Health inspection·August 9, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3. On August 6, 2024 at 11:36 AM, R56 was being settled into her bed for a nap by a CNA, then left the room. R56's call light was hanging off the side of the bed. R56 said she would call for help by pressing the call button. R56's face sheet showed she was admitted to the facility with diagnoses including hyperlipidemia, muscle weakness, osteoporosis, difficulty in walking, lack of coordination, and dysphagia. R56's MDS dated [DATE] showed R56 was cognitively intact and showed R56 required substantial assistance from staff for eating and oral hygiene, and was dependent on staff for toileting hygiene, shower/bath, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. R56's care plan dated July 15, 2021 showed R56 was at risk for falls related to decreased balance/mobility/ADL function, weakness, and disease process, with an intervention including Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. On August 8, 2024 at 1:19 PM, V16 (CNA) said the call lights should be clipped to the blanket in front of the resident so they could see it and could reach for it. V16 said if the resident was in the wheelchair, it should still be within reach to the resident. On August 8, 2024 at 1:24 PM, V17 (CNA) said the staff should give the call lights to the resident before leaving the room because the call light should always be placed within reach to the resident. V17 said if the resident was in the chair, she would bring it close to the chair or loop it around the chair, or clip it to the sheets. On August 8, 2024 at 1:30 PM, V18 (CNA) said the call lights need to be within reach of the resident, and if they are in the chair, to clip it to their shirt or onto the chair. On August 8, 2024 at 1:38 PM, V20 (LPN/Licensed Practical Nurse) said the call lights should always be where the resident can reach it, whether that be in their hands or clipped in front of their hands. On August 8, 2024 at 2:06 PM, V2 (DON/Director of Nursing) said the call lights should be within reach of the residents. V2 said if the resident was in the chair, the call light should still be reachable to the resident. The facility's Answering Call lights policy dated September 1, 2023 showed When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146029 If continuation sheet Page 2 of 19 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 08/09/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to invite 2 residents (R45, and R68) to their care plan meetings that were reviewed for care plans, in a sample of 34. Findings include: 1. On 08/06/24 at 12:14 PM, R45 said that she has not attended a care plan meeting, nor had she been invited to one since she has been admitted to the facility. R45's electronic health record showed that she was admitted to the facility on [DATE]. 2. On 08/06/24 at 12:14 PM, R68 said that she has not attended, nor has she been invited to a care plan meeting since she was admitted . 08/08/24 at 11:09 AM R68 was in her room with V8 (R68's son) and R68 again said that she has never attended or has been invited to a care plan meeting. Then V8 said that he comes and visits his mother twice a week and he receives notices from the facility about his mother's care but he has never received any invitation or notice for her care plan meetings. R68's electronic health records showed that she was admitted on [DATE]. On 08/08/24 at 02:37 PM, V1 (Administrator) said that the residents and representatives are to be invited to their care plan meetings so that the residents have a choice in their care and their family will know and are able to contribute to the resident's plan of care. V1 said that the facility should document in a progress note that the resident and representative was invited and if they attended. A record review was conducted during this survey from 8/6/24 - 8/8/24 and no documentation could be found showing R45, R68, and their representatives, were invited to and attended any care plan meetings for the past year. The facility was unable to provide any documentation showing that R45, R68, or their representatives were invited or attended their care plan meetings. The facility's Resident Comprehensive Care Plan policy with review date 03/21/2024 showed, To ensure the timeliness of each resident's personal centered baseline and comprehensive plan and to ensure that these care plans are reviewed and revised by and disciplinary team composed of individuals who have knowledge of the resident his or her needs each resident and resident representative if applicable is involved and developing the care plan and making decisions about his or her care. Care plan is to include participation of the resident and the resident's representative and explanation must be included in the residence medical records if participation of the resident and their resident representative is determined not practical for the development of the residence care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146029 If continuation sheet Page 3 of 19 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 08/09/2024 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 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 08/06/24 at 01:33 PM, R26 was observed with long jagged nails with a brown substance under the nails. R26 said that she was unable to remember the last time she was provided nail care and she would like for someone to provide it. Residents Affected - Some R46's 7/11/24 care plan showed, The resident has an ADL (activities of daily living) self-care and mobility usual performance deficit related to weakness, decrease mobility ADL function, decrease balance/strength. The resident will participate in performing her ADLs with staff assistance. Intervention - Personal Hygiene: Substantial/Maximal Assistance. R26's 8/1/24 MDS (minimum data set) showed in section GG under Personal Hygiene - R26 needs substantial maximal assistance. 5. On 08/06/24 at 11:59 AM, R30 was observed with his left hand contracted and his fingernails were not visible. R30's nails on his right hand were observed long, jagged and with a brown substance under the nails. R30's 7/6/24 Care Plan showed that R30 is at risk for Functional/ADL Status decline related to weakness, aging process, left hemiplegia related to CVA (cerebral vascular accident). Personal Hygiene: Substantial/Maximal Assistance. R30's 6/23/24 MDS section GG under personal hygiene showed R30 needs substantial/maximal assistance. 6. On 08/06/24 at 01:28 PM, R42 was observed with long jagged nails, with a brown substance under the nails. R42's 8/1/24 care plan showed, Resident has an ADL self-care and mobility usual performance deficit related to weakness, decreased mobility, recent fall, fracture of right femur. R42's care plan interventions showed, Personal Hygiene Assistance substantial/maximal assistance. R42's 5/9/24 MDS section GG under Personal Hygiene showed R42 needs substantial/maximal assistance. 7. On 08/06/24 at 12:14 PM, R45 was observed with long jagged nails with a brown substance under the nails. R45 said that she doesn't know the last time she was provided nail care and that it bothers her that it has not been done. R45's 7/15/24 care plan showed R45 has a risk for Self-Care Deficit. Provide assistance with ADLs as needed. R45's 7/1/24 MDS section GG under personal hygiene showed that R45 needs substantial maximal assistance. 8. On 08/06/24 at 01:25 PM, R49 was observed with long jagged fingernails with chipped nail polish on them. R49 said that staff does not do a good job providing nail care for her. R49's 5/18/24 MDS section GG under personal hygiene showed that R49 is dependent for care. 9. On 08/06/24 at 12:14 PM and on 08/08/24 at 10:52 AM, R68 was observed with long jagged fingernails with a brown substance under them. R68's 6/27/24 MDS section GG under personal hygiene showed that R68 needs substantial/maximal assistance. R68's 8/7/24 care plan showed, resident has an ADL self-care and mobility usual performance deficit related to weakness, hearth failure, coronary artery disease and dementia. The goal showed, will maintain current ADL function and participate in ADLs with staff through the review date. The Intervention showed, Personal Hygiene Assistance Level: Substantial/maximal assistance. 10. On August 6, 2024 at 1:35 PM, R12 was in the dining room had had facial hair, which was approximately 1.5 inches long on her chin. On August 8, 2024 at 10:11 AM, R12 still had facial hair 1.5 inches long on her chin. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146029 If continuation sheet Page 4 of 19 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 08/09/2024 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 Level of Harm - Minimal harm or potential for actual harm On August 8, 2024 at 1:19 PM, V16 (CNA/Certified Nurse Assistant) said the staff shave residents as needed or on shower days. V16 said female residents should not have facial hair, and they should be shaved. At 1:24 PM, V17 (CNA) said female residents should be shaved for dignity reasons. At 1:34 PM, V19 (CNA) said the facial hair should be removed for female residents, unless it was their preference to keep it on. At 1:41 PM, V14 (CNA) said the female residents should be shaved for dignity reasons. Residents Affected - Some On August 8, 2024 at 2:06 PM, V2 (DON/Director of Nursing) said it was her expectation for the staff to shave female residents. V2 said she had also bought tweezers for the staff to remove facial hair. R12's face sheet showed she was admitted to the facility for palliative care, Alzheimer's disease, congestive heart failure, polyosteoarthritis, anxiety disorder, hypertension, and repeated falls. R12's MDS (Minimum Data Set) dated June 14, 2024 showed R12 had severe cognitive impairment and was dependent on staff for personal hygiene. R12's care plan dated March 8, 2024 showed R12 had an ADL [Activities of Daily Living] self-care and mobility usual performance deficit. The facility's Activities of Daily Living policy dated November 14, 2023 showed Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care). Based on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) care to residents dependent on staff for personal hygiene and grooming. This applies to 10 of 10 residents (R12, R26, R30, R42, R44, R45, R49, R51, R59, and R68) reviewed for ADL's in a sample of 34. The findings include: 1. On 08/06/24 at 12:00 PM R44 was in the dining room eating lunch. R44 had long chin hairs. R44 said she wanted the chin hairs removed, but the staff does not help her remove them. On 08/07/24 at 11:33 AM R44 was sitting in the dining room. R44 still had long chin hairs. She stated she still wanted them removed. R44's face sheet showed multiple diagnoses which included hypertensive chronic kidney disease, primary generalized osteoarthritis, dementia, hypertension, lack of coordination, muscle weakness, osteoporosis, and adult failure to thrive. R44's MDS (MDS/Minimum Data Set) dated 05/08/24 showed R44 had moderate cognitive impairment. The same MDS showed R44 required substantial/maximal assistance with personal hygiene. R44's Personalized Care & ADL Deficit care plan revised on 12/20/23 showed a goal of considering R44's preferences when providing care and will complete ADL's with staff assistance. Interventions: substantial/maximal assistance with personal hygiene. 2. On 08/06/24 at 12:14 PM R51 was sitting in a wheelchair in the dining room. R51's fingernails had a dark colored substance underneath on both hands. On 08/07/24 at 4:22 PM R51's fingernails on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146029 If continuation sheet Page 5 of 19 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 08/09/2024 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 both hands continued to have a dark colored substance underneath. Level of Harm - Minimal harm or potential for actual harm R51's face sheet showed multiple diagnoses which included hypertensive heart and chronic kidney disease, diabetes, heart failure, muscle weakness, vascular dementia, anemia, hypertension, and peripheral vascular disease. R51's MDS dated [DATE] showed R51 had severe cognitive impairment. The same MDS showed R51 required substantial/maximal assistance with personal hygiene. R51's Alteration in ADL/Mobility performance care plan revised on 03/18/24 showed a goal of considering R51's preferences when providing care and completing ADL's. Interventions: substantial/maximal assistance with personal hygiene. Residents Affected - Some 3. On 08/06/24 at 11:17 AM R59 was sitting in recliner chair. R59's fingernails on her right hand had a dark colored substance underneath. On 08/07/24 at 10:50 AM R59's right hand fingernails continued to have a dark colored substance underneath. R59 stated she would like to have her nails cut and cleaned. R59's face sheet showed multiple diagnoses which included hypertensive chronic kidney disease, polyosteoarthritis, dementia, muscle weakness, vascular dementia, psychosis, hypertension, unsteadiness on feet, and hypothyroidism. R59's MDS dated [DATE] showed R59 had severe cognitive impairment. The same MDS showed R59 was dependent with personal hygiene. R59's ADL self-care performance deficit are plan revised on 02/21/24 showed a goal of R59 receiving assistance from staff to complete ADL and functional mobility task. Progress notes from 07/09/24-08/09/24 showed no documentation of R59 refusing care. On 08/07/24 at 11:15 AM V19 (CNA/Certified Nursing Assistant) said the residents nails should not be dirty. V19 said it is my responsibility to clean and trim the residents nails. All nails should be trimmed and cleaned after a shower and as needed. On 08/07/24 at 11:18 AM V22 (Registered Nurse) said residents nails should not be long or dirty. Nails should be cleaned and trimmed as needed. Residents could scratch themselves or put dirty fingernails in their mouth and get an infection from the bacteria. On 08/07/24 V22 said female residents should not have chin hairs. [NAME] hairs should be removed as needed. It is a dignity issue for a woman to have chin hairs. On 08/08/24 at 11:59 AM V2 (Director of Nursing) said residents should not have long, dirty fingernails. Nail care should be done as needed and on the shower days. Residents should be properly groomed on the shower days which includes nail care. If residents have dirty fingernails, they could get an infection. Women should not have chin hairs. [NAME] hairs should be removed when they are visible. [NAME] hairs are a dignity issue for women. It is expected that the CNA's and nurses properly groom the residents to maintain their dignity. The facility's Activities of Daily Living Policy effective date 12/01/23 showed- Policy: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Procedure: 2. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care). 4. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146029 If continuation sheet Page 6 of 19 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 08/09/2024 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 may be appropriate. 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 7 of 19 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 08/09/2024 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities for 2 residents (R45 & R68) in a sample of 34. Residents Affected - Few Findings include: 1. On 08/06/24 at 12:14 PM, R45 said that the facility does not provide activities for her while she is in her room. On 08/08/24 at 11:06 AM, R45 said that no one has come in and offered her any activities or pop in visits. R45 said that she would like to get out of her bed, but her legs hurt so that is why she stays in her bed. R45 said that since no one brings her any activities, the only thing she has to do is watch TV. On 08/07/24 at 03:51 PM, V13 (Life Enrichment Director) provided documentation for R45's activities from 7/1/24 - 8/7/24, and it only showed 3 entries, 7/2/24, 7/9/24 & 7/11/24. V13 said that staff are to offer activities to all residents every day and her expectations are for staff to document daily that they offered and if the resident refused. On 08/08/24 at 11:00 AM V13 provided the state surveyor with R45's 5/15/24 activities care plan and it showed, R45 prefers to spend time in her room in bed. R45 is accepting of pop in visits and converse with staff during these visits. The care plan goals showed, participate and accept pop in visits with staff three times weekly. The care plan interventions showed, provide in room pop in visits with resident to provide comfort and companionship. R45's 7/15/24 care plan showed Impaired Social Interaction. Resident Will Participate in Social Situations. Nurses, Social Worker and Activities staff - Encourage Resident to participate in social situations. Monitor Resident's level of social interaction. 2. On 08/06/24 at 12:14 PM, R68 said that she is not being provided any activities. On 08/08/24 at 10:46 AM, R68 said that the staff does not bring anything for activities to her room or offer her pop in visits. R68 said she would like to play computer games, and she has told the facility this since she was admitted . V8 (R68's son) was present during this time and he said that he comes to visit his mother twice a week and the staff does not bring his mother anything for activities. V8 said that his mother likes to stay in her room, but she likes to play computer games. On 08/07/24 at 03:51 PM, V13 said that staff is to do daily room visits and are to record it on the facility's computer program called LifeLoop. V13 then provided R68's LifeLoop documentation for July 7th 2024 to August 7th 2024. The documentation showed only 4 entries, 7/9/24, 7/11/24, 7/16/24 & 8/1/24. V13 was unable to find R68's activities care plan at that time. On 8/8/24 at 11:00 am, V13 provided the state surveyor with R68's 8/8/24 activities care plan. The care plan showed, R68's prefers to spend her leisure time in her room. R68 is accepting of pop in visits. R68 will make her needs known during this visits and express satisfaction with level of activity participation. The care plan goal showed will accept a minimum of 3 pop in visits a week and express satisfaction with level of activity participation. the interventions included: provide pop in visits to resident, provide invites to group activities, provide escort to and from activities when needed, provide monthly calendar for resident. On 08/06/24 at 01:19 PM V12 (Life Enrichment Assistant) said that the staff does not provide (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146029 If continuation sheet Page 8 of 19 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 08/09/2024 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 0679 activities to the residents that are in their beds every day. Level of Harm - Minimal harm or potential for actual harm On 08/08/24 10:43 AM V7 CNA (Certified Nurse's Assistant) said if residents are in bed, the staff does not bring any activities to them. V7 said that a part time staff comes around once or twice a week and reads newspapers or offers a drink to some of the residents who are in bed, but she does not bring any activities to the room like books or puzzles or anything like that. Residents Affected - Few 08/08/24 02:15 PM, V1 (Administrator) said that the facility has a list of residents who are on 1:1. V1 said that the activity staff/Life Enrichment staff, are to check on all the residents every day, offering activities even if it is to stay in their room. V1 said that this should be done to maintain their quality of life even if they are unable to participate in groups. The facility's Activities policy (no date) showed, It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan and preferences. Facility-sponsored groups, individual, and independent activities will be designed to meet the interest of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interactions within the community. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146029 If continuation sheet Page 9 of 19 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 08/09/2024 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 provide restorative nursing programs to residents identified with limited range of motion. This applies to 3 of 3 residents (R8, R53, and R55) reviewed for limited range of motion in a sample of 34. The findings include: 1. On 08/06/24 at 2:10 PM R53 was in bed, awake and alert. R53 had limited range of motion to both arms. R53's right and left foot was turned inwards. R53 said the facility was not helping her to exercise. On 08/08/24 at 1:17 PM R53 said she would be grateful to have exercises for her arms and legs from the facility. R53 said she hadn't been in therapy in a while. On 08/08/24 at 10:22 AM V23 (Director of Rehab) said R53 received occupational therapy from 02/22/24-03/14/24. V23 said the discharge therapy recommendations were an active range of motion restorative nursing program for both upper extremities. V23 said when residents are discharged from therapy and are referred to restorative, we give the restorative sheets to the director of nursing. R53's face sheet showed multiple diagnoses which included polyosteoarthritis, anemia, essential hypertension, unsteadiness on feet, muscle weakness, cerebral infarction, difficulty in walking, lack of coordination, and other symptoms and signs involving the musculoskeletal system. R53's MDS (MDS/Minimum Data Set) dated 07/10/24 showed R53 was cognitively intact. The same MDS showed R53 had functional limitations in range of motion to both upper and both lower extremities. R53's Functional Abilities assessment dated [DATE] showed R53 was dependent upon staff for toileting, bathing, dressing, and personal hygiene. R53's occupational therapy Discharge summary dated [DATE] recommendations showed: restorative active range of motion to both upper extremities for functional maintenance. R53 did not have physician orders or care plans for active range of motion. 2. On 08/06/24 at 11:08 AM R8 was in her room, sitting in a wheelchair. R8 was unable to raise her right arm. R8 said sometimes they come and help me exercise. On 08/08/24 at 01:20 PM R8 stated she would benefit from receiving therapy or exercises provided by the nursing staff. R8's face sheet showed multiple diagnoses which included diabetes, congestive heart failure, chronic kidney disease, gout, muscle weakness, lack of coordination, hypertension, and other symptoms and signs involving the musculoskeletal system. R8's MDS dated [DATE] showed R8 had moderate cognitive impairment. The same MDS showed R8 had functional limitations in range of motion to both upper and both lower extremities. R8's Functional Abilities assessment dated [DATE] showed R8 required partial/moderate assistance with toileting and personal hygiene. The same assessment showed R8 required substantial/maximal assistance with bathing. R8 did not have physician orders or care plans for restorative nursing programs. 3. On 08/06/24 at 1:54 PM R55 said her left shoulder is dislocated. R55 said it was an old injury prior to her being admitted to the facility. R55 said she is not going to have surgery; it is too risky. R55 said she was not receiving therapy. On 08/08/24 at 1:14 PM R55 said she would like to have some form of exercises to her arms. Stated her left arm is worse than the right and she doesn't want (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146029 If continuation sheet Page 10 of 19 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 08/09/2024 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 the right arm to get as bad as the left arm. Level of Harm - Minimal harm or potential for actual harm R55's face sheet showed multiple diagnoses which included diabetes, congestive heart failure, Parkinson's Disease, muscle weakness, difficulty in walking, hypertension, non-Hodgkin lymphoma, and other symptoms and signs involving the musculoskeletal system. R55's MDS dated [DATE] showed R55 was cognitively intact. The same MDS showed R55 had functional limitations in range of motion to one upper extremity and both lower extremities. R55 did not have physician orders or care plans for restorative nursing programs. Residents Affected - Few On 08/08/24 at 10:22 AM V23 said residents with impairments to their extremities should receive restorative nursing after discharge from therapy. Residents with impairments who do not receive restorative nursing could have a decline or possible contracture. On 08/08/24 at 11:59 AM V2 (Director of Nursing) said we do not have a restorative nurse at this time, but I am certified. We do not have any restorative nursing programs for any of the residents. The CNA's in the facility can do restorative programming. We lost our restorative CNA, and the restorative programs were not carried through even though the floor CNA's can do the programs. If residents have contractures, they can worsen. If they do not have contractures, they can develop one. The residents should be on a restorative program if they have impairments. If we got a recommendation for restorative from therapy, we should follow through. The facility's Restorative Nursing Policy effective date 09/01/23 stated: Policy-it is the policy of Franciscan Ministries to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Guideline: 3. A licensed nurse, or person designated by state regulations, will oversee the Restorative Nursing Program. 4. Licensed nurses, Certified Nursing Assistants, and Restorative Aides are trained on basic and maintenance care that may include: encouraging residents to remain active and assisting with exercises according to their individualized plan. 5. Residents, as identified during the assessment process, will receive restorative services. These services may include- a. passive or active range of motion. 6. Residents may receive restorative nursing services upon admission, when not a candidate for specialized rehabilitation services, when restorative needs arise during a longer-term stay, or upon discharge from therapy. 7. Potential candidates for restorative nursing services my be identified through one or more of the following processes: a. Physical assessments, b. MDS assessments, c. Specialized rehabilitation assessments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146029 If continuation sheet Page 11 of 19 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 08/09/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to put fall mats in place for R77, who was at a high fall risk. Residents Affected - Few This applies to 1 of 1 resident (R77) reviewed for accidents and supervision in a sample of 34. The findings include: On August 6, 2024 at 11:37 AM, R77 was lying in bed leaning on the left side. R77 had two fall mats folded up and left against the wall. R77's bed was not in the lowest position. On August 6, 2024 at 1:28 PM, R77 was sitting upright in bed, but neither fall mats were in place. On August 7, 2024 at 10:39 AM, R77 was lying in bed and the fall mat was only on the left side of the bed. R77's bed was not in the lowest position. On August 8, 2024 at 9:48 AM, R77 was lying in bed and the fall mat was only on the left side and there was a bedside table on the right side. On August 8, 2024 at 1:19 PM, V16 (CNA/Certified Nurse Assistant) said the fall mats should be on both sides of the bed and the bed needs to be lowered. V16 said fall mats were applied in case residents who rolled back and forth would not end up on the floor. On August 8, 2024 at 1:24 PM, V17 (CNA) said residents who were a fall risk should have their beds all the way down to the floor and hourly rounds should be done. V17 also said fall mats should be on both sides of the bed if the resident is in the bed. V17 said fall mats are used to cushion and decrease head and bodily injuries from falls. On August 8, 2024 at 1:30 PM, V18 (CNA) said residents who were a fall risk should be monitored frequently, have the call lights within reach, the bed should be in the lowest position, and the floor mats should be on both sides. On August 8, 2024 at 1:34 PM, V19 (CNA) said she would put the fall mats down if the resident was in bed, put the bed down to the ground, and make sure their call lights were accessible. On August 8, 2024 at 1:38 PM, V20 (LPN/Licensed Practical Nurse) said the residents who were at risk for falls would have fall mats ordered and placed on both sides. V20 said the bed should be in the lowest position, call lights should be within reach, and the resident should be frequently checked. On August 8, 2024 at 2:06 PM, V2 (DON/Director of Nursing) said if a resident has had a previous fall, they order bilateral floor mats, and the bed should be lowered. V2 said if the resident was in bed, the fall mats should be on both sides of the bed. R77's face sheet showed he was admitted to the facility with diagnoses including aphasia, atherosclerosis, fracture of right femur, hypertension, cognitive communication deficit, muscle weakness, and anemia. R77's MDS (Minimum Data Set) dated June 7, 2024 showed R77 was cognitively intact. R77's care plan dated January 10, 2023 showed R77 was at high risk for falls related to impaired balance, generalized weakness, history of recent fall with fracture, and recent hip hemiarthroplasty, with interventions including bilateral floor mats. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146029 If continuation sheet Page 12 of 19 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 08/09/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm The facility's Fall Prevention and Management policy dated May 23, 2023 showed A comprehensive fall prevention care plan is developed by the Interdisciplinary Team (IDT) based on the Morse Fall Scale results, environmental concerns if identified, resident, family, and support staff input, medical condition of the resident, and review of the Fall Prevention care plan. Residents Affected - Few As of August 9, 2024 at 2 PM, the facility was unable to provide a Fall Intervention policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146029 If continuation sheet Page 13 of 19 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 08/09/2024 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm Based on observation, interview, and record review, the facility failed to obtain monthly weights/reweights and recognize significant weight loss for a resident. Residents Affected - Few This failure resulted in R82's weight loss not being recognized until R82 sustained a 12.47% weight loss in 90 days. This applies to 1 resident (R82) reviewed for weight loss in a sample of 34 residents. The findings include: On 8/6/24 at 11:57 AM, R82 said she does not like the facility food. R82 said the food is bland and I don't eat much because the food doesn't look good. R82 said she doesn't like her meat chopped up. R82 said she weighed 150 pounds when she was admitted a year ago and the last time they weighed her she was 120 pounds. R82 said she does not receive any supplements. No supplements were seen in R82's room. R82's Face sheet shows an initial admission date of 8/19/23. R82's POS (Physician Order Sheet) shows order dated 12/22/23 for monthly weights, an order dated 10/24/23 for general diet mechanical soft texture, thin liquid consistency, and does not show a hospice order. V2's (DON's) weight change note written on 5/13/24 states R82 had poor appetite and weight loss and speech therapy to see R82 for possible upgrade of diet. Since 5/13/24, R82 did not have any notes written by V21 (Clinical Nutrition Manager/Dietician) or speech therapy. R82's 'Weights and Vitals Summary' shows her initial admission weight on 8/21/23 was 152 pounds. R82's weight on 5/9/24 is documented as 143.6 pounds. On 6/17/24 R82's weight was documented as 133 pounds, this weight was struck out by V21 (Clinical Nutrition Manager/Dietician) with a note showing reweight requested. R82 was not reweighed in June. R82's weight was not documented in the month of July 2024. R82's weight was not documented again until 8/6/24 as 120.8 pounds. This weight was again struck out by V21 with a note requesting reweight. As of 8/7/24 at 2:30 PM, R82 did not have an accepted weight documented since 5/9/24. At 2:30PM on 8/7/24, surveyor requested from V1 (Administrator) that R82 be weighed. On 8/7/24 at 4:28 PM V2 (DON/Director of Nursing) verbally notified surveyor that R82 was just weighed and the result was 125.7 pounds. On 8/7/24 at 4:28PM, V2 (DON) said she notified V21 (Clinical Nutrition Manager/Dietician) of R82's weight of 125.7 pounds and he was aware it was a significant weight loss. The weight change from 5/9/24 of 143.6 pounds to 125.7 pounds on 8/7/24 is a 12.47% weight loss in 90 days. As of 8/8/24 at 11:31 AM, R28's weight of 125.7 pounds verbalized to surveyor on 8/7/24 had still not been documented in her medical record. On 8/8/24 at 1:16 PM, V21 (Clinical Nutrition Manager/Dietician) said the facility's current policy is that every resident gets weighed at least monthly by the 5th of the month. V21 said if a resident's monthly weight is documented and it is 5 pounds more or less than the previous weight, he will strike it out and request a reweight. V21 said he requests a reweight by sending an email list of all residents who need to be reweighed to V2 (DON) and V4 (Wound Care Nurse). V21 verified that he emailed V2 and V4 that R82 needed to be weighed/reweighed on 6/17/24, 6/21/24, 7/8/24, 7/11/24, 7/17/24, and 8/6/24. V21 said if the resident's weight has not been entered by the 5th of the month it becomes an urgent priority. V21 said accurate weights are important because it is the first step in an accurate nutritional assessment. V21 said we don't want significant weight loss ever and R82 fell through the cracks. V21 said R82 should be evaluated by speech therapy. On 8/8/24 at 1:37 PM, V2 (DON) said she did not know why R82 was not reweighed after V21 requested reweights. V2 said she will take responsibility for R82's weight not being recorded on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146029 If continuation sheet Page 14 of 19 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 08/09/2024 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 0692 Level of Harm - Actual harm Residents Affected - Few 8/7/24 when it was taken because she was handed the written weight. V2 said she did not communicate to V21 on 8/7/24 that R82 was reweighed or what her weight was, contradicting what she had told surveyor on 8/7/24. V2 said speech therapy has never seen R82. V2 said she could not remember if she had ever talked to R82's nurse about obtaining an order for speech therapy after she wrote her weight change note in May of 2024. On 8/8/24 at 8:38 AM V2 said they used to have a restorative aide that was responsible for obtaining resident weights/reweights, but the aide had been gone for 2-3 months so they had put V4 (Wound Care Nurse) in charge of obtaining resident reweights. V2 said she wished V21 had been more vocal and communicated to her verbally that reweights were needed instead of sending email. V2 said R82's reweights fell through the cracks because her weights were struck out so she did not trigger as weight loss. On 8/8/24 at 12:21 PM, V4 (Wound Care Nurse) said V21 may have notified her that R82 needed a weight/reweight. V4 said when she receives the email from V21 she notifies the nursing staff to obtain the weight and she tries to make sure the staff get it done. V4 said, but I am not going to lie, I don't always catch a weight that is missed. On 8/8/24 at 2:41 PM, V24 (RN/Registered Nurse) said all residents require a monthly weight, she was not aware that her resident, R82, had not had a weight accepted since 5/9/24, and V4 (Wound Care Nurse) is responsible for notifying the nursing staff when a weight is needed. V24 said monitoring resident weights is important because they need to pay attention if a resident is not eating because of decreased appetite or if something else medically is going on with the resident. On 8/8/24 at 2:47 PM, V25 (CNA/Certified Nurse Assistant) said all residents need to be weighed once a month. V25 said monitoring resident weights is important because they want to make sure residents are maintaining their weights, and if they are losing weight, they want to make sure the resident is eating enough. V25 said V4 notifies them when a reweight is needed. V25 said she has fed R82 in the past and her appetite varies, sometimes R82 eats dinner and sometimes she says she doesn't want to eat dinner. R82's Care Plan dated 8/22/23 shows she is at risk for altered nutritional status related to advanced age. Interventions include honor resident's food preferences and monitor weight monthly. The facility's policy titled, Weight Management dated 3/1/21 states, Community nursing and dietary staff will cooperate to prevent, monitor, and intervene for undesirable weight loss or gain for our residents. Weight Measurements: The nursing staff will measure resident's weight on admission, and monthly thereafter . Monthly weights are to be completed and documented in the electronic medical record between the 1st and the 5th of each month as assigned. Communication: Any weight change as below will be retaken for confirmation. If the weight is verified, nursing or the dietician will notify the physician. Significant Changes are defined as more .than . 7.5% .within 90 days .Undesirable Weight Loss: Interventions for undesirable weight loss or gain should focus first on food .Interdisciplinary Team members should consider possible interventions relevant to their discipline. The physician may order tests, appetite stimulants, or medications as appropriate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146029 If continuation sheet Page 15 of 19 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 08/09/2024 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 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 observation, interview, and record review, the facility failed to discard expired food items from the dry storage and failed to properly store food items in the freezer by building ice on food packages, the walk-in freezer door side, and the floor. This applies to all 98 residents consuming food from the kitchen. The Findings Include: On 8/6/24 at 9:42 AM, during an initial kitchen tour with the dietary manager (V5), the kitchen dry storage was observed with one-quarter of 32-ounce (oz) peanuts expired on 7/24/24, one pound of opened Pistachio bag expired on 7/25/24, an opened almond bag with two pounds of almonds expired on 7/25/24, and an unopened white chocolate designer dessert sauce 16 oz expired on 11/2021. On 8/6/24 at 9:45 AM, V5 stated, Everyone, especially the stock person, is responsible for checking for expired food items, which should be discarded. On 8/6/24 at 9:50 AM, the freezer was observed with 2.5 pounds (lbs) of provolone cheese, opened but without a date or label. On 8/6/24 at 9:52 AM, V5 added, Opened food items should have a date/label. I will throw those out. On 8/6/24 at 9:55 AM, the walk-in cooler to walk-in freezer was observed with ice built up around the door sides (walk-in cooler to walk-in freezer), floor, and food packages, including two 20 pounds of meat rolls and 10-pound white fish. On 08/06/24 at 10:00 AM V6 (Chef) stated, We are contracted workers, and we notified the maintenance, and they notified the contractor 2-3 weeks ago. It seems like nobody wants to do anything with the condensation issues with the freezer. They said they placed the work order. The facility presented the Food and Supply Storage policy revised on 1/24 document: Procedures Cover, label, and date unused portions and open packages. Date and rotate items; first in, first out (FIFO). Discard food past the use-by or expiration date. On 08/07/24 at 02:21 PM, V2(Director of Nursing/DON) stated, We have no residents with a gastrostomy tube (GT) or nothing per oral (NPO). Hence all of our 98 residents are eating from the Kitchen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146029 If continuation sheet Page 16 of 19 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 08/09/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5.R96 is a [AGE] year-old female admitted on [DATE] with an admitting diagnosis, including an infected leg wound. Residents Affected - Some On 08/07/24 at 11:20 AM, V4 (Wound Care Nurse) provided wound care to R96's left lower leg open wounds without wearing a gown. On 08/07/24 at 11:31 AM, V3(Registered Nurse/RN) stated, R96 is done with her antibiotics and is on enhanced barrier precaution due to her lower extremity wounds. Staff should wear gowns and gloves when providing care to residents. On 08/07/24 at 11:30 AM, V4 (Wound Care Nurse) stated that she should have worn the gown to provide wound care to R96 as she is on enhanced barrier precaution; I forgot. The facility presented the Enhanced Barrier Precaution policy dated 4/1/24 document: Guidelines. 3. Implementation of Enhanced Barrier Precaution: b. Personal Protective Equipment (PPE) for enhanced barrier precaution is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room 4. High-contact resident care activities include: h. Wound Care: Any skin opening requiring a dressing. Based on observation, interview, and record review, the facility failed to do hand hygiene and glove change during incontinence care, wound care, and during the meal service. The facility also failed to use proper PPE (Personal Protective Equipment) for residents who were under EBP (Enhanced Barrier Precautions) during wound care. This applies to 6 residents (R45, R92, R68, R60, R14, and R96) reviewed for infection control in a sample of 34. The findings include: 1. On 08/06/24 at 12:28 PM V9 CNA (Certified Nurse's Assistant) was observed delivering lunch to residents that were in their rooms. V9, with ungloved hands, brought R45 her lunch plate, set it on her bedside table, moved R45's personal items that were on her bedside table around to make room for the plate, then opened the container of ice cream, opened the cloth napkin and handed R45 her utensils. V9 then went back into the hall, did not clean her hands, picked up R68's plate and brought the plate to R68's bedside table, adjusted R68's personal items on her bedside table, opened the ice cream, opened the napkin and gave the utensils, and then adjusted R68's bed using the bed control. V9 then left the room and did not clean her hands and came back with coffee and peaches off the food cart and gave the coffee and peaches to R68. Then V9 went into the bathroom and put on gloves but did not clean her hands and adjusted R68's bed again and provided her with water and cut up her food. R45 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146029 If continuation sheet Page 17 of 19 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 08/09/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some then asked V9 to cut up her food also. V9 removed her gloves, did not clean her hands, and put on new gloves and cut up R45's food. Then V9 removed her gloves, picked up R92's plate and brought it into R92's room. V9 did not clean her hands after removing her gloves. V9 then picked up R92's personal bottle of olive oil and poured the olive oil in R92's cup of coffee with her uncleansed hands. 2. On 08/08/24 at 09:22 AM V4 (Wound Care Nurse) was providing wound care for R60. V9 CNA (Certified Nurse's Assistant) was assisting with wound care, she was observed touching R60's bare skin while turning her and holding her in a sideline position while wound care was being provided. V9 was observed with gloves on her hands but did not have a gown on. V4 cleaned R60's sacral wound removed her gloves, did not clean her hands and did not remove her gown, and left the room to go to her medication cart to get another vial of normal saline and then came back into the room, did not clean her hands and put on new gloves and continued to clean R60's wound. Then after wound care was completed V10 CNA came into the room to assist V9 in incontinence care for R60. V9 then left out of the room, touching the door handle with her dirty gloved hands to get some washcloths from the hall. V4 returned to the room and was observed then putting on a gown. V9 then proceeded to clean R60's perineal and rectal/buttock area. Then V9 with same dirty gloved hands applied skin barrier protection to R60 buttocks and then removed her gloves and went into the bathroom. V9 then came out of the bathroom put on new gloves, touched R60's colostomy bag that was full of stool, and then opened and applied barrier cream to R60's perineal area. V9 then removed her gloves and put on a new pair of gloves but did not clean her hands. V9 then pulled the new brief between R60's legs and attached the brief on the left side. V4 then pulled out the soil brief from under R60 and then pulled out the new brief and attached it on the right side. V4 did not remove her gloves and clean her hands after touching the soil brief and before touching and attaching the new brief. Then V4 went into the bathroom and got 2 clean washcloths with her dirty gloved hands and gave one of them to V9. Then both V4 and V9 then clean R60's arm pits at the same time with those washcloths. Then both V9 and V4 with the same dirty gloved hands pulled R60 up in the bed, and V9 used the bed control to adjust the bed while still wearing the dirty gloves, and V4 was observed touching R60's bedrails with her dirty gloved hands. On 08/08/24 at 02:28 PM, V1 (Administrator) said that V4 should have had a gown on because R60 was on EBP. V1 said that the nurse should have removed her gown and washed her hands before going to the medication cart, and V4 should have removed her gloves and cleaned her hands before touching the door and getting clean wash clothes. V1 said that staff should have removed their gloves, cleaned their hands and put on new gloves before going to a clean area for infection control issues and cross contamination. 3. On 08/08/24 at 09:55 AM, V4 was observed providing wound care for R68. V4 cleaned the wound and then applied a new dressing to the wound. V4 did not remove her gloves and clean her hands before applying the new dressing. V4 then with dirty gloved hands, pulled up and attached R68's brief and then pulled up R68's blanket. V4 then used the bed control to adjust the bed and put R68's call light in reach. V4 then removed her gloves and cleaned her hands. On 08/08/24 at 10:07, V4 said that she should have removed her gloves and cleaned her hands after cleaning R68's wound and after finishing wound care and before touching R68's personal items. On 08/08/24 at 02:20 PM, V1 said that V4 should have removed her gloves and clean hands after cleaning the wound. The facility's Hand Hygiene policy dated 9/1/23 showed, staff in direct contact with resident will perform proper hand hygiene procedures to prevent the spread of infection to others . Hand Hygiene (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146029 If continuation sheet Page 18 of 19 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 08/09/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Table showed hand hygiene should be done: between resident contacts, after handling contaminated objects, before performing invasive procedures, after removal of protective equipment PPE including gloves, before and after handling clean or soiled dressings, linens, etcetera, before performing resident care procedures, after handling items potentially contaminated with blood body fluid secretions or excretions, and during resident care moving from a contaminated body site to a clean body site. Residents Affected - Some 4. On August 7, 2024 at 10:46 AM, V4 (Wound Care Nurse) provided wound care for R14. V4 removed R14's old dressing, removed her gloves, used ABHS (Alcohol Based Hand Sanitizer) and applied new gloves. V4 then used normal saline and gauze to clean V4's wound and grabbed the new dressing without glove change or hand hygiene and applied the new dressing to R14's wound. On August 8, 2024 at 1:50 PM, V4 said her gloves should have been changed and hand hygiene should have been done prior to handling the new dressing because the wound was dirty and she would want to make sure her gloves were clean prior to handling a new dressing. On August 8, 2024 at 2:06 PM, V2 (DON/Director of Nursing) said gloves should be changed and hand hygiene should be done when going from dirty to clean procedures, such as after cleaning the wound, prior to applying the new dressing. R14's face sheet showed she was admitted to the facility with diagnoses including stage 4 pressure ulcer, atrial fibrillation, generalized osteoarthritis, muscle wasting and atrophy, lack of coordination, low back pain, unsteadiness on feet, dementia, gastro-esophageal reflux disease, and hammer toes to the right and left foot. R14's POS (Physician Order Set) showed Enhanced barrier precautions (EBP) related to a wound/(indwelling urinary catheter). PPE to be utilized during high contact resident care activities. R14's MDS (Minimum Data Sheet) dated July 16, 2024 showed R14 was cognitively intact. R14's care plan dated August 7, 2024 showed Enhanced Barrier Precautions to be maintained. The facility's Hand Hygiene policy dated August 21, 2023 showed ABHS should be done when, during resident care, moving from a contaminated body site to a clean body site and Before applying and after removing personal protective equipment (PPE), including gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146029 If continuation sheet Page 19 of 19