Inspection·October 19, 2023

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some were long, jagged with black substances underneath. R73 stated that he wanted the staff to trim and clean his fingernails. V2 was present during the observation and heard R73's request. V2 acknowledged that R73's fingernails needed trimming and cleaning. R73's active care plan initiated on September 6, 2022 showed multiple interventions under personal care including, Hygiene x 1 staff. 3. R6 had multiple diagnoses including dementia with other behavioral disturbance, based on the face sheet. R6's quarterly MDS dated [DATE] showed that the resident was severely impaired with cognition and required extensive assistance from the staff with regards to personal hygiene. On October 16, 2023 at 12:02 PM, R6 was sitting in her wheelchair inside the unit dining room. R6 was alert and verbally responsive. R6's fingernails were long and with black substances underneath. R6 was asked if she wanted the staff to trim and clean her fingernails. R6 responded, yes. On October 17, 2023 at 10:42 AM, R6 was sitting in her wheelchair inside the unit dining room. R6 was alert and verbally responsive. R6's fingernails were long with black substances underneath. In the presence of V2, R6 stated that she wanted the staff to trim and clean her fingernails. During the observation, V2 acknowledged that R6's fingernails needed trimming and cleaning. R6's active care plan initiated on September 6, 2022 showed that the resident had ADL self-care deficit. The same care plan showed multiple interventions including, Hygiene: Extensive x 1 staff. 4. R65 had multiple diagnoses including dementia with other behavioral disturbance, generalized muscle weakness and cognitive communication deficit, based on the face sheet. R65's quarterly MDS dated [DATE] showed that the resident was severely impaired with regards to cognitive skills for daily decision making. The same MDS showed that R65 required extensive assistance from the staff with regards to personal hygiene. On October 16, 2023 at 10:50 AM, R65 was in bed, alert, verbally responsive but confused. R65's fingernails were long, jagged with black substances underneath. On October 17, 2023 at 10:44 AM, R65 was sitting in her wheelchair inside the unit nursing station. R65 was alert, verbally responsive at times but confused. R65's fingernails were long, jagged with black substances underneath. V2 was present during the observation and acknowledged that R65's fingernails needed to be trimmed and cleaned. R65's active care plan initiated on January 5, 2023 showed that the resident had ADL self-care deficit. The same care plan showed multiple interventions including, Hygiene: Extensive x 1 staff. On October 17, 2023 at 11:00 AM, V2 (Director of Nursing) stated that it is part of the nursing care and service to provide assistance to all residents needing assistance with trimming and cleaning of fingernails to ensure and maintain good hygiene and grooming. 5. R12's diagnoses on face sheet included encounter for palliative care, type 2 diabetes mellitus without complications, muscle weakness (generalized), gout. R12's Annual MDS dated [DATE] showed that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146029 If continuation sheet Page 2 of 16 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 146029 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Village 1270 Franciscan Drive Lemont, IL 60439 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 R12 was cognitively intact and required extensive one person assistance in personal hygiene. Level of Harm - Minimal harm or potential for actual harm R12's care plan initiated August 16, 2023, included that R12 is at risk for/has impairment skin integrity related to aged/fragile skin, incontinence, weakness, decrease mobility/ADL (activities of daily living) function, Candidiasis rash of diaper Area. Interventions for the same showed to avoid scratching and keep hands and body parts from excessive moisture, keep fingernails short, keep skin clean and dry, use lotion on dry skin. Residents Affected - Some On October 16, 2023, at 11:23 AM, R12 was lying in bed and had blackish substance under some nails with few of them jagged and or long. R12 was also noted to have scratch marks on arms with very dry flaky skin. R12 stated My skin is dry. They put a lotion on at times. On October 17, 2023 at 2:55 PM, V2 (Director of Nursing) was notified of the same. On October 18, 2023, at 9:18 AM, R12 was lying in bed and still noted had jagged nails with blackish substance underneath some of the nails. This was relayed to V18 (Licensed Practical Nurse) who acknowledged that R12's nails should be trimmed and stated that R12 has very dry skin and staff are to apply the anti-itch lotion (Camphor 0.5% Methanol) for the itchiness and dryness. 6. R22's face sheet included diagnoses of aphasia, mixed receptive-expressive language disorder, other lack of coordination, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R22's quarterly MDS dated [DATE], showed that R22 was severely impaired in cognition and required extensive one person assistance in personal hygiene. R22's care plan included that R22 is at risk for Self-Care Deficit and interventions included to provide assistance with ADLs as needed. On October 16, 2023 at 11:58 AM, R22 was in the dining room and noted to have several very long facial (upper lip) hair. R22 did not respond to queries. V12 (Certified Nursing Assistant, CNA) who was in the area stated that R22 needs assistance with grooming. V12 was notified about the presence of the long facial hair and V12 stated I will tell the CNA that takes care of her. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146029 If continuation sheet Page 3 of 16 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 146029 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Village 1270 Franciscan Drive Lemont, IL 60439 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to assess and provide supportive device to residents, to prevent further reduction in ROM (range of motion). This applies to 2 of 6 residents (R65 and R81) reviewed for range of motion in the sample of 21. The findings include: 1. R81 had multiple diagnoses including acquired absence of left hand, generalized muscle weakness and aphasia, based on the face sheet. R81's quarterly MDS (minimum data set) dated September 20, 2023 showed that the resident was severely impaired with cognition and required extensive to total assistance from the staff with regards to his ADLs (activities of daily living). On October 16, 2023 at 11:15 AM, R81 was in bed, alert, verbally responsive but confused. R81's right index, middle, ring and small fingers were deformed. R81 was not able to extend the mentioned right hand fingers and the right hand index, middle, ring and small fingers were in a clenched position. No supportive device was on R81's right hand to position the fingers, to prevent the clenching position. On October 17, 2023 at 10:40 AM, R81 was sitting in his wheelchair inside his room. R81 was alert and verbally responsive. R81's right index, middle, ring and small fingers were deformed and in a clenched position. R81 was not able to extend the above mentioned right hand fingers. No supportive device was on R81's right hand to position the fingers to prevent the clenching position. V2 (Director of Nursing) who was present during the observation was prompted to request the therapy department to screen and/or evaluate R81's right hand fingers. On October 18, 2023 at 12:30 PM, V16 (Occupational Therapist) stated that she had screened R81 on October 17, 2023 per facility request. V16 stated that during the screening of R81, four of R81's right hand fingers were deformed. V16 stated that the deformities were called, swan neck which involves the curving of the fingers from the joint. According to V16, R81's right hand fingers were in a constant clenched position due to the deformities. V16 stated that occupational therapy services were not recommended for R81, but she provided a palm protector for the resident to be applied by the staff on the resident's right hand to protect the skin on the palm area, for comfort and to use as a positioning/supportive device for sensory input to prevent R81's right hand fingers from constantly being in a clenched position. R81's order details dated October 18, 23 showed that the physician ordered to apply, Palm protector to right hand daily. May remove for hygiene and skin check. Every shift for right hand palm protector check palm protector on and in place. This order was obtained after the prompted therapy screening made on October 17, 2023. 2. R65 had multiple diagnoses including dementia with other behavioral disturbance, generalized muscle weakness and cognitive communication deficit, based on the face sheet. R65's quarterly MDS dated [DATE] showed that the resident was severely impaired with regards to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146029 If continuation sheet Page 4 of 16 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 146029 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Village 1270 Franciscan Drive Lemont, IL 60439 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cognitive skills for daily decision making. The same MDS showed that R65 required extensive assistance from the staff with most of her ADLs. On October 16, 2023 at 10:50 AM, R65 was in bed, alert, verbally responsive but confused. R65's left middle finger was in a clenched position and the resident could not extend her left middle finger. No supportive device was on R65's left hand to position the middle finger to prevent the clenching position of the left middle finger. On October 17, 2023 at 10:53 AM, R65 was sitting in her wheelchair inside her room. R65 was alert, verbally responsive at times but confused. R65's left middle finger was in a clenched position and the resident could not extend her left middle finger. No supportive device was on R65's left hand to position the middle finger to prevent the clenching position of the left middle finger. V2 who was present during the observation was prompted to request the therapy department to screen and/or evaluate R65's left middle finger. On October 18, 2023 at 9:11 AM, R65 was sleeping in bed. R65 had a palm protector on her right hand. V17 (Wound Care Nurse) was present during the observation and commented that the palm protector should be on the left hand. On October 18, 2023 at 12:21 PM, V16 stated that she had screened R65 on October 17, 2023 per facility request. V16 stated that during the screening of R65, the resident's left hand middle finger was in a clenched like position. According to V16, during the screening R65 did not allow her to touch her left middle finger, possibly due to pain whenever it is extended. V16 stated that occupational therapy services were not recommended for R65, but she provided a palm protector for the resident to be applied by the staff on the resident's left hand to protect the skin on the palm area, to use as a positioning/supportive device to prevent R65's left middle finger from constantly being in a clenched position and for comfort. R65's order details dated October 18, 23 showed that the physician ordered to apply, Palm protector to left hand daily. May remove for hygiene and skin check. Every shift for left hand palm protector check palm protector is on and in place. This order was obtained after the prompted therapy screening made on October 17, 2023. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146029 If continuation sheet Page 5 of 16 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 146029 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Village 1270 Franciscan Drive Lemont, IL 60439 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident received medication to treat hemorrhoidal pain. This applies to 1 of 1 resident (R44) reviewed for pain in a sample of 21. Residents Affected - Few The findings include: R44's face sheet documents a [AGE] year old female with diagnoses including Hypertension, Respiratory Failure, and unspecified Sciatica. R44's order summary report showed a physician's order to administer Preparation H External Cream 1% (hydrocortisone topical) to rectum topically as needed for Hemorrhoids once daily. On October 17, 2023, observed medication pass with V3 (ADON) from 11:51 AM to 12:44 PM. At approximately 12:20 PM, R44 stated her hemorrhoids hurt and her perineum area was really itchy. V3 asked R44 is your pain level a 4? R44 did not say what her pain level was. V3 went out of R44's room to prepare medications during which V3 had a phone call that she said was from a doctor. While V3 was on the phone, the surveyor asked R44 what her hemorrhoid pain level was on a scale of 1-10, one being very little pain and ten being unbearable pain. R44 stated her pain was a ten out of ten (10/10). R44 stated it hurts the worst when she is getting incontinence care. Surveyor asked if V3 uses a scale range when asking the resident what her pain level is. V3 stated she asked her earlier and told R44 a pain range. Surveyor then informed V3 that R44 said that her hemorrhoid pain was 10/10. On October 17, 2023 at 3:50 PM, observed R44's ADL care. R44 had stool on the anal area and the stool was also covering her hemorrhoids. R44's hemorrhoids were visualized after stool was cleaned off by the nurse assistant. R44 stated her hemorrhoids were painful. On October 18, 2023 at 1:50 PM, V2 (DON) stated [R44] has hemorrhoidal pain every day. V2 stated she expects staff to be give R44 the hemorrhoid cream every day. Review of R44's electronic medication administration record showed the hemorrhoid cream was not administered from October 15, 2023 through October 17, 2023. On October 18, 2023 at 1:30 PM, V19 (Medical Doctor) stated that if R44 is having hemorrhoid pain then she would expect the facility staff to give the resident hemorrhoid medication first. The facilities Pain Management Policy dated June 1, 2023 states and staff will identify individuals who have pain or who are at risk for having pain. The community, to the extent possible, to prevent or manage pain, will. 1. Recognize when the resident is experiencing pain. 2. Evaluate the existing pain and the cause(s); and 3. Manage or prevent pain, consistent with the comprehensive assessment and plan of are, current professional standards of practice, and the resident's goals and preferences. Protocol: 2. This also includes a review for any treatments that the resident currently is receiving for pain, including complementary (non-pharmacological) treatments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146029 If continuation sheet Page 6 of 16 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 146029 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Village 1270 Franciscan Drive Lemont, IL 60439 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to administer medications as ordered by the physician. There were 28 opportunities with 5 errors, resulting in 17.85% medication error rate. Residents Affected - Few This applies to 3 of 5 residents (R24, R44 and R350) observed during the medication pass in the sample of 21. The findings include: 1. On October 17, 2023 at 4:45 PM, V15 (Registered Nurse) prepared and administered multiple medications to R24 including Diclofenac sodium topical gel 1%. The label on R24's Diclofenac sodium topical gel 1% indicated to apply 4 grams to the resident's right knee. The tube containing the Diclofenac sodium topical gel 1% showed a label on the front, USE THE DOSING CARD ATTACHED INSIDE THE CARTON. This label was written in all capital bold fonts. The said tube of Diclofenac sodium gel was stored inside a clear plastic bag and not inside a carton, and no available dosing card was stored with it. During the application of the Diclofenac sodium gel, V15 placed a pea-sized amount on his gloved hand and applied the said amount of topical gel to R24's right knee. V15 was asked how he determined the amount of topical gel to apply to R24's right knee, since the label indicated to apply 4 grams. V15 responded, I just estimated and acknowledged that he applied approximately pea-sized amount. R24's order summary report showed an order dated September 22, 2023 for Diclofenac Sodium gel 1%. Apply to right knee topically every day and evening shift for pain, apply 4 gm (grams). On October 18, 2023 at 11:00 AM, V2 (Director of Nursing) provided the dosing card for the Diclofenac sodium topical gel 1%. The dosing card showed that this topical gel was a nonsteroidal anti-inflammatory drug used as arthritis pain reliever. The same dosing card showed a measuring guide indicating that for, Lower body dose 4.5 inches long (4 grams). On October 18, 2023 at 2:38 PM , V2 stated that the nurses should always follow the physician's order during medication administration. V2 stated that with regards to R24's Diclofenac Sodium topical gel, V15 should have used the dosing card to ensure that the right amount of medication was applied as ordered. 3) R44's face sheet documents a [AGE] year old female with diagnoses including Hypertension, Respiratory Failure, and unspecified Sciatica. R44's physician order summary shows the following: Aspirin oral capsule 81 mg. Give 81 mg by mouth one time a day for Analgesic. Dated October 11, 2023. PreserVision AREDS 2 oral capsule (Multiple Vitamins w/Minerals). Give 1 capsule by mouth one time a day for supplement. Dated October 11, 2023. On October 17, 2023 started observing medication pass at 11:51 AM with V3 (ADON). At 12:36 PM medication V3 (ADON) had prepared the medications for R44 and had them in a medication cup. Aspirin was not one of the medications that was prepared. V3 prepared 2 red pills of PreserVision AREDS 2 and put (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146029 If continuation sheet Page 7 of 16 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 146029 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Village 1270 Franciscan Drive Lemont, IL 60439 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few them in the small medication cup. The label on the PreserVision bottle with R44's name on it said give 1 tablet. V3 then went into R44's room to give the resident her medications. Surveyor asked V3 how many of the PreserVision was ordered for the resident, and V3 said, 2 pills. Surveyor informed V3 that the label on R44's PreserVision said to give 1 pill. V3 went and looked up the order in the resident's medication record and stated that the PreserVision dose should only be 1 pill. V3 then took out one of the red pills and discarded it. V3 then started giving R44 her pills one by one. After taking a couple pills, R44 said, is my aspirin in there? V3 said, Yes, it is. V3 then picked up a small light brown pill with the spoon and stated she believed that it was the aspirin. Surveyor informed V3 that aspirin was not one of the medications that V3 had prepared for R44 and put in the medication cup. V3 then went back to her cart, looked at the discarded pill packets, the order for aspirin, and in the resident's drawer then stated that the aspirin was not given. V3 started looking for an Aspirin to give R44. V3 found an 81mg enteric-coated aspirin in the house stock. The 81 mg Aspirin was small and white and V3 put one tablet in the pill cup for R44 and then went and administered it. The facility's Medication Administration Policy dated June 1, 2023 documents the following: Medications are administered in accordance with written orders of the prescriber. 2. On October 18, 2023, at 8:50 AM, V13 (RN/Registered Nurse) prepared R350's medications which included one tablet enteric coated aspirin 325 mg (milligrams) and two tablets eye multivitamin with minerals. V13 crushed the enteric coated aspirin and eye multivitamins with minerals along with R350's other medications and administered the medications to R350. On October 18, 2023, at 9:26 AM, V13 said she crushed R350's enteric coated aspirin prior to administering the medication. V13 continued to say she gave R350 the eye vitamin with minerals. R350's Order Summary Report dated October 18, 2023, showed an order dated October 2, 2023, for aspirin oral tablet delayed release 325 mg, one time a day. The report continued to show an order dated October 2, 2023, for May crush medications unless contraindicated, notes: may crush and give with food unless time release, enteric coated, or on the do not crush medication list. The report did not show an order for eye vitamins with minerals. R350's October 2023 MAR (Medication Administration Record) dated October 18, 2023, showed R350's eye vitamin with minerals was discontinued on October 15, 2023. On October 18, 2023, at 1:26 PM, V2 (DON/Director of Nursing) said enteric coated medications should not be crush and V13 should not have crushed R350's enteric coated aspirin. V2 continued to say medications should only be administered when there is a physician order. V2 said V13 should not have given R350 the eye vitamin with minerals since the medication was no longer ordered for R350. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146029 If continuation sheet Page 8 of 16 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 146029 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Village 1270 Franciscan Drive Lemont, IL 60439 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that 2 residents were given medications as prescribed by their physicians for Parkinson's disease and to prevent blood clotting. This applies to 2 of 2 residents (R16 and R57) reviewed for significant medication errors in a sample of 21. Residents Affected - Few The findings include: On October 17, 2023 at 11:51 AM, V3 (ADON) was observed passing morning medications. V3 stated she still had 8 more residents to pass medications to. Per the facility's medication pass times daily medications are given between 8:00 AM and 11:00 AM, and midday medications are given between 12:00 PM - 2:00 PM. 1) R16's face sheet documents an [AGE] year old female admitted to the facility on [DATE] with diagnoses that include Paroxysmal Atrial Fibrillation, Pulmonary Hypertension, Dysphagia, and extrapyramidal movement disorders. R16 Physician orders document the following: Apixaban 2.5 MG Give 1 tablet by mouth 2 times a day for blood thinner. Carbidopa-Levodopa 25-100 mg, give 1 tablet by mouth three times a day for Parkinson's disease. R16's electronic medical record reflects that none of R16's morning or afternoon medications were given including Apixanban and Carvidopa-Levodopa. Therefore R16 missed one dose of Apixanban and 2 doses of Carvidopa-Levodopa. R16's cognitive function care plans documents: Administer medications as ordered. 2) R57 face sheet documents a [AGE] year old male admitted to the facility on [DATE] with diagnoses that include Hypertension, Parkinsonism, and dysphagia. R57's physician orders document Carbidopa-Levodopa Tablet 25-100 MG, Give 2 tablets by mouth three times a day for Parkinson's. R57's electronic medical record reflects that none of R57's morning or afternoon medications were given including Carvidopa-Levodopa. Therefore, R57 missed 2 doses of Carvidopa-Levodopa. On October 18, 2023 at 1:10 PM, V3 stated she was not able to pass any medications to R57 or R16 during her day shift which covers the morning and afternoon medication pass. On October 18, 2023 at 1:39 PM, V19 (Medical Doctor) stated that Carbidopa -Levodopa and Apixaban are significant medications to have missed. V19 further stated that Apixaban is even more significant because it prevents blood clotting. V19 stated she expects medication to be given as ordered. The facility's Medication Administration Policy dated June 1, 2023 documents the following: Medications are administered in accordance with written orders of the prescriber. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146029 If continuation sheet Page 9 of 16 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 146029 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Village 1270 Franciscan Drive Lemont, IL 60439 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to serve pureed consistency Chicken Cacciatore and vegetables to residents on pureed diets. This applies 5 of 5 residents (R16, R21, R28, R67, R350) reviewed for pureed diets in the sample of 21. The findings include: Facility Diet Type Report showed that R16, R21, R28, R67, R350 were on pureed diets. On October 17, 2023, at 10:14 AM, the pureed meal prep by V14 (Cook) was observed in the facility kitchen. V14 stated that she is preparing 6 portions of pureed Chicken Cacciatore for the residents that are on pureed diets. V14 first added six 4 oz/ounce portions of cooked vegetable mixture (consisting of green and yellow peppers, canned diced tomatoes, roasted tomato sauce and steamed Brussels sprouts) that had been prepared earlier, into a blender and pureed the product. V14 then added six (3.5 oz) cooked chicken pieces to another blender with the chicken drippings and blended the same. V14 incorporated the pureed vegetables into the pureed chicken mixture and added minimal thickener and pureed it again. V14 stated that the mixture was ready for service and that she is going to pipe the contents into a plate and then reheat it. When taste tested, the pureed mixture had seed like small hard pieces. V6 (Director of Dining) and V9 (Executive Chef) who were in the area were notified of the same. V14 re-pureed the mixture for about another minute and stated that the item was ready. When taste tested again the seed like pieces remained as such. V10 (Chef) was called to the area and stated that the small hard pieces were seeds from the tomato. On October 17, 2023, at 2:28 PM, V7 (Dietitian), stated that the pureed products should have no lumps or seeds. V7 added the blender blades need to be changed and are on back order. Recipe (undated) for Pureed Chicken Cacciatore included to prepare poultry in a blender until it reaches a fine grind and gradually add 1st portion broth in a thin stream to poultry, blend until thoroughly combined, no lumps or bits. Remove from processor, place in bowl twice the volume of food product. Gradually add 1st portion thickener, fold into product with a wire whip or rubber spatula blend until smooth mashed potato consistency is reached. Facility policy titled Level 1 Pureed included as follows: Foods are totally pureed. No coarse textures or lumps of any sort are allowed. Fruits maybe pureed or well mashed without pulp, seeds, or skin and juices thickened to prescribed consistency. The policy also included foods allowed and not allowed and listed vegetables with chunks, lumps seeds or pulp are not allowed. 2) R16's face sheet documents an [AGE] year old female admitted to the facility on [DATE] with diagnoses that include Dysphagia, Paroxysmal Atrial Fibrillation, Pulmonary Hypertension, and extrapyramidal movement disorders. On October 16, 2023 at 10:34 AM, R16 stated she has told nurses and CNAs that it was hard to swallow the food because the consistency of her pureed diet was not correct. R16 stated she has found the pureed diet to be stringy and lumpy at times. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146029 If continuation sheet Page 10 of 16 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 146029 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Village 1270 Franciscan Drive Lemont, IL 60439 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 R16's physician orders dated 8/16/2022 document Fresh Benefits Diet. Puree texture, Nectar Thick liquid consistency. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146029 If continuation sheet Page 11 of 16 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 146029 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Village 1270 Franciscan Drive Lemont, IL 60439 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to serve nutrition supplements and diet consistency as ordered by the Physician. This applies to 4 of 5 residents (R16, R34, R87, R88) reviewed for dining in the sample of 21. The findings include: 1. On October 16, 2023, at 04:25 PM, R87 stated I don't get any extra dessert. I fill up my diet sheet and if I ask for ice cream or pudding I get it. R87 stated that she did not request for the same for lunch that day. R87's quarterly MDS dated [DATE], showed that R87 was cognitively intact. On October 16, 2023, at 11:50 AM, R87 received a lunch meal tray and did not receive any enhanced pudding. R87's diet order on POS included Enhanced Pudding two times a day 1 #8 scoop at lunch and dinner (start date August 11, 2023). 2. On October 17, 2023, at 11:59 AM, R16 received a room tray pureed meal and apple sauce for dessert. Diet ticket showed one 8 oz/ounce scoop FB (Fresh Benefits) vanilla pudding. R16 did not receive any enhanced pudding. R16's POS included diet order for Enhanced Pudding two times a day one #8 scoop at lunch and dinner (start date March 4, 2023). 3. On October 17, 2023, at 12:17 PM, R34 received a room tray of regular consistency meal. Diet ticket showed one 8 oz/ounce scoop FB vanilla pudding and R34 did not receive the same. R34's POS included diet order Enhanced Pudding two times a day 1# 8 scoop at lunch and dinner (start date October 9, 2023). 5. On October 16, 2023, at 12:07 PM, R88 received ground meat with limited gravy and pasta. R88 stated Its dry. I don't feel like eating it. I don't like this ground food. They are supposed to correct it and give me regular food. R88 ate his pasta and chilled pears and ice cream. V8 (R88's wife) present at the meal also stated that R88 was evaluated by Speech Therapist and diet was upgraded to Regular consistency. On October 17, 2023, at 12:04 PM, R88 received ground Chicken Cacciatore and R88 stated Whatever name they have on it, its terrible. R88 stated that he wants regular chicken. R88's meal ticket showed mechanical soft. R88's Comprehensive MDS dated [DATE], showed that R88 was cognitively intact. Nursing Progress notes dated October 10, 2023 included that R88 had a speech evaluation from speech therapist from hospice. R88's diet order on POS included General diet, Regular texture, Thin liquid consistency (start date October 10, 2023). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146029 If continuation sheet Page 12 of 16 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 146029 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Village 1270 Franciscan Drive Lemont, IL 60439 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On October 17, 2023, at 12:04 and 12:17 PM, V6 (Director of Dining) who was present in the dining room, was made aware of R88 receiving mechanical soft instead of regular food and above mentioned residents not receiving enhanced pudding as shown on diet card. On October 17, 2023, at 2:28 PM, V7 (Dietitian) stated that the residents should receive the diet as ordered [by the Physician]. V7 stated that the enhanced pudding is recommended for significant weight loss or inadequate nutrition intake and sometimes recommended for wound healing. V7 stated that the facility tries to give food first before adding other nutritional supplements. Facility Diet Type Report printed on 10/16/23 showed that R16, R34, R87 were on Enhanced Pudding for lunch and dinner and that R88 was on Regular diet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146029 If continuation sheet Page 13 of 16 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 146029 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Village 1270 Franciscan Drive Lemont, IL 60439 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy to offer residents the pneumococcal vaccine. This applies to 6 of 6 residents (R6, R14, R15, R22, R33, and R67) reviewed for immunizations in the sample of 21. Residents Affected - Some The findings include: 1. R6's EMR (Electronic Medical Record) showed R6 was admitted to the facility on [DATE], with multiple diagnoses including anemia, hypertension, and dementia. R6's Immunization Record showed R6 received the PPSV23 (Pneumococcal Polysaccharide Vaccine 23) on October 5, 2021. R6's Immunization Record did not show R6 received any additional pneumococcal vaccines. As of October 17, 2023, at 9:00 AM, the facility does not have documentation to show the facility offered the PCV15 (Pneumococcal 15-valent Conjugate Vaccine) or the PCV20 (Pneumococcal 20-valent Conjugate Vaccine) to R6 or R6's resident representative. 2. R14's EMR showed R14 was admitted to the facility on [DATE], with multiple diagnoses including osteoarthritis, hypertension, and polio. R14's Immunization Record showed R14 received the PPSV23 on September 6, 2021. R14's Immunization Record did not show R14 received any additional pneumococcal vaccines. As of October 17, 2023, at 9:00 AM, the facility does not have documentation to show the facility offered the PCV15 (Pneumococcal 15-valent Conjugate Vaccine) or the PCV20 (Pneumococcal 20-valent Conjugate Vaccine) to R14 or R14's resident representative. 3. R15's EMR showed R15 was admitted to the facility on [DATE], with multiple diagnoses including osteoarthritis, atrial fibrillation, hypothyroidism, and hypertension. R15's Immunization Record showed R15 received the PPSV23 on October 6, 2021. R15's Immunization Record did not show R15 received any additional pneumococcal vaccines. As of October 17, 2023, at 9:00 AM, the facility does not have documentation to show the facility offered the PCV15 (Pneumococcal 15-valent Conjugate Vaccine) or the PCV20 (Pneumococcal 20-valent Conjugate Vaccine) to R15 or R15's resident representative. 4. R22's EMR showed R22 was admitted to the facility on [DATE], with multiple diagnoses including heart failure, stroke, atrial fibrillation, seizures, and hypertension. R22's Immunization Record showed R22 received the PPSV23 on June 14, 2020. R22's Immunization Record did not show R22 received any additional pneumococcal vaccines. As of October 17, 2023, at 9:00 AM, the facility does not have documentation to show the facility offered the PCV15 (Pneumococcal 15-valent Conjugate Vaccine) or the PCV20 (Pneumococcal 20-valent Conjugate Vaccine) to R22 or R22's resident representative. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146029 If continuation sheet Page 14 of 16 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 146029 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Village 1270 Franciscan Drive Lemont, IL 60439 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Level of Harm - Minimal harm or potential for actual harm 5. R33's EMR showed R33 was admitted to the facility on [DATE], with multiple diagnoses including heart failure, chronic obstructive pulmonary disease, skin cancer, and dysphagia. R33's Immunization Record showed R33 received the PPSV23 on October 7, 2021. R33's Immunization Record does not show R33 received any additional pneumococcal vaccines. Residents Affected - Some As of October 17, 2023, at 9:00 AM, the facility does not have documentation to show the facility offered the PCV15 (Pneumococcal 15-valent Conjugate Vaccine) or the PCV20 (Pneumococcal 20-valent Conjugate Vaccine) to R33 or R33's resident representative. 6. R67's EMR showed R67 was admitted to the facility on [DATE], with multiple diagnoses including chronic kidney disease, hypertension, and hypothyroidism. R67's Immunization Record showed R67 showed received the PPSV23 on October 15, 2021. R67's Immunization Record does not show R67 received any additional pneumococcal vaccines. As of October 17, 2023, at 9:00 AM, the facility does not have documentation to show the facility offered the PCV15 (Pneumococcal 15-valent Conjugate Vaccine) or the PCV20 (Pneumococcal 20-valent Conjugate Vaccine) to R67 or R67's resident representative. On October 18, 2023, at 11:24 AM, V4 (Infection Preventionist Nurse) said the facility has not offered the PCV15 or PCV20 to any residents. V4 continued to say the facility follows the CDC (Centers for Disease Control and Prevention) recommendations for immunizations. An email dated October 18, 2023, at 12:58 PM, from the facility's pharmacy showed the pharmacy has the PCV20 available. The facility's policy titled Immunization Program, dated September 1, 2023, showed, Policy: [The facility] offers, as available, immunizations against seasonal influenza, other novel/pandemic influenza and pneumococcal pneumonia to all residents and associates. [The facility] encourages residents and associates to remain up to date on vaccinations per CDC recommendations to prevent transmission of influenza and pneumococcal and other respiratory viruses within the associate, resident, and volunteer population within the community. Procedure: .Current CDC Recommendations for age [AGE] years or older who have: . Previously received only PPSV23: one dose PCV15 or one dose PCV20 at least one year after the PPSV23 dose. If PCV15 is used, it need not be followed by another dose of PPSV23 . The Pneumococcal Vaccine Timing for Adults on the cdc.gov website, dated April 1, 2022, showed CDC recommends pneumococcal vaccination for adults [AGE] years old and older. For those who previously received PPSV23 but who have not received any pneumococcal conjugate vaccine, you may administer one dose of PCV15 or PCV20. Regardless of which vaccine is used (PCV15 or PCV20): the minimum interval is at least one year. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146029 If continuation sheet Page 15 of 16 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 146029 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Village 1270 Franciscan Drive Lemont, IL 60439 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a call light was accessible to a resident if they were lying on the bathroom floor. This applies to 1 of 1 resident (R352) reviewed for call light accessibility in the sample of 21. Residents Affected - Few The findings include: R352's EMR (Electronic Medical Record) showed R352 was admitted to the facility on [DATE], with multiple diagnoses including stroke with right sided paralysis, syncope, difficulty in walking, and tachycardia. The EMR continued to show R352 resided in the same room while residing in the facility. R352's MDS (Minimum Data Set) dated October 6, 2023, showed R352 had independent cognitive skills for daily decision making. The MDS continued to show on admission R352 required moderate assistance with transfers on and off the toilet. On October 16, 2023, at 10:41 AM, R352 was sitting in her wheelchair in her room. R352 said she has gotten stuck in her bathroom twice and the bathroom call light pull cord does not activate the call light. R352 wheeled herself into the bathroom and demonstrated the bathroom call light pull cord did not activate the call light. R352 pushed the bathroom call light located on the wall approximately 42 inches from the floor. R352 said she would not be able to reach the button if she were lying on the floor. On October 18, 2023, at 12:41 PM, R352 said shortly after her admission, a facility staff member told her the bathroom call light pull cord did not work and she would have to push the button located on the wall. On October 16, 2023, at 12:55 PM, V21 (RN/Registered Nurse) attempted to activate R352's bathroom call light using the pull cord. V21 said R352's bathroom call light pull cord did not work and she would notify maintenance immediately. On October 16, 2023, at 2:07 PM, V15 (RN) said he was R352's nurse shortly after she was admitted to the facility. V15 continued to say R352's bathroom call light pull cord was not working and V15 told the resident to push the call light button located on the wall. V15 said he did not notify maintenance of the bathroom call light pull cord not working. On October 18, 2023, at 1:40 PM, V22 (Director of Plant Operations) said he was unaware of R352's bathroom call light pull cord would not activate the call light prior to October 16, 2023. On October 18, 2023, at 2:43 PM, V2 (DON/Director of Nursing) said if a resident's call light is not working staff should immediately put in a work order to maintenance to get it fixed. V2 continued to say V15 should have created a work order immediately for R352's bathroom call light pull cord not working. V2 said R352 would not be able to activate the bathroom call light located on the wall from the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146029 If continuation sheet Page 16 of 16