Inspection·August 25, 2023

F 0755 b. Level of Harm - Minimal harm or potential for actual harm Right Drug-verify that correct drug is being given using med card, label and EMR (Electronic Medical Record) Residents Affected - Some c. Right Dose-verify that correct dosage is being given using med card, label, and EMR d. Right time-administer drugs per liberal med pass policy e. Right Route-verify that medication is being given by correct route using med card, label and EMR If the comparison is correct, the medication is to be punched from the bubble card into the medication cup with appropriate technique. Nursing must initial EMR for appropriate medication, date, and time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145921 If continuation sheet Page 2 of 7 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 08/25/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review, the facility failed to label multi dose vials of medication and multidose insulin pens when accessed. This has the potential to affect all 38 residents in the facility. Findings include: 1. On 8/24/23 at 2:50 PM V19, Registered Nurse (RN) removed a multi-dose vial of Tuberculin Purified Protein Derivative from the refrigerator in the medication room on the 100-Hall. The multi-dose vial was opened but did not have a date on the box or the vial indicating when the vial was opened. The instructions on the label on the box documented, Discard opened product after 30 days. V19 stated, I only work per diem. I don't know when this bottle was opened but I may be able to find out. 2. On 8/24/23 at 3:00 PM during observation of the 100-Hall medication cart with V19, there was an opened insulin pen with the label indicating it contained Novolog 70/30 insulin in the top drawer. This insulin pen had R32's last name only on it, but no label with medication instructions, dosage or prescription number, and there was no date on the pen documenting when it was opened. V19 stated she did not know there needed to be a label on the pen since R32's last name was written on it. She stated R32's spouse brings her medication into the facility from an outside pharmacy, and they send multiple pens in one box each time. V19 stated the pen should be discarded 30 days after being opened. On 8/24/23 at 3:37 PM V1, Administrator, sent an email which documented, The resident with the outside pharmacy-regarding the insulin pens; I called them and they said moving forward they can individually label each pen. I called her husband as well. He said he will make sure they do when he picks them up every time. I know it doesn't matter now, but I just wanted you to know that moving forward it will be fixed. On 8/24/23 at 4:30 PM V1 sent another email which documented, The pharmacy also called us back. They cannot legally open the box to label all of the pens, but they will send extra labels for us to use. On 8/25/23 at 9:19 AM V2, Director of Nursing (DON) stated she would expect any multi-dose bottles or vials to be dated as soon as they are opened and discarded per the instructions on the label. V2 stated the R32's insulin pen should have had a label on it with her name on it, and should have been dated when it was opened, and the Tuberculin test solution should also have been dated when it was opened because both of these medications are to be discarded after 30 days of opening them. V2 stated the TB test solution has the potential to be used for any resident requiring a TB test when admitted or an annual TB test if needed. On 8/24/23 at 4:05 PM V1 provided the facility's undated policy, Pharmacy Services Policy, which documents, (Facility) provides routine and emergency medications to all residents. (Facility) has a contracted pharmacy that delivers on a routine and emergent basis. Residents are free to utilize any pharmacy of their choosing and are made aware that if chosen pharmacy does not deliver, it will be the family's responsibility to bring all medications. Medications are labeled in accordance with accepted professional principles and include the expiration date when applicable. All medications are stored in locked compartments under proper temperature controls. The schedule II medications are stored (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145921 If continuation sheet Page 3 of 7 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 08/25/2023 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 0761 in a separate, locked compartment. Level of Harm - Minimal harm or potential for actual harm The facility's Resident Census and Conditions of Residents form, CMS 672, dated 8/22/23, documents there are 38 residents residing in the facility. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145921 If continuation sheet Page 4 of 7 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 08/25/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the Facility failed to ensure infection control guidelines were being followed and staff were using the correct Personal Protective Equipment (PPE) on contact isolation for 4 of 4 residents (R5, R35, R190, R191) reviewed for infection control in the sample of 35. Residents Affected - Some Findings include: 1.On 08/22/23 at 8:36 AM on R190's door was open and on the door was a sign posted documenting, Enhanced Barrier Precautions, clean hands, including before entering when leaving room, Providers and staff must also wear gloves and gown. R191's Door had Personal Protective Equipment hanging over the door with gloves, and gowns. V13, Certified Nursing Assistant (CNA), exited R191's room and was not wearing any gloves or gowns, without washing or disinfecting her hands. V13 had just came from the room and was carrying out a breakfast tray. V13 left R190's room and proceeded to check on residents on the 200-hall. A list of residents in the facility with contact isolation was provided and R190 was identified as having C-diff (Clostridioides difficile) a highly contagious infection. 2.On 08/22/23 at 8:46 AM on R191's room on the door was a sign posted documenting, Enhanced Barrier Precautions, clean hands, including before entering when leaving room, Providers and staff must also wear gloves and gown. R191's Door had Personal Protective Equipment hanging over the door with gloves, and gowns. V13, entered R191's without washing or disinfecting her hands. V13 had just came from R190's room. On 8/22/2023 at 8:50 AM, V13 provided care to R5 after she had finished with R191. On 8/22/2023 at 8:59 AM, V13 was observed not to wash her or disinfectant her hands and or follow the CDC guidelines for infection control and entered R35's room and brought him fresh drinking water. On 8/22/2023 at 9:11 AM, V13 stated, I did not wear any gowns when giving care to R191, but I should have followed the guides and disinfected my hands and wore a gown. It was just a mistake. I was in a hurry and forgot. On 8/25/2023 at 9:28 AM, V2, Director of Nursing stated, I would expect staff to always disinfectant their hands when coming and going into any room when the resident is on contact isolation and to wear gowns at all at times when a resident is positive for C-diff. The Facility undated Infection Control Policy Guidelines for Contact Precautions in Addition to Standard Precautions documents It is the policy of (Facility) to follow contact precautions as ordered in addition to standard precautions for residents on contact isolation. Wash hands with soap and water before wearing gloves. Gloves should be worn when entering the room. Gown when entering the room if you anticipate your clothing will come in contact with resident or environmental services such as doorknobs, bed rails or facet handles. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145921 If continuation sheet Page 5 of 7 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 08/25/2023 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to ensure antibiotics used, are effective to treat the organisms causing the infections for 2 of 20 residents (R27 and R22) reviewed for antibiotic stewardship in the sample of 35. Residents Affected - Few Findings include: 1. R27's undated Care Plan documents R27 has an ADL self-care performance deficit related to chronic kidney disease, atherosclerotic heart disease, major depression disorder, glaucoma, generalized weakness, incontinence, and poor mobility. The Infection Control Surveillance Log for March 2023 documents R27 had a Urinary Tract Infection (UTI) on 3/11/2023 but no organism was documented and 'No growth was documented on the surveillance log for the use of any antibiotics. R27's Physician Order Sheet (POS) for March 2023 documents, Cefdinir 300 MG (milligrams), give 1 capsule by mouth two times a day for urinary tract infection. R27's Medication Administration Record (MARS) dated 3/2023 documents Cefdinir 300 MG (milligrams), give 1 capsule by mouth two times a day for urinary tract infection. R27's MAR was documented as receiving cefdinir (antibiotic) for 5 days. On 8/24/2023 at 3:24 PM, a Culture and Sensitivity Report was requested for R27. No Culture and Sensitivity Report was provided but a Clinical Laboratory Report was provided that documents, on 3/11/2023 a urine culture was taken and documents, No further testing (including susceptibility) will be performed. The Lab Report does not document and information regarding Sensitivity or if Cefdinir would be appropriate or indicated for the use of Cefdinir. 2. R22's undated Care Plan documents she has an ADL self-care performance deficit related to acute respiratory failure with hypoxia, congestive heart failure, partial intestinal obstruction with colostomy status, anxiety disorder, spinal stenosis, transient cerebral disorder, incontinence, generalized weakness and poor mobility. R22's POS dated January 2023 documents Cipro Tablet 250 MG (milligrams) (Ciprofloxacin HCL) give 1 tablet by mouth two times a day related to urinary tract infection for 5 days. The Infection Control Log for the month of January 2023 does not document any infections or urinary tract infections for R22. R22's MAR dated January 2023 documents she was taking 250 milligrams of Cipro two times a day related to a urinary tract infection, 1 tablet my mouth, two times a day for 5 days. The MAR documents R22 only received 9 out of the 10 doses for the Cipro and misses a dose on 1/2/2023. R22's Progress notes does not document R22 was sent out to the hospital or was not in the facility for January 2, 2023, to January 6, 2023. On 8/25/2023 at 10:13 AM, V2, Director of Nursing stated, We provided you with all of the C & S reports that we had. If we did not provide them, then we do not have them. I would expect all urinary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145921 If continuation sheet Page 6 of 7 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 08/25/2023 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 0881 tract infections to have the organism documented on the infection control surveillance log. Level of Harm - Minimal harm or potential for actual harm The antibiotic Stewardship Policy with an effective date of 8/18/2023 documents, Therapeutic decisions regarding antibiotic statements from clinical and academies societies) that is appropriate for the care of Long-term care facility residents. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145921 If continuation sheet Page 7 of 7