Inspection·June 18, 2025

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's medical records were in agreement with his wishes for his advance directives. This applies to 1 of 6 residents reviewed for advance directives in a sample of 21. The findings include: On [DATE] at 09:18 AM, R54's Electronic Medical Record (EMR) did not contain a POLST form (Physician Order for Life-Sustaining Treatment) that showed he did not want CPR (cardio-pulmponary resuscitation). On [DATE] at 02:40 PM, R54's chart at the nurse's station contained an advance directive form that showed DNR (Do Not Resuscitate), dated and signed on [DATE] by R54. R54's Face Sheet showed he was a Full Code. On [DATE] at 10:06 AM, R54 said that no one from the facility asked him what his advance directives were. R54 said that he signed a DNR form 2 years ago, and he gave it to the facility, and that is his wish. R54's [DATE], MDS (Minimum Data Set) showed that R54's cognition is intact. On [DATE] at 4:55 PM, V11 (Resident Services Assistant) said that she did not use R54's DNR because it was from the state of Michigan. R54's [DATE] care plan showed a focus of Advance Directives, resident is currently a Full Code (desires full life-sustaining treatment) at this time. The goal was for the resident's advance directives wishes will be known and the intervention was to complete/update Advance Directives document. R54's [DATE] baseline Care Plan showed advanced directives will be monitored by Social Services. On [DATE] at 03:11 PM, V2 DON (Director of Nursing) said that advance directives are what the resident wants done at the end of life. V2 said that the advance directive forms should reflect the residents wishes and the forms should be in the residents' records. V2 said the form should be the same in the chart on the floor as in the resident's electronic records. V2 said that this needs to be done to ensure the staff are following the residents wishes and not deviating from it. The facilities Advanced Directive policy dated [DATE] shows that on admission staff will determine if the resident has executed an advanced directive, and if not determine whether the resident would like to formulate an advanced directive. Staff will provide the resident or representative information in the manner that is easily understood about the rights to refuse medical or surgical treatment and formulate an advanced directive. Upon admission should the resident have an advanced directive, a digital version will be uploaded and copies placed in the chart as well as communicated to staff. The social service department will periodically assess the resident for decision making abilities and approach the healthcare proxy or legal representative if the resident is determined to have decision making capacity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146110 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 146110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smith Crossing 10501 Emilie Lane Orland Park, IL 60467 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 0584 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview, and record review, the facility failed to provide a safe and homelike environment. Residents Affected - Few This applies to 2 of 2 residents (R2, R22) reviewed for environment in a sample of 21. The findings include: 1. On 6/15/25 at 10:40 AM, during initial tour, in R22's room, the base trim on the wall was more than halfway off and resting on the floor and it was extending into the doorway. On 6/16/25 at 10:20 AM, V19 (Director of Clinical Operations/RN-Registered Nurse) stated, EVS (Environmental Services), Housekeeping, and CNA (Certified Nursing Assistants) are supposed to do a work order to get it resolved. It's a team effort. If a CNA sees something like a loose baseboard, he or she is supposed to put in a work order. On 6/16/25 at 10:28 AM, V13 (Facilities Director) stated, whoever sees it first, be it nursing and/or housekeeping, they need to report it to me, so I can tell my staff to fix it. On 6/16/25 at 12:07 PM, R22 stated, Yes, I want that base board fixed. I don't know what happened. I don't want to fall over it. I've had a lot of falls here, but not because of that. R22's face sheet shows diagnoses of neurocognitive disorder with Lewy bodies and repeated falls. R22's MDS (Minimum Data Set) dated 4/24/25 shows she is cognitively intact. R22's care plan (6/8/25) shows she is at risk for falls related to disease process, weakness, and history of falls. R22 has poor safety awareness, and does not call for assistance at times. Intervention-R22 needs a safe environment with even floors free from spills and/or clutter. Facility's policy titled Preventative Maintenance dated (3/2025) shows: 2. Functions of maintenance personnel include, but are not limited to: a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. B. Maintaining the building in good repair and free from hazards . 2. On 06/15/25 at 12:23 PM, there was a 1 pound container of germicide wipes on R2's dresser. The instructions on the container showed: personal protection, wear appropriate barrier protectors, gloves, gowns, masks, or eye coverings. R2's diagnoses include cerebrovascular disease, Alzheimer's disease, dementia, and unspecified psychosis. On 06/17/25 at 03:21 PM, V2 DON (Director of Nursing) said that the germicide wipes should be securely stored and locked in the housekeeping designated storage area. V2 said that this should be done for patient safety, it would be harmful if the residents had contact with them, and that there is even a higher risk if the resident is confused. The facility's Accidents and Supervision policy dated May 2025 showed the resident's environment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146110 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 146110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smith Crossing 10501 Emilie Lane Orland Park, IL 60467 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 0584 will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assisted devices to prevent accidents this includes identifying hazards and risks. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146110 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 146110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smith Crossing 10501 Emilie Lane Orland Park, IL 60467 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 0628 Level of Harm - Minimal harm or potential for actual harm Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R13's progress notes show the following: Residents Affected - Some On 12/30/24 at 9:14 PM at 6 PM, (R13) observed supine on floor near window. Limb shortening noted to LLE (Left Lower Extremity). (R13) complained of pain to RLE (Right Lower Extremity), but unable to rate pain using number scale. This nurse called 911 and notified dispatch of unwitnessed fall. Called Fire Department. EMT (Emergency Medical Technician) arrived. (R13) sent to hospital emergency room. On 12/30/24 at 11:14 PM, (R13) admitted to ICU (Intensive Care Unit) with a diagnosis of subdural hematoma. On 12/31/24 at 7:56 PM, (R13) returned from hospital with POA (Power of Attorney) at bedside via stretcher with ambulance services. On 3/21/25 at 10:12 PM, Writer was called to (R13)'s room by the CNA (Certified Nursing Assistant). Writer observed (R13) sitting on the side of the bed on the floor. (R13) was bleeding from her head. Writer then called 911 and POA and other daughter. 911 came and got resident. On 3/22/25 at 6:36 AM, (R13) returned from the emergency department at 12:50 AM accompanied by daughter. (R13) sent out to ED (Emergency Department) by PM (Evening) shift nurse due to laceration to head related to fall. Review of R13's electronic medical record doesn't show a notice of transfer/ bed hold notification for R13's transfer to the hospital on 3/21/25. On 6/16/25 at 3:10 PM, V2 (DON-Director of Nursing) stated that R13 did not need notice of transfer/bed hold form because he was in the hospital less than 24 hours. 3. R7's electronic records showed that on 4/30/25, R7 was sent to the local community hospital because of a fracture to her right femur. No documents were present in R7's electronic records showing that the discharge and bed hold policies and forms were given to R7 or R7's representative. There was also no documentation of the Ombudsmen being notified of the hospital transfer. On 06/16/25 at 04:19 PM, V11 (Resident Services Assistant) said that R7 went to the hospital on 4/30/25 and returned on 5/1/25s so she was not given notification. V11 said that the facility does not give notification if the resident is sent to the ER and then returns. On 06/17/25 at 03:15 PM, V2 DON (Director of Nursing) said that his expectations are that the staff give written notice on bed hold and discharge transfers and the reason for transfer every time a resident is sent to the hospital or discharged . 4. R76's electronic records showed that he was discharged on 3/19/25. The records did not show that the facility notified the Ombudsman of R76's discharge. On 06/17/25 at 02:54 PM, V2 DON said that the facility is to notify the Ombudsman of all our discharges and transfers within 30 days. Based on interview and record review, the facility failed to provide residents and/or their representatives the bed hold notice upon transfer, written notification of the reason for transfer to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146110 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 146110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smith Crossing 10501 Emilie Lane Orland Park, IL 60467 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 0628 hospital or discharge, and failed to notify the ombudsman of the hospital transfer or discharge. Level of Harm - Minimal harm or potential for actual harm This applies to 4 of 4 residents (R7, R13, R75, R76) reviewed for discharge in a sample of 21. The findings include: Residents Affected - Some 1. R75's Face Sheet showed R75 was admitted to the facility on [DATE]. R75 had multiple diagnoses which included malignant neoplasm of colon, myalgia, anemia, atherosclerotic heart disease, elevated white blood cell (WBC), and hypertension. R75's Lab Results Report dated 03/28/25 showed WBC 14.9 (Reference Range 3.6-11.2), Hemoglobin 7.7 (Reference Range 12.0-18.0). R75's Progress Note dated 03/28/25 at 6:35 PM, showed Primary care physician NP (Nurse Practitioner) reviewed recent lab results from 03/28/25 and ordered to send resident to hospital due to abnormal hemoglobin and WBC (White Blood Cell) results. Writer phoned (Ambulance) for transportation to (Hospital). R75's EMR (Electronic Medical Record) contained no documentation of written notice for reason of transfer to the hospital provided to R75 and/or the representative. The EMR contained no documentation of notification of the ombudsman of the hospital transfer for 03/28/25. The EMR contained no documentation of the bed hold notice given to R75 and/or the representative. The facility was unable to provide documentation for written notification of the reason for transfer to the hospital and the bed hold notice for the hospital transfer on 03/28/25 given to R75 and/or the representative. The facility provided a copy of an email that was sent to the ombudsman on 06/16/25 notifying of the facility transfers to the hospital and discharges for the months of February, March, April, and May 2025. On 06/16/25 4:41 PM, V19 (Director of Clinical Operations) stated the ombudsman should be notified monthly of the transfers or discharges. V19 stated the ombudsman was not notified of the transfers to the hospital or discharges for the months of February, March and April 2025. V19 stated the bed hold policy is only given to the resident or their POA (Power of Attorney) if they are admitted to the hospital. V19 stated the bed hold policy and written notification for the reason for transfer or discharge was not given to R75. The facility's Bed Hold Notice Upon Transfer Policy last reviewed/revised June 2024 showed, Procedure: 1. Before a resident is transferred to the hospital or goes on therapeutic leave, the facility will provide to the resident and/or the resident representative written information that specifies: a. The duration of the state bed-hold policy during which the resident is permitted to return and resume residence in the nursing facility. 2. Nursing staff shall ensure that a copy of the Notice of Transfer/Bed Hold Notification Form will be sent with residents as they are transferred to a hospital or leave the facility on therapeutic leave. In the even of an emergency transfer of a resident, the facility will provide notice of the facility's bed-hold policy within 24 hours or as soon as practicable to the resident representative. The facility's Transfer and Discharge Policy last reviewed February 2025 showed, Policy Explanation and Compliance Guidelines: 4. The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: A. The specific reason and basis for transfer or discharge. 12. Emergency Transfers/Discharges- G. The Social Services Director, or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146110 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 146110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smith Crossing 10501 Emilie Lane Orland Park, IL 60467 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 0628 Level of Harm - Minimal harm or potential for actual harm designee, will provide copies of notices for emergency transfers to the Ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis. I. In situations where the facility has decided to discharge the resident while the resident is still hospitalized , the facility will send a notice of discharge to the resident and resident representative before the discharge and must also send a copy of the discharge notice to the ombudsman. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146110 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 146110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smith Crossing 10501 Emilie Lane Orland Park, IL 60467 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 Based on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) care to meet the needs of the residents. Residents Affected - Few This applies to 3 of 3 residents (R54, R59 & R60) reviewed for ADLs care in a sample of 21. The findings include: 1. On 06/15/25 at 12:04 PM, R54's nails were long and jagged. R54 said that the last time his nails were cut were when he did them himself. R54 said that he would like for staff to assist him with nail care. On 06/17/25 at 10:05 AM, R54's nails remained long and jagged. R54's 5/14/24 MDS (Minimum Data Set) showed that R54 needs partial/moderate assistance from staff for personal hygiene. R54's 05/14/25 care plan showed a focus of ADL self-care performance deficit related to weakness, disease process, and limited mobility. 2. On 06/15/25 at 12:36 PM, R59, had long hair on his face and chin. R59 said that it had bed about 10 days since he has been shaved and the long hair on his face bothers him and he wants to be shaved. On 06/16/25 at 03:05 PM, R59's long hair on his face and chin was still present. On 06/17/25 at 10:14 AM, R59's long hair on his face and chin remained and he said no one has come to shave him yet and he is still waiting. R59's 06/05/25 care plan shows a focus for ADL self-care performance deficit related to limited mobility, limited range of motion, and weakness. R59's 5/28/25 MDS shows that R54 is dependent on staff for personal hygiene. 3. On 6/15/25 at 10:38 AM, R60's hair was oily. R60's 05/22/25 MDS showed that her cognition is severely impaired, and she is dependent on staff for personal hygiene. On 06/17/25 at 02:46 PM, V2 DON (Director of Nursing) said that hair should be washed as scheduled on shower day and as needed. V2 said that residents should be shaved as frequently as needed and when they want it done. V2 said that nail care should be done as needed and at the resident's preference. The facility's Activities of Daily Living (ADLs) policy dated March 2025 showed care and services will be provided for activities of daily living including bathing, dressing, grooming, and oral care. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146110 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 146110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smith Crossing 10501 Emilie Lane Orland Park, IL 60467 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent the development of an unstageable pressure ulcer for a resident at moderate risk for skin breakdown. This failure led to a resident requiring skin grafting. Residents Affected - Few This applies to 1 of 4 residents (R59) reviewed for pressure ulcers in a sample of 21. The findings include: On 06/17/25 at 10:14 AM, a bright-red, quarter-sized, open wound was present on R59's sacrum. R59 had an indwelling urinary catheter. R59's electronic health records showed that he was admitted on [DATE], with R59's first pressure ulcer risk assessment completed on 3/4/2025. The assessment showed R59 was at moderate risk for skin breakdown. On 06/17/25 at 10:14 AM, V27 (Wound Nurse) stated that R59 had a stage 4 pressure ulcer. V27 said that R59's stage 4 pressure ulcer started as MASD (Moisture Associated Skin Damage) to R59's sacrum and the MASD could have been avoided by providing incontinence care and frequent repositioning. V7 provided R59's sacral wound measurement note titled Skilled March 2025 that showed the pressure ulcer was 3.0 x 2.0 x 0.1 (in centimeters-cm) and staged at unstageable, and it was acquired at the facility. The note showed the MASD area with the pressure ulcer was identified on 2/4/25. V7 said that as the MASD to R59's sacrum was being treated, the Wound Doctor determined an area of the MASD was actually a stage 2 pressure ulcer. V27 stated the stage 2 pressure wound then progressed to a stage 4 pressure wound. R59's 3/6/25 wound physician notes showed the sacrum wound was unstageable due to necrosis, and the size of the wound was 3 x 2 x 0.1 cm, with 60% necrotic tissue. V7 said that the 3/6/25 wound note was the initial measurement for R59's sacral pressure wound. R59's 6/12/25 wound physician notes showed the sacrum wound had progressed to as stage 4. The same note showed Skin Substitute Application Note: During today's visit this full thickness, chronic stage 4 pressure wound sacrum wound underwent the placement of a skin substitute graft . On 06/15/25 at 12:36 PM, R59 acknowleged he had a pressure wound. On 06/17/25 at 01:33 PM, R59 said that he got the wound to his sacrum from being in his bed and chair. R59 said that staff only reposition him two or three times a day and that he is incontinent of stool. R59 said that he just waits until the staff come to change him. R59's 5/28/25 MDS (Minimum Data Set) shows that R59's cognition is intact. On 06/17/25 at 01:46 PM, V28 CNA (Certified Nurse's Assistant) stated she is familiar with R59 and his stool is soft most of the time, and when she comes in in the morning, she finds R59 incontinent of stool most of the time. On 06/17/25 at 01:05 PM, V18 (Wound Physician) said that R59's pressure ulcer would have been avoidable with proper incontinence care and repositioning. V18 said that she had to provide R59 with substitute skin grafting because R59's wound healing was delayed. R59's 5/28/2025 MDS showed he was dependent on staff for toileting hygeine, and rolling over from left to right in bed. R59's bowel incontinence care plan (revised 2/14/25) showed he was at risk for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146110 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 146110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smith Crossing 10501 Emilie Lane Orland Park, IL 60467 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Actual harm Residents Affected - Few impaired skin integrity. The interventions included to check R59 every two hours and assist with toileting as needed and provide peri care after each incontinent episode. R59's stage 4 pressure ulcer care plan (initiated 3/4/2025) identified risk factors of bowel incontinence, poor mobility, aging fagile skin, and muscle wasting. Interventions showed Turn and reposition every two hours and as needed. R59's June 2025 physician's orders showed an order from 2/12/25 Turn and reposition every 2 hours and as needed. On 06/17/25 at 02:25 PM V2 DON (Director of Nursing) said that staff are to follow the physician orders, reposition every 2 hours, and do frequent rounds to check to see if the residents are soiled or not. V2 said that staff should do more frequent checks if the resident is incontinent of stool and does not let staff know. V2 said that the facility should educate the staff and resident to ensure frequent rounding is being done and to inform the resident to notify staff when he needs changing. V2 said staff should keep the resident's skin dry, change residents frequently, and frequently reposition residents. The facility did not provide a policy for prevention of pressure wounds. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146110 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 146110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smith Crossing 10501 Emilie Lane Orland Park, IL 60467 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review, the facility failed to provide peri-care in a manner that would prevent urinary tract infection, and failed to ensure that urinary catheter drainage bags are not touching the floor. This applies to 4 of 4 residents (R59, R128, R227, R330) reviewed for peri-care and catheter care in the sample of 21. The findings include: 1. Face sheet shows that R128 is 77 years-old who has multiple medical diagnoses including urinary retention. R128 has indwelling urinary catheter. On 6/15/25, at 11:10 AM, R128 was resting in her recliner with her urinary catheter bag resting on the floor. 2. R330's electronic medical record shows that R330 is 88 years-old. R330's restorative nursing program evaluation dated 6/16/25 shows that R330 has weakness and limited mobility. On 6/16/25, at 9:30 AM, V21 (Nurse) and V22 (Certified Nursing Assistant/CNA) rendered peri-care to R330 who had a bowel movement. They turned R330 on her side, then V22 proceeded to clean R330's rectum and buttocks. After cleaning R330's back perineum, they turned R330 on her back. V22 just patted the outer labia lightly with wet wipes and applied the incontinence brief without cleaning the whole frontal peri-area. Facility's Policy and Procedure for Perineal Care dated March 2023 shows: Policy: It is the practice of this this facility to provide perineal care to all incontinent residents during routine bath and as needed to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess skin breakdown. Definition: Perineal Care refers to the care of the external genitalia and the anal area. On 6/17/25, at 11:00 AM, V2 (Director of Nursing/DON) stated, the urinary drainage bag should not be placed on the floor to prevent potential contamination, and it is a part of infection control. V2 said when staff provide incontinence care, the staff must clean every part of the perineum to ensure there is no residual fecal matter or urine left on the skin surface to prevent infection and skin breakdown. 3. On 06/15/25 at 12:37 PM, R59's was in his bed with his bed in low position and his catheter bag was on the floor. R59's diagnoses include disorders of the bladder, retention of urine, presence of urogenital implants, dementia, and benign prostatic hyperplasia of lower urinary tract system. On 06/17/25 at 02:58 PM, V2 DON (Director of Nursing) said that the catheter bag and tubing should not be on the floor for safety reasons, the resident can trip and so that the catheter is not being tugged and pulled, and for infection control. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146110 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 146110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smith Crossing 10501 Emilie Lane Orland Park, IL 60467 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 0690 Level of Harm - Minimal harm or potential for actual harm 4. On 06/15/25 at 01:48 PM, R227 was in his recliner with his walker in front of him with his catheter bag hanging from the walker. The bag and tubing were touching the floor. R227 was very confused at that time. R227's diagnoses include legally blind, chronic kidney disease stage 3, benign prostatic hyperplasia lower urinary tract system, and presence of urogenital implants. Residents Affected - Few On 06/17/25 at 03:05 PM, V2 said that he expects staff to ensure proper positioning of the catheter bag, that it is off the floor and proper positioning to avoid pulling of catheter or dislodgement. The facility Catheter Care policy dated March 2025 did not show how catheter bags and tubing should be off of the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146110 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 146110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smith Crossing 10501 Emilie Lane Orland Park, IL 60467 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 0693 Level of Harm - Minimal harm or potential for actual harm Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review, the facility failed to obtain orders for gastrostomy tube (g-tube) flushes. Residents Affected - Few This applies to 2 of 2 residents (R64, R70) reviewed for gastrostomy tube in the sample of 21. The findings include: 1. On 6/16/25, at 12:53 PM, V16 (Nurse) administered Hydrocortisone and Midodrine tablets to R70 via g-tube. The medicines were crushed in separate cups and mixed with 30 ml of water. Prior to administration, V16 checked R70's g-tube placement by auscultating the abdomen and injecting 30 ml of air into the g-tube. V16 flushed the tube with 40 ml of water, prior to administration, in between the medications, and after administration. There was residue in both medicine cups, so V16 repeated the same cycle, mixing the residue with 30 ml of water and flushing the g-tube again with 40 ml of water prior to administration, in between medicine residue, and after administration. The water that was flushed or administered to R70 totaled to about 380 ml. When V16 completed the medication administration, V16 started setting up the g-tube feeding and stated she would program the water flushing in the g-tube pump at 165 ml every 4 hours, as ordered by the physician. On 6/17/25, at 10:48 AM, V2 (Director of Nursing/DON) stated staff should check for residual to ensure placement of the g-tube. The staff should flush the g-tube according to physician's order. The nurses should mix the crushed medication with water prior to administration. The expectation is to ensure that medication will go all the way through the tubing to the stomach for absorption and efficacy of medications. Facility's Policy and Procedure for Enteral Nutrition-Care and Treatment Feeding Tubes dated January 2025 shows: Policy: To utilize feeding tubes with interventions to prevent complications to the extent possible. Policy Explanation and Compliance Guidelines: 5. Licensed nurses will monitor and check that the feeding tube is in the right location (e.g., stomach or small intestines, depending on the tube). a. Tube placement will be verified before beginning of feeding and before administering medications. 6. Directions for staff on how to provide the following care: e. Frequency of and volume used for flushing, including flushing for medication administration, and what to do when a prescriber's order does not specify. The facility's policy does not have specific procedure on how to check placement of the g-tube. 2. On 6/15/25, at 4:09 PM, V17 (Nurse) administered Eliquis medication to R64 via g-tube. V17 checked the placement of R64's g-tube by auscultating R64's abdomen and pouring 5 milliliters (ml) of water into the tube. Then she poured the plain crushed (powdered) Eliquis into the syringe followed by 10 ml of water. V17 did not further flush the g-tube with additional water. R64's and R70's physician order summaries (POS) with regards to g-tube, have no indication that shows how much water and how often the g-tube should be flushed. R64's and R70's g-tube care plans do not have indications with regards to frequency and the amount of water to flush. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146110 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 146110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smith Crossing 10501 Emilie Lane Orland Park, IL 60467 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 Based on observation, interview, and record review, the facility failed to ensure that medications were administered as prescribed by the physician. There were 26 medication opportunities with 5 errors, resulting to 19.23% error rate. Residents Affected - Few This applies to 2 of the 5 residents (R19, R70) reviewed for medication administration in the sample of 21. The findings include: 1. On 6/15/25, at 4:56 PM, V15 (Nurse) administered multiple oral medications, and one eye drop solution (Genteal eye drop) to R19. The medications include, Carvedilol, Ropinirole, Duloxetine, Ferrous Sulfate EC (Enteric Coated), Polyethylene Glycol. V15 crushed all these medications prior to administration. After V15 administered these medications, V15 stated that was all R19's scheduled medications at 5 PM. R19's Medication Administration Record (MAR), shows that there were other medications scheduled for 5:00 PM, these include Docusate Sodium (liquid), Voltaren External Gel, and Lidocaine Patch. These medications were not observed given to R19. However, V15 signed it as given. On 6/16/25 at 5:20 PM, V15 confirmed that whatever medications that was observed administered to R19 on 6/15/25 were all the medications R19 received. 2. On 6/16/25, at 12:41 PM, V16 (Nurse) administered Hydrocortisone and Midodrine tablets to R70 via gastrostomy tube (g-tube). V16 crushed these medications separately and mixed them with 30 milliliters (ml) of water. By the time V16 arrived to R70's bedroom, the medications settled at the bottom of the cup. V16 poured the medications in and left a lot of medication residue at the bottom of the medicine cups. V16 proceeded to flush the g-tube and stated that she was finished with R70's medication administration. On 6/17/25, at 10:32 AM, V2 (Director of Nursing/DON) stated that nurses must follow physician order such as treatment process and medication as prescribed. All crushed medications mixed with water must be stirred completely prior to g-tube or oral administration to ensure that the full dose are given. The Ferrous Sulfate EC should not be crushed because it changes the integrity of the medication. All enteric coated medications can't be crushed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146110 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 146110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smith Crossing 10501 Emilie Lane Orland Park, IL 60467 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 4. On 6/16/25, at 9:30 AM, R330 was resting on her bed and just had a bowel movement on the bed pan. V22 (CNA) provided peri-care with the assistance of V21 (Nurse). V22 cleaned R330's back perineum, removed the bed pan, emptied the stool into the toilet, returned to R330, and continued to clean R330's frontal perineum. V21 and V22 applied a clean incontinence brief and assisted to reposition R330. V22 changed her gloves in between all these tasks without performing hand hygiene. Residents Affected - Some On 6/17/25, at 11:01 AM, V2 (DON) stated the staff must perform hand hygiene and change gloves in between tasks, such as dirty to clean tasks, to prevent cross contamination and spread of infection. Facility's Policy and Procedure for Hand Hygiene dated December 2024, shows: Policy: All staff will perform proper hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Additional considerations: The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Based on observation, interview, and record review, the facility failed to perform hand hygiene while providing personal care for 3 residents and failed to contain biohazard garbage for 2 residents. This effects 5 of 8 residents (R330, R41, R227, R60 & R59) reviewed for infection control in a sample of 21. The findings include: 1. On 06/15/25 at 10:38 AM, V4 and V5 CNAs (Certified Nurse's Assistants) were providing incontinence care for R60. R60 was standing up in the bathroom next to the toilet and V4 with her gloved hands removed R60's soiled brief, cleaned her perineal area, and without changing her gloves or performing hand hygeine, put on a clean brief, pulled up R60's pants then grab R60's wheelchair, sat R60 in it, and then moved R60 to the sink. On 06/17/25 02:52 PM V2 DON (Director of Nursing) said that his expectations are that staff change their gloves and clean their hands when moving from a dirty area to a clean one for infection prevention and cross contamination. 2. On 06/16/25 at 03:05 PM, V25 & V26 CNAs were providing incontinence care for R59. V25 with his gloved hands transferred R59 from his wheelchair to his bed, pulled his pants down below his knees, opened R59's brief, cleaned the perineal area and catheter tubing, adjusted R59's bed, repositioned R59 in the bed, removed R59's brief, grabbed the wipes, wiped R59's buttocks, applied a clean brief, adjusted R59 in the bed, used the bed control to raise R59's head, then V25 removed R59's shoes and pants. Only at that time did V25 remove his gloves and put on new gloves, but without performing hand hygeine. Then V25 dropped R59's blanket on the floor, put heel protectors on R59's feet, put a pillow between R59's legs, and picked up R59's blanket from the floor and put it on R59, put a pillow on the right side of R59's body, adjusted the sheets on the bed, used the bed control to raise R59's head of bed, put the call light within reach, moved R59's bedside table next to his bed, and adjusted his personal items on the table, including R59's drink. After that, V25 removed his gloves and cleaned his hands. On 06/17/25 at 02:58 PM V2 DON (Director of Nursing) said that staff are to perform hand hygiene, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146110 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 146110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smith Crossing 10501 Emilie Lane Orland Park, IL 60467 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 clean their hands and change their gloves after leaving a dirty area and before putting on new gloves for infection prevention, cross contamination of surfaces, and for resident safety. The facility's Hand Hygiene policy dated December 2024 shows all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. Residents Affected - Some 3. On 06/15/25 at 01:41 PM, V10 CNA was in R227 and R41's room. V10 pulled a full red bag of trash out of the red biohazard waste container and dropped it on the floor. V10 then pulled items out of the bottom of the red container and out of the yellow biohazard container and placed them into the open red bag on the floor. V10 left the bag on the floor and went into R227 and R41's bathroom. On 06/15/25 at 01:45 PM, V10 said that she should not have dropped the bag on the floor because it could contaminate the floor. V10 said that she did it because she was getting garbage out of the containers. V10 said that she is agency staff, and she has not had any training on infection control in over 2 years. The facility's Infection Prevention and Control Program dated December 2024 showed the facility established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146110 If continuation sheet Page 16 of 16