Inspection·December 31, 2025

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few physical aggression particularly during care interactions with CNA (Certified Nurse Assistant)s. Intervention: Monitor behaviors to ensure staff and resident safety while exploring appropriate interventions. She needs assistance with daily ADL ( Activity of daily livings) care, impaired functional mobility/wheelchair bound, resistive to care, 2 staff will be present to provide ADLs at all times. She is at risk for abuse and neglect. She is cognitively impaired. Diagnosis of dementia, psychosis, depression, and anxiety. Prefers to be in her room, social isolation. Reported for resistive to care verbally and behavioral aggression. Abuse care plan was not updated after allegation of abuse on 12/24/25. No abuse/neglect assessment was found for 2025. No abuse assessment was done after abuse allegation incident in October and December 2025.On 12/31/25 at 10:56AM, V6 RN (Registered Nurse) said that she is the regular nurse and the assigned nurse on the day of incident (12/24/25 3-11 shift) . Around 4pm, V7 CNA reported of observing bruise on R1's right wrist and forearm. V6 RN assessed R1's right wrist bruise measuring 4cm x 3cm and right forearm bruise measuring 2cm x 2cm. R1 denied pain upon assessment. V6 notified primary care physician and ordered x-ray of right hand. She notified V3 Family member, who is a resident in another unit and visited R1. Around 9pm, V3 informed V6 that she called police officer because she believed that the bruises are from abusing R1. Around 10pm, the police officer came and conducted investigation. V6 updated V1 and V2 of the incident. V6 said that R1 is prone to bruising due to anticoagulant medication side effects and her behavioral issues of agitations. She may swing her arms when agitated and may hit hard objects. V6 said that they used to apply Geri sleeves to protect her upper arms, but she refused. V6 did not remember if she documented it. V6 said that they used Broda chair/padded chair to R1. V6 said that they did not use padded side rails, but they use pillow to each side of the bed for protections. Informed V6 that R1 was observed today, using high back wheelchair not padded. R1's room was observed with 2 pillows only in her room. V5 CNA said that she used 2 pillows on her head and does not use pillows on bilateral side rails as protection when in bed. V6 said that they can use devices such as Geri sleeves and padded side rails or pillows as protection for R1 from injury.On 12/31/25 at 12:04PM, V2 SSD said that he did not complete abuse/neglect assessment. The last time he attempted to complete annual assessment for 8/15/25, but V3 Family member refused. V2 said that he did not document R1 or V3 refusal of abuse assessment. No abuse assessment was done in Oct and [DATE] after allegation of abuse or incident of bruising on unknown injury. There was no abuse assessment was done on MDS significant change of condition dated 11/3/25. No abuse assessment done for 2025. V1 Administrator said that they should document any refusal of assessment of abuse. Abuse assessment should be completed after each allegation of abuse and assessment corresponding to MDS/Resident assessment review.On 12/31/25 at 1:30PM, V1 Administrator said that they don't have policy on Resident safety /Prevention of injury. Facility's policy on Abuse Prevention revised 8/2025 indicated: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes, but is it not limited to, freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse and physical or chemical restraint to required to treat the resident's symptoms. The objective of the abuse policy is to comply with the seven-step approach to abuse and neglect detection and prevention. Prevention: A. The community will develop and implement policies and procedures to aid our community in prevention and prohibiting all types of abuse, neglect or mistreatment of our residents. C. Implement preventive measures to address factors that may lead to abusive situations for example: 5. Involve the resident/family group council in developing, monitoring and evaluating the community's abuse prevention program. 8. Monitor associates on all shifts to identify inappropriate behaviors towards residents9. Identification, ongoing assessment, care planning and appropriate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146180 If continuation sheet Page 2 of 6 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 146180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ascension Nazarethville Place 300 North River Road Des Plaines, IL 60016 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 0607 interventions and monitoring of residents with needs and behaviors that may lead to conflict or neglect. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146180 If continuation sheet Page 3 of 6 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 146180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ascension Nazarethville Place 300 North River Road Des Plaines, IL 60016 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 facility failed to ensure to provide adequate supervision and develop new care plan intervention to prevent injury/bruising to resident who has history of injury of bruising. This deficiency affects one (R1) of three residents reviewed for Adequate supervision and Prevention of Injury.Findings include:On 12/31/25 at 9:12AM, V3 Family member said that she was notified by nurse that R1 had bruised on right hand and forearm last week. R1 had incidents of found bruises in the facility. V3 said that they are not doing anything to prevent her from having these bruises. V3 believed that R1 is being abused.On 12/31/25 at 9:27AM, V1 Administrator said that last week 12/24/25, R1 was observed to have bruises on her hand. V1 said he already submitted facility reported incident to IDPH. V1 said that R1 had incident reported last [DATE] due to unknown bruising on her left eyebrow. V3 Family member/R1's sister who is also a resident in the facility in another unit, who keeps on calling the IDPH for abuse allegations. V3 is accusing facility of abusing R1 due to her occurrences of bruises. He said that R1 has behavioral issues of agitation and physical aggression. She has tendency to resist care and swing her arms that may hit hard objects. R1 is on blood thinning medication which bruising is expected side effects.On 12/31/25 at 9:33AM, Observed R1 up in high back chair in the 2nd floor hallway near the nursing station. She is alert to herself and responsive but irritated and does not want to be bothered.On 12/31/25 at 9:35AM, V4 LPN (Licensed Practical Nurse) said that she is the assigned nurse for R1. She said, that R1 is alert but confused and has behavioral issues of agitation and resistive to care. R1 had history of bruises due to her medication side effects and agitations. She has tendency to swing her arms when resisting care and may hit hard objects. V4 said that R1 needs assistance with ADLs (Activity of daily living) and transfers. She needs 2-person mechanical lift transfer. V4 said that R1 has bilateral floor mats. V4 said that they are not using Geri sleeves (Protective sleeves), or side rails pad for R1. for Surveyor asked V4 to check bruises on right hand and forearm. Observed fading bruises yellow green discoloration on right dorsal hand and forearm. R1 said she did know what had happened to her hand and does not want to be bothered. Observed R1's room with V4 LPN. Observed bilateral floor mats against the wall. 2 pillows on the bed.On 12/31/25 at 9:44 AM, V5 CNA (Certified Nurse Assistant) said that she is the assigned CNA for R1. R1 is alert but confused and has behavioral issues of agitation and resistive to care. She is aware that R1 has bruised on her right hand. R1 has tendency to swing her arms when resisting care and may hit hard objects. V4 said that R1 needs assistance with ADLs and transfers. She needs 2-person mechanical lift transfer. V4 said that R1 has bilateral floor mats. V4 said that they are not using Geri sleeves, or side rails pad for R1.On 12/31/25 at 10:17AM, Both V1 Administrator and V2 Social Service Director (SSD) said that V3 Family member called multiple times to IDPH for allegations of resident abuse to R1. All allegations are unsubstantiated. Both said that abuse /neglect assessment are done upon admission, quarterly, annual, significant change or in allegation of abuse.On 12/32/25 at 10:30AM, Review R1 medical records with V1 Administrator. R1 is re- admitted on [DATE] with diagnosis listed in part but not limited to Parkinson's disease, Atrial fibrillation, Congestive heart failure, Hypertension, Type 2 Diabetes Mellitus, Stage 3 chronic kidney disease, Dementia, Anxiety disorder, Depression, Cognitive communication deficit, Psychosis, History of falling. Active physician order sheet indicated: Alprazolam 0.25mg tablet by mouth every 8 hours as needed for anxiety. Eliquis 2.5mg tablet by mouth twice a day for atrial fibrillation. Escitalopram 5mg tablet by mouth every day for Depression. Donepezil 10mg tablet by mouth every day for Alzheimer's disease. Active comprehensive care plan indicated: Cognitive loss/dementia. She demonstrates altered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146180 If continuation sheet Page 4 of 6 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 146180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ascension Nazarethville Place 300 North River Road Des Plaines, IL 60016 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 level of cognitive function due to unspecified dementia, depression, anxiety disorder and unknown psychosis as evidenced by intermittent episodes of verbal and physical aggression particularly during care interactions with CNAs. Intervention: Monitor behaviors to ensure staff and resident safety while exploring appropriate interventions. She needs assistance with daily ADL care, impaired functional mobility/wheelchair bound, resistive to care, 2 staff will be present to provide ADLs at all times. She is at risk for pressure ulcer and other skin related injuries. 10/11/25 left eye redness and closed linear lesion of left forehead/healed. CT of head and cervical spine done. Intervention: Observe skin for redness and breakdown during routine care. She is at risk for complications from blood thinning medication. Eliquis as ordered. Monitor for presence of absence of signs of active bleeding such as hematuria, petechiae, bruising, bloody stool or nosebleed at least daily. Total body checks for all anticoagulants except for ASA are done with baths by CNAs and once a week by licensed nurse. This will be recorded on the treatment records. She is at risk for abuse and neglect. She is cognitively impaired. Diagnosis of dementia, psychosis, depression, and anxiety. Prefers to be I her room social isolation. Reported for resistive to care verbally and behavioral aggression. Informed V1 that Abuse care last updated 10/17/25. No abuse/neglect assessment was found for 2025. No abuse assessment was done after abuse allegation incident in [DATE]. No documentation found regarding skin assessment at least daily monitoring for bruising as medication side effects of anticoagulant medication Eliquis as indicated in care plan. Skin impairment was not updated of bruises found on right hand and forearm. Last care plan conference held with V3 Family member was 9/18/25. No care plan conference with the family after V3's multiple abuse allegation against the facility leading to multiple visits from IDPH. There is no documentation of IDT meeting to develop new care plan interventions to prevent re-occurrence of bruising or protecting R1 from bruising. V1 Administrator said that care plan should be updated. V1 said that he will address all the above concerns.On 12/31/25 at 10:56AM, V6 RN (Registered Nurse) said that she is the regular nurse and the assigned nurse on the day of incident (12/24/25 3-11 shift). Around 4pm, V7 CNA reported of observing bruise on R1's right wrist and forearm. V6 RN assessed R1's right wrist bruise measuring 4cm x 3cm and right forearm bruise measuring 2cm x 2cm. R1 denied pain upon assessment. V6 notified primary care physician and ordered x-ray of right hand. She notified V3 Family member, who is a resident in another unit and visited R1. Around 9pm, V3 informed V6 that she called police officer because she believed that the bruises are from abusing R1. Around 10pm, the police officer came and conducted investigation. V6 updated V1 and V2 of the incident. V6 said that R1 is prone to bruising due to anticoagulant medication side effects and her behavioral issues of agitations. She may swing her arms when agitated and may hit hard objects. V6 said that they used to apply Geri sleeves to protect her upper arms, but she refused. V6 did not remember if she documented it. V6 said that they used Broda chair/padded chair to R1. V6 said that they did not use padded side rails, but they use pillow to each side of the bed for protections. Informed V6 that R1 was observed today, using high back wheelchair not padded. R1's room was observed with 2 pillows only in her room. V5 CNA said that she used 2 pillows on her head and does not use pillows on bilateral side rails as protection when in bed. V6 said that they can use devices such as Geri sleeves and padded side rails or pillows as protection for R1 from injury.On 12/31/25 at 11:08AM, V8 CNA said that regular CNA and the assigned CNA in the morning incident on 12/24/25. R1 is alert but confused with behavioral issues of agitation and resistance to care. She dressed R1 by herself. She did not observe any bruising not redness on R1's hand but she complaint of pain which she reported to the nurse on duty, and she was given pain medication. She said that R1 does not use Geri sleeves and did not use bilateral pillows on side rails as protection. V8 said that R1 should have skin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146180 If continuation sheet Page 5 of 6 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 146180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ascension Nazarethville Place 300 North River Road Des Plaines, IL 60016 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 protection devices such as Geri sleeves or padded siderails.On 12/31/25 at 12:04PM, V2 SSD said that he did not complete the abuse/neglect assessment of R1. The last time he attempted to complete annual assessment for 8/15/25, V3 Family member refused. V2 said that he did not document R1 or V3 refusal of abuse assessment. No abuse assessment was done in Oct and [DATE] after allegation of abuse or incident of bruising on unknown injury. There was no abuse assessment was done on MDS significant change of condition dated 11/3/25. V1 said that they should document any refusal of assessment of abuse. Abuse assessment should be completed after each allegation of abuse and assessment corresponding to MDS review.On 12/31/25 at 1:30PM, V1 Administrator said that they don't have policy on Resident safety /Prevention of injury. Facility unable t provide policy on Resident safety / Prevention of injury.Facility's policy on Comprehensive person-centered care plan revised 10/2021 indicated: Policy statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs, that are identified through evaluation and assessment, is developed and implemented for each resident. Policy interpretation and implementation: N. Assessment of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.Facility's policy on Abuse Prevention revised 8/2025 indicated: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes, but is it not limited to, freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse and physical or chemical restraint to require treating the resident's symptoms. The objective of the abuse policy is to comply with the seven-step approach to abuse and neglect detection and prevention. Prevention: A. The community will develop and implement policies and procedures to aid our community in prevention and prohibiting all types of abuse, neglect or mistreatment of our residents. C. Implement preventive measures to address factors that may lead to abusive situations for example: 5. Involve the resident/family group council in developing, monitoring and evaluating the community's abuse prevention program. 8. Monitor associates on all shifts to identify inappropriate behaviors towards residents9. Identification, ongoing assessment, care planning and appropriate interventions and monitoring of residents with needs and behaviors that may lead to conflict or neglect. Event ID: Facility ID: 146180 If continuation sheet Page 6 of 6