Health inspection·July 14, 2023

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure an IV (intravenous) dressing was changed. Residents Affected - Few This applies to 1 of 2 residents (R203) reviewed for IV use and maintenance. Findings include: On 7/11/23 at 10:47 AM, R203 was in bed in his room. R203 said he was admitted to the facility because he needs IV antibiotics for infection. R203 said he is on two different antibiotics and will be here at the facility for four weeks. R203 had an implanted port/central venous catheter access site on his right upper chest for the antibiotic infusions. The date on the dressing of the central line that showed when the dressing was last changed was 7/3/23 (eight days earlier). R203's current Physician Order Sheet (POS) shows the following orders: access Port-A-Cath change Huber needle and dressing weekly, Meropenem-Sodium Chloride Intravenous solution reconstituted 1 gram (GM)/50 milliliters (ML) three times a day for infection until 8/4/23 and Sulfamethoxazole-Trimethoprim Intravenous solution 400-80 milligrams (MG)/5 ml three times a day for infections until 8/4/23. R203's face sheet dated 7/13/23 showed that R203 had diagnoses of intracranial abscess and granuloma, small cell B-cell lymphoma, sepsis and viral infection. On 7/11/23 at 3:10 PM, V8 (Registered Nurse-RN) said the catheter dressing is done weekly by the third shift nurses and as needed. V8 stated if the nurse is unable to change it, they should endorse it to the oncoming nurse. V8 confirmed that the date on dressing was 7/3/23 and that it should have been changed on 7/10/23 by the night shift nurse. On 7/13/23 at 9:45 AM, V2 (Director of Nursing-DON) said catheter dressing changes is done weekly by the third shift nurses, if they are busy, they should inform the morning shift nurses and it needs to be changed for infection control reasons. The facility's IV (Intravenous) Dressing Changes policy (undated) states that the purpose of this procedure is to prevent catheter-related infections associated with contaminated, loosened, or soiled catheter-site dressings. Change the dressing if it becomes damp, loosened or visibly soiled and at least every 5-7 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146125 If continuation sheet Page 2 of 8 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 146125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hearthwood Snf Senior Living 829 Carillon Drive Bartlett, IL 60103 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to assess for pain and address pain during wound dressing changes. Residents Affected - Few This applies to 1of 1 resident (R253) reviewed for pain management in sample of 20. The findings include: R253's skin impairment care plan (revised 6/30/23) shows that R253 has an actual impairment to skin integrity to his legs, left and right upper arms, left ankle, left 4th toe, left bunion, right lateral big toe, scrotum, groin (related to edema with multiple dry blood blisters), chronic venous stasis ulcers, moisture-associated skin damage/rash, and skin tears, and R253 has diagnoses of multiple wounds, bruises, and skin tears. R253's pressure ulcer care plan (revised 6/30/23) showed he also has pressure injuries to his right and left buttocks and on his left heel. Interventions on R253's pressure ulcer care plan include to treat pain as per orders prior to treatment/turning to ensure [R253's] comfort and he prefers to be positioned with [head of bed] elevated for comfort. On 7/12/23 at 2:12 PM, V9 (Wound Care Nurse/Licensed Practical Nurse-LPN) completed wound dressing changes on R253. V9 was assisted by V11 (CNA-Certified Nurse Assistant Supervisor/Scheduler), and V10 (Wound Care Doctor) was at the bedside to assess and measure R253's wounds. V9 informed R253 of the dressing changes and gathered supplies. V9 and V11 removed both of R253's pressure-relieving boots and the pillows from under R253's knees. V9 then removed old dressing on R253's right upper arm. When V9 removed it, R253 flinched and said, Ow. V9 proceeded to remove old dressings on R253's left forearm and left upper arm, and R253 grimaced and said, ow that hurts- I want to sit up. V9 informed R253 that he will get up after the dressing change and that he needed to turn on his side and V11 assisted V9 with turning R253 to his right side. As they were turning R253, he grimaced again and said, Ow. V9 removed the old dressing on R253's buttocks and R253 said, Ouch. V9 apologized and V11 said, Take a deep breath. R253 grimaced and said again that he wanted to sit up and V11 said, Hang in there. V10 measured the wounds on R253's left forearm and left upper arm and V9 cleansed R253's skin tears on the left forearm and left upper arm with normal saline and applied skin prep. R253 said, Ouch and said he wanted the head of his bed elevated, V9 put the head of his bed up and did not ask R253 about his pain. V9 applied skin prep, the treatment, and covered the wound on R253's buttocks while R253 kept saying ow, ow, and ouch. V10 informed R253 to hold on and that he could get up when the dressing change was completed. V9 moved to the wound on his left toes; V9 removed dressing, R253 said Ouch, that hurts. V9 cleansed the wound on R253's left third and fourth toe and applied skin prep and dressings. During the treatment application, R253 said, Don't do that, whatever you are doing, it hurts. V9 said she was almost done. V9 and V11 repositioned R253 after the dressing changes. The observation of the dressing changes was from 2:12 PM to 3:00 PM. On 7/12/23 at 3:01 PM, V9 said R253 gets Acetaminophen 500 mg every 12 hours, and he received the last dose in the morning and was not sure if R253 receives any narcotic medication. R253's current Physician Order Sheet (POS) shows that R253 has the following orders: Acetaminophen 500 milligram (MG) by mouth every 12 hours for pain management. R253's July 2023 Medication Administration Record (MAR) showed that R253 received Acetaminophen 500 mg on 7/12/23 at 8:00 AM, six hours earlier. R253's pain care plan (revised 6/30/23) showed interventions of encourage/educate resident of methods to notify staff of pain and effectiveness of interventions, and review orders to identify pain relief medications or treatments, notify practitioner if ineffective. On 7/13/23 at 9:50 AM, V2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146125 If continuation sheet Page 3 of 8 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 146125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hearthwood Snf Senior Living 829 Carillon Drive Bartlett, IL 60103 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete (Director of Nursing-DON) said that if the resident is in visible pain or distress, the nurse should have checked the last time the resident got medication and if it was effective and see why the resident was still in pain. The facility's policy Pain Management Clinical Protocol (undated) stated that the nursing staff will identify any situations or interventions where an increase in the resident's pain maybe anticipated, for example, wound care, ambulation, or repositioning. Staff will provide the elements of a comforting environment and appropriate physical and complementary interventions. Event ID: Facility ID: 146125 If continuation sheet Page 4 of 8 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 146125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hearthwood Snf Senior Living 829 Carillon Drive Bartlett, IL 60103 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 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 properly label/date, seal/store, and remove expired food items and maintain a hazard free kitchen. Residents Affected - Many This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: Facility Resident Census and Condition of Residents (Form CMS--Centers for Medicare and Medicaid Services--672) dated 7/11/23 documents that the total census was 53 residents. On 7/13/23 at 11:41AM, V1 (Administrator) said all 53 residents eat from the facility kitchen. On 7/11/23 starting at 10:11AM, the facility kitchen was toured in the presence of V13 (Assistant Director of Dining Services/Dietician) and V12 (Executive Chef). On 7/11/23 at 10:24AM in kitchen refrigerator #3 the following food items were found: 1. A fully thawed half ham, dated 5/9/23. 2. An unlabeled/undated/uncovered tray of raw catfish. The catfish was placed below a tray of raw salmon and visible condensation was seen dripping from the salmon tray onto the catfish. At 10:24AM, V12 (Executive Chef) said the catfish should be covered because there is a risk of cross contamination when left uncovered. 3. A tray of 17 filets labeled chicken bacon wrap dated 6/13. At 10:30AM, V12 (Executive Chef) said the filets were thawed and served yesterday and the leftovers should have been thrown in the garbage yesterday. 4. A large deep silver bin labeled chicken teriyaki dated 6/23. At 10:30AM, V12 (Executive Chef) said 6/23 is the date the food was frozen and they should have written a defrost date. 5. A small deep silver bin with unlabeled/undated cinnamon rolls. 6. A small deep silver bin labeled feta cheese and dated 6/24/23. At 10:35AM, V12 (Executive Chef) said the feta cheese is expired; it should have been thrown away after 14 days. On 7/11/23 at 10:36AM in kitchen refrigerator #4, four large trays of defrosting chicken thighs were found uncovered and unlabeled/undated. At 10:36AM, V12 (Executive Chef) said the trays of chicken should be covered. On 7/11/23 at 10:41AM and 7/12/23 at 11:40AM in Freezer #5, water was observed dripping from the ceiling at freezer entrance and a layer of bumpy, chunky, and thick ice was observed on the floor. On 7/11/23 at 10:41AM, V12 (Executive Chef) said to be careful when walking into the freezer. On 7/13/23 at 10:52AM, V13 (Dietician) said all foods should be labeled and dated for food safety. V13 said thawed/defrosted food should be labeled with defrost date to ensure food is discarded by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146125 If continuation sheet Page 5 of 8 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 146125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hearthwood Snf Senior Living 829 Carillon Drive Bartlett, IL 60103 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 the correct date for food safety. V13 said all foods in the refrigerator should be sealed/covered to prevent contamination and risk of foodborne illness to the residents due to bacteria growth. V13 said the ice on the floor of the freezer is a fall hazard for kitchen staff. The facility's policy titled, Food Storage Policy revised 1/2/2023 states, .4. Food and non-food supplies are to be clearly labeled. 5. Prepared food items will be used, frozen, or discarded within 7 days of preparation . 7. All food items will be stored in air tight packaging 11. All food stored in coolers shall be stored .not subject to .contamination by condensation . The facility's policy titled, Labeling, Dating, and Storage of Received and Prepared Foods Policy revised 1/2/2023 states, .4. Any food items prepared in house will be labeled with food name and date of preparation. Prepared foods will be sealed air tight and placed in appropriate food storage areas. 5. All food storage areas will be monitored regularly to discard any outdated food items from inventory stock. The facility's undated policy titled, Maintenance Service states, Policy Interpretation and Implementation 2 b. maintaining the building in good repair and free from hazards .d. maintaining the heat/cooling system, refrigerator, . in good working order . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146125 If continuation sheet Page 6 of 8 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 146125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hearthwood Snf Senior Living 829 Carillon Drive Bartlett, IL 60103 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** Residents Affected - Some Based on observation, interview and record review, the facility failed to have visitors follow its Personal Protective Equipment (PPE) policy by having visitors visiting COVID-positive resident without having, mask, gown, gloves, and goggles. The facility also failed to perform hand hygiene with glove use during blood sugar checks and after intravenous medication administration and failed to contain oxygen and CPAP (Continuous Positive Airway Pressure) or BIPAP (Bilevel Positive Airway Pressure) mask and tubing to prevent contamination. This applies to six out of 20 (R21, R104, R203, R303, R304, R305) residents reviewed for infection control in the sample of 20. The findings include: 1. On 7/13/23 at 9:32 AM, R104 (COVID positive) observed with a PPE box at the door side. R104 has a visitor/daughter at the bedside without having a mask, gloves, gown, and goggles. V6 (Licensed Practical Nurse/LPN) was observed standing in the hallway talking to R104's visitor at the bedside. On 7/13/23 at 9:35 AM, V6 instructed the visitor to wear PPE when V6 noticed the presence of the surveyor. On 07/13/23 at 09:53 AM, V6 stated, R104 was admitted last night and had tested COVID positive in the Hospital. Everybody should wear a mask and gown to go to [R104's] room. On 7/13/23 at 10:32 AM, V16 (Infection Preventionist) stated, Everyone, including staff and visitors, should wear PPE. The nurses should educate the family to wear gowns, masks, gloves, and goggles for isolation resident rooms. The family should be educated on PPE use with COVID residents. The facility presented PPE Policy Statement (Revised October 2018) documenting: 7. Visitors and residents asked to comply with transmission-based precautions are educated on the proper use of PPE and provided with equipment at no charge. 2. On 7/11/2023, at 3:20 PM, V8 (RN-Registered Nurse) administered an IV (Intravenous) antibiotic to R203. R203 had an implanted port on his right chest. After the medication was hung and all used supplies were discarded, V8 (RN) took off her gloves without performing any hand hygiene and left R203's room. V8 opened her computer and documented. R203's admission Records showed he was admitted on [DATE] with a diagnosis of sepsis. 3. On 7/11/2023, at 11:43 AM, V6 (Licensed Practical Nurse/LPN) put on gloves without performing any hand hygiene and checked R304's blood sugar level. Afterwards, V6 removed his gloves and did not perform any hand hygiene. V6 (LPN) then went to the medication cart and documented. R304's admission Record showed diagnosis of diabetes mellitus, type II. R304's POS (Physician Order Sheet) shows order for blood sugar checks before meals and at bedtime. 4. On 7/11/2023, at 11:53 AM, V6 (LPN) put on gloves without performing any hand hygiene and obtained a blood sample from R21. After the procedure, V6 discarded all the used supplies and removed his gloves and did not perform hand hygiene. V6 (LPN) then put on new gloves and prepared R21's insulin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146125 If continuation sheet Page 7 of 8 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 146125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hearthwood Snf Senior Living 829 Carillon Drive Bartlett, IL 60103 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 and injected R21's insulin into her abdomen. Level of Harm - Minimal harm or potential for actual harm 5. On 7/11/2023, at 11:16 AM, R303's CPAP mask and tubing were lying on the nightstand unprotected. R303's oxygen tubing was draped around the oxygen concentrator machine with part of the tubing touching the floor. Residents Affected - Some 6. On 7/11/2023, at 10:47 AM, R305's BIPAP mask and tubing were seen draped on top of the machine unprotected. R305's oxygen tubing and mask were seen draped around the oxygen concentrator with part of the tubing touching the floor. On 7/13/2023, at 9:44 AM, V2 (DON-Director of Nursing) said if oxygen masks and tubing and CPAP/BIPAP masks and tubing were not in use, they should be contained in a bag to prevent contamination and for infection control purposes. V2 said hand hygiene should be done before putting on gloves and after taking off gloves. V2 said hand hygiene is important especially when taking care of an implanted port and administering IV (intravenous) antibiotic medication because the resident already has an ongoing infection. Facility's undated Handwashing/ Hand Hygiene Policy stated the following: .2. All personnel shall follow the handwashing/ hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.7. Use and alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . b. Before and after direct contact with residents; c. Before preparing or handling medications; d. Before performing any non-surgical invasive device (e.g., catheters, IV access sites); i: after contact with resident's intact skin; m: After removing gloves. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. Facility's undated Policy on Administering Medications by IV stated that hand antisepsis should be performed after medication administration. Facility's undated Policy on Storage of Drugs and Biologicals stated 9. O2 tubing, CPAP/BIPAP and masks should be washed and placed in a bag (dated) bedside after every use. If any of these devices are in room however not being used, should be placed in a bag, and sealed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146125 If continuation sheet Page 8 of 8