Health inspection·July 12, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview, and record review, the facility failed to provide a comfortable, appropriately lit environment for residents. Residents Affected - Few This applies to one resident (R19) reviewed for homelike environment in a sample of 25. The findings include: R19's MDS (Minimum Data Set) dated 2/22/24 shows her cognition is intact. On 7/9/24 at 11:08 AM, R19 said her heating and air conditioning unit and her over bed light have been broken for a couple of months, at least 8 weeks. R19 said she has notified the staff multiple times about her concerns and somebody downstairs at the front desk put the work orders in. R19 said a maintenance man came in and looked at the broken light and said he needed to order a part to fix it but it has not been fixed yet. R19 said she needs the over bed light turned on to be able to read and write because the two table lamps in the room are not bright enough. Surveyor noted at this time the heating and air conditioning unit on the wall was set to 54 degrees but the air blowing out was barely cool and the light switch on the wall when flipped on did not power on the over bed light. Both table lamps were on and the lighting in the room was very dim. On 7/11/24 at 1:09 PM, V11 (Director of Environmental Services) said he has been working in the facility for 3 months and he is responsible for all of the maintenance repairs. V11 said he is made aware of the work orders in the facility through the (Maintenance Work Order System). V11 said he did not know R19's over bed light and heating and air conditioning unit were not working. V11 said any light in the facility that is out is a problem and it should be fixed immediately. V11 said he is aware that new fixtures need to be ordered for a few rooms and he brought it to the attention of management about a month ago. On 7/11/24 at 1:53 PM, V1 (Administrator) said the Work Order Report prints from the (Maintenance Work Order System) and maintenance is responsible to review all work orders. The facility provided Work Order Report from 1/10/24 through 7/10/24 shows R19 notified staff and work orders were entered on 5 different occasions: 4/26/24, 4/29/24, 5/15/24, 5/24/24, and 5/26/24. All work orders mention the over bed light not working and the 5/26/24 work order mentions the heater seems to be broken. The facility's policy titled, Reporting Maintenance Issues last revised April 2022 states, Responsible Party: Director of Environmental Services .2. All work orders submitted into (Maintenance Work Order System) will be addressed within a reasonable timeframe . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146143 If continuation sheet Page 2 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146143 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on interview and record review, the facility failed to refer a resident for level II PASARR (Pre admission Screening and Resident Review) evaluation and determination who was recently diagnosed with newly evident MD (Mental Disorder). This applies to one resident (R38) reviewed for PASARR in a sample of 25. The findings include: R38's Face sheet shows an admission date of 11/25/2019 with primary diagnosis of Type 2 Diabetes Mellitus. R38 had an OBRA (Omnibus Budget Reconciliation Act) screening completed on 10/8/2019 that showed mental illness was not suspected. R38's Face sheet shows a new diagnoses of Psychotic Disorder with Delusions due to known Physiological Condition dated 12/17/2019 and Recurrent Major Depressive Disorder dated 6/25/2021. R38 does not have a diagnoses of Dementia. On 7/9/24 at 10:47 AM, R38 was observed lying in bed, asleep, with her clothes and shoes on. On 7/11/24 at 12:55 AM, V12 (Admissions Director) said PASARR screens are done to make sure the resident is safe to be in a skilled nursing facility and they are receiving all of the services that they need. V12 said she is not sure if a PASARR level II is supposed to be done if a resident gets a new mental illness diagnosis after they are admitted . On 7/11/24 at 1:53 PM, V1 (Administrator) said once a resident is admitted , there is nothing that will initiate a level II PASARR; PASARR is only done at point of entry. V1 said if a resident has a new onset of mental illness after admission, a PASARR level II is not required. R38's Care Plan dated 4/15/24 shows R38 displays conflictual difficult behavior with other persons related to delirium, poor/ineffective coping skills, attempting to cope through believing that she is superior to others, general intolerance and limited ability to deal with frustration, difficult time adjusting to life in the long term care facility, complaints/concerns about other residents, covert/open conflict with or repeated criticism of staff, unprovoked expressions of anger towards staff and peers (example: may approach a neutral party and become verbally abusive). Care Plan created 3/15/2020 states the resident has a psychological well-being problem related to adjustment disorder and psychotic disorder with delusions. The facility's policy titled PASRR dated July 2020 and last reviewed March 2024 states, Policy: The purpose of this policy is to ensure that individuals with mental illness and intellectual disabilities receive the care and services that they need in the most appropriate setting. The PASRR will be evaluated annually and upon any significant change for those individuals identified .Procedure: .The facility will refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or related condition for a level II review . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146143 If continuation sheet Page 3 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146143 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2024 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 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 follow professional standards of care while performing blood sugar checks on residents. Residents Affected - Few This applies to two of five residents (R54, R84) reviewed for blood glucose monitoring in a sample of 25. The findings include: 1. On 7/9/24 at 12:09 PM, V6 (RN-Registered Nurse) went to R54's room to do his blood glucose monitoring. V6 wiped R54's right middle finger with alcohol and pricked it with a lancet. Instead of wiping the first drop of blood with a gauze, V6 used an alcohol wipe to clean it. V6 then proceeded to use the second drop of blood to obtain a blood sugar reading of 209 MG/DL (Milligrams/Deciliter). R54's face sheet shows an admission date of 4/20/21. Diagnoses include type 2 diabetes mellitus without complications. R54's POS (Physician Order Sheet) shows an order to do blood glucose monitoring before meals and at bedtime. R54's care plans show he has diabetes mellitus and has blood glucose monitoring done before meals, bedtime and as needed. 2. On 7/9/24 at 12:21 PM, V6 went to R84's room to perform his blood glucose monitoring. V6 wiped R84's right middle finger with alcohol. Then she pricked the finger with a lancet. Instead of wiping the first drop of blood with a gauze, she used an alcohol wipe to clean it. V6 then proceeded to use the second drop of blood to obtain a blood sugar reading of High. At 12:25 PM, V6 rechecked R84's blood sugar on the other hand. V6 wiped R84's left middle finger with alcohol. Then she pricked the finger with a lancet. Instead of wiping the first drop of blood with a gauze, she again used an alcohol wipe to clean it. V6 then proceeded to use the second drop of blood to obtain a blood sugar reading of 600. V6 then informed the physician and obtained new orders of insulin. R84's face sheet shows an admission date of 6/18/224. Diagnoses include type 2 diabetes mellitus without complications. R84's POS shows an order to complete blood glucose monitoring before meals and at bedtime. R84's care plans show she has diabetes mellitus and has blood glucose monitoring before meals and at bedtime. On 7/10/24 at 12:05 PM, V2 (DON-Director of Nursing) said, Yes, we were cited for this during our last annual survey. I in-serviced my staff that they should be using a gauze to wipe off the first drop of blood after poking the finger instead of an alcohol wipe. It may cause a false high or low. I'm reading some research on it. I don't know the real answer. My staff should be following our policy if it's mentioned in our policy. Facility's policy tiled Blood Glucose Monitoring (May 2023) shows: The presence of alcohol when not allowing puncture site to dry prior to obtaining blood may result in inaccurate results. Facility's validation of competency for Blood Glucose Monitoring shows the following steps: Clean the resident's finger with antiseptic wipe and let dry. Use the lancet to prick the side of the fingertip to obtain a drop of blood. Apply the drop of blood to the glucose test strip, following manufacturer's instructions. Read the display for blood glucose level. Give the resident gauze or cotton ball to apply directly to the finger prick site. Apply (adhesive bandage) as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146143 If continuation sheet Page 4 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146143 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2024 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 ensure each resident received adequate supervisvion and assistance to prevent falls. This applies to one residents (R14) reviewed for accident hazards in a sample of 25. Findings include: On 7/9/24 at 11:34 AM, R14 was reclining on her bed. R14 stated she fell earlier in the day. Observed that bed is not in a low position. R14 stated, earlier in the morning, she needed to urinate and so she pulled the call light. R14 stated nobody answered the call light for an hour and she needed to use the bathroom urgently. R14 stated she got up by herself and wheeled herself to the bathroom in her wheelchair. R14 stated, when she stood up to transfer onto the toilet seat, she fell onto the floor and hurt her right hip. R14 stated she still had pain in her right hip. On 7/11/24 at 11:54 AM, V2 (DON-Director of Nursing) stated, all patients must have call lights within their reach. V2 stated, room rounds are done by nursing staff and management staff every couple hours so that whoever goes in should either provide the help that the resident needs or ask someone who can provide that help. On 07/11/24 at 12:23 PM, V1 (Administrator) stated, all residents must receive help from the staff in a timely manner. R14's Post Fall Neurological Evaluation dated 7/10/24 at 7:14 AM showed, R14 is alert and oriented to time, place, person and situation. R14's face-sheet showed she was admitted to the facility on [DATE]. R14's Fall Risk Evaluation dated 6/26/24 showed that she is a high risk for falls. Risk Management document on Unwitnessed Fall dated 7/9/24 at 6:15 AM showed, Patient description: Patient states she fell when trying to get to the bathroom because she really needed to go. She now complains of right hip pain. Nursing description: I was sent to the room after another staff RN was called into the room by this resident's room-mate. Patient states that she fell trying to get into the bathroom when she fell and is complaining of pain in her right hip . R14's Care-Plan dated 6/26/24 addressed, R14 is at risk for falls. The interventions included anticipate and meet resident's needs. R14's Progress Notes did not show any description of the incident aside from a progress note dated 7/9/24 at 7:34 AM that showed, (R14's) emergency contact #1 has been made aware of the unwitnessed fall. Facility policy on fall prevention reviewed 05/2024 showed, .Each resident residing at this facility will be provided services . And each resident receives adequate supervision and assistive devices to prevent accidents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146143 If continuation sheet Page 5 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146143 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2024 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 0697 Provide safe, appropriate pain management for a resident who requires such services. 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 ensure resident's pain was managed. This failure resulted in a resident experiencing pain rated at 10 out of 10. Residents Affected - Few This applies to 1 resident (R28) reviewed for pain management in a sample of 25. Findings include: On 7/9/24 at 12:27 PM, R28 was sitting on her wheelchair in her room. R28 stated she went for over 24 hours without her Percocet pain medication and was in severe pain. R28 stated she was crying with pain and that her pain was over the roof. R28 rated her pain then as a 10 out of a 1-10 scale. R28 stated the nurse had informed her that they were out of her Percocet and were waiting for the pharmacy to deliver it. R28's Minimum Data Set, dated [DATE] showed R28 is cognitively intact. R28's POS (Physician Order Sheet) for July 2024 showed, Percocet Oral Tablet 10-325 MG (Oxycodone/Acetaminophen 10/325)- Give 1 tablet by mouth every 4 hours as needed for severe pain- pain scale of 6-10. R28's Face Sheet showed she was admitted on [DATE] with diagnoses of fibromyalgia, rheumatoid arthritis, and encounter for orthopedic aftercare, among others. R28's 6/22/24 skin impairment care plan showed she has actual skin impairment related to R28's lumbar-3 / lumbar-4 extreme lateral interbody fusion and lumbar decompression. R28's care plan dated 6/21/24 showed R28 has potential for pain, with interventions to anticipate the resident's need for pain relief and respond immediately to any complaint of pain. R28's Individual Patient's Narcotic Record showed R28 was receiving Percocet regularly, averaging 5-6 doses a day. The Records showed R28 received five doses daily on 7/3/24, 7/4/24, 7/5/24, 7/6/24, and 7/9/24 and six doses on 7/2/24 and 7/10/24. One of the Records showed the last Percocet dose from the card was removed for administration on 7/7/2024 at 3:00 PM. The facility Convenience Box medications list showed the Box included six tablets of R28's ordered dose of Oxycodone/Acetaminophen 10/325 (Percocet), and also Oxycodone/Acetaminophen 5/325 (Percocet) 6 tablets. R28's July 2024 Medication Administration Record (MAR) showed R28 received pain medication doses on 7/7/2024 at 5:56 AM, 10:20 AM, (no 3:00 PM dose documented as administered), and 6:45 PM, with the last one at 11:01 PM (when her pain was rated at a 7). R28's other Individual Patient's Narcotic Record showed the new card of Percocet was delivered on 7/9/2024, with the first dose being signed out for administration on 7/9/2024 at 3:00 AM. R28's MAR showed the dose was administered on 7/9/2024 at 2:45 AM (when her pain was documented as 9), over 27 hours after the previous 11:01 PM dose on 7/7/2024. This same MAR showed R28 received one dose of acetaminophen 500 milligrams at 3:12 AM on 7/8/24 for pain rated at 9. The acetaminophen order showed Give one tablet by mouth every six hours as needed for mild pain and prior to wound dressing with pain scale of 1-5. Documentation for R28's pain level at 4:00 PM showed her pain was rated at 7. R28's care plan dated 6/21/24 showed R28 receives opioid medications. June 21, 2024 care plan interventions from the opioid care plan showed Administer ANALGESIC medications as ordered by physician. Monitor/document side effects and effectiveness [every] shift; and Review pain medication for efficacy. Assess whether pain intensity acceptable to [R28] .administer analgesic medications as ordered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146143 If continuation sheet Page 6 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146143 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2024 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete by physician, monitor side effects and effectiveness [every] shift. R28's July 2024 MAR showed Pain-Evaluate Pain every shift for Pain Evaluation and there are spaces for Pain levels on Day shift, Evening shift, and Night shift. Pain values entered for each shift were 0, 7, and 7, respectively, although there is no specific time of day included for the documented pain level values. Facility policy on Pain Management revised 05/2024 showed, It is the policy of the facility to respect and support the resident's right to optimal pain assessment and management. Procedure: It is the responsibility of all clinical staff to assess and periodically reassess the resident for pain and relief from pain . Event ID: Facility ID: 146143 If continuation sheet Page 7 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146143 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2024 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based observation, interview, and record review, the facility failed to remove expired items from and clean resident refrigerators. Residents Affected - Few This applies to one of one resident (R37) reviewed for personal refrigerators in a sample of 25. The findings include: On 7/9/24 at 10:42 AM, during initial tour, surveyor went to R37's room. Inside R37's refrigerator, the following observations were made: Two (l lb, 8 oz) (pounds/ounces) cartons of vanilla low-fat yogurt had a best by date of 4/19/24; one (1lb, 8 oz) carton of vanilla low-fat yogurt had a best by date of 5/2/24. In two different plastic bags there were slices of ham and cheese. The bags had a foul odor and the cheese had mold on it. On the label, it showed it was packed on 6/19/24. The freezer section of the fridge was dirty and stained. On 7/9/24 at 10:44 AM, R37 stated, The staff check my refrigerator every day. I don't know why those items are still there. I thought they threw it out. If they are expired, then I don't want them. I don't want to get food poisoning. On 7/9/24 at 1:45 PM, V1 (Administrator) stated, It's an all hands on deck process. Nurses, CNA's (Certified Nursing Assistants) and all staff are responsible for doing rounds and checking the resident refrigerators. Staff is to make sure all expired food is removed. R37's face sheet shows an admission date of 4/29/22. R37's MDS (Minimum Data Set) dated 6/3/24 shows a BIMS (Brief Interview for Mental Status) score of 15, which means she is cognitively intact. Facility's policy titled Resident/Visitor Food Policy (May 2023) shows: If the item is labeled by the food producer with an expiration date, the nurse will confirm the current date is within the labeled time line. Any perishable food (s) must be discarded after two hours of unrefrigerated time. If there is any question of how long a food item has been unrefrigerated, it must be discarded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146143 If continuation sheet Page 8 of 8