flank area. V6 was asked if R239 had two wounds and V6 said no, that the one adhesive dressing dated 1/2/65 was the dressing for R239's nephrostomy, and the dressing dated 1/6/25 was her pressure wound. The 1/2/25 dressing was observed peeling off at the bottom of the dressing. After V6 provided wound care to R239's pressure wound, she did not provide care to R239's nephrostomy site even after seeing that the dressing was not fully intact. R239's 11/18/24 Physician's orders showed, Site: Right side of back nephrostomy insertion site. Cleanse wound with Normal Saline or wound cleanser. Pat wound dry. Apply border gauze daily and PRN (as needed) if loose/soiled. Every day shift. On 1/9/25 at 09:34, V2 (Director of Nursing) said that her expectations are that the nurse change R239's nephrostomy dressing daily as ordered. V2 said this should be done to check the site for infection and to prevent infections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 8 of 21 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 01/10/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to have fall interventions in place for 2 of 5 residents (R3 & R94) who are at risk for falls in a sample of 29. Residents Affected - Few The findings include: 1. On 01/7/25 at 11:25 AM, R3 was in her room and stated she had a concern with her bed moving when she tries to get into her bed from her wheelchair. R3 said that she grabs the Halo (specialized safety ring attached to the bed frame) at the top of her bed to pull herself up out of her wheelchair and stabilize herself to transfer into her bed. R3 said that every time she does it, her bed moves. The wheels on R3's bed were unlocked at this time and the bed moved easily when pushed. R3 stated she has a history of falling. R3's diagnoses include difficulty in walking, and lack of coordination. R3's 10/15/24 care plan showed that R3 is at risk for falls with interventions including the resident needs a safe environment. On 01/09/25 at 09:47 AM, V2 DON (Director of Nursing) said that the wheels on R3's bed should be locked to prevent her from falling. On 01/09/25 at 10:08 AM V2 (DON) tested R3's bed with R3 present and the bed moved. Additionally, the Halo on the left side of the bed was not secured and spun around when touched. 2. On 01/07/25 at 10:54 AM, R94 was observed in her wheelchair with no shoes on her feet and her socks were not non-skid or non-slip socks. R94 said that she has a history of falls. R94 said that a couple of weeks ago she slipped out of her wheelchair while in her room, and again while in her bathroom she leaned forward while sitting on her wheelchair attempting to pull the bathroom call light and again slipped out of her wheelchair. R94's diagnoses include history of falls, difficulty in walking, and unsteadiness on feet. R94's 10/15/24 care plan showed that R94 is at a risk for falls with interventions including ensure that R94 is wearing appropriate footwear and follow the facility's fall protocol. On 01/09/25 at 09:45 AM, V2 (DON) said that R94 should be wearing proper footwear while in the wheelchair. The facility's Falls Guidelines date 1/2014 showed to consistently identify and evaluate residents at risk for falls to prevent or reduce injuries related to falls. The policy showed that the facility provides an environment that is free from hazards over which the facility has control. The policy showed under Fall Prevention: Identification of hazards and risk factor: Environmental rounds. Fall management: develop and implement interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 9 of 21 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 01/10/2025 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to attempt gradual dose reductions (GDR) for residents taking psychotropic medications. This applies to 2 of 3 residents (R82 and R109) reviewed for unnecessary medications/psychotropic medications in a sample of 29. The findings include: 1. Review of R109's Electronic Medical Record (EMR) shows the following diagnoses of traumatic brain injury, dementia, attention deficit hyperactivity disorder, bipolar disorder and major depressive disorder. R109's physician order shows that R109 has the following orders, Citalopram 20 mg give 1 tablet a day for antidepressant, Quetiapine 50 mg, give 1 tablet for bipolar disorder, Trazadone 150 mg give 1 tablet orally at bedtime for depression. Per the facility's Psychotropic and Sedative/Hypnotic Utilization report, it showed that R109 had GDR done on 4/14/24 for Citalopram 20 mg, Quetiapine 50 mg and Trazadone 150 mg. The next evaluation for GDR was supposed to be in October of 2024; there is no documentation that the GDR was attempted or done in October of 2024. There is also no documentation on behavior monitoring for R109. On 1/9/25 at 1:17 PM, V2 (Director of Nursing/DON) said GDR are to be done every quarterly and the last GDR for R109 was done in April of 2024, R109 was not evaluated in October. V2 said she does not have documentation of behavior monitoring on R109; she said they switched EMR systems, and nothing transferred into their current EMR system. 2. R82 is an [AGE] year-old female admitted on [DATE] with an admitting diagnosis including psychosis, major depression, and anxiety disorder. A review of R82's Physician Order Sheet (POS) documents that R82 is getting Lorazepam 1 milligram (mg)/0.5 milliliter (ml) every six hours as needed for anxiety, Olanzapine 5 mg three times a day for psychosis, Trazadone 150 mg at bedtime for depression, and Clonazepam 0.5 mg as needed for anxiety/agitation. A review of R82's clinical progress note does not indicate any GDR was attempted to decrease the psychotropic medication dose. The review also shows any signed psychotropic medication consent in place for Lorazepam, Olanzapine, Trazadone, and Clonazepam. On 1/9/25 at 9:32 AM, V2 (Director of Nursing/DON) stated, Our Psychiatrist retired last March, and we haven't attempted any GDR for R82. To avoid unnecessary medication doses, GDR should be attempted quarterly for the resident's benefit. The facility presented the Behavior and Psychotropic Medication Management Guideline document: b. For Psychotropic Medications- Gradual Dose Reduction is attempted per regulatory guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 10 of 21 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 01/10/2025 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to administer medications as ordered, in ordered dosages. There were 28 opportunities with 2 errors, resulting in a 7.14% error rate. Residents Affected - Few This applies to 2 (R51 and R84) of the 5 residents observed in the medication pass. Findings include: 1. R51's Face Sheet shows diagnoses of dementia, atrial fibrillation, heart failure, cardiac pacemaker, hypertensive heart disease, and atherosclerosis. On 1/8/25 at 8:43 AM, V12 (LPN/Licensed Practical Nurse) administered two Potassium Chloride ER (extended release) 10 meQs (milliequivalents) tablets orally for a total of 20 meQs to R51. R51's POS (Physician Order Sheet) and MAR (Medication Administration Record) show an order dated/started 9/10/24 for Potassium Chloride 10 meQs ER 1 tablet orally two times a day (9 am and 5 pm). On 1/8/25 at 1:51 PM, V12 (LPN) said she gave R51 two 10 meQ tabs of potassium chloride, not 1 tab. V12 confirmed that she could see R51's POS showed an order to give one 10 meQ tablet of potassium chloride twice a day, but V12 had a note on the side of the order that said to give two tabs. V12 said she was going to clarify with the doctor how much potassium should be given. V12 said R51 had not had any recent blood work done to check his potassium level. On 1/9/25 at 9:15 AM, V2 (DON/Director of Nursing) said a potassium chloride order should not show two different doses to be administered, and if it does, the nurse should clarify the order with the doctor BEFORE administering the medication. V2 said giving too much potassium can be harmful to the resident's heart. 2. R84's Face Sheet shows diagnoses of chronic kidney disease, dementia, osteoporosis, and retention of urine. On 1/8/25 at 9:08 AM, V13 (LPN) administered Vitamin D3 125 mcg (micrograms) tablet orally to R84. R84's POS and MAR showed an order dated 9/10/24 for Vitamin D3 50 mcg cap orally one time a day at 9 AM. On 1/8/25 at 1:59 PM, V13 (LPN) said she gave R84 125 mcg Vitamin D capsule and removed the bottle back out of her medication cart to verify dosage. V13 was then shown the order in R84's chart to compare the order to the dosage on the bottle that was given to R84. V13 confirmed that she gave R84 75 mcgs MORE than the physician ordered dose. On 1/9/25 at 9:15 AM, V2 (DON) said she was not sure if there was harm in giving a resident more Vitamin D3 than prescribed. Springhouse Nurse's Drug Guide 2007 shows adverse reactions of Vitamin D include arrhythmias, impaired kidney function, bone and muscle pain, and bone demineralization. R84's Care Plan dated 10/22/24 shows R84 has renal insufficiency related to stage 3 kidney failure. The facility's policy titled, Administration Procedures for all Medications effective 11/4/14 states, Policy: To administer medications in a safe and effective manner. Procedures: .C. Review 5 Rights (3) times: 1) a. Check MAR/TAR for order . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 11 of 21 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 01/10/2025 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 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. 11. On 1/7/25 at 2:02 PM, R238 was in her room and on her bed side table was 1 prescription bottle of Miconazole nitrate 2% powder (Antifungal) and 1 prescription bottle of Sodium Chloride 0.65% nasal spray. R238 said that she uses the nasal spray twice a day. A review of R238's Order Summary report did not show any orders for Miconazole Nitrate 2% powder or Sodium Chloride 0.65% nasal spray. On 1/9/25 at 09:56 AM V2 (DON) said that medications should not be at the residents' bedside 10. On 1/7/25 at 12:38 PM, R287 was observed in bed; R287 had just finished his lunch. On R287's bedside table, there was tube of Glutose 15 (raises low blood sugar), a bottle of Refresh liquid gel (lubricating eye drops), and a bottle of Fluticasone Propionate nasal spray. R287 said the medications were his and he uses them daily. Review of R287's Electronic Medical Record (EMR) shows the following diagnoses of Chronic Obstructive Pulmonary Disease with acute Exacerbation, dysphagia, Type 2 Diabetes Mellitus, allergic rhinitis and dependence on supplemental oxygen. R287's Minimum Data Set (MDS) of 12/27/24 shows that his cognition is moderately impaired. Review of R287's current physician order shows that he has an order for Fluticasone Propionate Nasal Suspension 1 spray in both nostrils one time a day. R287 does not have an order for the eye drops, or the Glutose 15. R287 does not have an order that states the medications can be stored in the residents' rooms. On 1/9/25 at 8:49 AM, V2 (Director of Nursing/DON) said they do not have residents that can self-administer their medications and there are no residents that can store medications at their bedside. V2 said there is a risk that residents could be double medicating, or there could be an interaction with the medications that they are providing for the residents, hence they need to be aware of the medications the residents are taking. V2 said there should be a physician order for residents to have medications stored at the bedside, and the residents needs to be assessed in order to store medications at the bedside. The medications would also need to be locked. The facility's Storage of Medications policy (effective date 10/25/2014) states that medications and biologicals are stored safely, securely, and properly. The medication supply is accessible only by licensed personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Based on observation, interview, and record review, the facility failed to safely and securely store all resident medications. This applies to 11 residents (R64, R108, R74, R120, R37, R43, R72, R82, R5, R287, and R238) reviewed for medication storage in a sample of 29. Findings include: On 1/9/25 at 11:34 AM, the medication storage room on V14's (LPN/Licensed Practical Nurse) unit was checked in her presence. Upon entrance into the medication storage room, the medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 12 of 21 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 01/10/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm refrigerator holding resident narcotics was found unlocked (narcotics were not double-locked) and the key to the refrigerator was hanging on a hook inside the medication storage room. V14 (LPN) said that is where the narcotic key is always kept. The following resident narcotics were found in the unlocked medication refrigerator: Residents Affected - Some 1. R64's 2 vials of Lorazepam 2 mg/mL oral solution. 2. R108's Lorazepam 2 mg/mL oral solution. 3. R74's Lorazepam 2 mg/mL oral solution. 4. R120's Lorazepam 2 mg/mL oral solution. 5. R37's Lorazepam 2 mg/mL oral solution. On 1/9/25 at 11:41 AM, the medication storage room on V15's (LPN) unit was checked in her presence. Upon entrance into the medication storage room, the medication refrigerator holding resident narcotics was found without a lock on it. The narcotics were not double-locked. The following resident narcotics were found in the medication refrigerator without a lock on it: 6. R43's Dronabinol 5 mg capsules. 7. R72's Lorazepam 2 mg/mL oral solution. 8. R82's Lorazepam 2 mg/mL oral solution. 9. R5's Lorazepam 2 mg/mL oral solution. On 1/9/25 at 12:33 PM, V2 (DON/Director of Nursing) said all resident narcotics/controlled substances should be double-locked. V2 said medication refrigerators in medication storage rooms should have a lock on them because they hold controlled substances. V2 said the medication storage room is to be kept locked as well as the medication refrigerator inside the medication storage room. V2 said only nurses should have access to the keys for the medication storage room and the medication refrigerator. V2 said the key in V14's medication storage room is kept hanging on the wall because they only have one key to the refrigerator and never made copies of it for each nurse to have a key. The facility's policy titled, Controlled Substance Storage effective 10/25/14 states, Policy: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations. Procedures: A. The director of nursing, in collaboration with the consultant pharmacist, maintains the facility's compliance with federal and state laws and regulations in the handling of controlled substances. Only authorized licensed nursing and pharmacy personnel have access to controlled substances. B. Schedule II- V medications and other medications subject to abuse or diversion are stored in a permanently affixed, double-locked compartment separate from all other medications or per state regulation . If a key system is used, the medication nurse on duty maintains possession of the key to controlled substance storage areas. Back-up keys to all medication storage areas, including those for controlled substances, are kept by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 13 of 21 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 01/10/2025 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 0761 the director of nursing or designee . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 14 of 21 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 01/10/2025 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 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 maintain the kitchen facility in a manner to prevent foodborne illness. Residents Affected - Many This applies to 128 residents in the facility receiving dietary services. Findings include: On 01/08/25 10:06 AM V1 Administrator confirmed 128 residents were being served from dietary services on 1/7/25. 1. On 01/07/25 at 10:01 AM, the dry storage contained: An opened one- gallon jar of mayonnaise dated 12/31/24 labeled refrigerate after opening. An opened one-gallon bottle of barbeque sauce dated 12/31/24 labeled refrigerate after opening. An opened 793-gram bag of chocolate pudding and a 24-ounce bag of butterscotch pudding without use by or opened on dates. Two 6-pound 9-ounce dented cans of yellow cling peaches. One 6-pound 3-ounce dented can of sauerkraut. On 01/09/25 at 01:15 PM, V21 (Dietary Director) stated the barbeque sauce and mayonnaise should be refrigerated once opened to prevent the growth of bacteria. Dented cans should be separated and not use because we don't know how deep the dent is or if the can was punctured and leaking. The food could be contaminated, and rust could develop inside of the cans if exposed to air causing illness or medical issues. The shelving in dry storage V21 identified as the location for dented cans did not have dented can signage. 2. On 01/07/25 at 10:13 AM, the plate warmer which was stacked with clean plates, was dirty and covered with crumbs and food splatters. On 01/09/25 at 01:15 PM, V21 stated, kitchen equipment should be kept clean to prevent cross contamination. The facility policy Storage and Handling of Cleaned Equipment and Utensils dated June 2023 states the food contact surfaces of equipment are protected from splash, dust and other contamination. 3. On 01/07/25 at 10:14 AM, the walk-in cooler contained: An opened 25-pound bucket of hard-boiled eggs delivered on 12/24/24. Eggs did not have an opened on or use-by date. Two pitchers identified by V21 as orange juice, one pitcher identified as cranberry juice and five-liter container identified as fruit punch- none had a label to identify contents or use-by dates. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 15 of 21 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 01/10/2025 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 A 16-quart container with sliced pickles did not have a label to identify contents or any dates. Level of Harm - Minimal harm or potential for actual harm Five small facility serving cups identified by V21 as vanilla yogurt did not have any labels or dates. Residents Affected - Many A large piece of meat identified by V21 as a ham roast (which was rewrapped in plastic wrap dated 1/3/5) and a large raw pork loin in factory packaging, were both stored over a box of bagged shredded cabbage and a stalk of celery. Three 10-ounce packages of corn tortillas and a bottle of pinot grigio. V21 stated the tortillas and wine belongs to staff. On 01/09/25 at 01:15 PM, V21 stated, employee food items should not be stored with the facility food because we cannot verify the vendor, where it came from or what is in it, and it could be inadvertently served to residents. Meat products should not be stored over vegetables because they could drip blood or juice on them causing illness. 4. On 01/07/25 at 10:37 AM, the walk-in cooler contained: Two bags of brown liquid without labels or dates. A bag identified by V21 as chicken patties did not have a label or dates. An opened bag identified as French fries did not have a label or dates. An opened 40-ounce bag of onion rings did not have an opened on or use by date. On 01/09/25 at 01:15 PM, V21 stated it is important to label food items with the contents and dates so that expired food items aren't being served and so that we know what the items contains. Residents who have food sensitivities may have an allergic reaction if they are served food which contents aren't verified. 5. On 01/07/25 at 10:47 AM, a shelf near the stove contained a 32-ounce bottle of disinfectant spray, a 4-ounce bag of disinfectant spray, a four-ounce bag of fryer cleaning pucks, a four-ounce bottle of hand sanitizer and a four- ounce bottle of hand sanitizer. On a seasoning shelf, an opened 20-ounce bottle of mustard labeled refrigerate after opening. A large bin of flour with no opened-on or use-by date. A large bin of sugar with no opened-on or use-by date. The toaster oven was crusty and greasy. Stored on a shelf under the toaster ovens was a 26-ounce bottle of disinfectant cleaner and a 32-ounce bottle of surface sanitizer. Four 3.5-gallon containers with items V21 identified as flakes of corn, bran with raisins, crisped rice and O's cereals that were not labeled or dated. On 01/09/25 at 01:15 PM, V21 stated, cleaning products should not be stored in the food preparation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 16 of 21 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 01/10/2025 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 Residents Affected - Many areas when food is being prepared because they could contaminate the food and cause illness or send someone to the hospital. The facility policy Food Storage dated June 2023 states Refrigerator and freezer temperatures will be monitored twice daily and recorded on temperature monitor logs by culinary personnel. Food and non-food supplies are to be clearly labeled. Leftover foods are labeled, dated immediately placed under refrigeration and used within 72 hours or discarded. No personal food items will be stored with food items. 6. On 01/07/25 at 10:55 AM, V21 tested the sanitizer level in the three-compartment sink. V21 stated the multi-quat sanitizer is automatically measured out and should measure at 50ppm (parts per million). When tested, sanitizer solution in the three-compartment sink measured at 10ppm with test strips with max range of 200ppm. V22's (Dishwasher) documentation for the sanitizing solution concentration in the three-compartment sink done on 1/7/24 measured 400ppm. V22 stated he turns the dial on the sanitizing solution and let it run until the water's color turns pink. V22 stated he wrote down the result on the log located in the office. V21 stated no red disinfecting buckets were in use during the survey. V21 stated they were using no-rinse food safe surface wipes. On 01/09/25 at 1:15 PM, V21 stated, he purchased the kitchen disinfectant wipes being used in the kitchen instead of the red sanitization bucket. V21 stated there is no facility policy that covers the uses of the disinfecting wipes, and his supervisor did not clear him to use the wipes. 7. The kitchen logs for food temperature, freezer, walk in cooler, sanitizer solution concentration, and dishwasher were reviewed from October 2024 - January 7,2025. The logs reviewed had incomplete documentation daily. On 01/09/25 at 01:15 PM, V21 stated, food temping is important to make sure food being served is fully cooked and have documentation if someone says it's cold or raw. Checking the cooler and freezer log assures food items are held at the proper temperatures. Assuring the sanitization level makes sure we are cleaning properly. The facility policy Sanitation and Infection Control dated June 2023 states, monitoring of food temperatures will be recorded throughout food production and delivery. Wiping cloths shall be clean, rinsed frequently in an approved sanitizing solution and shall only be used to wipe food spills and dining tables. Utilize and fill red buckets with sanitizing solution and replace every 2 hours. Sanitizer should read at 200ppm. Three-sink sanitizing method- use a test kit or other device that accurately measures the concentration of the sanitizing solution. The concentration for a multi quat sanitizing solution is 200- 400 ppm. All chemicals and toxic materials shall be stored separately from each other in a place used for no other purpose and away from all food or food contact equipment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 17 of 21 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 01/10/2025 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R64 is an [AGE] year-old female admitted with an admitting diagnosis including Gastrostomy Tube (GT) feeding. A review of R64's physician order sheet (POS) documented administering feeding with Jevity 1.2 at 50 milliliters per hour (ml/hr) from 7:00 PM to 10:00 AM. Residents Affected - Some On 1/7/25 at 10:18 AM, R64's entry door was observed with an EBP sign to wear gloves, gown, and mask to provide high-contact resident care activities. No PPE (Personal Protection Equipment) box is available at the door side. On 1/7/25 at 10:25 AM, observed V4 (CNA) providing incontinent care to R64 without wearing a gown. At 10:27 AM, V5 (LPN) stated that R64 was on EBP due to GT feeding and that staff should wear gloves and a gown while changing the EBP resident. On 1/8/25 at 10:40 AM, V2 (DON) stated, The CNA (V4) should have worn gown while changing an EBP resident. On 1/9/25 at 10:30 AM, during an infection control interview, V3 (Infection Preventionist) stated that the staff should wear gloves and a gown when providing high-contact resident care activities to EBP residents. A review of the facility presented Enhanced Barrier Precaution Guidelines revised on 3/21/24 document: Enhanced Barrier Precaution refers to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with MDRO (Multi-Drug Resistant Organism) as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). 2. Initiation of Enhance Barrier Precaution b. Implement enhanced barrier precautions for residents with any of the following: ii indwelling medical devices (eg., central lines, hemodialysis catheters, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO. 3. On 1/9/25 at 11:09 AM, R387 was observed in a contact isolation room with signage indicating to wear gowns and gloves to go inside the room. R387 was observed with two visitors sitting in chairs without wearing gowns. A review of R387's Physician Order Sheet (POS) document: Maintain contact precaution due to ESBL (Extended Spectrum Beta-Lactamase) every shift. On 1/9/25 at 11:19 AM, V3 (Infection Preventionist) stated that the visitors are supposed to wear a gloves and gown and she will educate the visitors/family. The facility presented Isolation - Categories for Transmission Based Precaution (effective date: 01/20/24) document: Contact Isolation: Use PPE appropriately, including gloves and gown. Wear a gown and gloves for all (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 18 of 21 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 01/10/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some interactions involving contact with the resident or the resident environment. Donning PPE upon room entry and properly discarding before exiting the resident room is done to contain pathogens. 6. On 1/7/25 at 12:56 PM, V11 CNA (Certified Nurses' Assistant) was observed feeding R20 and R29 at the same time, using the same hand, and never cleaning her hands in-between residents. V11 sat in-between R20 and R29. R29 was on V11's right side, and R20 was on V11's left side. V11 used her right hand to feed both R20 and R29 alternating bites between residents, but never cleaning her hands in-between residents. On 01/09/25 at 09:53 AM, V2 (DON) said that staff should clean their hands in-between feeding residents for infection control. The facility's Hand Hygiene Guideline dated 08/2024 showed that appropriate hand hygiene is essential in preventing transmission of infectious agents. The policy showed that hand hygiene is essential to prevent the spread of infection from resident to resident. The policy shows that hand hygiene is recommended immediately before touching a resident, after touching a patient or patient surroundings, after contact with blood, bodily fluids, or contaminated surfaces. 4. On 1/7/25 at 10:59 AM, during initial rounds on the 1st floor, V7 (Housekeeping) was observed cleaning R25's room. V7 had on mask and gloves and was going in and out of R25 room while she was cleaning and getting supplies from her cleaning cart outside the room. R25 had Contact Isolation sign on his door, with a PPE (Personal Protective Equipment) supply bin right outside the door. V7 said R25 was on isolation for MRSA (Methicillin Resistant Staphylococcus Aureus); V7 said she should be wearing full PPE while cleaning the resident's room. On 1/8/25 at 10:31 AM, V6 (Wound Care Nurse) was providing wound care treatment to R25's left and right foot. V3 (Infection Preventionist/IP) was assisting V6 with the wound care; during the wound care, V24 (R25's wife) came into the room without full PPE. Review of R25's Electronic Medical Record (EMR) shows the following diagnoses of sepsis, pneumonitis due to inhalation of food and vomit, ESBL resistance, MRSA, unspecified Escherichia Coli (E. Coli), pressure ulcer of sacral region stage 2, and pressure ulcer of left heel stage 4. On 1/8/25 at 10:17 AM, V3 (IP) said R25 was on contact isolation for ESBL (enzymes that make some bacteria resistant to many antibiotics) and MRSA in his sputum. V3 said staff should be wearing full PPE (gown, gloves, mask) when they enter R25's room. On 1/8/25 at 11:22 AM, V3 said resident's family members should also be wearing full PPE when they are in contact isolation rooms. 5. On 1/7/25 at 12:03 PM, V4 (CNA) provided incontinent care to R30. V4 informed R30 of the incontinent care, washed hands, put on gloves and gathered supplies. V4 raised R30's bed up, then moved the garbage can from the left side of the bed to the right side of the bed, and informed R30 to turn to her left side, facing the window. V4 removed R30's soiled brief, R30 had a bowel movement. V4 used wipes to clean R30 buttocks, removed the soiled brief and threw the soiled brief in the trash can. The trash can did not have a trash bag. The soiled brief stained the trash can with bowel movement, there was brown streaks in the trash can. V4 changed gloves, used wet wash clothes to clean R30's perineal area and buttocks. V4 changed gloves again and used a dry towel to dry R30's perineal area and buttocks. V4 then repositioned R30 in bed, then put the soiled brief and wipes from the trash can in a trash bag and took the trash out. The trash can still had brown streaks from the soiled brief. V4 did not perform hand hygiene with each glove change. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 19 of 21 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 01/10/2025 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 Level of Harm - Minimal harm or potential for actual harm On 1/9/24 at 9:01 AM, V2 (Director of Nursing/DON) said there should be trash bags in the trash cans for infection control reasons; also there should be hand hygiene with each glove change. Based on observation, interview and record review, the facility failed to maintain infection control practices that prevent the spread illness and disease. Residents Affected - Some This applies to 6 of 7 residents (R20, R25, R29, R30, R32, R64 and R387) reviewed for infection control in a sample of 29. Findings include: 1. R32 admitted to the facility with diagnoses that includes Parkinson's, dementia, congestive heart failure, arthritis, left artificial hip joint and dysphagia. R32 physician's orders includes hospice care services and enhanced barrier precautions related to wounds. On 01/07/25 at 04:05 PM, R32's bedroom door had EBP (Enhanced Barrier Precautions) signage. There was no PPE (Personal Protective Equipment) located outside of the room or anywhere nearby for entering R32's bedroom. V17 Hospice CNA (Certified Nursing Assistant) was bathing R32 without wearing an isolation gown. V17 had thrown soiled linens on the floor near R32's bed. V17 stated there was no isolation gown available for her use. V17 stated she informed facility staff the prior week that there were no isolation gowns available. On 01/07/25 at 04:10 PM, V16 (CNA) entered R32's room to assist with bathing and repositioning and did not put on an isolation gown. V16 stated PPE should be located outside of R32's room and she should have worn gloves and a mask for EBP to assist with care. On 01/07/25 at 04:58 PM, V12 LPN (Licensed Practical Nurse) assigned to R32 stated R32's EBP are related to her wounds. Staff are only required to wear an isolation gown when they are doing a dressing change. If the wound is covered and the dressing is intact staff are not required to wear an isolation gown. V12 stated PPE is in the medication room. The medication room is locked, and CNA's do not have access. On 01/07/25 at 05:03 PM, V18 CNA assigned to R32 stated PPE gown is not required for R32 because although EBP signage is on the door, there were no supplies outside the room for her use and no red biohazard bin near the room door. On 01/09/25 at 02:22 PM, V2 DON (Director of Nursing/DON) stated R32 in on EBP for her wound and staff should have worn a gown to give her bed bath. V2 stated anytime care is being provided a gown should be worn. V2 stated if there are no supplies available outside the room, the nurse should be giving the CNAs the PPE to use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 20 of 21 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 01/10/2025 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation interview and record review, the facility failed to provide a safe, comfortable, and homelike environment for 1 of 3 residents (R114) who were reviewed for environment in a sample of 29. Residents Affected - Few The findings include: On 01/07/25 at 11:10 AM, R114 was observed in his bed and the bed control was observed wrapped around the Halo (specialized safety ring attached to the bed frame) on the right side of R114's bed. The wires to the cord were exposed about a foot in a half in length and one white wire was broken from the control. On 01/09/25 at 10:13 AM V2 DON (Director of Nursing) and the State Surveyor went into R114's room, R114 was in his bed, and the bed control was observed wrapped around the Halo on the top right side of R114's bed. V2 unwrapped the bed control and about 2 and ½ feet of the top of the cord was missing the protective plastic covering, exposing all of the wires. The white colored wire was broken away from the control. The bed control was plugged into the outlet. V2 said that the broken bed control was a safety issue. On 01/09/25 at 09:50 AM V2 said that the residents should not have broken bed controls in their rooms because if they have exposed and or broken wires the resident could get shocked, and the bed control could malfunction. V2 said that her expectations are that staff notify maintenance immediately. The facility's General Safety Precautions policy dated February 2014 showed that equipment is not to be used if it is not safe. Report all unsafe acts or conditions to the supervisor as soon as practical. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145901 If continuation sheet Page 21 of 21