Health inspection·October 4, 2024

F 0558 approaches including but not limited to call light within reach at all times in room. Level of Harm - Minimal harm or potential for actual harm R32's care plan documents in part, R32 is at risk for falls and/or fall related injury and approaches including but not limited to keep equipment within reach (i.e. call bell, phone, urinal etc.). Residents Affected - Few R32's care plan documents in part, R32 requires extensive assist with ADLS (Activities of Daily Living). Facility document titled, Answering the Call Light dated 01/2024 documents in part, the purpose of this procedure is to respond to the resident's requests and needs and when the resident is in bed or confined to a chair be sure the call light is within reach of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145960 If continuation sheet Page 2 of 23 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 145960 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ascension Resurrection Life 7370 West Talcott Avenue Chicago, IL 60631 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 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow their discharge against medical advice policy for 1 (R120) resident reviewed for discharge in a sample of 26. Findings Include: R120 was admitted to the facility on [DATE] with diagnosis not limited to Epilepsy, Mild Intermittent Asthma, Unspecified Fall, Obesity, Syncope and Collapse and Unilateral Primary Osteoarthritis. Based on review of R120's progress note, R120 was admitted to the facility at 04:00 PM on 08/05/24 and left the facility AMA (Against Medical Advice) on 08/05/24 at 07:30 PM. Progress note dated 08/05/24 10:26 PM document in part: Resident admitted at 4 pm with dx (diagnosis) multiple falls at home with head injury. 7 staples intact to the back of the head. Syncope, epilepsy, seizure disorder, elevated troponin, obesity, asthma, right knee pain, osteoarthritis. Resident's medications reviewed with resident and resident's nephew. All prescriptions faxed to pharmacy; writer called pharmacy for medications to be delivered. Resident's skin check done noted: 7 staples to the back of the head, right knee bruised, and swollen skin moles noted on the resident's right thigh, and resident's lower and upper back bruising to both upper extremities. Resident looks very anxious. Resident's nephew went to get resident some things from her house and seizure medications from home. 7:30 PM writer was called by another nurse that resident and her nephew is in the back elevator, and they are trying to leave the facility. Writer spoke with the resident's nephew, and he stated: I don't take any orders from anybody, just my aunt and she wants to leave. Nurse Practitioner and Director of Nursing notified. Resident and resident nephew took all resident's belongings. On 10/02/24 at 02:59 PM telephone contact was attempted to interview V20 (Registered Nurse) the nurse who was assigned to and documented on R120 with no response. On 10/02/24 at 02:25 PM V3 (Former Director of Nursing/Nurse Supervisor) stated I was the Director of Nursing until 09/01/24. When asked did she (V3) recall the incident with R120, V3 responded, Yes, I sort of remember. The resident has to sign an Against medical Advice form. When V20 (Registered Nurse) called me, R120 and the nephew were on the elevator and already gone. V20 was trying to talk to R120's nephew and that is when he said I don't take orders from anyone. V20 said that she was trying to get them to come back so that she could talk to them. When R120's nephew came back to the facility that is when they decided R120 was not going to stay. If there was an attempt to talk to the resident or family about the AMA, it should have been documented. The attempt to have R120 sign an AMA probably should have been documented, yeah, I guess so. On 10/03/24 at 11:35 AM telephone contact was attempted to interview V20 (Registered Nurse) the nurse who was assigned to and documented on R120 with no response. Policy: Titled Discharging a Resident Without a Physicians Approval (Against Medical Advice) last approved 01/24 document in part: A physician's order should be obtained for all discharges, unless a resident or representative is discharging himself or herself against medical advice. Policy Interpretation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145960 If continuation sheet Page 3 of 23 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 145960 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ascension Resurrection Life 7370 West Talcott Avenue Chicago, IL 60631 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 0622 Level of Harm - Minimal harm or potential for actual harm and Implementation: C. If the resident or representative insist upon being discharged without the approval of the Attending Physician, the resident and/or representative must sign a Release of Responsibility form. Should either party refuse to sign the release, such refusal must be documented in the resident's medical record and witnessed by two associates. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145960 If continuation sheet Page 4 of 23 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 145960 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ascension Resurrection Life 7370 West Talcott Avenue Chicago, IL 60631 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure a resident's initial preadmission screening was completed prior to admission to the nursing facility for 1 (R40) out of 2 sampled residents reviewed for Preadmission Screening and Resident Review (PASARR). Residents Affected - Few Findings Include: R40's clinical records show an initial admission date of 3/27/24 with included diagnoses not limited to Major Depressive Disorder, Bipolar Disorder and Generalized Anxiety Disorder. R40's Notice of PASRR Level I Screen Outcome shows a review date of 8/14/24. On 10/02/24 at 9:52 AM, interviewed V15 (Business Development Coordinator) and stated that R40's PASARR was done after admission because R40 came from home. At 11:29 AM, interviewed V1 (Administrator) and stated PASSAR screening is done prior to admission to make sure that residents being admitted are eligible and meet the requirements to come to the nursing facility. V1 stated if it was somebody coming from a community the facility is doing post screen and should be done right away. The facility's policy titled, PASARR (Pre admission Screening & Resident Review) dated 1/23 reads in part: The community will not admit any new resident who is suspected of having: A serious mental illness, unless: the state mental health authority determines that the physical and mental condition of the individual requires the level of services provided by the facility; the state mental health authority determines whether or not the individual requires specialized services for mental illness; and these determinations are based on an independent physical and mental evaluation that is performed prior to admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145960 If continuation sheet Page 5 of 23 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 145960 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ascension Resurrection Life 7370 West Talcott Avenue Chicago, IL 60631 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to follow a resident's (R64's) and their representative's wishes for no hospitalization for 1 out of 3 residents reviewed for hospice. Residents Affected - Few Findings include: R64's Face Sheet documents in part a Code Status of NO CPR (cardiopulmonary resuscitation). R64's Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form documents in part wishes for Do Not Attempt Resuscitation/DNR, Comfort-Focused Treatment: Primary goal of maximizing comfort. Request transfer to hospital only if comfort needs cannot be met in current location. POLST signed/active since [DATE]. R64's [DATE] Physician Orders document in part: Patient has a DNR (Do Not Resuscitate) Order signed [DATE] and Do Not Hospitalize with an order/start date of [DATE]. On [DATE] at 11:41 AM, V25 (R64's Family Member) stated facility transferred R64 to the hospital against their wishes. V25 stated facility transferred R64 around Sunday ([DATE]) at 6:15 AM. Facility didn't call the family until around 7:27 AM - after they already transferred R64 to the hospital. V25 stated the facility was not supposed to transfer R64 to the hospital. The hospital started treating R64 for sepsis and that was not supposed to happen. V25 stated R64 didn't want treatment and only wanted comfort care. V25 stated the family provided this information when the advanced directives were signed at the facility. V26's (Agency Nurse) progress note dated [DATE] documents in part that V26 heard R64 coughing and found R64 with yellow mucous coming from nose and mouth. R64 was lethargic and nonverbal. V26 sent R64 to the hospital for evaluation and treatment. Attempted telephone interview with V26 on [DATE] at 8:13 AM - no answer. On [DATE] at 8:43 AM, V3 (Former Director of Nursing/Registered Nurse Supervisor) stated facility was aware that R64 and R64's representatives did not want R64 hospitalized . V3 does not know why V26 sent R64 to the hospital via 911 (emergency services). V3 stated staff didn't inform V3 until after R64 was already sent out to the hospital for evaluation. V3 stated R64 is on hospice, wants only comfort measures, and does not want hospitalization. Facility's Procedure: Advance Directives and Code Status policy (last approved 06/2024) documents in part: Advance directives will be respected in accordance with state law and community policy. Choice reviewed routinely, at the quarterly care conference, when there is a significant change and per resident/resident representative request. Facility's Resident Rights policy (last approved 06/2022) documents in part: It is the policy of [facility] to promote and protect the right of residents residing in our ministry. Residents are entitled to exercise their personal and legal rights and privileges to the fullest extent possible. The Illinois Long-Term Care Ombudsman Program's Residents' Rights for People in Long-Term Care Facilities guide (Rev. 11/18) documents in part that residents have the right to make their own choices. Residents have the right to request, refuse, and/or discontinue any treatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145960 If continuation sheet Page 6 of 23 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 145960 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ascension Resurrection Life 7370 West Talcott Avenue Chicago, IL 60631 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to correctly set an air loss mattress based on weight for one (R32) of 8 residents reviewed in a total sample of 26 for pressure wound treatment services. Residents Affected - Few Findings include: On 10/01/24 at 12:34 PM, R32 was lying in bed on air loss mattress. The air loss mattress was set at setting 4 indicating 250-pound weight per the display panel. On 10/01/24 at 1:24 PM, R32 was lying in bed on air loss mattress. Air loss mattress still set at 4 indicating 250-pound weight. V6 (Registered Nurse) observed the mattress setting at 4 on the display panel and stated R32 does not weight 250 pounds. V6 stated the Maintenance Department sets the rate of the air loss mattress when they deliver the mattress to the room. On 10/01/24 at 1:26 PM, V16 (Director of Facilities Management) came into R32's room and stated V16's department delivers the air loss mattress to the resident's room, but the nurse is the one who sets the rate of the air loss mattress. V16 stated V16's staff does not know the weight of the resident so they would not know what the mattress should be set at. V16 stated the setting of the air loss mattress is based on the resident's weight. On 10/01/24 at 1:27 PM, V7 (Certified Nursing Assistant) felt R32's mattress and said, it feels really hard. On 10/01/24 at 1:28 PM, V6 felt R32's air loss mattress and stated the mattress very firm and it should be softer. On 10/01/24 at 1:30 PM, surveyor felt the pressure of R32's air loss mattress and it was extremely tight and firm. There was no give in the mattress when the surveyor attempted to squeeze the outside of the mattress pressing inward. On 10/01/24 at 2:04 PM, observed V6 and V7 using total body mechanical lift to weigh R32 which indicated R32 weighed 108.2 pounds. On 10/02/24 at 5:01 PM, V3 (Former Director of Nursing/Registered Nurse Supervisor) stated residents have a Braden Scale assessment completed upon admission and readmission. V3 stated a Braden Scale Assessment it is an assessment tool used to identify a resident's risk for developing a skin breakdown so measures can be put in place to prevent a skin breakdown from occurring. R32's last Braden Scale Assessment determined R32 was at risk for developing a skin breakdown but R32 is not at high risk. R32 recently had a stroke and is now in bed a lot more because R32 cannot move R32's left side. V3 stated prior to this R32 was able to self-propel herself around the facility and could walk using a walker. V3 stated now that R32 is in bed more often that puts R32 at a higher risk for a skin breakdown. V3 stated R32's family requested for R32 to use an air loss mattress because of R32's decreased mobility and spending longer periods of time in bed. V3 stated V3 thinks use of the air loss mattress is a good idea due to R32's weakness and inability to move her left side and because R32 is in bed all day other than when R32 gets up for therapy. V3 stated the air loss mattress is setting is based on the resident's weight. V3 stated the nurses should know that the air loss mattress is set (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145960 If continuation sheet Page 7 of 23 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 145960 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ascension Resurrection Life 7370 West Talcott Avenue Chicago, IL 60631 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few based on the resident's weight and set the air loss mattress accordingly. V3 stated the mattress should feel pretty soft because the air should be able to flow back and forth. V3 said, you don't want it extra firm. V3 stated too much firmness is not good because the tightness causes more pressure which is something you do not want. R32 has diagnosis which includes but not limited to Hemiplegia Affecting Left Dominant Side, Cellulitis of Left Upper Limb, Hypertensive Heart Disease with Heart Failure, Chronic Diastolic (Congestive) Heart Failure, Atherosclerotic Heart Disease, Cardiomegaly. Paroxysmal Atrial Fibrillation. R32's MDS (Minimum Data Set) from 08/17/24 BIMS (Brief Interview for Mental Status) score is 07 out of 15 indicating severely impaired cognition and section G (Functional Status) documents in part R32 requires partial/moderate assistance with toileting hygiene. Note MDS reassessment pending from most recent hospital readmission [DATE]. R32's Braden Risk Assessment Report dated 09/21/24 documented in part, R32's at moderate risk with risk score of 13 based on bedfast activity (confined to bed), limited mobility (unable to make frequent or significant changes independently), friction & shear (requires moderate to maximum assistance in moving), nutrition very poor (never eats a complete meal). R32's care plan dated 08/11/23 documents in part, R32 is at risk for alteration in skin integrity related to decreased mobility, bladder incontinence and left sided weakness due to ICH (Intracerebral Hemorrhage). R32's Physician Orders dated 10/01/24 documents in part, air loss mattress to bed setting 1. R32's Visual Body Map dated 10/02/24 does not document any skin wounds. Facility provided policy titled, Support and Surface Guidelines dated 01/2024 documents in part, the purpose of this procedure is to provide guidelines for the assessment of appropriate pressure relieving devices for resident at risk of skin breakdown, redistributing support surfaces are to promote comfort for bed or chair bound residents, prevent skin breakdown, promote circulation and provide pressure relief or reduction, and when an individual is identified to be at risk for development of pressure injuries an elected form of pressure relieving/redistribution support surface such as foam, gel, static air, alternating air or air loss when lying in bed will be initiated. Facility provided Owner's Manual for R32's air loss mattress documents in part, the air loss mattress is a flotation therapy mattress which provides pressure management to assist in the prevention and treatment of pressure ulcers and operating instruction include but not limited to when the resident is placed on the mattress surface, the mattress firmness is adjusted automatically after the resident's height and weight are entered on the display panel. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145960 If continuation sheet Page 8 of 23 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 145960 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ascension Resurrection Life 7370 West Talcott Avenue Chicago, IL 60631 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 Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records reviews, the facility failed to follow the fall care plan intervention for one resident (R98) of 8 residents reviewed for falls out of a total sample of 26. Findings Include: R98's diagnosis includes but not limited to Unspecified Dementia with Agitation, Repeated Falls, Anxiety Disorder. R98's clinical records show R98 has a history of multiple falls. R98's Minimum Data Set (MDS) dated [DATE] shows R98 had severe cognitive impairment and requires partial/moderate assistance with chair to bed to chair transfer. R98's fall care plan documents in part, resident is at risk for falls due to impaired mobility and weakness, moderate vascular dementia with mood disturbance and resident takes psychoactive medications. One of R98's fall care plan interventions initiated on 07/10/24 reads, floor mats in when resident is in bed and thick mats to extend sleeping area dated 09/07/24. R98's Fall Risk Assessment completed 09/22/24 documents in part that R98 has a grand score of 40 indicating Significant Risk for Falls. On 10/02/24 at 3:49 PM, V32 (Restorative Nurse) stated a Fall Risk Assessment is completed for every resident upon admission, quarterly and post-fall which gives a score to determine the resident's fall risk. V32 stated the score results are as follows: 0-15 minimal fall risk; 16-35 moderate fall risk; 36 or greater is significant fall risk. V32 stated all residents get a fall risk care plan upon admission, and this is updated quarterly, annually, significant change, and post fall. V32 stated the care plan interventions are updated after each fall and the interventions are specific to the resident needs. V32 stated R98 has had multiple falls and every time R98 has had a fall new intervention have been added to R98's fall care plan. V32 stated R98's fall care plan interventions should be followed to prevent R98 from falling again. On 10/01/24 at 11:20 AM, observed R98 sitting in the unit dining room eating lunch. In R98's room surveyor observed R98's bed in the lower position and locked. No floor mats or bolster pads were observed in R98's room. No floor mats or thick mats located in the bathroom, behind the door, under the bed or on the side of the wall in R98's room. R98 did not have a closet in the room. On 10/03/24 at 7:45 AM, observed R98 sitting in the unit dining room eating breakfast. Walked into R98's room. No floor mats or thick mats seen in R98's room at bedside, in bathroom, under the bed, behind the door or against the wall in R98's room. R98 did not have a closet in R98's room. On 10/03/24 at 7:50 AM, V31 (Certified Nursing Assistant/CNA) stated V31 is the CNA assigned to R98 today and V31 is familiar with R98 because V31 routinely covers the memory impaired unit where R98 lives. V31 stated the residents on this unit are very confused and require constant monitoring. V31 stated R98 has a history of falling so the staff must watch R31 all the time. V31 stated when V31 starts work at 7:00 AM, R98 is usually already out of bed and sitting in the dining room because typically the night CNA gets R98 out of bed. V31 stated sometimes V31 must get R98 out of bed at times especially if there is agency CNA covering the night shift. V31 stated, I've never seen R98 with pads on the floor or bolster pads in R98's room. V31 said, I don't believe she (R98) uses any. V31 stated R98 has no restrictions or devises used (no floor mats, no bolster pads, thick mats) when R98 is in bed. V31 stated when V31 puts R98 back to bed for a nap after lunch if R98 is willing V31 puts R98's bed in the lowest position. V31 said, I don't put mats or pads on her floor or bolsters on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145960 If continuation sheet Page 9 of 23 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 145960 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ascension Resurrection Life 7370 West Talcott Avenue Chicago, IL 60631 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 side of her (R98) bed. V31 said, no one ever told me she (R98) needs them when she (R98) is in bed. V31 stated there are other residents on the unit who require floor mats and for those residents the floor mats are kept in the room behind that resident's door when they are not in use to keep them out of the way. V31 stated R98 does not use floor mats or bolsters. V31 stated otherwise, they would be stored behind R98's door and there are not any floor mats in R98's room. Residents Affected - Few On 10/03/24 at 8:20 AM, V32 (Restorative Nurse) stated R98 is supposed to be using thick bolsters mats on both sides of R98's bed and that anytime R98 is in the bed the thick mats should be in place. V32 stated the purpose of the thick mats is to extend R98's sleeping area for R98's resident's safety to minimize R98's risk for falling. V32 stated R98 should be using the floor mats or thick bolster mats because R98 gets restless when R98 is in bed and R98 is at a higher risk for falling when R98 is in the bed. V32 stated If the thick bolster mats or floor mats are not using for R98 there is at increased risk for R98 to fall. V32 observed no floor mats or thick bolster pads in R98's room. V32 stated, maybe they are being cleaned. Facility provided policy titled, Falls dated 01/2024 which documents in part, purpose is to prevent and/or reduce the number of falls by providing an individualized, person-centered care approach with communities managing fall risk through the process of assessment, planning, implementing and evaluation and a resident's care plan is evaluated and revised based on the resident's response, outcomes, and needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145960 If continuation sheet Page 10 of 23 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 145960 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ascension Resurrection Life 7370 West Talcott Avenue Chicago, IL 60631 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) On 10/01/24 at 11:04 AM, R273 was lying in bed alert and verbally responsive. Surveyor observed R273's nebulizer machine was turned off, on top of R273's nightstand with the tubing connected and was hanging down to the floor with no date labeled and not inside a plastic bag. R273's nebulizer mask was on top of the counter sink not inside a plastic bag and no resident's name or date labeled. R273 stated R273 has Bronchitis and Pneumonia and receives nebulizing treatment three to four times a day. Residents Affected - Few On 10/03/24 at 12:33 PM, interviewed V3 (Former Director of Nursing/Registered Nurse Supervisor) and stated nebulizer tubing and mask should be placed inside a plastic bag with the resident's name and date when not in used. R273's clinical records show R273 was re-admitted in the facility on 9/19/24 with diagnoses included but not limited to Pneumonitis, Acute Respiratory Failure, and Anemia. R273's Minimum Data Set, dated [DATE] shows R273 is cognitively intact. R273's physician orders show R273 is receiving nebulizing treatment every shift. The facility's policy titled; Administering Medications Through a Small Volume (Handheld) Nebulizer dated 1/24 reads in part: E. When treatment is complete, turn off nebulizer and disconnect T-piece, mouthpiece and medication cup. H. Rinse and disinfect the nebulizer equipment according to manufacturer's guidelines. J. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. K. change equipment and tubing every seven days, or according to community protocol. Based on observation, interview and record review the facility failed to follow their policy and procedure to ensure a.) oxygen equipment was dated and changed weekly, b.) physician orders for oxygen administration rate were followed, c.) nebulizer equipment was stored in a plastic bag with the resident's name and date on it when not in use. These failures have the potential to affect two (R9, R273) of eight residents reviewed for respiratory care in a total sample of 26. Findings include: 1.) On 10/01/24 at 12:20 PM, observed R9 lying in bed with oxygen infusing via nasal canula and oxygen concentrator set between 3-4 liters per minute. The humidifier bottle was not dated. The oxygen tubing had a bright orange label which documented, Change Sunday 09/22/24 at 6AM On 10/01/24 at 12:26 PM, V6 (Registered Nurse/RN) looked up R9's oxygen order in R9's paper medical record and stated R9's physician order is for R9 to receive 2 liters per minute continuously via nasal canula. V6 stated the oxygen infusion rate is checked every shift by the nurse on duty. V6 stated R9 cannot adjust the rate because R9 is bed bound, and R9 cannot reach it. On 10/01/24 at 12:29 PM, V6 observed R9's oxygen concentrator and said, it is set at 3.5L/minute. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145960 If continuation sheet Page 11 of 23 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 145960 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ascension Resurrection Life 7370 West Talcott Avenue Chicago, IL 60631 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 0695 Level of Harm - Minimal harm or potential for actual harm V6 said, I'm going to decrease the rate to 2 liters because that is what the order is for. V6 looked at the bright orange label on the R9's oxygen tubing and stated the tubing was changed 09/22/24 at 6 AM. V6 stated it is the night shift who is responsible for changing the oxygen tubing. V6 stated V6 does not know how often the oxygen tubing is changed. V6 looked at R9's humidifier bottle and stated the humidifier bottle should be dated but it is not. Residents Affected - Few On 10/02/24 at 5:10 PM, V3 (Former Director of Nursing/Registered Nurse Supervisor) stated the oxygen infusion rate should match the physician orders and it is the nursing staff's responsibility to check the infusion rate when they make their round and pass out medication. V3 stated the oxygen tubing should be changed every Saturday by the night shift (11-7). V3 stated the oxygen tubing should be changed weekly for sanitation and infection control reasons. V3 stated the humidifier bottle should be dated when a new bottle is placed. V3 stated whether the oxygen tubing was change on 09/22/24 or was due to be changed on 09/22/24 it was still late because it should have been changed 09/28/24 or 09/29/24. R9 has diagnosis which includes but not limited to Unspecified Dementia, Moderate with Anxiety, Senile Degeneration of Brain, Anemia, Neuromuscular Dysfunction of Bladder, Adjustment Disorder with Mixed Anxiety and Depressed Mood, Retention of Urine, Dependence of Supplemental Oxygen, Pressure Ulcer of Sacral Region Stage 3. R9 admitted to hospice 08/02/24 with diagnosis Senile Degeneration of Brain. R9's Physician Orders October 2024 documented in part, change oxygen tubing and humidifier bottle weekly dated 12/01/23 and oxygen at 2 liters via nasal cannula continuously dated 09/05/23. R9's MDS (Minimum Data Set) from 09/04/24 BIMS (Brief Interview for Mental Status) score is 2 out of 15 indicating severely impaired cognition and R9's uses oxygen therapy and under hospice care. R9's nursing care plan dated 05/27/24 documents in part R9 requires oxygen therapy due to chronic hypoxic respiratory failure and history of pulmonary embolism and interventions include but not limited to administer R9's oxygen as ordered and change R9's tubing per protocol. Facility provided policy titled, Oxygen Administration dated 12/2022 documents in part, review the physician's orders for oxygen administration, adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered and label and date the humidifier bottle and oxygen tubing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145960 If continuation sheet Page 12 of 23 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 145960 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ascension Resurrection Life 7370 West Talcott Avenue Chicago, IL 60631 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to ensure that a resident (R221) was free of any significant medication errors for one out of five residents reviewed for medication administration. Residents Affected - Few Findings include: R221's Face Sheet and Physician Orders document in part a medical diagnosis of Essential (primary) hypertension (high blood pressure). R221's Care Plan documents in part a Potential for alteration in blood pressure related to diagnosis of hypertension (Problem onset: 09/26/2024). Approaches include Medications as ordered and monitor for side effects. On 10/01/2024 at 8:54 AM, V28 (Agency Registered Nurse) prepared R221's morning medications. Surveyor observed V28 prepare Apixaban (Eliquis), Furosemide, and Carvedilol for R221. At 9:12 AM, R221 took the oral pills. At 9:14 AM, V28 stated [V28] completed R221's medication pass and continued to R87's room. Surveyor reviewed R221's October 2024 eMAR (Electronic Medication Administration Record). It documents in part a 9:00 AM dose for Losartan Potassium 25 MG (milligram) one tablet by mouth. V28 did not administer it during 10/01/2024 observations and did not sign it off on the eMAR as given. Losartan drug class is an Angiotensin receptor blockers and is used to treat high blood pressure. On 10/03/2024 at 8:28 AM, V3 (Former Director of Nursing/Registered Nurse Supervisor) acknowledged that R221 has an active order for Losartan and V28 didn't sign it off on the eMAR. V3 stated it was a missed dose. Facility's Medication Administration Schedule policy (last approved 09/2023) documents in part: Medications shall be administered according to established schedules and per resident preference, as appropriate. The nursing associates will administer according to the order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145960 If continuation sheet Page 13 of 23 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 145960 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ascension Resurrection Life 7370 West Talcott Avenue Chicago, IL 60631 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, interviews, and record reviews, the facility failed to dispose eye drops after the discard date, refrigerate an unopened insulin pen, and lock a medication cart when not in use or in view for two out of four carts reviewed for medication storage and labeling. The facility also failed to properly dispose of R76's controlled medication after opening and failed to ensure controlled medications for R64 were under a double lock for 1 of 4 medication carts and 1 of 2 medication rooms reviewed for medication storage and labeling. Findings include: 1.) On 10/01/2024 at 2:14 PM, surveyor reviewed the medication cart designated for the intermediate and memory-impaired units with V6 (Registered Nurse). There was a bottle of Systane Gel Eye Drops for R44. The written open date was 8/28 and the written discard date was 9/28. V6 stated V6 did not notice the discard date that morning. V6 stated staff should have tossed the medication and V6 will reorder it. R44's Physician Orders document in part Systane Gel Eye Drops place one (1) drop into both eyes twice a day. 2.) In the same medication cart, there was an unopened Levemir (insulin) Flexpen 100 units for R19. The label on the packaging reads to refrigerate until use. V6 stated the Levemir Flexpen was unopened and should have been in the fridge. R19's Physician Orders document in part an order for Levemir Flexpen 100 unit/milliliter give 25 units subcutaneously every morning for Type 2 Diabetes Mellitus. 3.) On 10/02/2024 at 8:55 AM, surveyor observed V29 (Registered Nurse) prepare medications for R173. At 9:06 AM, V29 entered R173's room with the prepared medications and closed the bedroom door leaving the medication cart in the hallway unlocked and unsupervised. R173 took the medications at 9:08 AM. At 9:10 AM, V29 and surveyor exited the room. The medication cart remained unlocked. V29 stated there were medications for 11 residents on the cart. Facility's Storage of Medications policy (last approved 01/2024) documents in part: The community shall store all drugs and biologicals in a safe, secure, and orderly manner. The nursing associates shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner. The community shall not use discontinued, outdated, or deteriorated drugs or biologicals. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport suck items shall not be left unattended if open or otherwise potentially available to others. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Facility's Discarding and Destroying Medications policy (last approved 01/2024) documents in part: Medications will be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances. 4.) R76's Physician Orders documented in part an order for Tramadol Hydrochloride 50 MG (milligram) tablet take one tablet by mouth every six hours as needed for pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145960 If continuation sheet Page 14 of 23 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 145960 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ascension Resurrection Life 7370 West Talcott Avenue Chicago, IL 60631 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some According to the Drug Enforcement Administration - Diversion Control Division, Tramadol is a Schedule IV controlled substance. On 10/01/2024 at 2:37 PM, surveyor reviewed the controlled medications bin in the medication cart with V27 (Registered Nurse). R76's Tramadol 50 MG blister pack had nine pills. The ninth pill slot was torn and taped over. V27 stated V27 didn't know who did that or why they did it. V27 stated the nurse was supposed to discard the pill once it was opened. On 10/03/2024 at 8:28 AM, V3 (former Director of Nursing/Registered Nurse Supervisor) stated R76's Tramadol should have been disposed of after the nurse broke the seal. V3 stated the nurse should have disposed the controlled medication with another nurse as witness. 5.) On 10/01/2024 at 9:20 AM, V5 (Certified Nursing Assistant) entered the utility room to retrieve ice water. On 10/01/2024 at 3:14 PM, V28 (Agency Registered Nurse) let surveyor into the first-floor utility room. Other non-nurse staff such as V5 entered the utility room multiple times earlier in the day. Inside the room there was a locked refrigerator designated for medications. In the refrigerator there were two bags of controlled medications for R64. The first bag had 20 prefilled syringes of Lorazepam (antianxiety medication) and the second bag had 10 prefilled syringes of Lorazepam. These two bags were with the other medications (vaccinations and insulins) in the fridge and not in another designated locked area. R64's Physician Orders document in part that R64 was taking the medication for anxiety and nausea. According to the Drug Enforcement Administration - Diversion Control Division, Lorazepam is a Schedule IV controlled substance. On 10/01/2024 at 2:48 PM, V4 (Infection Preventionist) and V27 (Registered Nurse) stated controlled medications should be under double lock. On 10/03/2024 at 8:28 AM, V3 stated facility had to order lockboxes for the controlled medications in the fridge. V3 stated the controlled medications are now under double lock. Facility's Controlled Substances policy (last approved 06/2022) documents in part: The community shall comply with laws, regulations, and other requirements related to handling, storage, disposal, and documentation of schedule II-V and other controlled substances. Controlled substances must be stored in the locked medication room or medication cart in a locked container, separate from containers for any non-controlled medications. Unless otherwise instructed by the Director of Nursing Services, when a resident refuses a non-unit dose medication (or it is not given), or a resident receives partial tablets or single dose ampules (or it is not given), the medication shall be destroyed and may not be returned to the container. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145960 If continuation sheet Page 15 of 23 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 145960 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ascension Resurrection Life 7370 West Talcott Avenue Chicago, IL 60631 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview and record review, the facility failed to serve mechanical soft food to a resident on mechanical soft diet order. This failure affected 1 (R19) of 4 residents reviewed for mechanical soft diet prepared in the facility's kitchen, in a total sample of 26 residents. Findings Include: On 10/01/24 at 11:26 AM, observed R19 eating in the unit dining room. R19 had a large plate of salad with raw Romaine lettuce, tomato wedges, chopped hardboiled egg, bacon pieces and chunks of chicken. Observed R19 putting a piece of lettuce and bacon in R19's mouth and then using R19's fingers to take the lettuce and bacon back out of R19's mouth and placing the semi chewed lettuce and bacon on the side of R19's plate. Observed R19's meal ticket which read Mechanical Soft, CCD (Controlled Carbohydrate Diet) and pink piece of paper titled, Food Substitution Request for lunch checked Alternative Menu and the words mech handwritten on the bottom of the form. On 10/01/24 at 11:32 AM, V10 (Activity Aide) observed the large salad plate in front of R19 and stated R19 usually gets ground food not regular like that. On 10/01/24 at 11:34 AM, V13 (Registered Dietitian) stated residents on mechanical soft diets receive ground meats, no raw vegetables. V13 stated most residents on a mechanical soft diet have difficulty chewing and/or swallowing and if a resident on a mechanical soft diet received a regular diet texture there is a risk that resident could cough and choke and aspirate the food meaning the food goes into their lungs instead of down their esophagus. V13 stated the ground diets today received ground meatloaf as their main entrée and the menu alternative for regular diets is Barbeque Chicken Salad. V13 observed R19's large plate of salad and stated that is what the regular diet consistencies were given as a menu alternative. V13 stated R19 requested the alternative entrée which was the Barbeque Chicken Salad but V13 stated R19 should not have received that Barbeque Chicken Salad because the meat is not ground, and it contains raw vegetables which are not allowed on a mechanical soft diet. V13 said, it was a mistake. V13 stated mechanical soft diets never receive raw vegetables like salad because they are too difficult to chew. On 10/01/24 at 11:38 AM, observed V11 (Dining Services Director) remove the large salad plate from R19. Observed piles of semi chewed pieces of lettuce and bacon in a pile on the side of R19's plate. On 10/02/24 at 11:10 AM, V11 stated on 10/01/24 at lunch the alternative option to meatloaf was ground chicken salad for residents on a mechanical soft diet. V11 stated the mechanical soft diets should not have received the regular Barbeque Chopped Chicken salad because they are not supposed to get lettuce and tomato wedges and the chicken was not ground. V11 stated, R19 receiving the regular Barbeque salad was a mistake, and that R19 should have received ground chicken salad instead. R19's diagnoses includes but not limited to Unspecified Dementia, Type II Diabetes Mellitus, Hyperlipidemia, Hypertension, Major Depressive Disorder, Weakness, Unsteadiness on Feet. R19's Physician Orders October 2024 documents in part, Controlled Carbohydrate Diet, Mechanical Soft Texture with Thin Liquids order date 10/20/21. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145960 If continuation sheet Page 16 of 23 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 145960 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ascension Resurrection Life 7370 West Talcott Avenue Chicago, IL 60631 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R19's MDS (Minimum Data Sheet) dated 08/26/24 documents in part, BIMS (Brief Interview for Mental Status) 3 out of 15 indicating severe cognitive impairment, and nutritional approaches include mechanically altered diet. R19's nutrition care plan documents in part, R19 follows a CCD (Carbohydrate Controlled Diet, mechanical soft texture with thin liquids, goal is no chewing or swallowing difficulties and interventions includes to provide diet as ordered: CCD, mechanical soft with thin liquids. R19's meal ticket dated Tuesday, 10/01/24 documents in part Mech (Mechanical Soft), CCD (Carbohydrate Controlled Diet) with a pink slip titled, Food Substitution Request with Alternate Menu checked. Facility Diet Spreadsheet for Tuesday, 10/01/24 documents mechanical soft diet alternative for lunch to be Basic Chicken Salad. Facility policy titled Liberalized Diet List undated documents in part, always follow the diet spreadsheet to know what is appropriate to serve for each diet, we honor the resident's individual food preferences but still have to serve the correct consistency and for mechanical soft no fresh fruit or vegetables, nothing hard to chew, meats are ground with a gravy or sauce over the top to ease chewing, ground food must be processed using the food processor to ensure the right consistency is achieved. Ground means ground, not chopped. Kitchen policy titled, Diet Orders and Other Resident Information dated 01/24 documents in part, the food and nutrition department plans and serves meals based on approved diet list and diet extensions/spreadsheets. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145960 If continuation sheet Page 17 of 23 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 145960 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ascension Resurrection Life 7370 West Talcott Avenue Chicago, IL 60631 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record reviews, the facility failed to a.) ensure all food items were labeled with an opened and use by date, b.) discard expired food based on use by date documented on label, c.) follow manufacturer guidelines for storage. These failures have the potential to affect all 132 residents receiving food prepared in the facility's kitchen. Findings include: On 10/01/24 at 9:12 AM, V11 (Dining Services Director/Certified Dietary Manager) stated all items are marked with a received by label which contain the date the item was delivered. V11 stated the kitchen uses a label machine to generate label stickers to put on all prepared or opened refrigerated items and opened non-refrigerated food items. The label stickers generated by the label machine has an area to write in the name of the product, the opened date (today's date) and the use by date or expiration date (Good Thru). V11 stated the use by or best by dates vary depending on what the product is. V11 stated the kitchen staff should be making sure all food items are labeled and that they are discarding any items past their use by, or expiration date based on the date written on the label stickers to keep the resident's safe. On 10/01/24 at 9:24 AM, observed in the Walk-In Refrigerator the following items: 1.) Two containers of prepared mashed potatoes with a label sticker documenting today's date 09/27/24 and good thru 09/30/24. V11 stated the mashed potatoes were left over and should have been discarded on 09/30/24. 2.) A small bowl of cooked oatmeal with a label sticker documenting product as grain and today's date 09/27/24 and good thru 03/26/25. V11 stated the person who filled out the label using the label machine incorrectly labeled the item which is why the good thru date was wrong. V11 stated the good thru or used by date should have been 09/30/24 which means the items should have been thrown out 09/30/24. On 10/01/24 at 9:35 AM, observed in [NAME] Prep Area/Spice Rack the following item: 1.) An opened two-quart container of Low Sodium Soy Sauce labeled with a label sticker documenting today's date 03/27/24 and good thru date 09/27/24. Observed on the back of the product manufacturer printed on label Refrigerate After Opening. V11 stated the item should have been discarded on or before 09/27/24 based on the good thru date written on the label sticker. V11 stated to V12 (Chef Manager) it says on the label that it should be refrigerated after opening. V12 read the manufacturer label and said, yes, this should have been refrigerated. On 10/01/24 at 9:39 AM, observed in Dry Storage Room the following items: 1.) A large bin of panko breadcrumbs labeled with label sticker documenting today's date 03/12/24 and good thru 09/12/24.V11 observed the label and stated that needs to be switched out. It is expired based on the label. 2.) An opened 25-pound bag of pearled barley with no label on it. V11 stated the pearled barley should have a label on it with an opened and expiration date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145960 If continuation sheet Page 18 of 23 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 145960 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ascension Resurrection Life 7370 West Talcott Avenue Chicago, IL 60631 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm 3.) A opened 25-pound bag of dried milk labeled with a label sticker documenting today's date 01/29/24 and good thru 09/28/24. V11 stated the label expired so the item will be thrown out. Facility provided document titled, Resident Listing Report with report date 10/10/24 listing 132 residents with their diet orders. Residents Affected - Many Facility provided document titled, Patients Who Are NPO undated with one resident's name listed. Facility provided policy titled Food and Supply Storage dated 1/24 which documents in part, 1.) All food, non-food items, and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and the wholesomeness of the food for human consumption. 2.) Cover, label and date unused portions and open packages. Complete all section on the orange labeling system. Products are food through the close of business on the date noted on the label. 3.) Discard food past the use by date or expiration date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145960 If continuation sheet Page 19 of 23 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 145960 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ascension Resurrection Life 7370 West Talcott Avenue Chicago, IL 60631 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 observations, interviews, and record reviews, the facility failed to a.) follow their policies by not wearing the appropriate Personal Protective Equipment (PPE) for residents on Enhanced Barrier Precautions (EBP) during high-contact resident care activities for 4 (R8, R28, R54, R223) residents and b.) handle and contain soiled linen during linen changing and transport. These failures have the potential to affect all residents residing on the first floor and second floor units. Residents Affected - Some Findings Include: 1.) R28 has diagnosis not limited to Acute Embolism and Thrombosis of Femoral Vein, Bilateral, Localized Edema, Polyneuropathy, Unsteadiness on feet, Mature T/NK-Cell Lymphoma, Muscle Spasm, Thrombocytopenia and Heart failure. R28's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. Physician Order dated 09/06/24 document in part: Enhanced Barrier Precaution due to wound. Care Plan Document in part: Place (EBP) Enhance Barrier Precaution signage and PPE (Personal Protective Equipment) supplies at entrance to resident room. R28 is incontinent of bladder. On 10/01/24 at 12:09 PM surveyor entered R28 room with signage posted on the door indicating Enhanced Barrier Precautions and observed bed linen, a blue pad, and a gown on the floor in front of the sink near the entrance door. R28 was observed sitting in a wheelchair at the bedside. The surveyor asked R28 who placed the linen on the floor. R28 responded, the certified nurse assistant left all of that junk on the floor since I got up about 10:30 AM. On 10/01/24 at 12:12 PM the surveyor asked R28 if it would be alright to press the call light. R28 agreed. At 12:13 PM V18 (Certified Nurse Assistant/CNA) entered R28 room. The surveyor asked V18 was there a reason the linen was on the floor. V18 responded, I was going to get back to it. I will take care of it now. V18 retrieved a pair of gloves from the glove box on the wall then exited R28's room. V18 returned to R28 with a linen hamper, put on the pair of gloves then began picking up the bed linen, blue pad and gown from the floor placing them in the linen hamper. V18 then exited the room with the hamper. The surveyor asked R28 did V18 wear a gown when she was providing his care. R28 responded, No, V18 did not wear a gown. On 10/01/24 at 12:15 PM V18 (CNA) stated I changed R28 bed and brief then had to put someone else on the toilet. I was going to come back to it. Surveyor asked V18 did she wear PPE (Personal Protective Equipment) when she (V18) provided R28's care. V18 responded, Yes, I wore gloves. I toileted and changed R28's brief. Surveyor made V18 aware of the Enhanced Barrier Precaution was posted on R28's door that indicates Everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: wear gloves and a gown for the following high-contact resident care activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, changing briefs or assisting with toileting, Device care or use: intravenous line, urinary catheter, ostomy, feeding tube, & tracheostomy. Wound Care: any skin opening requiring a dressing. V18 stated I should have worn a gown. On 10/02/24 at 10:56 AM V4 (Infection Preventionist) stated when a resident is on EBP (Enhanced Barrier Precautions) the type of PPE (Personal Protective Equipment) that should be worn are gloves and a gown for any high contact. Including: Any time you are close to someone with an indwelling (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145960 If continuation sheet Page 20 of 23 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 145960 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ascension Resurrection Life 7370 West Talcott Avenue Chicago, IL 60631 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some medical device that sticks on the outside of the body and goes inside the body. PICC (Peripherally Inserted Central Catheter) lines and Midlines but peripheral IV (intravenous) are not. During patient care, transferring, helping cleanup, bathroom, showering, linen change, during wound care, gastric tube and manipulating the indwelling medical device you need to wear a gown and gloves. It depends if there is an MDRO or not they are more susceptible, and we are to protect the resident. If a resident has an MDRO Enhanced Barrier Precautions is more to prevent the spread of MDRO's in nursing homes. If the linen is to be removed and if it was unexpected, we have extra clear bags. The linen should not have been put on the floor because if there is an infection it is on the floor. That is just a standard of nursing care. She should have worn gloves and gown when caring for the resident on Enhanced Barrier Precautions and not just gloves. When doing wound care, a gown and gloves should be worn. On 10/04/24 V1 (Administrator) emailed an (EBP) Enhance Barrier Precaution In-service with a list of staff names and signatures but no specific topics that were covered. Policy: Titled Enhanced Barrier Precautions Last Revised 03/24 document in part: EBP (Enhanced Barrier Precautions) in addition to Standard and Contact Precautions, shall be implemented during high-contact resident care activities when caring for residents that have an increased risk for acquiring and/or transmitting a multidrug-resistant organism (MDRO) such as a resident with wounds, indwelling medical devices and residents with colonization with an MDRO. Purpose: to prevent opportunities for the transfer of MDRO's to associate's hands and clothing during care. 1. Enhanced Barrier precautions (EBP) are an infection control intervention designed to reduce transmission if resistant organisms that employs targeted gown and gloves use during high contact resident care activities when contact precautions do not otherwise apply. 2. EBP are indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status. 4. Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing. 5. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions Include: 1. Dressing. 2. Bathing/showering. 3. Transferring. 4. Providing Hygiene. 5. Changing linens. 6. Changing briefs or assisting with toileting. 8. Wound care. Titled Environmental Services - Laundry and Linen last approved 01/24 document in part: The purpose of this policy is to provide a process for the safe and aseptic handling, washing and storage of linen. Standard Precautions: C. Consider all soiled linen to be potentially infectious and handle with standard precautions. Transmission - Based Precautions: A> If a resident is placed in Transmission-Based Precautions linen will be handled, stored, and transported to prevent the spread of infection, by use of appropriate personal protective equipment. Bagging and Handling Soiled Linen: A. Soiled linen should be placed directly into a covered laundry hamper which can contain the moisture. C. Place any linen saturated with blood or body fluids into a leak-resistant bag before placing it into the hamper. Titled Infection Prevention and Control Program review 04/24 document in part: 4. The (IPCP) Infection Prevention and Control Program is designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Titled Standard Precautions last approved 01/24 document in part: B. Standard Precautions shall (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145960 If continuation sheet Page 21 of 23 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 145960 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ascension Resurrection Life 7370 West Talcott Avenue Chicago, IL 60631 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some apply to the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. B. Gloves 2. Gloves are worn when in direct contact with a resident who is infected or colonized with organisms that are transmitted by direct contact. D. Gowns 1. Wear a gown (clean, non-sterile) to protect skin and prevent soiling of clothing during procedures and resident care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions or causing soiling of clothing. G. Linen: 1. Linen soiled with blood, body fluids, secretions, excretions are handled and processed in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and avoids transfer of microorganisms to other residents and environment. Titled Transmission Based Precautions reviewed 04/24 document in part: Standard Precautions: Standard Precautions include hand hygiene, environmental cleaning and disinfection, risk assessment with use of appropriate personal protective equipment (PPE) based on activities being performed, injection and medication safety, and proper handling of sharps and linens. 1. Gloves - worn when contact with blood, or other potentially infectious materials, mucous membranes, in-intact skin, potentially contaminated skin, or contaminated equipment could occur. 2. Gowns - worn during procedures and resident care activities when HCP (Health Care Provider) uniform or clothing may contact blood/body fluids, secretions, and excretions. 7. Proper Handling of Linens - Handled in a manner that prevents transfer of microorganisms to others and to the environment; soiled linen is contained. 2.) R223 is a resident of the facility. R223's Face Sheet and Physician Orders document in part a medical diagnosis of cellulitis of the left lower limb. R223's Physician Orders document in part an order for Enhanced Barrier Precautions due to [urinary] catheter and wounds (start date 9/25/2024). R223's Care Plan documents in part that R223 is at risk for acquiring or transmitting infection due to the indwelling urinary catheter and wound to the left foot (onset 9/24/2024). Approaches include to Follow established infection prevention protocol including Enhanced Barrier Precautions and Staff to wear gowns and gloves for high contact resident care. On 10/01/2024 at 12:09 PM, there was an Enhanced Barrier Precautions (EBP) sign posted on R223's door. It documented in part to wear gown and gloves when changing linen and providing hygiene. At 12:10 PM, V23 (Agency Nurse) and V24 (Contracted CNA) were in the room with R223. V23 and V24 did not don gowns. At 12:13 PM, V24 left R223's room to get an incontinence pad. V24 stated they were changing R223. V23 was in the room emptying a urinal into the bathroom. V23 wore gloves but did not have a gown on. At 12:14 PM, V24 returned to R223's room. V24 grabbed gloves from the PPE (Personal Protective Equipment) bin outside of R223's room but did not don a gown. At 12:21 PM, V23 exited R223's room carrying a soiled incontinence pad with gloved hand. It was not contained in a bag. V23 carried the soiled incontinence pad down the hall and deposited it in a soiled linen hamper outside of R31's room. At 12:25 PM, V24 did not know why R223 was on EBP. V24 stated R223 was on basic precautions. V24 stated V23 and [V24] did not wear a gown during R223's care. 3.) On 10/1/24 at 11:14 AM, R8 was lying in bed and noted an Enhanced Barrier Precautions signage posted on R8's door. V5 (CNA) was interviewed and stated V5 was assigned to R8 and was about to dress and get R8 up. V5 stated V5 helps answering call lights for all first-floor residents and helps cover other residents when other CNAs go on break. At 11:21 AM, Surveyor observed V5 provided (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145960 If continuation sheet Page 22 of 23 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 145960 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ascension Resurrection Life 7370 West Talcott Avenue Chicago, IL 60631 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 incontinence care to R8 without proper PPE. V5 wore gloves but did not wear the isolation gown. Level of Harm - Minimal harm or potential for actual harm R8's clinical records show a physician order of Enhanced Barrier Precautions (start date 7/1/24). R8's care plan shows R8 is on Enhanced Barrier Precautions due to colonization with Multidrug-Resistant Organism (MDRO), Vancomycin-Resistant Enterococci (VRE) in urine. Residents Affected - Some 4.) On 10/2/24 at 9:24 AM, R54 was lying in bed and an Enhanced Barrier Precautions signage posted on R54's door. At approximately 9:32 AM, Surveyor observed V3 (Former Director of Nursing/Registered Nurse Supervisor) performed wound treatment for R54 without wearing proper PPE. V3 wore gloves but did not wear the isolation gown. V3 stated R54 has stage 2 sacral pressure ulcer with daily wound treatment. V3 stated she is helping the facility today with troubleshooting dealing with families and other issues that will arise. R54's clinical records show a physician order of Enhanced Barrier Precautions (start date 7/26/24). R54's care plan shows R54 is on Enhanced Barrier Precautions due to wound. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145960 If continuation sheet Page 23 of 23