Health inspection·March 30, 2023

F 0550 The State Regulation's Interpretive Guidelines regarding Dignity shows: Level of Harm - Minimal harm or potential for actual harm Staff should address residents with the name or pronoun of the resident's choice, avoiding the use of labels for residents such as feeders or walkers. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146128 If continuation sheet Page 2 of 22 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 146128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plymouth Place 315 North LA Grange Road LA Grange Park, IL 60526 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 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Potential for minimal harm Based on observation and interview, the facility failed to ensure that survey results conducted by Federal or State surveyors were place in a conspicuous area accessible for anyone to see without asking for them. This has the potential to affect all 62 residents in the facility. Residents Affected - Many The findings include: The Facility Census Report dated 3/27/2023 shows that there were 62 residents at the skilled unit of the facility. On 3/28/2023 at 10:00 A.M., residents' group meeting was held. R1, R24, R28, R61, R65, R66 and R154 have attended the meeting. They all said that they do not know where the survey results were kept. Multiple attempts were tried by the surveyor and explained regarding survey report. Again, these residents that attended the meeting have given a consensus answer that they do not know where the survey report was kept. During the first day of the survey on 3/27/2023, the survey result was not seen anywhere by the facility's entrance lobby nor was it noted on the lobby of the third floor of the facility's building where it is the designated floor for the skilled unit. On 3/28/2023 at 1:55 P.M., surveyor asked V4 (Senior Director of Clinical Services) where the survey results were kept. V4 showed the survey results binder that was placed on top of the desk at the lobby of the third floor. There was no posting to indicate where to find the survey result binder. The survey result binder was mixed with other information such as the activity calendar and offender notification. This makes it difficult to determine without asking where the survey results were. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146128 If continuation sheet Page 3 of 22 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 146128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plymouth Place 315 North LA Grange Road LA Grange Park, IL 60526 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure privacy during provisions nursing care. This applies to 2 of the 5 residents (R9, R67) reviewed for privacy during personal care of 20 sampled residents. Residents Affected - Few The findings include: 1. On 3/28/23 at 1:12 PM, V24 (Wound Care Nurse) provided wound care to R67. During wound care, it was observed that R67 had a bowel movement. After the completing the wound care, V24 notified a staff that R67 needed peri-care. R67 was left naked from the waist below while waiting for V20 (Certified Nursing Assistant/CNA) to arrive. V24 and two state representatives were inside the bedroom while R67 was resting in bed uncovered/naked. 2. On 3/28/23 at 2:25 PM, V22 (CNA) and V24 (Wound Care Nurse) rendered peri-care to R9. After completing the care, V22 and V24 applied a new incontinence brief and was about to close the brief when prompted by state representative to check suprapubic catheter dressing. The dressing was wet. V22 left the room to call V25 (Nurse). While waiting for V25, R9 was left with his lower area uncovered and naked, leaving no privacy. V24 and state representative was inside the room at the time that R9 was lying in bed naked from the waist down, waiting for V25. 03/29/23 02:26 PM, V2 (Director of Nursing/DON) stated that staff must provide privacy and dignity during provision of care, like limiting amount of exposed body. Facility's Policy and Procedure for Perineal Care indicates: Steps in Procedure: 6. Raise the gown or lower the pajamas. Avoid unnecessary exposure of the resident's body. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146128 If continuation sheet Page 4 of 22 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 146128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plymouth Place 315 North LA Grange Road LA Grange Park, IL 60526 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 0585 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on interview and record review, the facility failed to ensure that grievances from residents were addressed. Residents Affected - Some This applies to 7 residents (R1, R24, R28, R61, R65, R66 and R154) reviewed for grievances in the sample of 20. The findings include: On 3/28/2023 at 10:00 A.M., residents' group meeting was held. R1, R24, R28, R61, R65, R66 and R154 attended the meeting. They all said that they need more staff because it takes time for their call lights to be answered and accommodate their needs. They said they use their call lights when they need fresh water, change incontinence briefs and need to be assisted back to bed. They further said nothing was done about their concerns. Review of the Residents Council Minutes that was held monthly from March 2022 to March 2023 was reviewed. The following were concerns that were discussed during the Residents' Council Meeting: -03/08/2022: not enough staff and it takes a long time for the call lights to be answered. -04/06/2022: nursing department is always short-staffed. It takes a long time for the call lights to be answered. -05/10/2022: (V1, Administrator) joined the meeting and discussed staffing issues. -06/07/2022: Residents mentioned that whenever they pressed their call lights, it takes someone a while to come and help them. -07/05/2022: Residents mentioned that when they press their call lights no one comes. -08/02/2022: Residents asked the protocol for answering call lights. V2 (Director of Nursing) said 10-15 minutes is reasonable, if 2 people required, up to 20 minutes. -09/06/2022: Residents asked if there will be more CNAs (Certified Nurse Assistant) hired. -10/4/2022: Occasionally call lights take long to be answered. -11/01/2022: Not enough nurses. -12/06/2022: Call light times response times exceed 20 minutes. -01/03/2023: No one on the floor answer call lights as CNAs takes their lunch break at the same time. -02/07/2023: It seems that only one CNA for both North and South side of the unit. Call lights should be answered sooner and checked frequently. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146128 If continuation sheet Page 5 of 22 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 146128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plymouth Place 315 North LA Grange Road LA Grange Park, IL 60526 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 0585 -03/16/2023: Residents inquired about staffing ratio of nurses and CNAs. Level of Harm - Minimal harm or potential for actual harm On 3/28/2023 at 4:30 P.M., it was discussed with V1 (Administrator) and V4 (Senior Director of Clinical Services) regarding resolutions of the residents' concern that kept unresolved for the past year for timely call light response and staffing needs. There was no documentation presented that these grievances were addressed. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146128 If continuation sheet Page 6 of 22 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 146128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plymouth Place 315 North LA Grange Road LA Grange Park, IL 60526 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** 3. Face sheet shows that R67 is 80 years-old who has multiple medical diagnoses which include unsteadiness in the feet, difficulty walking, urinary tract infection, acute kidney failure and severe sepsis with septic shock. Minimum Data Sheet (MDS) dated [DATE] shows that R67 is alert and oriented. She requires extensive assistance for grooming and hygiene. Residents Affected - Few On 3/27/23 at 5:13 PM, R67 was resting in bed and was noted with long jagged fingernails with black/brown substances underneath the nails, and long facial hair on the chin about half inch in length. R67 stated that she wants her nails to be clipped and her facial hair/whiskers needs to be cut or flocked. On 3/28/23 at 1:37 PM, R67 was resting in bed and was noted with with long jagged fingernails and facial whiskers. R67 stated that she is waiting for someone to provide her with nail and facial care. R67 added that a staff member came in 2 days ago to ask if she wanted her nails clipped. However, the staff did not come back for follow up. On 3/29/23 at 2:58 PM, V2 (Director of Nursing/DON) stated that the staff must ensure that the residents nails are clean and clipped and with regards to facial hair, staff must offer shaving. Based on observation, interview and record review, the facility failed to assist residents identified as needing assistance with personal hygiene. This applies to 3 of 6 residents (R31, R54, R67) reviewed for activities of daily living in the sample of 20. The findings include: 1. R31's diagnoses on EMR (Electronic Medical Records) included need for assistance with personal care, fracture of right shoulder girdle, part unspecified, subsequent encounter for fracture with routine healing, unspecified macular degeneration, cognitive communication deficit, history of falling. R31's admission MDS (Minimum Data Set) dated 1/6/23 showed that R31 is intact in cognition and requires extensive assistance in personal hygiene. R31's care plan initiated 3/21/23 included that R31 has chronic ADL/activities of daily living decline due to advanced aged, declining visual status. Intervention included that as per facility protocol to check nail length and trim and clean on bath day and as necessary. On 03/28/23 at 11:26 AM, R31 was seated in the dining room and noted to have tuffs of facial hair on her chin and long nails (1-2 inches) with some of them jagged and with blackish substance underneath the nail beds. R31 stated that she would like her facial hair removed and nails cut and cleaned. This was relayed to V14 (Registered Nurse). 2. R54's EMR included diagnoses of Parkinson's disease, history of falling, unsteadiness on feet, presence of right artificial hip joint, encounter for surgical aftercare following surgery on the digestive system. R54's quarterly MDS dated [DATE] showed that R54 is moderately impaired in cognition and requires limited one-person physical assistance with personal hygiene. R54's care plan initiated 3/3/23 included that R54 has chronic decline in ADL self-care performance deficit related to Parkinson's diagnosis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146128 If continuation sheet Page 7 of 22 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 146128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plymouth Place 315 North LA Grange Road LA Grange Park, IL 60526 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 03/27/23 at 12:54 PM, R54 was in her room and had multiple facial hair across her chin. R54 stated needs help from staff. On 03/28/23 at 11:26 AM, R54 was in her room and still had multiple facial hair on her chin. R54 stated that she would like it removed and this was relayed to V14. Residents Affected - Few On 03/29/23 at 3:12 PM, V2 (Director of Nursing) stated that it is the responsibly of staff to offer grooming and if the resident wants it, to find a way to meet their need. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146128 If continuation sheet Page 8 of 22 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 146128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plymouth Place 315 North LA Grange Road LA Grange Park, IL 60526 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 - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to reposition a resident per plan of care to offload pressure for a resident who has pressure ulcer injury. This applies to 1 of 6 residents (R63) reviewed for pressure sores in the sample of 20. Residents Affected - Few The findings include: R63's EMR (Electronic Medical Records) included diagnoses of paraplegia, unspecified, pressure ulcer of sacral region, stage 4, type 2 diabetes mellitus without complications, acute infarction of spinal cord (embolic)(non-embolic), spinal stenosis, lumbar region without neurogenic claudication. R63's Quarterly MDS (Minimum Data Set) dated 1/17/23 showed that R63 was cognitively intact and required extensive assistance of 2 person physical assist for transfers. Wound care Physician Wound Evaluation and management summary dated 03/28/23 documents that R63 has a healing Stage 4 pressure injury. R63's nursing care plan revised 2/16/23 included that R63 has a slow-healing stage 4 pressure ulcer on her sacrum. Interventions included to limit sitting to wheelchair for 1-2 hours (initiated 2/16/22). Please turn and position me frequently (initiated 2/01/22). On 03/27/23 at 10:47 AM, R63 was seated on motorized wheelchair in her room. R63 remarked My bottom hurts me. I have a [pressure] sore and did not get it here. Its a long story. There is some kind of pad I am sitting on. I am only supposed to sit up in the wheelchair for only 2 hours a day. Some days it goes longer. Today they got me up at 10:15 AM which is earlier than usual. They use the lift to get me up. During intermittent checks between 10:47 AM and 12:43 PM, R63 was noted to be seated in the same position on her wheelchair in her room. On 03/27/23 at 12:43 PM, R63 was seen seated on her motorized wheelchair in her room and stated I'm still up. On 03/27/23 at 03:01 PM, R63 was lying in bed and stated They just put me in bed at 2:20 PM. I wrote it down. I have been up in my chair from 10:20-2:20 PM for 4 hours. I buzzed [Put call light on] 40 minutes ago before that and nobody came. On 03/29/23 at 3:09 PM, V2 (Director of Nursing) stated that if a resident has a pressure sore injury, it is appropriate to offload the pressure by repositioning or propping the resident up. V2 stated that some of the resident's have a chair time for certain amounts of time and the staff are encouraged to follow the plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146128 If continuation sheet Page 9 of 22 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 146128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plymouth Place 315 North LA Grange Road LA Grange Park, IL 60526 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. Based on interview and record review, the facility failed to provide PROM/Passive Range of Motion for a resident who has limited range of motion. This applies to 1 of 4 residents (R63) reviewed for range of motion in the sample of 20. The findings include: R63's EMR (Electronic Medical Record) included diagnoses of paraplegia, unspecified, pressure ulcer of sacral region, stage 4, type 2 diabetes mellitus without complications, acute infarction of spinal cord (embolic)(non-embolic), spinal stenosis, lumbar region without neurogenic claudication. R63's quarterly MDS (Minimum Data Set) dated 1/17/23 showed that R63 was cognitively intact and that restorative programs was performed for at least 15 minutes a day in the last 7 calendar days. R63's nursing care plan revised 1/13/2022 included that R63 needs assistance with ADL/activities of daily living self-care performance deficit related to stage 4 wound to sacrum secondary to paraplegia. Intervention for the the same included to provide gentle ROM/range of motion exercises to R63's bilateral lower legs two times a day. On 03/27/23 at 10:51 AM, R63 was seated on motorized wheelchair with blue colored protective boots on bilateral feet. R63 stated They are supposed to exercise my legs everyday but they don't always do it. They haven't done it in a long time. My 100 days of therapy are up a while ago. On 03/29/23 at 2:16 PM and 2:33 PM, V17 (Minimum Data Set Co-Ordinator) stated that the facility does not have a restorative program and although the State mandates a 15 minute or more ROM/PROM per day, the facility just does maintenance program once the residents are discharged from Medicare. On 03/29/23 at 12:04 PM, V15 CNA (Certified Nursing Assistant) stated that when he is assigned as a CNA to R63, he usually does the ROM exercises on R63's legs for 15 minutes per day. V15 added that this is done prior to getting R63 up out of bed into her wheelchair. V15 stated that he has not worked with R63 for 6 weeks and that the CNA that is assigned to R63 should do the ROM. V15 also stated that he does not document the same once ROM is done. On 03/29/23 at 12:07 PM, V16 (Physical Therapist) stated that R63 was discharged from Physical Therapy on 10/31/22. V16 stated that the CNA's should document electronically when ROM is given on the POC (Plan of Care) Response History. Review of PROM (Passive Range of Motion) documentation on POC Response History from 3/16/23-3/27/23 showed that 15 minutes of PROM twice a day was done only on 3/27/23. The following days also showed that PROM was done for less than 15 minutes daily: 3/17/23 at 18:17 for 3 minutes 3/20/23 at 19:51 for 5 minutes 3/24/23 at 23:11 for 5 minutes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146128 If continuation sheet Page 10 of 22 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 146128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plymouth Place 315 North LA Grange Road LA Grange Park, IL 60526 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 3/25/23 at 20:05 for 5 minutes Level of Harm - Minimal harm or potential for actual harm 3/26/23 at 09:17 for 3 minutes, and at 19:37 for 5 minutes Residents Affected - Few On 03/29/23 at 03:19 PM, V2 (Director of Nursing) stated that PROM is an individualized program designed for resident care. V2 stated that PROM exercise is offered to R63 and staff are required to follow plan of care. V2 added that R63 has been known to prefer V15 (CNA) doing the PROM treatment. On 03/29/23 03:42 PM, V12 (Registered Nurse) stated that she is familiar with R63 and has not been known to refuse PROM therapies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146128 If continuation sheet Page 11 of 22 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 146128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plymouth Place 315 North LA Grange Road LA Grange Park, IL 60526 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The electronic medical record (EMR) shows that R15 is 90 years-old who has multiple medical diagnoses to include dementia, muscle weakness and abnormality of gait and mobility, and unspecified fracture of the upper end of the right humerus, subsequent encounter for fracture with routine healing. Minimum Data Sheet (MDS) dated [DATE] shows that R15 is cognitively impaired and requires extensive assistance when being transferred. On 3/28/23 at 11:17 AM, V22 and V23 (Both Certified Nursing Assistants/CNA) transferred R15 from wheelchair to toilet via sit to stand. While being transferred, R15's knees were bent 45 degrees, like in a squat position, his hands were holding on to the bar handle of the sit to stand while his upper torso and armpits were hanging in the sling. R15's feet did not bear weight during transfer. R15's fall risk assessment dated [DATE] shows that R15 is moderately at risk for fall. 3. The electronic medical record (EMR) shows that R49 is 75 years-old who has multiple medical diagnoses which include dementia, cognitive communication deficit, and need for assistance with personal care. MDS dated [DATE] shows that R49 requires extensive assistance for transfer. On 3/29/23 at 10:44 AM, V18 (CNA) brought R49 to the bathroom with a wheelchair for toileting. V18 did not use a gait belt to assist R49, instead, she (V18) assisted R49 to stand by pulling up his waistband. R49 stood up unsteadily, then V18 proceeded to clean his back peri-area for incontinence care. On 3/29/23 at 2:49 PM, V2 (Director of Nursing/DON) stated that a resident on a sit to stand can have flexion in the knees but needs to be able to maintain standing balance and must be able to bear weight. V2 added, when transferring a resident who can stand and pivot, the staff must use a gait belt. This is for safety and proper body mechanics. R49's fall risk assessment dated [DATE] shows that R49 is a high risk for fall. Based on observation, interview and record review, the facility failed to ensure safety while transporting a resident in a wheelchair. R18 was transported by staff without legs rests attached to the wheelchair and fell forward when R18 placed her feet down. This resulted in R18 requiring sutures and an emergency room visit. The facility also failed to ensure proper techniques were utilized for R15 and R49 during transfers. This applies to 3 of 4 residents (R15, R18, R49) reviewed for falls and supervision in the sample of 20. The findings include: 1. R18's EMR (Electronic Medical Record) included that R18 is a [AGE] year old female with diagnoses of Alzheimer's disease with late onset, unsteadiness on feet, difficulty in walking, not elsewhere classified, unspecified abnormalities of gait and mobility, muscle weakness (generalized), bilateral primary osteoarthritis of knee, paranoid personality disorder, other specified anxiety disorders, atherosclerotic heart disease of native coronary artery without angina pectoris. R18's MDS (Minimum Data Set) dated 3/15/2023 showed that R18 was moderately impaired in cognition and required extensive assistance of one person physical assist for locomotion on and off unit. R18's nursing care plan revised 2/3/2023 included that R18 has been observed wandering in wheelchair when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146128 If continuation sheet Page 12 of 22 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 146128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plymouth Place 315 North LA Grange Road LA Grange Park, IL 60526 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 - Actual harm confused and/or disoriented but is easily redirected. Interventions included to distract R18 from wandering by offering pleasant diversions, structured activities, food, conversation, television, books, identify pattern of wandering and intervene as appropriate, provide structured activities, inquire if R18 needs to be toileted or in pain. Residents Affected - Few Incident Note dated 3/26/22 18:52 included as follows: [R18] was being wheeled in wheelchair by staff and tipped forward falling to the floor. [R18] bumped to right side of forehead causing a laceration above the right eye. Area covered. Medical Doctor notified orders to send 911 ER/emergency room for evaluation. Facility nurses' notes 'Transfer to Hospital Summary' dated 3/26/2023 19:12 included as follows: 911 in facility and R18 transferred to ER. R18 remains alert and verbal at the time of transfer. Bleeding controlled. Report given to RN/Registered Nurse at hospital. POA (Power of Attorney) and supervisors aware. On 03/27/23 at 10:33 AM, R18 was lying in bed with a bandage wrapped around her head above her eye and R18 was noted to have bruising and swelling under her right eye. R18 remarked They had to sew my head up at the hospital last night. I fell here. Everybody was with me. I don't know how many people. I want to rest now and don't want to talk anymore. On 03/28/23 at 08:59 AM, R18 was propped up in bed eating breakfast and had a dressing on the right side of forehead. Regarding the fall incident of 3/26/23, R18 stated I was in my wheelchair outside the room, and they started pushing me. There were 3-4 people around. I think it was outside in the hallway. When I fell it was very hard on the floor and there was nothing soft about it. On 03/28/23 at 10:26 AM, V13 (Certified Nursing Assistant) stated that she saw R18 ambulating by wheelchair down the opposite hallway of where R18's room was. V13 added that R18 has periods of confusion from time to time and tends to wander the hallway. V13 stated that she noted that R18 was more confused than usual that evening. V13 continued she said she doesn't want to go to the bathroom. She doesn't have a footrest on wheelchair as she can propel herself with her feet. I told her that I was going to take her back to her room and to lift her feet up. As I started to wheel her down the hallway to her room, she suddenly put her feet down that caused her to fall forward. She fell on the carpet and hit her forehead and there was some bleeding. There was a housekeeper close by and I told her to go get the nurse. It was the change of shift around 7:00 PM and V12 RN (Registered Nurse) was with the night nurse who was taking over. On 03/28/23 at 1:35 PM, V12 stated I was standing down the hallway and V13 was attempting to wheel R18 to her room. R18 is independent and able to propel to move her wheelchair. R18 put her feet down and when she fell, she had a laceration above her right eye. I evaluated her and there was bleeding to her forehead and wrapped it and put an ice pack. She was sent out by calling 911. Hospital discharge papers dated 3/27/23 included for resident to follow up with the primary care doctor for further evaluation of head injury and removal of two sutures in 5-7 days for laceration to forehead. On 03/29/23 at 09:24 AM, V2 (Director of Nursing) stated that he did not report R18's injury to IDPH (Illinois Department of Public Health). V2 added that if there are sutures, it is reportable. V2 stated that R18 did not have sutures as the report he got from nursing is to apply antibiotic and keep open to air. V2 stated that R18 was sent to the ER as she was on anticoagulants and had a risk for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146128 If continuation sheet Page 13 of 22 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 146128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plymouth Place 315 North LA Grange Road LA Grange Park, IL 60526 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 blood clots. When V2 was notified by surveyor that the ER report showed that R18 received two sutures, V2 stated that he was not aware of the same and will have to verify the same. Level of Harm - Actual harm Residents Affected - Few On 03/29/23 at 10:57 AM and 11:07 AM, V2 stated that after further investigation it was verified that R18 had received sutures to the forehead. V2 stated that if there was an injury, he should have received a call from nursing after the incident and that he did not receive the same. V2 stated that he is going to submit a late reportable. V2 added that R18 has cognitive impairment, and this indicates that R18 is not capable to comply with direction to put feet up. V2 stated that based on root cause analysis for best intent for R18's safety, is to use a leg rest during transfer. Initial and Final Notification of Incident of 3/26/23 included that assessment was completed on 3/29/23 and revealed that R18 right eyebrow was swollen and red and had two sutures for the laceration to forehead with steri strips applied. Assessment for fall included that R18 will benefit from leg rest during wheelchair transport due to inability to elevate feet during transfer or notify staff of rest periods needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146128 If continuation sheet Page 14 of 22 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 146128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plymouth Place 315 North LA Grange Road LA Grange Park, IL 60526 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 - Some 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 incontinence care in a manner that would prevent urinary tract infection (UTI). The facility also failed to provide urinary indwelling catheter care for residents who have this urinary device. This applies to 4 of 5 residents (R9, R15, R49, R67) reviewed for incontinence and indwelling urinary catheter care in the sample of 20. The findings include: 1. The electronic medical record (EMR) shows that R67 is 80 years-old who has multiple medical diagnoses to include urinary tract infection, acute kidney failure and severe sepsis with septic shock. On 3/28/23 at 1:21 PM, V20 (Certified Nursing Assistant/CNA) provided incontinence care to R67 who was wet with urine and had a bowel movement. V20 cleaned R67's frontal perineum, such as the groins and pubic area. However, V20 failed to clean the outer and the inner labia. 2. The electronic medical record (EMR) shows that R15 is 90 years-old who has multiple medical diagnoses to include dementia, urinary retention, muscle weakness and abnormality of gait and mobility. R15 has a suprapubic catheter. On 3/28/23 at 11:17 AM, V22 and V23 (Both CNA) R15 to the toilet. R15 had a bowel movement. The drainage bag of the catheter was placed on the floor. The suprapubic dressing of R15 was detached, hanging on the tubing, and soaked with urine. V23 cleaned R15's back peri-area. After cleaning the back perineum, V22 and V23 proceeded to apply the incontinence brief and pulled the pants back in place without cleaning the suprapubic catheter. They did not clean the area and the catheter tube. They did not call the nurse to clean him up. R15's physician order sheet (POS) dated 3/2/22 has an instruction to keep the indwelling (Foley) catheter drainage bag off the floor. 3. The electronic medical record (EMR) shows that R9 is 88 years-old who has multiple medical diagnoses which include UTI, urinary retention, Benign Prostatic Hyperplasia, Diabetes Mellitus, muscle weakness, and functional quadriplegia. R88 has a suprapubic catheter. On 3/28/23 at 2:25 PM, V22 (CNA) and V24 (Wound Care Nurse) rendered peri-care to R9. V22 wiped R9's groins and scrotal area, but failed to clean the shaft, while V24 cleaned the surrounding area of the suprapubic dressing. V22 and V24 applied a new incontinence brief and was about to close the brief when prompted by state representative to check suprapubic catheter dressing. The dressing was wet. V22 left the room to call a nurse. On 3/28/23 at 2:35 PM, V25 (Nurse) came into the room and cleaned the surrounding area of the insertion site of the suprapubic catheter. V25 proceeded to apply gauze dressing. However, V25 failed to clean the tubing of the suprapubic catheter. 4. The electronic medical record (EMR) shows that R49 is 75 years-old who has multiple medical diagnoses which include Dementia and urinary tract infection (UTI). R49 has urinary indwelling catheter. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146128 If continuation sheet Page 15 of 22 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 146128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plymouth Place 315 North LA Grange Road LA Grange Park, IL 60526 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 On 3/29/23 at 10:44 AM, V18 (CNA) assisted R49 to the toilet and provided peri-care. R49 had a bowel movement. Prior to providing peri-care, V18 placed R49's urinary bag on the bathroom floor and proceeded to wipe R49's back perineum (rectal and buttocks area). After the back peri-care, she applied a new incontinence brief, pulled up R49's pants back in place, and propelled him back to the bedroom. V18 did not clean R49's frontal perineum and did not provide urinary catheter care. Residents Affected - Some On 3/29/23 10:47 AM, V19 (R49's Caregiver) stated that R49 is more confused now because he has UTI. On 3/29/23 02:32 PM, V2 (Director of Nursing/DON) stated that when provide incontinence care, the staff must ensure that every portion of the peri-area is being cleaned. The staff should clean whatever is contaminated by feces and urine which include the labia, labial folds for female. For the male they should clean the groins, pubic area, and the complete shaft. If the resident has a catheter the staff must clean the insertion site and surrounding area down to the catheter away from the body. This is to prevent infection and promote healthy living. Facility's Policy and Procedure for Perineal Care indicates: Purpose: The purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections, and skin irritation, and to observe the resident's skin condition. Procedure: For a female resident: b. Wash perineal area, wiping from front to back. (1) Separate labia and wash area downward from front to back. For a male resident: b. Wash perineal area, starting with urethra and working outward. c. If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. e. Wash and rinse urethral area using a circular motion. f. Continue to wash the perineal area including the penis, scrotum, and the inner thighs. Facility's Policy and Procedure for Indwelling Urinary Catheter Care indicates: Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Procedure: b. Be sure that catheter tubing and drainage bag are kept off the floor. Facility's Policy and Procedure for Suprapubic Catheter Care indicates: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146128 If continuation sheet Page 16 of 22 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 146128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plymouth Place 315 North LA Grange Road LA Grange Park, IL 60526 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Purpose: The purpose of this procedure is to prevent skin irritation around the stoma site and to prevent infection of the resident's urinary tract. Procedure: 6. Wash around the catheter site with soap and water. Wash the outer part of the catheter tube with soap and water. Event ID: Facility ID: 146128 If continuation sheet Page 17 of 22 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 146128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plymouth Place 315 North LA Grange Road LA Grange Park, IL 60526 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation interview and record review, the facility failed to follow recipe guidance to prepare pureed quiche and failed to follow the menu spreadsheet to serve portion sizes for pureed diets at the lunch meal. This applies to 2 of 2 residents (R103 and R254) reviewed for pureed diets in the sample of 20. The findings include: 1. On 03/27/23 at 10:09 AM, the pureed meal prep was observed in the facility kitchen done by V9 (Cook). V9 had a recipe in front of her and V9 stated that she is preparing for 3-4 residents. On clarification, V9 stated that she is preparing for 2 residents on the skilled unit first. V9 wore gloves and put 2 slices of quiche on weighing scale, showing the total weight of the contents as 10 oz/ounce. Each slice of quiche was 1/6 of a 9 inch quiche. V9 then transferred the 2 quiche slices into a blender. V9 added 8 oz of hot water to the blender and pureed it to a smooth watery consistency. V9 added 2 tablespoons of thickener and pureed mixture again to form a pudding consistency. V9 transferred contents into a dish and stated that the item is ready for service after reheating in the steamer. Production Recipe (undated) for Pureed Broccoli and Cheese Quiche included as follows: Obtain 6 servings (Portion per serving =1/8 pie) of above food and place into a blender. Add liquid/water/broth in 1 oz/ounce increments and blenderize until product is smooth, no bits or chunks. The same recipe did not include thickener as an ingredient. On 03/28/23 at 8:31 AM, V6 (Registered Dietitian) was asked to clarify the recipe procedure and serving portions. V6 stated that one serving is 1/6th of a pie as shown on the menu spread sheet. V6 stated that the facility just changed their vendor the previous month and are in the process of getting recipes for food items prepared. V6 stated that the recipe used was from the previous vendor and is not the accurate portion serving size. On 03/29/23 at 10:19 AM, V6 brought the new recipe for pureed quiche from the current vendor and stated that the cook should have used only 1 oz of water per serving of quiche (1/6th of a pie) and added no thickener. The new recipe V6 referred to also did not include thickener as an ingredient to be added when pureeing the quiche. 2. On 03/27/23 at 11:53 AM, the lunch meal service was observed in the 3rd floor dining room. All pureed items were noted to have #12 scoop sizes which was verified with V5 (Senior Director of Support Services) who was in the vicinity. Menu spread sheet for week 5 Cycle menu showed that pureed diets to receive 6 oz of pureed quiche and 4 oz of pureed Italian Greens and Tater tots. Facility Utensil Guideline showed that #12=3 oz portion, #8 =4 oz portion On 03/27/23 at around 12:20 PM, R254 received two #12 scoops of pureed quiche, one #8 scoop of mashed potatoes and one #12 scoop of tater tots served by V10 (Health Care Server) from the tray line steam table in the dining room. V10 stated that R254 does not like vegetables. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146128 If continuation sheet Page 18 of 22 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 146128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plymouth Place 315 North LA Grange Road LA Grange Park, IL 60526 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 03/27/23 at 12:35 PM, R103 received two #12 scoops of pureed quiche, one #12 scoop each of pureed tater tots and Italian green beans served by V11(Lead server). On 03/28/23 at 8:31AM, V6 stated that the servers have a scoop guidance posted in the serving area and it should be followed. On review of the same, it was noted that the facility scoop guidance was not guidance from the manufacturer of scoops and V6 was asked to provide the same. On 03/28/23 at 10:40 AM, V6 came back with a color coded scoop guidance from the manufacturer of the scoops which showed that #12=2 2/3 oz or 1/3 cup. [1/3rd cup is approximately=2.5 oz], and #10=3 oz serving/scoop. V6 agreed that the servers should have used two #10 scoops to serve the pureed quiche in order to serve 6 oz of the same. V6 also stated that a #8 scoop should have been used to serve the pureed tater tots and pureed green beans in order to receive 4 oz of the same as shown on the menu spreadsheet. Facility diet type report showed that R103 and R254 were on pureed diet consistency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146128 If continuation sheet Page 19 of 22 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 146128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plymouth Place 315 North LA Grange Road LA Grange Park, IL 60526 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 wash pots and pans in a sanitary manner and failed to maintain ingredient containers in sanitary condition. Residents Affected - Many This applies to all 62 residents that receive foods prepared in the facility kitchen. The findings include: Facility Resident Census and Conditions of Residents form (CMS Form 672) dated 03/27/23 showed that the census of the facility was 62. Facility provided information that there was no residents on NPO (Nothing by mouth) status on 03/27/23. On 03/27/23 starting at 9:40 AM, the initial tour of the facility kitchen was done in the presence of V7 (Executive Chef). At the 3-compartment sink, V8 (Utility Employee) was seen washing dirty pots and pans. V8 was wearing gloves and went from washing the dirty pans and then dipping the pans into the sanitizer and putting away cleaned pans without changing gloves or washing hands. V8 was also seen cleaning the dirty side with the same gloves and then go back to tackle a fresh batch of dirty pans and repeat the process from dirty to clean side. V7, who was present, was made aware that the pans were not cleaned in a sanitary manner. The area under the pureed prep area, had multiple large containers stored on a shelf that had particles of food debris and whitish substance on the shelf. The following containers were covered with dust and blackish substance over the covers and/or bottles: [NAME] vinegar with Balsamic (1 gallon), Demiglace Sauce Mix, Canola oil 128 fluid oz/ounce, Pure Sesame oil 56.1 fluid oz. There was also an opened container with no lid of 25% Extra Virgin Olive oil. There were also two weighing scales that was covered with dust and white powdery substance. V7 stated that these weighing scales are used for service as needed. On 03/28/23 at 10:11AM, V5 (Senior Director of Support Services) stated that when going from dirty to clean side, V8 should have removed his soiled gloves, used soap and water to wash hands, and put on new gloves. V5 also added that the white powdery substance seen on the shelf was food thickener used in food preparation and that the area of food prep should be maintained in a clean condition. Facility Policy titled Handwashing and Disposable Glove Use (Original date 10/19) included as follows: Policy: Handwashing and disposable Glove Use Purpose: Handwashing is the single most effective means to prevent the spread of infection. Procedure: 5. Gloves shall be discarded after each use, and also if they become soiled, if they become torn, or if they become contaminated FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146128 If continuation sheet Page 20 of 22 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 146128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plymouth Place 315 North LA Grange Road LA Grange Park, IL 60526 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** Based on observation, interview, and record review, the facility failed to follow standard infection control practices related to hand hygiene and glove changing during the provisions of care. The facility also failed to ensure that a patient who is on contact isolation stays in her room to prevent potential spread of infection. This applies to 5 of the 20 residents (R9, R15, R49, R67, R204) reviewed for infection control. Residents Affected - Some The findings include: 1. The electronic medical record (EMR) shows that R204 is 90 years-old who has multiple medical diagnoses which include Alzheimer's Disease, Cognitive Communication Deficit, and Extended Spectrum Beta Lactamase (ESBL) in the urine. Minimum Data Set (MDS) dated [DATE] shows that R204's Brief Interview for Mental Status (BIMS) score was 3 which means she that she is cognitively impaired and is incontinent of urine. On 3/27/23 at 10:05 AM, during unit observation with V20 (Certified/CNA), R204 was observed roaming in the hallway on her wheelchair. V20 stated that R9 likes to roam around the unit. Later that same day at 12:34 PM, R204 was observed in the dining room eating with another resident at the same table. V21 (Nurse) stated that R204 is on contact precaution for ESBL and should be eating in her room. On 3/28/23 at 6:06 PM, V22 (CNA) assisted R204 to the toilet. After R204 voided, V22 provided peri-care R204's peri-area. V22 changed gloves, however, she did not perform hand hygiene in between glove changing. On 3/29/23 at 3:03 PM, V2 (Director of Nursing/DON) stated that R204 has behavior of coming out of her room. R204 needed to be redirected. She has moments of forgetfulness. V2 confirmed that R204 is on isolation and should be in her room to prevent spread of infection. 2. The electronic medical record (EMR) shows that R15 is 90 years-old who has multiple medical diagnoses to include Dementia, muscle weakness and abnormality of gait and mobility. On 3/28/23 at 11:17 AM, V22 and V23 (Both CNA) assisted R15 to the toilet. who had a bowel movement. V23 cleaned R15 using a wet wipe, V23 changed gloves but did not perform hand hygiene from dirty to clean task. 3. The electronic medical record (EMR) shows that R67 is 80 years-old who has multiple medical diagnoses to include urinary tract infection and severe sepsis with septic shock. On 3/28/23 at 1:21 PM, V20 rendered incontinence care to R67 who was wet with urine and had a bowel movement. V20 change gloves multiple times during the care, however, she did not perform hand hygiene in between changing of gloves. 4. The electronic medical record (EMR) shows that R9 is 88 years-old who has multiple medical diagnoses which include urinary tract infection (UTI). R9 has a suprapubic catheter. On 3/28/23 at 2:35 PM, V25 (Nurse) cleaned R9's suprapubic area, changed gloves and applied dressing to the catheter without hand hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146128 If continuation sheet Page 21 of 22 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 146128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plymouth Place 315 North LA Grange Road LA Grange Park, IL 60526 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 5. R49 is 75 years-old who has multiple medical diagnoses which include Dementia and urinary tract infection (UTI). R49 has urinary indwelling catheter. On 3/29/23 at 10:44 AM, V18 (CNA) assisted R49 to the toilet and provided peri-care. R49 had a bowel movement. Prior to providing peri-care, V18 placed R49's urinary bag on the bathroom floor and proceeded to wipe R49's back perineum (rectal and buttocks area). After the back peri-care, she applied a new incontinence brief, pulled up R49's pants back in place, assisted R49 to sit on the wheelchair, V18 then placed the catheter bag to the wheelchair and propelled R49 back to the bedroom while wearing same soiled gloves. On 3/29/23 02:40 PM, V2 (Director of Nursing/DON) stated that staff must perform hand hygiene prior to care, anytime a staff move to another portion of the body and upon completion of care. Change glove if it becomes visibly soiled or touches something dirty prior to moving to another portion of the body or surface. This is to prevent contamination and to prevent infection. Facility's Infection Prevention and Control Manual Transmission-Based Precaution indicates: Contact Precautions: When standard precautions alone are not able to prevent the transmissions of infections or communicable diseases, transmission-based precautions are indicated. Contact Precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, spread by direct or indirect contact with the resident or resident's environment. Contact precautions also apply where the presence of excessive wound drainage, fecal incontinence, or other discharges from the body suggest an increased potential for extensive environmental contamination and risk transmission. It is the policy of this facility that in addition to Standard Precautions, Contact Precautions will be used to prevent the healthcare acquired spread of organisms that can be transmitted by direct resident contact (hand or skin-to-skin contact that occurs when performing resident-care) or by indirect contact (touching) with environmental surfaces or contaminated residents care equipment. Facility's Policy and Procedure for Hand Hygiene shows: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Procedure: 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: h. Before moving from a contaminated body site to a clean body site during resident care. j. After contact with blood or bodily fluids. m. After removing gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146128 If continuation sheet Page 22 of 22