Inspection·July 19, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident the way she was speaking. It was more than speaking loudly for someone hard of hearing. I don't think anyone should be treated that way. When I went back in the room, there was feces all over the bathroom. That may have been the problem, but I am not sure. Either way that did not give her the right to speak to her the way she was speaking to her. On 7/18/2023 at 2:30PM V8, Social Services Director, stated, I was alerted on 4/21/2023 that (V5) had yelled at (R2) and (V5) was being verbally abusive to (R2). I asked (R2's), roommate (R5) because she was there when it happened. I asked her if (V5) spoke rudely to (R2), and (R5) said 'yes'. (R5) said she felt safe but was concerned about retaliation. Because of this we had to let (V5) go. (R2) did not comprehend what had happened and could not tell us any details. It was the roommate who was able to confirm what had happened to (R2) and (V4). On 7/18/2023 at 3:30PM V3, Assistant Director of Nursing, ADON, stated the incident involving R2 and V5 was reported the day after the incident occurred. V3 stated We followed the chain of command letting all parties know. The staff member did not report to us until the next day. We then tried to speak to (R2), but she did not remember anything and could not tell us anything. (R5) told us everything that happened. I don't know why (V4) waited until the next day to say anything. I would expect staff to notify management immediately not the next day. We did not interview any other residents about abuse. Only (R2) and (R5). We saw no need to interview any others since the incident happened in R2's and in R5's room. The Undated Abuse Policy documents, It is the policy of (Facility) to encourage and support all residents, staff, families, visitors, volunteers and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property from abuse, neglect, misappropriation of resident property, and exploitation. The Policy documents A board member, licensee, administrator, licensed nurse, employee, or volunteer of a nursing home shall not physically, mentally, or emotionally abuse, mistreat, or neglect a resident. Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation, or misappropriation shall immediately report to the nursing home administrator. The policy documents Definitions of Abuse and Neglect Abuse- Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. Abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Verbal abuse includes, but is not limited to: threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145921 If continuation sheet Page 2 of 6 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 07/19/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to report allegations of abuse immediately to the Executive Director, which delayed the abuse investigation for 1 of 3 residents (R2) reviewed for reporting of abuse in the sample of 19. Findings include: R2's Facility's Verbal Abuse Investigation, dated 4/20/2023 document, It was reported on the night of April 20, 2023, by a staff member, that (V5, Certified Nursing Assistant) yelled at (R2) during care. (V5) is a CNA at the facility. (V5) was the CNA for (R2) on the evening shift. During the bedtime rounds, (V4), Housekeeping/Laundry Assistant, reported hearing (V5) yelling at (R2) to 'stand up'. (V4) also reported that (R2's) roommate, (R5), then yelled She has alzheimer's. Don't you be yelling at her. An investigation was conducted on April 21, 2023, by (V3), Assistant Director of Nursing, ADON. (R5) has no cognitive impairments. When asked about the incident, (R5) stated (V5) yelled at (R2). (V5) told (R2) to stand up. It upset (R2) who yelled back I'm trying to. (V5) stated (R2's) depend was full of feces and it went on the floor during the transfer. (R2) reported hearing the frustration in (V5's) voice. Since a staff member heard the incident, and an alert resident also heard the incident, (V5) was terminated as soon as today April 21. 2023. Social Service also spoke to (R5) who told the same story. (V5) was asked for her side of the story. (V5) said that she did not yell at (R2). (R2's) Power of Attorney, was notified of the incident and outcome. (V10), Medical Doctor, MD, was notified. Nursing is to follow up with (R2) every shift for the next 72 hours. Social Services conducted a visit today with (R2). (R2) does not recall the incident. (R2) was pleasant. Her appetite remains unchanged. No signs of depression noted. R2's 4/21/2023 4:56PM Incident Note documented It was reported on the night of 4-20-23 a CNA (certified nursing assistant) yelled at (R2) to stand up. An investigation was conducted all parties were all notified. (R2) continues to be pleasant. She does not recall the incident. Appetite is unchanged. (R2) is currently in the dining room for supper. R2's Progress Notes dated 4/21/2023 at 4:10PM documented Social Services visit conducted regarding verbal abuse incident. R2's mood is happy/pleasant. Social Service (SS) asked resident if there was anything she would like to talk about or any concerns she may have. (R2) stated that she is happy and feels she is fortunate to have her family. Social Service will continue to follow. On 7/18/2023 at 3:00PM V4, Housekeeping/Laundry, stated, I was here working that night because I remember (V5) had (R2) on the (manual stand assistance device). (R2) and (V5) were arguing. (V5) was speaking unprofessionally to (R2). (V5's) tone was unprofessional, and no one should speak to a resident the way she was speaking. It was more than speaking loudly for someone hard of hearing. I don't think anyone should be treated that way. When I went back in the room, there was feces all over the bathroom. That may have been the problem, but I am not sure. Either way that did not give her the right to speak to her the way she was speaking to her. V4 stated that the Administrator and DON were not in the facility so she told them the next day. On 7/18/2023 at 3:30PM V3, Assistant Director of Nursing, ADON, stated, The incident involving (R2) and (V5) was reported the day after the incident occurred. We followed the chain of command letting all parties know. The staff member (V4) did not report this to us until the next day. We then tried to speak to (R2), but she did not remember anything and could not tell us anything. (R5), the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145921 If continuation sheet Page 3 of 6 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 07/19/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few roommate told us everything that happened. I don't know why (V4) waited until the next day to say anything. I would expect staff to notify management immediately not the next day. On 7/18/2023 at 1:00PM V1, Administrator, stated V5, Certified Nursing Assistant, CNA, was terminated for raising her voice to R2. The incident happened on 4/19/2023 but wasn't reported to us until 4/20/2023. V1 stated V5 was terminated over the phone. The Facility's undated abuse policy states Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation or misappropriation shall immediately report to the nursing home administrator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145921 If continuation sheet Page 4 of 6 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 07/19/2023 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse and failed to protect residents from further abuse by allowing an alleged perpetrator of abuse to have contact with residents for 19 of 19 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19) reviewed for abuse investigation in the sample of 19. Residents Affected - Some Findings include: R2's Facility's Verbal Abuse Investigation dated 4/20/2023 document, It was reported on the night of April 20, 2023, by a staff member, that (V5, Certified Nursing Assistant) yelled at (R2) during care. (V5) is a CNA at the facility. (V5) was the CNA for (R2) on the evening shift. During the bedtime rounds, (V4), Housekeeping/Laundry Assistant, reported hearing (V5) yelling at (R2) to stand up. (V4) also reported that (R2's) roommate, (R5), then yelled She has alzheimer's. Don't you be yelling at her. An investigation was conducted on April 21, 2023, by (V3), Assistant Director of Nursing, ADON. (R5) has no cognitive impairments. When asked about the incident, (R5) stated (V5) yelled at (R2). (V5) told (R2) to stand up. It upset (R2) who yelled back I'm trying to. (V5) stated (R2's) depend was full of feces and it went on the floor during the transfer. (R2) reported hearing the frustration in (V5's) voice. Since a staff member heard the incident, and an alert resident also heard the incident, (V5) was terminated as soon as today April 21. 2023. Social Service also spoke to (R5) who told the same story. (V5) was asked for her side of the story. (V5) said that she did not yell at (R2). (R2's) Power of Attorney, was notified of the incident and outcome. (V10), Medical Doctor, MD, was notified. Nursing is to follow up with (R2) every shift for the next 72 hours. Social Services conducted a visit today with (R2). (R2) does not recall the incident. (R2) was pleasant. Her appetite remains unchanged. No signs of depression noted. On 7/19/2023 at 2:00PM V1 stated the Social Services Director (SSD) oversaw the investigation for the incident with R2 on 4/19/2023. On 7/18/2023 at 2:30PM V8, SSD, stated I was alerted on 4/20/2023 that V5 had yelled at R2 to stand up. I am not sure who I told about the abuse first. I did not write down statements from other residents. On 7/18/2023 at 3:30PM V3, Assistant Director of Nursing, ADON, stated We did not interview any other residents about abuse. Only (R2) and (R5). We saw no need to interview any others since the incident happened in R2's and R5's room. The facility's schedule was reviewed and documented V5 worked on Hall one on 4/19/2023. V5's Timecard was reviewed and documented that V5 worked the entire shift on 4/19/23 and was not sent home after alleged abuse occurred with R2. On 7/18/2023 at 1:00PM, staff and resident interviews were requested regarding the abuse allegation between V5 and R2 on 4/20/23. No further documentation was provided of any other resident or staff interviews for the night of 4/19/2023 and into morning of 4/20/23. Only interviews provided were on the initial report. On 7/19/2023 at 1:30PM the facility provided documentation of residents living residing on the hall the incident occurred on 4/19/2023 into morning of 4/20/23. Residents listed are as follows: R1, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145921 If continuation sheet Page 5 of 6 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 07/19/2023 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 0610 R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19. Level of Harm - Minimal harm or potential for actual harm Facility's undated abuse policy documents It is the policy of (Facility) that reports of abuse (mistreatment, neglect, abuse, and injuries of unknown source, exploitation, and misappropriation of property) are promptly and thoroughly investigated. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145921 If continuation sheet Page 6 of 6