Health inspection·August 3, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to change a resident's PICC (Peripherally Inserted Central Catheter) line dressing per facility policy. The facility also failed to measure and document the resident's external length of her catheter per infusion nursing standards of practice. This applies to 1 of 1 resident (R200) reviewed for PICC lines in a sample of 20. Residents Affected - Few The findings include: POS (Physician Order Sheet), printed 8/1/23, shows R200's diagnoses included acute osteomyelitis of the right ankle and foot and deep vein thrombosis. The physician orders show facility staff were to monitor R200's IV (Intravenous) insertion site for any signs or symptoms of fluid leaking every shift. MDS (Minimum Data Set), dated 7/21/23, shows R200 was cognitively intact. On 7/31/23 at 11:05 AM, R200 was sitting in her room and had a PICC line inserted into her left upper arm. The PICC line dressing was dated 7/25/23 and had red blood visible under transparent PICC line dressing and antimicrobial disk. R200 stated the blood had been present and visible since 7/30/23 but no staff had attempted to change the dressing. R200 also stated when the hospital staff inserted her PICC line, they told R200 her PICC line dressing needed to be changed every seven days. R200 stated after seven days at the facility. R200 began asking facility staff to change her PICC line dressing. R200 stated her dressing was not changed at the facility until 7/25/23. admission nursing progress note, dated 7/14/23, shows R200 was admitted to the facility with a PICC line venous access. Review of R200's progress notes, dated 7/14/23 to 7/24/23, fail to show R200's PICC line dressing was changed at the facility. Review of R200's clinical record also fails to show R200's baseline measurements were recorded on admission for her arm circumference or external length of her PICC line. MAR (Medication Administration Record), dated 7/1/23 to 7/31/23, showed R200 had no physician orders for PICC line dressing changes until 7/25/23. The MAR shows R200 received a physician order on 7/25/23 that included, PICC Line dressing change and measurement of Arm Circumference and length of exposed PICC line after every PICC Line change and change cap on admission and every 7 days. The MAR shows R200's PICC line dressing was changed on 7/25/23 however no measurements were recorded in the clinical record. MAR, dated 8/1/23, shows on 8/1/23 R200's dressing was changed, R200's arm circumference was measured to be 30 cm (centimeters), and R200's exposed PICC line was 10 cm. Review of the clinical record fails to show what R200's baseline arm circumference or exposed PICC line measurements for comparison and fails to show the resident's measurements were taken/recorded prior to 8/1/23. On 8/01/23 at 3:48 PM, V2 (Director of Nursing) stated it was his expectation that on admission the facility admitting nurse should obtain a resident's initial arm circumference and external catheter length during hospital transfer report for residents who were admitted with PICC lines. V2 also stated the admitting nurse was also responsible for obtaining initial physician orders for PICC line dressing changes. V2 stated facility nursing staff were expected to measure the resident's arm circumference and external catheter length on admission and during each dressing change. V2 stated it was his expectation that PICC line dressings should be changed every 7 days and as soon as possible if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146143 If continuation sheet Page 2 of 15 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 146143 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Hanover Park 2000 West Lake Street Hanover Park, IL 60133 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 0684 blood was identified under the dressing. Level of Harm - Minimal harm or potential for actual harm Review of R200's care plan as of 7/31/23 failed to show PICC line monitoring interventions regarding measuring R200's arm circumference or exposed PICC line length. Review of R200's care plan updates, dated 8/1/23, showed R200's care plan interventions were revised to include the following interventions: 1. Change R200's PICC line and cap every seven days. 2. Measure arm circumference and exposed PICC line length at the time of the dressing change. 3. Monitor the IV insertion site and report to the physician any signs and symptoms of fluid leaking or drainage. Residents Affected - Few The Infusion Nursing Standards of Practice, revised 2021, shows, Measure the external CVAD (Central Venous Access Device) length at each dressing change or when catheter dislodgement is suspected and compare to the external CVAD length documented at insertion Change transparent semipermeable membrane (TSM) dressings at least every 7 days (except neonatal patients) or immediately if dressing integrity is disrupted (e.g., lifted/detached on any border edge or within transparent portion of dressing; visibly soiled; presence of moisture, drainage, or blood) or compromised skin integrity is present under the dressing Facility policy/procedure Central Line Care, revised 4/2023, shows, Following the initial 24 hours dressing change an RN (Registered Nurse) or LPN (Licensed Practical Nurse) will change the injection cap and the dressing at minimum weekly or any time the dressing becomes moist, loosened or soiled. The policy/procedure fails to show that staff were to obtain baseline measures of R200's arm circumference or external length of the PICC line and document them in the clinical record. The policy/procedure also fails to show that staff were to measure the resident's arm circumference or external length of her PICC line each dressing change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146143 If continuation sheet Page 3 of 15 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 146143 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Hanover Park 2000 West Lake Street Hanover Park, IL 60133 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement fall interventions after a resident fell to prevent further fall occurrences. This applies to 1 of 2 residents (R49) reviewed for falls in the sample of 20. The findings include: The EMR (Electronic Medical Record) showed R49 was admitted to the facility on [DATE], with multiple diagnoses including stroke, blind, end stage renal failure, left leg amputation, and hypertension. R49's MDS (Minimum Data Set) dated 7/04/2023 showed R49 had moderate cognitive impairment. The MDS continued to show R49 required extensive assistance from facility staff for bed mobility and was totally dependent on facility staff for transfers. R49's Fall Risk Evaluation dated 6/27/2023, showed R49 was a high risk for falls. On 7/31/2023, at 12:35 PM, R49 was in bed laying on his right side, in his room located at the end of the hallway from the nurses' station. R49 was positioned on the right side of the bed with his lower body was hanging over the edge of the bed. This surveyor immediately alerted facility staff of R49's position to ensure R49's safety. Facility documentation dated 6/28/2023, showed R49 had an unwitnessed fall on 6/28/2023 at 7:40 AM. The documentation continued to show R49 slid out of bed. The documentation showed interventions following R49's fall included facility staff to ensure R49 is in the correct position while in bed. Facility documentation dated 7/03/2023, showed R49 had an unwitnessed fall on 7/03/2023 at 12:30 AM. The documentation continued to show R49 slid out of bed. The documentation showed interventions following R49's fall included facility staff to monitor R49 closely. Facility documentation dated 7/03/2023, showed R49 had an unwitnessed fall on 7/03/2023 at 11:00 AM. The documentation continued to show R49 rolled out of bed. The documentation showed interventions following R49's fall included facility staff to provide R49 with floor mats when in bed and keep bed at lowest position. Facility documentation dated 7/22/2023, showed R49 had an unwitnessed fall on 7/22/2023 at 11:45 AM. The documentation continued to show R49 rolled out bed. The documentation showed interventions following R49's fall included facility staff to ensure R49 is in the correct position while in bed. Facility documentation dated 7/24/2023, showed R49 had an unwitnessed fall on 7/24/2023 at 2:27 AM. The documentation continued to show R49 slid out of bed. The documentation showed interventions following R49's fall included facility staff to ensure R49 is in the correct position while in bed. On 8/02/2023, 3:31 PM, V26 (LPN/Licensed Practical Nurse/Restorative Nurse) said R49 had multiple falls and continued to fall. V26 said an intervention for positioning R49 correctly in bed was implemented on 6/28/2023. V26 continued to say the same fall intervention was implemented after R49's fall on 7/22/2023, and then R49 fell again on 7/24/2023. V26 said she has not implemented new fall (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146143 If continuation sheet Page 4 of 15 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 146143 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Hanover Park 2000 West Lake Street Hanover Park, IL 60133 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete interventions after R49's fall on 7/22/2023 and 7/24/2023. V26 continued to say if R49 fell again, then V26 would discuss R49's falls with the IDT (Interdisciplinary Care Team) members to see if they have any other fall interventions for R49. R49's fall care plan dated 4/17/2023, showed Actual fall, on 6/28/2023; 7/3/2023. The care plan continued to show multiple interventions dated 6/29/2023, including Staff to make sure patient is in the correct position while in bed. The care plan does not show interventions were put in place following R49's falls on 7/22/2023 and 7/24/2023. Event ID: Facility ID: 146143 If continuation sheet Page 5 of 15 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 146143 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Hanover Park 2000 West Lake Street Hanover Park, IL 60133 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their policy to provide a resident with incontinence care. This applies to 1 of 2 residents (R49) reviewed for bowel and bladder incontinence in the sample of 20. The findings include: The EMR (Electronic Medical Record) showed R49 was admitted to the facility on [DATE], with multiple diagnoses including stroke, left leg below the knee amputation, end stage renal disease, and legal blindness. R49's MDS (Minimum Data Set) dated July 4, 2023, showed R49 had moderate cognitive impairment. The MDS continued to show R49 required extensive assistance from facility staff for bed mobility, toilet use, and personal hygiene. The MDS showed R49 was always incontinent of bowel and bladder. R49's skin integrity care plan dated June 28, 2023, showed, [R49] has a Potential/At Risk for alteration in skin integrity due to risk factors associated with Chronic or End Stage Renal Disease, Immobility, Poor Skin turgor. The care plan continued to show multiple interventions dated June 28, 2023, including, Provide peri-care after each incontinent episode and apply barrier cream. The facility's Wound Report dated July 31, 2023, showed R49 had a stage four pressure ulcer on his coccyx. On July 31, 2023, at 12:33 PM, V15 (CNA/Certified Nursing Assistant) and V16 (CNA) entered R49's room to reposition R49. V16 said R49's incontinence brief was soiled with urine. V16 removed R49's soiled incontinence brief. V15 and V16 applied a clean incontinence brief to R49. V15 and V16 exited R49's room. V15 or V16 did not clean R49's perineal area. On August 2, 2023, at 3:05 PM, V2 (Director of Nursing) said when providing incontinence care, facility staff should clean the resident's genitals, groin, and buttocks. The facility's policy titled, Incontinence Care dated May 2023, showed, General: Incontinence care is provided to keep residents as dry, comfortable and odor free as possible. It also helps in preventing skin breakdown. Procedure: .5. Removed soiled clothing and linen. 6. Clean peri area with appropriate cleanser and dry . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146143 If continuation sheet Page 6 of 15 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 146143 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Hanover Park 2000 West Lake Street Hanover Park, IL 60133 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow physician orders for positioning a resident receiving tube feeding. This applies to 1 of 1 resident (R87) reviewed for tube feeding in the sample of 20. The findings include: The EMR (Electronic Medical Record) showed R87 was admitted to the facility on [DATE], with multiple diagnoses including aspiration pneumonia, gastrostomy, acute respiratory failure, gastro-esophageal reflux disease, and stroke. R87's MDS (Minimum Data Set) dated 7/07/2023 showed R87 was cognitively intact. The MDS continued to show R87 required extensive assistance with bed mobility and was receiving tube feeding. R87's Order Summary Report dated 8/02/2023 showed an order dated 6/12/2023, for Aspiration precautions: patient to be greater than 45 degrees during and 30 minutes after feeding. R87's swallow precaution care plan dated 4/26/2023, showed [R87] has swallowing precautions. The care plan continued to show multiple interventions dated 6/12/2023, including, [R87] to be upright greater than 45 degrees during feedings. On 7/31/2023, at 11:45 AM, R87 was lying in bed with his head resting on one pillow, with tube feeding running at 65 mL (milliliters) per hour to his G-tube (Gastrostomy Tube). R87's head of the bed was elevated approximately 20 degrees. R87 had a Swallow Precautions sign above R87's bed. On 7/31/2023, at 11:48 AM, V26 (LPN/Licensed Practical Nurse/Restorative Nurse) repositioned R87 in bed. V26 elevated R87's head of the bed higher than previously positioned. V26 said R87's head of the bed is now at 30 degrees. On 7/31/2023, at 11:50 AM, V12 (LPN/Licensed Practical Nurse) said R87 was currently receiving tube feeding. V12 continued to say she was not sure if R87's head of the bed needed to be elevated. On 8/02/2023, at 8:47 AM, R87 was lying in bed with his head resting on one pillow, with tube feeding running at 65 mL per hours to his G-tube. R87's head of the bed was elevated approximately 15 degrees. R87 had a Swallow Precautions sign above R87's bed. On 8/02/2023, at 8:47 AM, V12 (LPN) R87 was receiving tube feeding. V12 continued to say R87's head of the bed was less than 30 degrees. On 8/02/2023 at 9:10 AM, V2 (Director of Nursing) said residents receiving tube feedings should have the head of the bed at 30 to 45 degrees to prevent aspiration. On 8/02/2023 at 9:35 AM, V2 said R87's head of the bed was not elevated to 30 degrees because a CNA (Certified Nursing Assistant) had provided care to R87 and failed to elevate the head of the bed after completing care. V2 said the expectation is CNAs should elevate the head of the bed at 30 degrees following care. V2 continued to say the expectation is facility staff follow physician orders and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146143 If continuation sheet Page 7 of 15 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 146143 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Hanover Park 2000 West Lake Street Hanover Park, IL 60133 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 elevate R87's head of the bed to 45 degrees while he is receiving tube feeding. Level of Harm - Minimal harm or potential for actual harm On 8/02/2023 at 12:19 PM, V21 (SLP/Speech Language Pathologist) said R87 was hospitalized in June 2023 with aspiration pneumonia. V21 continued to say when R87 was readmitted to the facility on [DATE], aspiration precautions were put in place, including elevating R87's head of bed greater than 45 degrees when receiving tube feeding. V21 continued to say R87 has a Swallow Precautions sign above his bed so facility staff are aware of R87's head of the bed elevation requirements. Residents Affected - Few R87's Swallow Precautions sign dated 6/12/2023, showed R87 is to be positioned upright, greater than 45 degrees, during feedings. The facility's policy, titled Tube Feeding dated 05/2023, showed Policy: .7. Head of the bed should be elevated 30-45 degrees unless ordered differently by the physician . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146143 If continuation sheet Page 8 of 15 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 146143 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Hanover Park 2000 West Lake Street Hanover Park, IL 60133 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. Based on observation, interview and record review, the facility failed to ensure that controlled medications are reconciled every shift by the oncoming and off-going nurse, failed to ensure controlled substance counts were correctly documented on the Controlled Substance Proof of Use form, and failed to ensure all controlled substances have an accountability form to prevent controlled substance diversion. This applies to 3 residents (R4, R7 and R8) reviewed for controlled substances in the total sample of 20 residents. Findings include: V10 (RN/Registered Nurse) was observed on 8/1/2023 at 11:25AM counting the controlled substances on the 3 [NAME] medication cart. R7's-controlled substance accountability sheet for Lyrica (Pregabalin) 75 mg capsules documented 2 capsules in the package, however only 1 capsule was remaining. V10 reviewed the administration record and verified that one dose was administered the previous evening by V9 (RN). V10 added that V9 was back on duty the evening of 8/01/2023, V9 could sign out this medication. V10 also stated that R7 had 2 different bingo cards for this medication, and this may have led to the confusion. R7's POS (Physician Order Summary) documents an active order for Lyrica Oral Capsule 75 mg (Pregabalin) Give 1 capsule by mouth one time a day every Mon, Wed, Fri related to Type 2 Diabetes mellitus with diabetic polyneuropathy. On 8/1/23 at 1:16 PM, V9 (RN) was observed completing the controlled substance count of the 2 East medication cart. The Shift Change Accountability Record for Controlled Substances showed that for 8/1/23 the initials of the nurse for the 1st shift On were missing. V9 stated that she (V9) usually signs it at the end of the shift when she's completed passing all medications. V9 confirmed that she (V9) did a controlled substance count with the off-going nurse at the start of her (V9) shift, and so she (V9) should have signed in the On column at that time. On 8/1/23 at 1:38 PM, while still conducting the controlled substances count with V9, R8's Controlled Substances Proof of Use form for Norco 5/325 0.5 tablet documented a quantity remaining of 5.5 tablets, however, the surveyor observed 4.4 tablets remaining in the medication card. V9 stated that R8 takes the Norco at 9 am and 1pm so she (V9) already administered it. V9 added, I usually just sign it off in the EMAR first then I write it in. R8's Controlled Substances Proof of Use form was also noted with 5 entries missing the date, time, and nurse's signature. Review of R8's MAR verified that V9 administered the two doses of Norco at 9 am and 1 pm. R8's POS documents an active order dated 7/20/23 for Norco Oral Tablet 5-325 mg (Hydrocodone-Acetaminophen) Give 0.5 tablet by mouth every 4 hours as needed for pain. On 8/1/23 At 1:48 PM, R4's refrigerated Lorazepam 2mg/ml (milligrams/milliliter) was observed with V9. A 3 ml discrepancy was noted from the proof of use document that indicated the entry of 6/15/2023 with 17 ml remaining. V9 verified that R4's Lorazepam had 14 ml, a 3 ml difference. V9 stated, I haven't noticed this, Another full, unopened bottle of Lorazepam 2mg/ml belonging to R4 was noted with no Controlled Substance Proof of Use form associated with it. Additionally, an unopened bottle of Morphine Sulfate 100 mg/5ml 30 ml belonging to R4 was found in the medication refrigerator, but no Controlled Substance Proof of Use form associated with it in the red binder kept in the medication cart. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146143 If continuation sheet Page 9 of 15 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 146143 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Hanover Park 2000 West Lake Street Hanover Park, IL 60133 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 On 8/1/23 at 2:07 PM, V2 (DON/Director of Nursing) stated that R4's additional Lorazepam and Morphine were being supplied by hospice and not the facility's pharmacy but acknowledged that each controlled medication should have its own accountability sheet because, If it's not accounted for, it's easy to miscount or be lost. V2 also acknowledged that each time a medication is signed out on the Controlled Substances Proof of Use form, each box should be filled in appropriately. Residents Affected - Few R4's POS documents an active order dated 8/1/23 for Lorazepam Oral Concentrate 2 mg/ml (milligram/milliliter). Give 0.5 ml by mouth every 4 hours as needed for anxiety for 14 days, and an active order dated 4/12/23 for Morphine Sulfate (Concentrate) oral solution 100 mg/5ml give 0.5 ml by mouth every 2 hours as needed for moderate pain. Review of R4's MAR (Medication Administration Record) from April-August 2023 compared to R4's Controlled Substance Proof of Use form showed that the dates and times that the Lorazepam was administered in the MAR did not match up completely with the dates and times documented on the Controlled Substances Proof of Use. On 8/1/23 at 11:35 AM, V2 (DON) stated that the purpose of the accountability logs is To make sure the counts are right. V2 added that the process when administering a controlled substance is to sign it off in both the eMAR (Electronic Medical Record) but also on the accountability sheet. V2 stated that it is possible that a nurse forgets to sign the accountability sheet but, in that case, they follow up with the nurse and check the eMAR to ensure the dose was given. V2 stated that the importance of the controlled substances accountability sheet is to make sure the count is correct and it it's not, to find out what happened to make sure nothing is being taken personally. On 8/3/23 at 1:44 PM, V2 (DON) stated that a new company took over the facility in June so he (V2) cannot speak to what was documented previously for R4's Lorazepam on the MAR or accountability sheet. However, V2 stated that he (V2) made the medical director aware of the discrepancy and they discontinued the Lorazepam order since R4 has been refusing it. V2 acknowledged that the MAR and the accountability sheet should match to verify the doses given. The 4/2023 Controlled Medications facility policy documents, in part, .Procedure: All controlled drugs will be reconciled every shift including those drugs stored with other medications .A controlled medication accountability record is prepared when receiving or checking in a Schedule II, III, IV or V medication .Schedule II drugs stored in the facility will be counted each shift by one (1) licensed nurse from the off-going and one (1) licensed nurse from the oncoming shift and both licensed staff members will sign the Controlled Substance Count Sheet .The oncoming nurse will sign his/her name in the sign-in space on the form after all medications have been reconciled. The off-going nurse will sign his/her name in the sign-out space on the form after all medications have been reconciled. If the count is incorrect, the CNO (Chief Nursing Officer) and/or designee will be notified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146143 If continuation sheet Page 10 of 15 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 146143 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Hanover Park 2000 West Lake Street Hanover Park, IL 60133 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to attain a less than five % (percent) medication error rate. There were two medication errors out of 29 medication opportunities resulting in a 6.89% medication error rate. This applies to 1 of 5 residents (R348) reviewed for medication administration in the sample of 20 residents. Residents Affected - Few The findings include: V11 (Registered Nurse/RN) was observed on 8/02/2023 at 9:51AM to prepare and administer scheduled 9 am medications for R348. Two of those medications included a ferrous sulfate (iron) 325 mg, black-coated tablet, and a metoprolol 25 mg ER (Extended Release) tablet. V11 proceeded to place these two medications, among other medications prepared at the same time, into a plastic pouch and crushed all the medications together. V11 mixed the crushed medications with applesauce and at 10:03 AM administered the medications by spoon to R348. On 8/2/23 at 4:39 PM, the surveyor inquired if extended-release medications or iron can be crushed. V2 (DON/Director of Nursing) stated during interview of 8/02/2023 that she was unsure if extended released medications or iron should be crushed. V2 stated, I really don't know the answer to that, and stated that he (V2) would have to ask the pharmacist. On 8/3/23 at 8:23 AM, V25 (Pharmacist in Charge) stated that metoprolol ER if it is scored, can be cut in half, however it cannot be crushed. V25 added that crushing it can ruin the extended-release mechanisms. V25 also stated that iron Should not be split, chewed or crushed. R348's POS documents orders for Metoprolol Succinate ER Tablet Extended Release 24-hour 25 mg, give 1 tablet by mouth in the morning for HTN (Hypertension) and Ferrous Sulfate Oral Tablet 325 (65 Fe) mg (Ferrous Sulfate) give 1 tablet by mouth in the morning for supplement. The 04/2023 Administration of Medications facility policy documents, in part, .13. Crush medications only if the label indicates so. If it is not labeled, do not crush. The 6/13/23 Oral Medications that Should Not Be Crushed or Altered table from LexiComp that was provided to the surveyor by V25 documents, in part, The following table contains drugs available in the US or Canada that have characteristics that may make it inappropriate to crush or alter the dosage form to help facilitate drug delivery .Generally, medications which should not be crushed fall into one of the following categories: Extended Release Products: The formulation of some tablets is specialized as to allow the medication within it to be slowly released into the body . Page 17 of 49 lists Drug product: ferrous sulfate, Dosage form: tablet, Reason/comments: delayed release. Page 26 of 49 lists Drug product: Metoprolol Succinate ER, Dosage form: tablet, Reason/comments: extended release. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146143 If continuation sheet Page 11 of 15 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 146143 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Hanover Park 2000 West Lake Street Hanover Park, IL 60133 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure eye drops and insulin were properly stored and labeled. This applies to 5 residents (R16, R50, R73, R96, and R98) reviewed for medication storage and labeling in the sample of 20. The findings include: The 3 [NAME] medication cart was observed on [DATE] at 9:45AM with V10 (RN/Registered Nurse). 1. R96's Latanoprost soln (solution) 0.005% eye drops were noted with a sticker on the side of the packaging reading Date opened and Date expired that was blank. V10 stated, We normally just follow the discard date. The discard date on the pharmacy label was [DATE]. R96's POS (Physician Order Summary) documents an active order dated [DATE] for Latanoprost Solution 0.005% Instill 1 drop in both eyes at bedtime. 2. R98's Toujeo solostar (insulin glargine) injection 300 U/ml (units/milliliter) was observed with an open date of 7/30 but no discard date was written on the insulin. When the surveyor inquired how long the insulin is good for once it's opened, V10 stated, I'll say two weeks because most of these medicines just last a week or two then I have to re-order them. In the same plastic bag with the Toujeo pharmacy label, an insulin aspart flexpen 100 unit/ml was observed with a date of 7/30 written on the flexpen with a black marker and a number 311. No pharmacy label or resident identifier was noted on the flexpen as well as no discard date. V10 acknowledged that 7/30 is the open date. V10 stated that R98 was admitted to the facility after 8 pm so the flexpen was taken out of the emergency box which is why it doesn't have R98's name on it. R98's POS documents an active order dated [DATE] for Insulin Aspart Subcutaneous Solution Pen-Injector 100 unit/ml Inject 25 unit subcutaneously with meals for Type 2 DM (Diabetes Mellitus) and an active order dated [DATE] for Toujeo SoloStar Subcutaneous Pen-Injector 300 unit/ml (insulin glargine) Inject 45 unit subcutaneously two times a day for Type 2 DM. On [DATE] at 11:35 AM, V2 (DON/Director of Nursing) stated, If it's opened usually it needs to have an expiration date written on it. The expiration date will tell you the open date. V2 stated that insulin is good for 30 days from the time that it's opened. V2 stated that he (V2) expects the sticker with Date opened and Date expired to be filled out for both insulin and eye drops. V2 added, The whole goal is to make sure it is not utilized longer than it's good for. V2 stated that you cannot go off the discard date because it depends on manufacturer's recommendations once the product is opened. 3. The 2 East medication cart was observed with V9 (RN) on [DATE] at 1:16PM. R50's Latanoprost soln 0.005% eye drops were observed with a no open date or expiration date. R50's POS documents an active order dated [DATE] for Latanoprost solution 0.005% Instill 1 drop in both eyes at bedtime for Dry Eyes. 4. On [DATE] at 9:26 AM, The 2 North medication cart was observed with V18 (RN) on [DATE] at 9:26AM. A box of Novolog 100 units/ml vial belonging to R16 was noted with a blue sticker reading (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146143 If continuation sheet Page 12 of 15 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 146143 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Hanover Park 2000 West Lake Street Hanover Park, IL 60133 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Refrigerate until opened. V18 confirmed that the orange cap was still on the vial inside the box, so it was unopened. R16's POS documents an active order dated [DATE] for Novolog Injection Solution 100 unit/ml (insulin aspart) Inject 15 units subcutaneously with meals for DM (Diabetes Mellitus). 5. A clear, plastic bag containing 8 sealed boxes of Latanoprost 0.005% soln belonging to R73 was observed in the second drawer of the 2 North medication cart. Each individual package of Latanoprost contained a yellow sticker reading, Refrigerate before opening. V18 confirmed that all 8 boxes were sealed and unopened. R73's POS documents an active order dated [DATE] for Latanoprost Ophthalmic Solution 0.005% Instill 1 drop in both eyes at bedtime for glaucoma. On [DATE] at 3:21 PM, V24 (Pharmacist) stated that the reason why a sticker is placed on eye drops with an open date and an expiration date is because different eye drops have different expiration dates. V24 stated that Latanoprost is only good for 6 weeks once it's opened. V24 also stated that a Novolog insulin aspart pen is good for 28 days once opened and Toujeo is good for 56 days at room temperature once opened. Regarding medications with no pharmacy label, V24 stated that would be up to facility policy as to how to proceed. On [DATE] at 3:38 PM, V25 (Pharmacist in Charge) stated, Insulin and certain eye drops need to be refrigerated until opened to maintain the stability of the product. As long as the medication stays refrigerated then it's good by the manufacturer's expiration date. However, V25 added that once the eye drops or insulin is opened, it needs to have the open date and expiration date written on is since the expiration date might differ from the manufacturer's expiration date. The 01/2020 Medication Labeling and Storage facility policy documents, in part, Policy: Medications are labeled in accordance with facility requirements and state and federal laws. All drug containers will be labeled, and drug labels must be clear, consistent, legible and in compliance with state and federal requirements. Procedure: . Upon opening of insulin pens, the licensed nurse will write the date of expiration. Improperly or inaccurately labeled medications are rejected and returned to the dispensing pharmacy. The provider pharmacy permanently affixes labels to the outside of prescription containers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146143 If continuation sheet Page 13 of 15 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 146143 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Hanover Park 2000 West Lake Street Hanover Park, IL 60133 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 their policy to put on proper Personal Protective Equipment (PPE) before entering a Contact Isolation room, failed to perform hand hygiene after leaving the room and failed to change soiled gloves during incontinence care. This failure applies to 2 of 2 residents (R49 and R52) reviwed for infection control from a total sample of 20 residents Residents Affected - Few 1. The EMR (Electronic Medical Record) showed R52 was admitted to the facility on [DATE], with multiple diagnoses including clostridium difficile, end stage renal disease, right leg below the knee amputation, and diabetes. The MDS dated [DATE], showed R52 was cognitively intact. The MDS continued to show R52 required set up help from facility staff when eating. R52's Order Summary Report dated August 2, 2023, showed an order dated June 26, 2023, for contact isolation for clostridium difficile. On May 31, 2023, at 12:23 PM, R52 was lying in bed. R52's door to her room showed a sign for contact isolation. V17 entered R52's room to deliver a lunch tray. V17 was not wearing a gown or gloves. V17 touched R52's moistened wipe package on her bedside table and touched R52's bedside table. V17 exited R52's room and did not perform hand hygiene. V17 then delivered lunch trays to R81 and R47's rooms. On August 2, 2023, at 3:07 PM, V2 (DON/Director of Nursing) said the expectation is facility staff should be donning PPE (Personal Protective Equipment) when entering a resident's room who is on contact precautions. V2 continued to say facility staff should perform hand hygiene when exiting a contact isolation resident room. The facility's policy, titled Infection Control Policy, dated May 2023, showed, Policy: This facility will facilitate safe care of all residents and staff with known or suspected communicable disease by establishing and maintaining an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This policy applies to all staff members from all departments of this facility, including direct and indirect care staff, contracted staff, consultants, volunteers, and others who provide care and services to residents on behalf of the facility, and students in a facility-supported training program, contracted and vendors of facility, residents residing in the facility, and visitors of the facility . This facility will follow all recommendations for Transmission Based Precautions . Residents with clostridium difficile infection will be placed on special contact precautions. Special contact precautions require the use of gowns and gloves upon entry to room, soap and water for hand hygiene after contact with the resident or their care environment . 2. The EMR (Electronic Medical Record) showed R49 was admitted to the facility on [DATE], with multiple diagnoses including stroke, left leg below the knee amputation, end stage renal disease, and legal blindness. R49's MDS (Minimum Data Set) dated July 4, 2023, showed R49 had moderate cognitive impairment. The MDS continued to show R49 required extensive assistance from facility staff for bed mobility, toilet use, and personal hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146143 If continuation sheet Page 14 of 15 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 146143 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Hanover Park 2000 West Lake Street Hanover Park, IL 60133 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 On July 31, 2023, at 12:33 PM, V15 (CNA/Certified Nursing Assistant) and V16 (CNA) donned gloves and provided incontinence care to R49. V16 removed R49's soiled incontinence brief and said R49's incontinence brief was soiled with urine. V16 placed R49's soiled incontinence brief in the trash bin. While using the same soiled gloves, V16 applied a clean incontinence brief to R49, V16 touched R49's linens and repositioned R49, and V16 touched R49's pillow. Residents Affected - Few On August 2, 2023, at 3:05 PM, V2 (DON/Director of Nursing) said the expectation of facility staff is to change their gloves and perform hand hygiene when moving from a dirty site to a clean site. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146143 If continuation sheet Page 15 of 15