Inspection·September 12, 2022

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 9/12/2022 at V18, CNA, stated that R11 makes attempts to transfer self. V18 stated that R11 is difficult to redirect. V18 stated that maintenance needs to take a look at the cord to the alarm because they are frayed. The facility's Fall Policy, dated 5/26/16, documents It is the policy of (facility) to provide Fall Management and provide a plan in an effort to reduce fall risk. Interventions will be utilized as needed to encourage reduced risk. Those interventions may include, but are not limited to, a fall risk assessment completed upon admission and quarterly, implementing appropriate interventions for those residents at risk, and addressing risks in the plan of care. Based on observation, interview, and record review, the facility failed to follow fall interventions and provide safe transfers for 2 of 5 residents (R11, R28) reviewed for accidents/incidents in the sample of 24. Findings include: 1. R28's Care Plan, dated 8/8/22, documents (R28) has had actual falls with no injuries occurring 10/6/19, 10/30/19, 11/26/19, 11/10/20, 12/29/20, 4/6/22, 6/12/22 related to poor balance, unsteady gait, and visual deficit. Interventions: Please use a mechanical sit to stand for my transfers as needed. Especially when I am feeling weak, I require a walker and extensive staff assistance for all pivot transfers to assist my balance. Continue interventions on the at-risk plan, assist me in developing a restorative program to improve and maintain my ambulation and gait. Encourage me to participate, non-skid strips have been applied on the floor in front of my recliner. Encourage/educate me to utilize them when I am transferring. Remind me to wear grippers, tennis shoes, or appropriate footwear prior to any transfers. It continues (R28) is at moderate risk for falls related to deconditioning, gait/balance problems, vision deficit, a high score on fall risk assessment, and generalized weakness. Interventions: Be sure my call light is within reach and encourage me to use it for assistance as needed, follow facility fall protocol. Update my fall assessment quarterly and PRN (as needed.) Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT (interdisciplinary team) as to causes. It continues (R28) has an ADL (Activities of Daily Living) self-care performance deficit related to generalized weakness, osteoarthritis, limited mobility, and right ankle fracture as evidenced by requiring assistance with ADLs. Interventions: I require extensive assist by two staff members for all transfers. If I am having difficulty, please use a mechanical sit to stand with two staff assistance. I use my motorized wheelchair for mobility. R28's Minimum Data Set (MDS), dated [DATE], documents that R28 is cognitively intact and requires extensive assistance from one staff member for bed mobility, transfers and toilet use. R28 requires limited assistance from one staff member for personal hygiene, bathing and dressing. R28 is occasionally incontinent of urine and always continent of bowel. R28's Fall Risk, dated 5/25/21, documents that R28 is a high fall risk with a score of 10. R28's Fall Risk, dated 8/4/22, documents that R28 is a high fall risk with a score of 15. R28's Restorative Nursing Program, dated 1/21/21, documents Program Goal: Standing Balance; 1. Introduce self and explain what you want her to do. 2. Apply gait belt and secure chair. 3. Instruct her to stand once balance obtained instruct on exercises. 4. Resident to complete BUE (bilateral upper extremities) of cards, pegs, or cones in standing. 5. Resident to tolerate standing for one to three (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145921 If continuation sheet Page 2 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145921 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hitz Memorial Home 201 Belle Street Alhambra, IL 62001 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 minutes. Level of Harm - Minimal harm or potential for actual harm R28's Restorative Note, dated 1/27/22, documents Ambulation program was discontinued related to resident refusal to participate. Limited assist with most ADL's. Transfers unsteady at times. Uses motorized scooter for locomotion. Encouraged to participate in UE (upper extremities)/LE (lower extremities) exercises one to two times weekly as tolerated. Stand and pivot for transfers. Residents Affected - Few R28's Post Fall Evaluation, dated 4/6/22, documents Date/Time of Fall: 4/6/22 at 4:10 AM. Activity at time of fall: Transferring bed to chair. Was the reason for the fall evident? Yes, Reason for fall: Lost balance, feeling weak. Pre-Fall Risk Score 10, Post-Fall Risk Score 12. Fall Details Note: Resident lowered to ground by staff during transfer from bed to wheelchair. States she is feeling weak. VS (vital signs) 112/60, 97.6, 102, 22. Conclusion: Did resident's current medical condition contribute to the fall? Yes. Current medical conditions: Weakness, Recent Hospitalization. Does the resident have a history of prior falls: Yes, at Facility. There is no documentation whether a gait belt was used. R28's Restorative Note, dated 4/30/22, documents Due to fracture to RLE (right lower extremity) ADL assistance is extensive/total at this time. (Full body mechanical) lift for most all of transfers times two staff. Using bed pan with extensive/total assist times one or two staff. Extensive times two staff for bed mobility. Limited/extensive assist with dressing. Bed baths given related to cast on RLE. A&O (Alert and Oriented) per baseline. ROM encouraged to other extremities. R28's Post Fall Evaluation, dated 6/12/22, documents Date/Time of Fall: 6/12/22 at 9:20 AM, Activity at the time of fall: Pivot Transfer. Was the reason for the fall evident? Yes, Reason for fall: Lost balance pivot transferring with staff assist. Pre-Fall Risk Score 12, Post-Fall Risk Score 15. Fall Details Note: Resident lost balance pivot transferring with staff times one assist. Resident began to fall causing staff to fall with resident landing on staff member. Bruise noted to resident left hand. Staff uninjured. ROM (Range of Motion) WNL (within normal limits). Resident skin assessed including back of head with no deformity/injury noted excluding bruise to hand. MD (Medical Doctor) and POA (Power of Attorney) notified. Contributing factors: Resident states knee gave out during pivot transfer. Conclusion: Did resident's current medical condition contribute to the fall? Yes. Current medical conditions: Weakness to left knee. Does the resident have a history of prior falls: Yes, at facility. There is no documentation whether a gait belt was used. R28's Restorative Note, dated 7/29/22, documents Limited with most ADL's. Uses scooter for locomotion. Pivot for transfers with extensive one or two staff assistance. Provides own oral care and hand/face washing. Extensive assist with bed mobility one or two staff. Feeds self after setup. Walking boot to RLE related to fracture. Refuses to participate in programs often. ROM to tolerated joints encouraged daily. R28's Restorative Note, dated 8/24/22, documents Walking boot was discharged several days ago per Ortho MD. Continues to be limited/extensive assist with transfer, but balance has improved some with boot off. Encouraged to complete AROM (Active Range of Motion) daily as tolerated. Does not ambulate. Scooter used for mobility. Limited assist with most ADL's (Activities of Daily Living). Independent with oral care and face/hand washed. Extensive assist with perineal-care. On 9/6/22 at 2:10 PM, R28 stated I have fallen since I have been here and even prior to being here. The staff does assist me with my transfers. The staff has used a belt around me before, but they don't use it very often. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145921 If continuation sheet Page 3 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145921 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hitz Memorial Home 201 Belle Street Alhambra, IL 62001 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 On 9/6/22 at 12:05 PM, V10, CNA (Certified Nursing Assistant), assisted R28 from her electric wheelchair to her recliner with no gait belt used. R28 stood up and pivoted herself to the recliner with V10 standing by and not holding onto R28. R28 appeared to be weak and having difficulty in the transition from her wheelchair to her recliner. Residents Affected - Few On 9/8/22 at 10:25 AM, V1, Administrator, stated The staff do use the gait belt on some residents. On 9/12/22 at 2:00 PM, V39, CNA, stated We should be using a gait belt when assisting (R28). She is becoming weaker lately and we are now using a sit-to-stand with her for transfers. I asked therapy if they could assess her again to help with her strength. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145921 If continuation sheet Page 4 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145921 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hitz Memorial Home 201 Belle Street Alhambra, IL 62001 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. R25's MDS dated [DATE] documents R25 is incontinent of bowel and bladder and requires extensive assist with toileting. On 9/6/2022 at 10:47 AM, R25 stated she was hurting down there. On 9/6/2022 at 11:05 AM, V17, CNA, and V38, CNA, were performing incontinent care. V38 stated, We have a big 'bowel movement/mess'. It is all the way up her back. At this time, there was feces in R25's groin folds and pubic area. V17 wiped R25's groin with a washcloth. V17 used the same washcloth with feces on it to wipe R25's labia. V17 then turned R25 over, removed her gloves, but did not use hand hygiene. V17 then began cleaning R25's buttocks. Based on observation, interview and record review the facility failed to appropriately perform incontinent care and perform complete care for 5 of 5 residents (R5, R16, R18, R25, R32) reviewed for incontinence in the sample of 24. Findings include: 1. R18's Care Plan, revision date 2/22/2021, documents (R18) has an ADL (activities of daily living) self-care performance deficit r/t (related to) Dementia, generalized weakness, and Osteoarthritis. It also documents TOILET USE: I require extensive assist by 1-2 staff with toileting and peri-care. Ensure I am remaining clean and dry at least every 2 hours & PRN (as needed). R18's Minimum Data Set (MDS), dated [DATE], documents that R18 is occasionally incontinent of urine. On 9/7/2022 at 1:45 PM, observed V18, CNA (Certified Nursing Assistant), assisted R18 with toileting. V18, and V19, SSD (Social Service Director)/CNA, transferred R18 from the wheelchair to the toilet using the standup lift. V18 worked the remote to assist R18 into the standing position revealing R18's heavily soiled pants. V18 placed R18 in front of the toilet and removed R18's heavily urine soiled brief and pants. V18 assisted R18 onto the toilet. Upon completion of toileting, V18 assisted R18 into the standing position, using the standup lift, and performed peri care. V18 used wash cloths with spray cleanser to cleanse R18's outer labia with one wipe from behind. V18 used a separate towel to cleanse R18's buttocks and anus. V18 pulled up R18's clean undergarment and pants. V18 did not cleanse the perineum, the inner labia, and thighs. On 9/12/2022 at 3:22 PM, V2, Registered Nurse (RN), stated that when a resident is incontinent, she expects the staff to clean all areas of incontinence. V2 stated that if a resident is incontinent and then goes to the toilet, she expects the staff to perform incontinent care and cleanse all areas of incontinence. 2. R5's Care Plan, dated 8/25/22, documents (R5) has an ADL self-care performance deficit related to history of CVA (Cerebral Vascular Accident) with left sided deficit, poor mobility, DM-II (Diabetes Mellitus two), neuropathy, and generalized weakness. Interventions: I require extensive assist by two staff with turning and repositioning. I am flaccid on my left side, so be careful when you assist me, I require extensive assist by two staff with toileting. I prefer to use a bedpan. I require (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145921 If continuation sheet Page 5 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145921 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hitz Memorial Home 201 Belle Street Alhambra, IL 62001 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm total assist by one staff with all perineal care. I am incontinent of urine and continent of bowel. Please assist me with staying clean and dry at least every two hours and PRN(as needed), I require a mechanical lift with extensive assist by two staff with all transfers. I require total assist with all mobility and transportation in wheelchair. It continues (R5) has impaired skin integrity related to incontinence, DM II, CVA with left sided weakness, and poor mobility. Residents Affected - Some R5's MDS, dated [DATE], documents that R5 is cognitively intact and is totally dependent on two staff members for transfers, toilet use and bathing. R5 requires extensive assistance from two staff members for bed mobility and dressing. R5 is frequently incontinent of urine and occasionally incontinent of bowel. On 9/12/22 at 1:05 PM, V1, Administrator, stated I would expect staff to provide complete and timely incontinent care for residents who are incontinent and/or needing assistance after using the toilet. On 9/7/22 at 10:25 AM, R5 was sitting on bed pan in bed and ready to get cleaned up. V10, CNA, had a bucket of water and wash cloths ready and donned gloves. V10 wiped once from top down the middle of R5's vagina and once from top down each groin. V10 did not dry the areas. R5 turned to left side, bedpan removed and V10's buttocks and anal area wiped once while reaching between R5's legs from front to back. Without drying the areas, an incontinence brief was applied. R5 was rolled to her right side and the incontinence brief was secured and pulled up with no further cleaning. 3. R16's Care Plan, dated 7/1/22, documents (R16) has an ADL self-care performance deficit related to deconditioning, poor mobility and balance, and generalized weakness. Interventions: I require extensive assist by two staff with toileting and perineal care. I am incontinent at times and require total assist by one staff for perineal care when I am in bed. Please assist me with staying clean and dry every two hours and PRN, I require a mechanical Sit-to-stand lift with two staff assistance for transfers. It continues (R16) has impaired skin integrity related to pressure ulcer, immobility, incontinence, and a low Braden score. R16's MDS, dated [DATE], documents that R16 is cognitively intact and requires extensive assistance from two staff members for most of her ADL's. R16 is always incontinent of urine and occasionally incontinent of bowel. On 9/7/22 at 10:40 AM, R16 put her call light on as she was done using the restroom. V10 and V17, CNA, in to assist R16 using a sit-to-stand lift. R16 was lifted off the toilet. While standing and holding onto the lift device handles, V17 wiped R16's buttocks and anal area. V17 then reached between R16's legs and wiped from front to back once with no cleaning of R16's front side and no drying done after all cleansing. V17 doffed her soiled gloves and donned clean ones. An incontinent brief was then placed on R16. 4. R32's Care Plan, dated 8/2/22, documents (R32) has an ADL self-care performance deficit related to multiple pelvic fractures, Osteoarthritis of bilateral knees, generalized weakness, and history of falls. Interventions: I require extensive assist by one staff with toileting and perineal care. I am occasionally incontinent of B&B (bowel and bladder). I require total care with perineal care during incontinence episodes. Ensure I am remaining clean and dry at least every two hours and PRN, I require a Mechanical sit to stand with extensive assist by two staff for all mobility. It continues (R32) has impaired skin integrity related to generalized weakness, incontinence, and poor mobility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145921 If continuation sheet Page 6 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145921 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hitz Memorial Home 201 Belle Street Alhambra, IL 62001 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R32's MDS, dated [DATE], documents R32 is cognitively intact and requires extensive assistance from one staff member for toilet use. R32 is frequently incontinent of urine and always continent of bowel. 9/07/22 at 10:010 AM, V10 and V17 assisted R32 from the toilet to her recliner using a sit-to-stand lift. Both CNA's donned gloves. R32 held onto the lift device bar as V10 was lifting her off the toilet. V17 wiped R32's buttocks and reached between R32's legs and wiped once from front to back and did not wipe the front pubic area of R32. There was no drying of R32 after cleansing her. An incontinence brief was put on R32. V17 doffed her gloves after wiping and no new gloves applied. The facility's Perineal Care Policy and Procedure (female perineal care), undated, documents It is the policy of (facility) to do perineal care on incontinent female residents every two hours when toileting and PRN to reduce the risk of infection and maintain hygiene. It continues, Procedure: 13. Separate the labia and clean downward from front to back with one stroke. Discard and get clean washcloth repeating steps for right and left side of the labia using a clean washcloth for each stroke. No more than three strokes between glove removal and hand sanitizing. Discard all used washcloth into the soiled linen bag. 14. Remove gloves and wash/sanitize hands. 15. [NAME] clean gloves. 16. Pat the area with a clean towel. 17. Help resident turn onto side away from you. 18. Roll soiled linen under resident, remove gloves and sanitize hands. 19. [NAME] clean gloves and place clean linens under resident. 20. Apply perineal wash to washcloth. 21. Cleanse perineal rectum from front to back with one stroke starting at vagina and moving towards anus. Discard and get a clean washcloth repeating the same step until area clean. No more than three strokes between glove removal and hand sanitizing. Discard all used washcloths into the soiled linen bag. 22. Apply perineal wash to wash cloth. 23. Cleanse the visible posterior thigh and buttock using a front to back motion with one stroke per washcloth until area clean. No more than three strokes between glove removal and hand sanitizing. 24. Remove gloves and wash/sanitize hands. 25. [NAME] clean gloves. 26. Pat the area dry with a clean towel. 27. Help resident turn to the opposite side. 28. Remove soiled linen roll previously placed, remove gloves and sanitize hands. 29. [NAME] gloves and pull through clean linen previously placed. 30. Repeat the same technique to cleanse opposite buttock and posterior thigh as listed in step 23. 31. Sanitize hands and don clean gloves. 32. Pat areas dry with clean towel and apply barrier cream. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145921 If continuation sheet Page 7 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145921 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hitz Memorial Home 201 Belle Street Alhambra, IL 62001 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the Facility failed to use the services of a Registered Nurse (RN) to serve as Director of Nursing (DON) on a full-time basis. This has the potential to affect all 40 residents living in the facility. Findings include: On 9/6/22 at 10:35 AM, V1, Administrator, stated (V2) was our DON but she stepped down on 2/22/22 and only works floor shifts. She is still considered our DON though. We also have two ADON's (Assistant Director of Nursing) who are only LPN's (Licensed Practical Nurse), but they are taking care of the responsibilities of the DON until we can find another DON. On 9/7/11 at 11:35 AM, V1 stated, We have not had a full time DON since last December. The interim DON always works the floor. We are trying to hire a full time DON. On 9/7/22 at 1:52 PM, V4, ADON, stated, I do not believe we have a policy regarding DON staffing. We just follow the regulations. The Facility's Resident Census and Conditions of Residents form, (CMS 672), dated 9/6/22, documents the Facility had a census of 40 residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145921 If continuation sheet Page 8 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145921 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hitz Memorial Home 201 Belle Street Alhambra, IL 62001 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to perform hand hygiene, post signage for isolation, wear PPE (personal protective equipment) appropriately and keep the doors of COVID positive residents closed to prevent/control the spread of COVID-19. This failure has the potential to affect all 40 residents residing in the facility. Residents Affected - Many Findings include: 1. The Facility provided a list that documents, At this time, there is five residents who are positive for COVID. It further documents those residents are R6, R14, R20, R31 and R35. On 9/6/2022 at 8:45 AM, R6's door was open. There was no signage on the door to indicate type of precautions and what personal protective equipment required to enter room and provide care for resident. On 9/7/2022 at 10:30 AM, R6's door was open. On 9/8/2022 at 2:30 PM, R6's door remained open. 2. On 9/6/2022 at 8:45 AM, R14's door was open. There was no signage on the door to indicate type of precautions and what personal protective equipment required to enter room and provide care for resident. On 9/7/2022 at 10:30 AM, R14's door was open. On 9/8/2022 at 2:30 PM, R 14's door remained open. 2. R35's Care Plan, dated 8/12/2022, documents (R35) is at risk for COVID-19. It continues initiate quarantine isolation precautions x (times) 14 days upon admission or re-admission to facility unless resident is fully vaccinated or has fully recovered from COVID-19 infection in previous 90 days. Monitor every shift for s/s (signs and symptoms) of COVID-19 such as fever, cough, shortness of breath, fatigue, loss of taste or smell, sore throat, or congestion. Notify MD (medical doctor) and follow facility protocol if symptoms appear. Obtain rapid COVID-19 antigen test or SARS-CoV-2 RT PCR (lab testing) as required and as needed by facility guidelines for infection control. The Facility's COVID-19 testing log, not dated, documents R35 tested positive for COVID on 9/1/2022. R35's Orders - Administration Note, dated 9/1/2022 at 11:56 AM, documents Note Text: BinaxNOW COVID-19 Ag Card Kit 1 kit in each nostril as needed for COVID-19 PRN (as needed) Administration was: Effective Test result is positive. R35's Health Status Note, dated 9/5/2022 at 10:56 PM, documents Note Text: Pt (patient) positive for COVID. Complaints of occasional cough, runny nose and lethargy. Pt afebrile. Quarantine cont. (continued). R35's Infection Note, dated 9/6/2022 at 2:20 AM, documents Note Text: Monitoring continues r/t (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145921 If continuation sheet Page 9 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145921 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hitz Memorial Home 201 Belle Street Alhambra, IL 62001 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 - Many (related to) positive COVID-19 status. T (temperature) 97.8. Lungs clear bilaterally. SpO2 (oxygen saturation) 97% ORA (on room air). Respirations even and non-labored. Occasional non-productive cough continues. Isolation precautions maintained r/t COVID-19. On 9/6/2022 at 9:33 AM, observed R35 in reclining chair in room. R35's room door open. No signage on the door or near room indicating type of precautions and what personal protective equipment required to enter room and provide care for resident. On 9/8/2022 at 2:33 PM, R35 sitting in recliner in room. R35's room door open to hallway. On 9/8/2022 at 2:33 PM, R35 sitting in recliner in room. R35's room door open to hallway. 3. R20's Care Plan, documents that (R20) is at risk for COVID-19. It also documents Initiate quarantine isolation precautions x 14 days upon admission or re-admission to facility unless resident is fully vaccinated or has fully recovered from COVID-19 infection in previous 90 days. Monitor every shift for s/s of COVID-19 such as fever, cough, shortness of breath, fatigue, loss of taste or smell, sore throat, or congestion. Notify MD and follow facility protocol if symptoms appear. R20's Progress Notes, dated 9/5/2022 1:21 AM, documents Late Entry: Note Text: Pt (patient) tested positive for COVID during routine testing. Asymptomatic. Pt notified POA (Power of Attorney) himself and POA called this nurse back for information R20's Infection Note, dated 9/6/2022 at 2:25 AM, documents Note Text: Isolation precautions-maintained r/t positive COVID-19 status. Resident remains asymptomatic at this time. T 98.3. SpO2 96% ORA. Respirations even and non-labored. No distress noted at this time. R20's Medication Administration Record (MAR) documents that R20 was having symptoms of COVID on 9/6/2022. The Facility's COVID-19 Testing log, not dated, documents that R20 tested positive for COVID on 9/5/2022. On 9/6/2022 at 9:35 AM, observed R20 in reclining chair in room with two red trash cans in the room. No signage on the door or near room indicating type of precautions and what PPE required to enter room and provide care for resident. No PPE located outside of R20's room. PPE located on a cart across the hall outside of another resident doorway. No sign on the cart indicating what resident to utilize on and what PPE to use. On 9/6/2022 at 9:35 AM, R20 stated that he is on isolation but does not know why. R20 stated that he did test positive for COVID. R20 stated that he had symptoms and the facility tested him yesterday or the day before and, he was positive. R20 stated that the staff comes in with mask but not sure about the eyewear. R20 stated that the staff does not always wear the gown and gloves. On 9/7/2022 at 9:15 AM, observed two signs posted on R20's door documenting 1. STOP Airborne Precautions Everyone must: Clean their hands, including before entering and when leaving the room. Put on a fit-tested N-95 or higher-level respirator before room entry. Remove respirator after exiting the room and closing the door. Door to room must remain closed. 2. Stop Contact Precautions Everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145921 If continuation sheet Page 10 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145921 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hitz Memorial Home 201 Belle Street Alhambra, IL 62001 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 - Many entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. 4. R31's Care Plan, revision date 11/18/21, documents (R31) is at risk for COVID-19. It also documents Initiate quarantine isolation precautions x 14 days upon admission or re-admission to facility unless resident is fully vaccinated or has fully recovered from COVID-19 infection in previous 90 days. Monitor every shift for s/s of COVID-19 such as fever, cough, shortness of breath, fatigue, loss of taste or smell, sore throat, or congestion. Notify MD and follow facility protocol if symptoms appear. The facility's COVID-19 Testing log, not dated, documents that R31 tested positive for COVID on 9/1/2022. R31's MAR documents that R31 was having symptoms of COVID in the month of September. On 9/6/2022 at 9:37 AM, R31 observed in chair in room. R31's room door open to hallway. No signage on the door or near room indicating type of precautions and what personal protective equipment required to enter room and provide care for resident. On 9/7/2022 at 9:15 AM, observed two signs posted on R20's door documenting 1. STOP Airborne Precautions Everyone must: Clean their hands, including before entering and when leaving the room. Put on a fit-tested N-95 or higher-level respirator before room entry. Remove respirator after exiting the room and closing the door. Door to room must remain closed. 2. Stop Contact Precautions Everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. On 9/8/2022 at 2:30 PM, R31 sitting in recliner in room. R31's room door open to hallway. On 9/12/2022 at 12:25 PM, observed R31 sitting in recliner in room. R31's room door open to hallway. 5. On 9/6/22 at 12:10 PM, V11, Dietary Aide, was passing lunch trays to residents on the hall going in and out of every room with his N-95 mask under his nose, no hand hygiene between residents' tray delivery and set up. 6. The facility provided a list of unvaccinated residents. R7, R12, R22, R36, and R37 were listed as residents that were unvaccinated. R7, R12, R22, R37, and R36 were in quarantine. No signs indicating quarantine or isolation observed outside their doors. On 9/6/2022 at 9:30 AM, R7, R12, R22, R36 and R37 were observed in their rooms. No precautions in place. On 9/6/2022 at 2:00 PM, V4, ADON (Assistant Director of Nursing), verified that the facility had 5 COVID positive residents. When asked how would visitors know what PPE to wear when entering rooms? V4 stated that you would be talking about signs on doors. V4 stated he would make sure they are put (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145921 If continuation sheet Page 11 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145921 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hitz Memorial Home 201 Belle Street Alhambra, IL 62001 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 in place. Level of Harm - Minimal harm or potential for actual harm On 9/8/2022 at 11:06 AM, V23, [NAME] County Health Department, stated that they were not aware of the facility having an active outbreak or that the facility had multiple resident's positive for COVID. V23 stated V4 notifies them of the outbreaks, but the current outbreak has closed. V23 stated that the Department was unaware of any subsequent outbreaks since 7/22/22 or there being five COVID positive residents in building. V23 stated that she had given guidance to the facility in the past. V23 stated that the residents that tested positive for COVID should be placed on a unit. V23 stated that for the residents that are unvaccinated, precautions should be put in place due to exposure. Residents Affected - Many On 9/8/2022 at 2:28 PM, V4, ADON, stated that the facility did not move the residents to a specific location. V4 stated that the unvaccinated residents are on precautions. When asked how is that communicated? V4 stated that each nurse's station had a list. V4 stated that the facility is treating COVID as facility wide and each resident is in their own private room. V4 stated that unvaccinated residents should be quarantined. V4 stated that there is a list of those residents at the nurse's station. V4 stated that I guess we would need some signage posted so visitors will know what to do as far as PPE. On 9/8/2022 at 2:36 PM, V21, Registered Nurse (RN), stated that she did not have a list of unvaccinated residents on quarantine. On 9/8/2022 at 2:38 PM, V13, Receptionist, stated that she does not have a list of unvaccinated residents that are on quarantine. V13 stated that the residents on isolation or quarantine have a sign on their door. The facility's COVID-19 Policy and Procedure, not dated, documents COVID outbreak response: The facility will split into 3-color coded sections (e.g. Red/Yellow/Green) to assist with isolation and maintaining the spread of COVID-19 throughout the facility. Red Unit: Section of the facility designated to temporarily house residents with confirmed or suspected COVID-19. Initial designation of Red unit begins at the east end of 100 hall and will be known as the COVID care unit. It also documents that Residents should only be placed on the COVID-19 Care unit (Red) if they have confirmed COVID-19 infections. The facility's Infection Control Policy-Guidelines, not dated, documents Isolation Precautions: Transmission Driven Isolation Precautions are utilized in addition to Universal Precaution. If a resident is on isolation, a card placed outside the residents room indicates the need to see the nurse before entering. 7. R5's Care Plan, dated 8/25/22, documents (R5) has an ADL (Activity of Daily Living) self-care performance deficit related to history of CVA (Cerebral Vascular Accident) with left sided deficit, poor mobility, DM-II (Diabetes Mellitus two), neuropathy, and generalized weakness. Interventions: I require extensive assist by two staff with turning and repositioning. I am flaccid on my left side, so be careful when you assist me, I require extensive assist by two staff with toileting. I prefer to use a bedpan. I require total assist by one staff with all perineal care. I am incontinent of urine and continent of bowel. Please assist me with staying clean and dry at least every two hours and PRN (as needed), I require a mechanical lift with extensive assist by two staff with all transfers. I require total assist with all mobility and transportation in wheelchair. R5's Minimum Data Set (MDS), dated [DATE], documents that R5 is cognitively intact and is totally (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145921 If continuation sheet Page 12 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145921 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hitz Memorial Home 201 Belle Street Alhambra, IL 62001 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 dependent on two staff members for transfers, toilet use and bathing. R5 is frequently incontinent of urine and occasionally incontinent of bowel. On 9/12/22 at 1:09 PM, V1, Administrator, stated I would expect the staff to complete hand hygiene before resident care, after glove changes, and after care of the resident. Residents Affected - Many On 9/7/22 at 10:25 AM, R5 was sitting on bed pan in bed and ready to get cleaned up. V10, CNA, and V17, CNA, was assisting R5 with perineal care. There was no hand hygiene done by either CNA prior to care. Both CNA's donned gloves. V10 performed incontinent care. V10 removed her soiled gloves and with no hand hygiene done, donned clean gloves on. R5's pants were then put on her, gloves doffed with no hand hygiene after care was done. 8. R32's Care Plan, dated 8/2/22, documents (R32) has an ADL (Activities of Daily Living) self-care performance deficit related to multiple pelvic fractures, osteoarthritis of bilateral knees, generalized weakness, and history of falls. Interventions: I require extensive assist by one staff with toileting and perineal care. I am occasionally incontinent of B&B (bowel and bladder). I require total care with perineal care during incontinence episodes. Ensure I am remaining clean and dry at least every two hours and PRN (as needed) R32's MDS, dated [DATE], documents R32 is cognitively intact and requires extensive assistance from one staff member for toilet use. R32 is frequently incontinent of urine and always continent of bowel. On 9/07/22 at 10:010 AM, V10 and V17 assisted R32 from the toilet to her recliner using a sit-to-stand device. Both CNA's donned gloves with no hand hygiene prior to, R32 held onto device bar as V10 was lifting her off the toilet. V17 doffed her gloves after cleansing R32 and no new gloves applied. The sit-to-stand device was moved into the hall and was not wiped off after R32 was holding bars while on the toilet. The device was then pulled into R16's room. No hand hygiene was done by either CNA after gloves removed. The manufacturer's Instructions for use, dated 6/2018, documents It is recommended that equipment, accessories and slings supplied by (company) are regularly cleaned and/or disinfected between each resident use if necessary, or daily as a minimum. If the slings and equipment need cleaning, or are suspected of being contaminated, follow the cleaning and/or disinfection procedures recommended below, before re-using the equipment. This is especially important when using the same equipment for another resident, to minimize the risk of cross infection. The facility's Perineal Care Policy and Procedure (female perineal care), undated, documents It is the policy of (Facility) to do perineal care on incontinent female residents every two hours when toileting and PRN to reduce the risk of infection and maintain hygiene. It continues, Procedure: 5. Wash hands. and 11. [NAME] gloves. 13. Separate the labia and clean downward from front to back with one stroke. Discard and get clean washcloth repeating steps for right and left side of the labia using a clean washcloth for each stroke. No more than three strokes between glove removal and hand sanitizing. Discard all used washcloth into the soiled linen bag. 14. Remove gloves and wash/sanitize hands. 15. [NAME] clean gloves. 16. Pat the area with a clean towel. 17. Help resident turn onto side away from you. 18. Roll soiled linen under resident, remove gloves and sanitize hands. 19. [NAME] clean gloves and place clean linens under resident. 20. Apply perineal wash to washcloth. 21. Cleanse perineal rectum from front to back with one stroke starting at vagina and moving towards anus. Discard and get a clean washcloth repeating the same step until area clean. No more than three strokes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145921 If continuation sheet Page 13 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145921 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hitz Memorial Home 201 Belle Street Alhambra, IL 62001 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 - Many between glove removal and hand sanitizing. Discard all used washcloths into the soiled linen bag. 22. Apply perineal wash to wash cloth. 23. Cleanse the visible posterior thigh and buttock using a front to back motion with one stroke per washcloth until area clean. No more than three strokes between glove removal and hand sanitizing. 24. Remove gloves and wash/sanitize hands. 25. [NAME] clean gloves. 26. Pat the area dry with a clean towel. 27. Help resident turn to the opposite side. 28. Remove soiled linen roll previously placed, remove gloves and sanitize hands. 29. [NAME] gloves and pull through clean linen previously placed. 30. Repeat the same technique to cleanse opposite buttock and posterior thigh as listed in step 23. 31. Sanitize hands and don clean gloves. 32. Pat areas dry with clean towel and apply barrier cream. 33. Discard all soiled linens in trash bag and secure closed, discard all trash items in trash bag and secure closed. 36. Wash hands and offer fluids. The facility's CMS form 672 dated 9/6/2022 documents that there are 40 residents residing at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145921 If continuation sheet Page 14 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145921 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hitz Memorial Home 201 Belle Street Alhambra, IL 62001 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 ensure complete documentation of Pneumococcal vaccine administration and/or refusal in 4 of 4 residents (R15, R18, R22, R28) reviewed for immunizations in the sample of 24. Residents Affected - Some Findings include: 1. R15's Face Sheet documents R15 is (age 82) and was admitted to the facility on [DATE]. R15's Minimum Data Sheet (MDS) dated [DATE] documents R15 is cognitively intact. R15's Immunization Report, dated 9/7/2022, documents Pneumovax Dose 1 and Pneumovax Dose 2 (Pneumococcal vaccines) were refused. The facility did not provide documentation for these refusals. 2. R18's Face Sheet documents R18 is (age 93) and was admitted to the facility on [DATE]. R18's MDS dated [DATE] documents R18 is moderately cognitively impaired. R18's Immunization Report dated 9/7/2022 does not document any Pneumonia vaccine being offered or administered. The facility did not provide documentation that the first or second Pneumonia vaccines were offered. 3. R22's Face Sheet documents R22 is (age 81) and was admitted to the facility on [DATE]. R22's MDS dated [DATE] documents R22 is cognitively intact. R22's Immunization Report dated 9/7/2022 documents R22 refused Pneumovax Dose 1. The facility did not provide any documentation regarding this refusal, or a second dose being offered. 4. R28's Face Sheet documents R28 is (age 89) and was admitted to the facility on [DATE]. R28's MDS, dated [DATE], documents R28 is moderately cognitively impaired. R28's Immunization Report, dated 9/7/2022, documents Pneumovax Dose 1 Refusal. No documentation of refusal was provided by facility. The Immunization Report does not document Pneumovax Dose 2 being offered or administered. On 6/9/22 at 2:43 PM, V4, Infection Control Prevention Nurse, stated, I was working here when (R15), (R18), and (R28) refused their Pneumonia shots. It was just a verbal refusal, so I did not document anything about that. Perhaps that is a practice I need to start. The Facility's Policy and Procedure for Influenza, Pneumococcal, and COVID-19 Immunizations which is not dated documents, Upon admission every resident will be offered all immunizations. If a resident has previously received the vaccination, a record will be obtained if possible and added to chart. The Pneumococcal vaccine will be offered to all residents over 65 years in age or with aged 19-64 with certain underlying medical conditioner per CDC (Centers for Disease Control) recommendations and resident's MD (Medical Doctor) policy. Pneumococcal vaccines will be monitored by Infection Control (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145921 If continuation sheet Page 15 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145921 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hitz Memorial Home 201 Belle Street Alhambra, IL 62001 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 Nurse. If a resident has not had an immunization, Infection Control Nurse will obtain a consent from the resident/POA (Power of Attorney). 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: 145921 If continuation sheet Page 16 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145921 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hitz Memorial Home 201 Belle Street Alhambra, IL 62001 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 0886 Perform COVID19 testing on residents and staff. 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 conduct routine COVID-19 testing of all employees to assist in preventing transmission of COVID-19 into the facility. This has the potential to affect all 40 residents in the facility. Residents Affected - Many Findings include: On 9/6/22 at 8:00 AM, upon entry to the facility there was a sign on Facility's Visitor Entrance door that read, We are COVID positive at this time. The Facility's Contract Tracing form, undated, documents there was a COVID positive staff member, V34, Maintenance Director, on 8/25/2022. The Facility's COVID-19 test results printed on 9/8/22 at 10:45 AM, document three residents (R14, R31, R35) tested positive for COVID on 9/1/22, and two residents (R6, R20) tested positive for COVID on 9/5/2022. The Facility's COVID-19 Staff Vaccination Status for Providers provided by the Facility on 9/6/22, documents the Facility has 54 employees. The Facility's Staff Testing list documents a total of 36 staff members were tested for COVID one or more times during the week of 8/25/22 to 9/1/22. On 9/6/22 at 2:01 PM, V4, Infection Control Preventionist (ICP), stated, I realize the number of staff on the testing log does not match the number of staff in the facility. It falls short. On 9/7/22 at 10:28 AM, V16, Contracted Physical Therapist stated, I have only been working in the facility for about a month. I have not yet tested in the facility because my days here do not coincide with the facility's test dates. I had COVID in January 2022 but have not had it since. My employer has not been testing me either. On 9/7/2022 at 1:30 PM, Facility's Staff COVID-19 Testing Log was reviewed. V16 is not documented as having been tested since outbreak began on 8/25/22. On 9/7/22 at 1:52 PM, V4 stated, I follow the broad-based approach when we have an outbreak. I have no good answer for the contracted employee testing. I will fix it and make sure it is right going forward. On 9/8/22 at 11:07 AM, V23, [NAME] County Health Department, stated Testing should be done at least weekly for everyone during the outbreak unless they have had COVID-19 in the last 90 days. The Facility's COVID-19 Policy & Procedures, updated 7/29/22, documents, COVID Outbreak Testing Protocol: Broad Based Approach: This approach requires testing of all residents and HCP (Healthcare Personnel) regardless of vaccination status when a single cases of COVID-19 is identified in the facility. Continue to test all residents and HCP every 3-7 days until there are no more positive cases for 14 days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145921 If continuation sheet Page 17 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145921 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hitz Memorial Home 201 Belle Street Alhambra, IL 62001 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 0886 The Resident Census and Condition of Residents Form (CMS 672), dated 9/6/2022, documents that the facility has 40 residents living in the facility. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145921 If continuation sheet Page 18 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145921 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hitz Memorial Home 201 Belle Street Alhambra, IL 62001 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 0888 Ensure staff are vaccinated for COVID-19 Level of Harm - Actual harm Based on observation, interview, and record review, the facility failed to ensure staff are vaccinated for COVID-19. The facility failed to develop a policy that includes a process for ensuring staff are vaccinated for COVID-19, medical or religious exemptions, and a contingency plan for staff who are not vaccinated and do not have an exemption or temporary delay. This has the potential to affect all 40 residents in the facility. Residents Affected - Some Findings include: On 9/6/22 at 8:00 AM, upon entry to the facility there was a sign on Facility's Visitor Entrance door that read, We are COVID positive at this time. The facility's COVID-19 test results printed on 9/8/22 at 10:45 AM, documents three residents (R14, R31, R35) tested positive for COVID on 9/1/22, and two residents (R6, R20) tested positive for COVID on 9/5/2022. The facility's Contract Tracing Form, undated, documents that V34, Maintenance Director, had COVID symptoms on 8/23/2022 and tested positive on 8/25/2022. It also documents V40, RN (Registered Nurse), had COVID symptoms on 9/2/22 and tested positive for COVID on 9/3/2022. The facility's COVID-19 Staff Vaccination Status for Providers list documents the following staff members are not vaccinated with one dose of a single dose vaccine or all doses of a multiple vaccine series without exemption or temporary delay: V8, Housekeeping/Laundry Aide; V9, CNA (Certified Nursing Assistant); V14, Activities Director; V19, Social Services Director; V20, Dietary Aide; V21, RN, V22, Housekeeping/Laundry Aide; V24, Dietary Aide; V25, Dietary Aide; V26, LPN (Licensed Practical Nurse); V27, Housekeeping/Laundry Aide; V28, Dietary Aide; V29, CNA, V30, Dietary Aide; and V31-V33, all CNAs. The Staff Vaccination Matrix Calculator documents that the facility has 54 employees. Of these employees, 16 are unvaccinated, indicating a 31.5% unvaccinated rate. On 9/8/22 at 9:05 AM, V20 stated she is not vaccinated and generally works Monday through Friday in the facility. On 9/8/22 at 9:07 AM, V14 stated he is not vaccinated and works Monday through Friday in the facility. On 9/8/22 at 9:09 AM, V21 states she works 32 hours per week in the facility and has not been vaccinated for COVID-19. On 9/8/22 at 9:11 AM, V8 stated she usually works Monday through Friday and every other weekend and has not received the COVID vaccine. On 9/8/22 at 9:12 AM, V22 stated she has not been vaccinated for COVID and works Monday through Friday in the facility. 9/8/22 at 9:14 AM, V19 stated she works Monday through Friday in the facility and has not been vaccinated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145921 If continuation sheet Page 19 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145921 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hitz Memorial Home 201 Belle Street Alhambra, IL 62001 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 0888 Level of Harm - Actual harm On 9/6/22 at 2:01 PM, V4, Infection Control Preventionist (ICP), stated the facility's outbreak status began toward the end of August 2022. He confirmed that the COVID-19 Staff Vaccination Status for Providers list is correct and there are 17 unvaccinated staff members without any exemption or delays. He stated he did not have any documentation regarding employees who were not vaccinated. Residents Affected - Some On 9/7/22 at 3:18 PM, V4 stated, I do not have any documentation regarding employee vaccine refusals. I assume they are all for personal reasons. We have not had any changes in employee roles based on vaccination status. I believe IDPH (Illinois Department of Public Health) recommends that we attempt to vaccinate all staff. On 9/8/2022 at 1:50 PM, V19 stated that she is not vaccinated. V19 was asked if she had a religious or medical exemption, and she stated that she did not know what an exemption was. V19 stated that she had not been educated or spoken to about an exemption. On 9/8/22 at 1:52 PM, V22 stated she has not heard of vaccine exemptions before. On 9/8/2022 at 1:56 PM, V21 stated she was not vaccinated by choice. When asked if she had an exemption, V21 stated that she did not have an exemption and the facility did not request one. On 9/8/2022 at 2:00 PM, V14 stated that he was not vaccinated. V14 stated that he did not have an exemption for his vaccination and did not know what an exemption was. V14 stated that no one had talked to him or educated him about vaccine exemptions. On 9/8/2022 at 2:28 PM, V4 stated that (V8, V9, V14, V19-22, V24-33) do not have exemptions. V4 stated that in the beginning there were a couple of staff that had exemptions, but after that the staff just verbally refused. V4 verified there was a meeting around 7/12/22 about COVID vaccination, but he was unsure if exemptions were discussed. The facility's COVID-19 Policy & Procedures updated 7/29/22 documents, Core Principles of COVID-19 Prevention: Vaccination. Covid-19 vaccines available in the United States are effective at protecting people from getting seriously ill, being hospitalized , and even dying. The policy does not address a process to ensure 100% staff vaccination requirement by CMS (Centers for Medicare and Medicaid Services) rate is met, medical or religious exemptions, or contingency plans for those not vaccinated without exemptions or temporary delays. The Resident Census and Condition of Residents Form (CMS 672), dated 9/6/2022, documents that the facility has 40 residents living in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145921 If continuation sheet Page 20 of 20