Health inspection·April 25, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm The facility's undated policy regarding advance directives showed 9. If resident has chosen any other advance directive from current OBRA (Omnibus Budget Reconciliation Act) definitions and guidelines, resident will have a valid POLST form or alternative state issued document placed in the physical chart 12. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. Residents Affected - Few 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 04/25/2024 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 0695 Provide safe and appropriate respiratory care 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 administer oxygen to a resident as ordered by the physician. This applies to 1 of 1 resident (R42) reviewed for oxygen in a sample of 16. Residents Affected - Few The findings include: Face sheet, dated April 23, 2024, shows R42's diagnoses include respiratory failure with hypercapnia, congestive heart failure, bradycardia, atrial fibrillation, obstructive sleep apnea, and anxiety disorder. Physician order, initiated July 17, 2023 and discontinued April 22, 2024 at 2:13 PM, shows R42 had a physician's order for continuous oxygen to be administered at 5 liters per minute via nasal cannula. Care plan, initiated April 22, 2024, shows R42 had orders for oxygen therapy related to congestive heart failure and his care plan interventions included providing oxygen as ordered. On April 22, 2024 at 11:38 AM, R42 was resting in his bed with his nasal cannula placed in his nose. R42's oxygen concentrator was turned on and R42's oxygen was set to deliver 3.5 liters per minute. At 1:33 PM, R42's oxygen remained set to deliver 3.5 liters per minute of oxygen. At 1:52 PM, V9 (CNA/Certified Nursing Assistant) examined R42's oxygen concentrator setting and stated the oxygen was set to deliver 3.5 liters per minute of oxygen. At 1:55 PM, V15 (Infection Control Nurse) and V16 (Licensed Practical Nurse) both examined R42's oxygen concentrator and stated R42's oxygen was set to deliver 3.5 liters per minute of oxygen. Facility policy Oxygen Administration, revised October 2023, shows, Verify that there is a physician's order for the procedure. Review the physician's order of facility protocol for oxygen administration 8. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute 10. Adjust the oxygen delivery device so that is comfortable for the resident and the proper flow of oxygen is being administered 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 04/25/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that a narcotic medication was not borrowed from one resident and given to another resident. This applies to 1 of 5 residents (R306) reviewed for medication administration in the sample of 16. The findings include: R306 is an [AGE] year old female admitted to the facility on [DATE] with medical diagnoses that include syncope and collapse, history of falling, pain in right shoulder, and presence of cardiac pacemaker. R306 has a physician order dated April 21, 2024 for hydrocodone/acetaminophen 5/325 milligrams (mg) give 1 tablet every 4 hours as needed for moderate pain. R48 also has a physician order dated April 14, 2024 for hydrocodone/acetaminophen 5/325 mg - give 1 tablet by mouth every 8 hours as needed for pain. On April 22, 2024 at 11:13 AM while observing 3rd floor split cart and narcotic reconciliation, V12 (Registered Nurse) stated that the narcotic count would be off because he gave one of R48's hydrocodone/acetaminophen 5/325 mg tablets to R306. V12 stated that R306 has an order for hydrocodone/acetaminophen 5/325 mg but did not have a prescription for Hydrocodone 5/325 yet. V12 stated they are waiting for R306's doctor to send a prescription for hydrocodone/acetaminophen 5/325 mg. R48's controlled drug receipt record for hydrocodone/acetaminophen 5/325 mg showed that R48 had 17 tablets remaining. However, the actual count in the medication blister card was 16 tablets remaining. V12 stated that it is the facility's policy not to share one resident's narcotic medication with another resident. V12 also stated that he was not able to pull the hydrocodone/acetaminophen 5/325 mg tablet for R306 from the backup medication supply machine because there was no prescription available to be processed by the pharmacy at that time. Review of R306's medication administration record shows that hydrocodone-acetaminophen 5/325 mg was given to R306 on April 22, 2024 at 9:22 AM On April 23, 2024 at 10:41 AM, V12 stated R306's hydrocodone-acetaminophen 5/325 mg came that day. V12 stated he was able to get a prescription from the doctor yesterday afternoon via fax. V12 stated he then faxed the prescription to the pharmacy. On April 24, 2024 at 11:05 AM, V13 (Pharmacist) stated that an order is not an actual prescription when dealing with narcotics. V13 stated that they received an order for R306's Hydrocodone/acetaminophen 5/325 mg via fax on April 22, 2024 at 10:32 am. V13 state that the prescription came later in the day at 2:08 PM. V13 stated the facility would not be able to pull hydrocodone/acetaminophen 5/325 mg from the backup medication supply machine without a prescription. V13 stated that the nurse should not share narcotic medications with other residents. V13 stated that if the doctor has not signed the prescription and approved a narcotic medication then the facility should not administer the medication. On April 24, 2024 at 1:33 PM, V2 (Director of Nursing) stated there must be a prescription for a narcotic to be administered. V2 stated it is their policy not to take from one resident's medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete 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 04/25/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete and give it to another resident. V2 stated without a prescription for a narcotic medication, the physician is not giving his permission to administer the medication. V2 stated it is their policy not to give a narcotic medication until the pharmacy receives a valid prescription and agrees to its distribution. The facility's administering medications policy showed in-part, under Policy interpretation and implementation: 10. The individual administering the medication checks the label to verify the right resident, right medication, right dose, right time, right route, and right documentation of administration when giving the medication. 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 04/25/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on observation, interview, and record review, the facility failed to identify and monitor behaviors and provide diagnosis targeted for a prescribed antipsychotic medication. This applies to 1 of 5 residents (R15) reviewed for unnecessary medications in the sample of 16. The findings include: On April 22, 2024 at 10:57am, R15 was in a wheelchair in the resident room. R15 was dressed, groomed, and calm. R15 answered questions with slight nods only. R15's affect was flat. According to the facility Face Sheet, R15 has diagnoses at admit, March 17, 2024, with diagnoses including pneumonia; urinary tract infection; weakness; shortness of breath; acute respiratory failure with hypoxia; unsteadiness on feet; dysphagia, oropharyngeal phase; unspecified atrial fibrillation; thoracic aortal aneurysm; hyperlipidemia; unspecified dementia, unspecified severity with other behavioral disturbance; anxiety disorder unspecified; other recurrent depressive disorders; anemia unspecified; presence of other vascular implants and grafts; essential (primary) hypertension; constipation unspecified. The physician order sheet (POS) shows an order for Quetiapine Fumarate (an anti-psychotic medication) 50 milligrams by mouth at bedtime for anxiety. The order is dated March 17, 2024. The diagnosis list includes no psychotic illness that would necessitate the use of an antipsychotic medication. The PASRR (Preadmission Screening and Record Review) for R15, dated March 15, 2024, shows PASRR Level 1 Determination: No Level 2 required - No SMI (severe mental illness). There is no record of monitoring R15's behavior in the facility record. A Progress Note dated April 1, 2024 at 3:50 pm, from the psychiatric Nurse Practitioner (V7) shows R15 has a history of screaming and resisting care and notes these behaviors are not occurring at the time of the examination and refers to no other diagnostic criteria for the use of an antipsychotic medication. On April 24, 2024 at 12:25 pm, V19 (Spouse to R15) stated R15 was not taking quetiapine or Seroquel (the brand name for quetiapine fumarate) at home before being hospitalized immediately prior to admission to the facility on March 17, 2024. The facility provided their policy titled Psychotropic Medication Use. The policy includes: 1. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. 2. The Attending Physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others. (continued on next page) 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 04/25/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm 7. Psychotropic medications shall generally be used only for the following conditions/diagnoses as documented in the record, consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders (current and subsequent editions): a. Schizophrenia; Residents Affected - Few b. Schizoaffective disorder; c. Schizophreniform disorder; d. Delusional disorder; e. Mood disorders (e.g. bipolar disorder, depression with psychotic features, and treatment refractory major depression); f. Psychosis in the absence of dementia; g. Medical illnesses with psychotic symptoms and/or treatment-related psychosis or mania (e.g. high dose steroids); h. Tourette's Disorder; i. Huntington Disease; j. Hiccups; k. Nausea and vomiting associated with cancer or chemotherapy. 8. Diagnoses alone do not warrant the use of antipsychotic medication. In addition to the above criteria, antipsychotic medications will generally only be considered if the following conditions are also met: a. The behavioral symptoms present a danger to the resident or other; AND: (1) the symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations; delusions, paranoia or grandiosity; or (2) behavioral interventions have been attempted and included in the plan of care, except in an emergency. 11. Antipsychotic medications will not be used if the only symptoms are one or more of the following: a. Wandering; b. Poor self-care c. Restlessness; (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 04/25/2024 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 0758 d. Impaired memory; Level of Harm - Minimal harm or potential for actual harm e. Mild anxiety; f. Insomnia; Residents Affected - Few g. Inattention or indifference to surroundings; h. Sadness or crying alone that is not related to depression or other psychiatric disorders; i. Fidgeting; j. Nervousness; or k. Uncooperativeness. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146125 If continuation sheet Page 8 of 8