Inspection·February 9, 2023

F 0550 required extensive assistance for bed mobility, transfers, toilet use and personal hygiene. Level of Harm - Minimal harm or potential for actual harm On 2/9/23 at 8:56 AM, V10 (LPN) said R34 is able to make her needs known. R34 is alert and oriented, but can be forgetful. She is able to stand, but needs assistance from at least one staff member. R34 will use her call light when she needs something. I've never heard her yelling or hollering out. She does get concerned about things, like today she has an appointment and she's anxious about being late or missing it. R34's room is close to the nurses' station and this hall isn't very long. If R34 was yelling or hollering out, then the staff should be able to hear her. V10 said if R34 was hollering or yelling, then I would check on her right away because that's not normal for her. Residents Affected - Few On 2/9/23 at 10:28 AM, V2 (Director of Nursing - DON) said R34 hasn't been at the facility very long. The surveyor described R34's concern with V2, DON. V2 said she was not aware of that happening, but her room is close to the nurses' station. They should be answering the call lights in a timely manner and if R34 was hollering, then the staff should be able to hear her. The facility's undated Resident Rights Packet showed, As a long-term care resident in Illinois, you are guaranteed certain rights, protections and privileges according to state and federal laws. Your rights to dignity and respect: .You facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life . You rights to safety: . Your facility must provide services to keep your physical and mental health, at their highest practical levels. Your facility must be safe, clean, comfortable, and homelike . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 2 of 14 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 145004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crescent Care of Elgin 180 South State Street Elgin, IL 60123 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** Based on observation, interview and record review, the facility failed to ensure a resident who needs extensive assistance of one staff member during meals was provided the lunch meal and assisted in a timely manner for 1 of 2 residents (R11) reviewed for activities of daily living (ADLs) in the sample of 22. Residents Affected - Few The findings include: R11's admission Record, printed by the facility on 2/8/23, showed she had diagnoses including dementia, congestive heart failure, dysphagia, oropharyngeal phase (swallowing problems occurring in the mouth and/or throat), muscle weakness, protein-calorie malnutrition and cognitive communication deficit. R11's Order Summary Report, provided by the facility on 2/9/23, showed an order for general/regular diet of mechanical soft consistency texture (foods broken down into smaller pieces or that are softer, making them easier to chew), pleasure feeds as tolerated with aspiration precautions. The Order Summary Report showed R12 was on Hospice care. R11's facility assessment dated [DATE] showed she had severe cognitive impairment (BIMS score of 6 on the brief interview of mental status tool used to determine cognitive level). The facility assessment showed R12 required extensive assistance of one staff member physically assisting her when eating. R11's care plan (no date on care plan received) showed she had impaired cognitive function or impaired thought processes related to dementia, difficulty making decisions, and short-term memory loss. R11's ADL (activities of daily living) care plan (no date) showed she has an ADL self-care deficit related to a stroke. The ADL care plan does not address R11's required needs during meals. R11's care plans showed she had a history of unplanned weight loss and the goal was that she would consume 75% of two or three meals a day. R11's care plans showed she had a potential nutritional problem related to diet restriction of mechanical soft diet. Interventions in place were to Provide, serve diet as ordered. Monitor intake and record every meal. Pleasure feed as tolerated with aspiration precautions. On 2/7/23 at 12:50 PM, V15 (Certified Nursing Assistant-CNA), V16 (Licensed Practical Nurse-LPN) and V17 (Resident Care Assistant-RCA) were collecting trays from resident rooms after the residents were finished eating. V15-V17 were placing the trays back in the tray cart. V15 was asked if R11 was going to be provided with a tray and assisted for the lunch meal. V15 said Oh, hasn't anyone fed her yet. V15 went to the tray cart and got R11's tray. There were 12 trays in the cart. 11 of them were returned trays, from resident's that had already finished the lunch meal. The other tray was R11's. V15 took the tray to R11's room and started assisting her with her meal. On 2/08/23 at 11:21 AM, V18 (R11's daughter) was feeding R11 a cheeseburger and an orange drink for lunch. R11 was eating well and ate all of the cheeseburger. V18 said the only concern she had with the care R11 receives is that sometimes she will come in and R11's breakfast or lunch tray will still be on the bedside table next to her bed and it is not touched. V18 said the silverware will still be clean and the food is not touched. V18 said she is concerned they (staff) are not feeding R11 sometimes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 3 of 14 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 145004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crescent Care of Elgin 180 South State Street Elgin, IL 60123 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 2/9/23 at 9:04 AM, V5 (LPN) said whichever CNA is assigned to a room where the resident needs assistance, or needs to be fed, is the one that is responsible for feeding them. On 2/9/23 at 9:05 AM, The facility's Daily Assignments sheet for 2/7/23 showed V15 was the CNA assigned to R11 on 2/7/23. Residents Affected - Few On 2/9/23 at 9:07 AM, V15 CNA said he was in feeding another resident. V15 said he assumed one of the other CNAs had fed R11 her lunch on 2/7/23. On 2/09/23 at 9:15 AM, V2 (Director of Nursing-DON said whoever is assigned the resident is generally the one that feeds them. V2 said all of the staff help out. V2 said R11 doesn't like anyone helping her eat. V2 said staff should still offer her a tray and assist her with the meal. The facility provided document titled (Facility) Meal Hours showed the lunch meal was from 11:40 AM through 1:00 PM, with the second floor meal times being 11:40 AM through 12:20 PM. The facility's Midnight Census Report, printed by the facility on 2/7/23, showed R11 resided on the second floor of the facility. R11's weight history showed a loss of 2.2 pounds from 12/6/22 through 2/7/23. The facility's policy and procedure titled Assistance with Meals, with a revision date of July 2017, showed Residents shall receive assistance with meals in a manner that meets the individual needs of each resident .Residents Requiring Full Assistance: 1. Nursing staff will remove food trays from the food cart and deliver the trays to each resident's room. 2. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 4 of 14 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 145004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crescent Care of Elgin 180 South State Street Elgin, IL 60123 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to identify an area of pressure prior to becoming a stage 3 pressure ulcer. This applies to one of four residents (R23) in the sample of 22 reviewed for pressure. Residents Affected - Few The findings include: The facility face sheet for R23 shows diagnoses to include dementia, congestive heart failure, type 2 diabetes mellitus and severe protein-calorie malnutrition. The facility assessment dated [DATE] shows R23 to have severe cognitive impairment and requires extensive assistance of one for her bed mobility. The same assessment shows R23 to be at risk for developing pressure ulcers/injuries. On 2/8/2023 at 1:20 PM, R23 was observed receiving wound care to her coccyx area. V3 wound nurse said her wound is not getting any better and not getting any worse. V3 said she (R23) is seen weekly by the wound care Nurse Practitioner and was told her wound would be chronic due to her declining health conditions. V3 said the wound was found on 10/5/2023 and was staged as a stage 3 pressure ulcer. V3 said she expects the staff to inspect her skin during all care and report to her any changes in the skin such as redness or changes in the condition of the skin. V3 said pressure ulcers should be found prior to becoming a stage 3 pressure ulcer. On 2/9/2023 at 9:50 AM, V2 Director of Nursing said she would expect the staff to find a pressure ulcer prior to it becoming a stage 3 . The Nurse Practitioner note dated 10/5/2023 shows a stage 3 pressure ulcer to R23's coccyx. The note shows the wound has healthy tissue present and is 1 centimeter (CM) by 0.5 CM and 0.1 CM deep. The following week on 10/12/2023 the Nurse Practitioner note shows the wound is now covered in slough (dead tissue) and was changed to an unstageable pressure ulcer. The area measured 1.3 CM by 0.7 CM and was 0.1 CM deep and had necrotic (dead) adipose tissue exposed. The facility policy dated July 2017 for prevention of pressure ulcers/injuries shows 4. inspect the skin on a daily basis when performing personal care or ADL's. a. identify any signs of developing pressure injuries i.e. nonblanchable erythema, darkly pigmented skin, inspect for changes in skin tone, temperature and consistency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 5 of 14 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 145004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crescent Care of Elgin 180 South State Street Elgin, IL 60123 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 supervise a wandering resident while he entered another residents room and failed to supervise residents with dysphagia while eating in their rooms. This applies to three of six residents (R72, R34, R65) in the sample of 22 reviewed for supervision. The findings include: On 2/7/2023 at 9:20 AM, room mates R7 and R38 said a resident in a wheelchair will come into their room and touch their things. R7 said one time she pushed his wheelchair backwards and this resident slapped at her arms. R38 said that same resident slapped at her foot as she yelled at him to leave her room. Both R7 and R38 said this resident would yell and swear at them when they yelled at him to leave their room. R38 said she is [NAME] of him. Both residents identified this resident as R72. R7 and R38 could not say when these incidents happen but it is daily occurrence that R72 opens their door and attempts to come in. Sometimes he comes in and sometimes he just looks in and then shuts the door and leaves. The facility assessment dated [DATE] for R7 shows her to cognitively intact. The facility assessment for R38 dated 12/15/2022 shows her to cognitively intact. On the afternoon of 2/7/2023, R72 was observed wheeling himself up and down the halls. Occasionally R72 would attempt to turn the door knobs of the closed doors on the hallway. On 2/8/2023 and 2/9/2023 R72 was observed with the same behavior. The facility face sheet for R72 shows diagnoses to include Alzheimer's Disease and anxiety. The facility assessment dated [DATE] shows R72 to severe cognitive impairment and uses a wheel chair as a mobility device. On 2/9/2023 at 9:05 AM, V4 Certified Nursing Assistant (CNA) said R72 wanders the halls in his wheel chair and will check the doors along the hall. V4 said he needs redirection to stay out of other residents rooms. V4 said both R7 and R38 are alert and oriented. On 2/9/2023 at 9:15, V5 Licensed Practical Nurse (LPN) said she has witnessed R72 enter other resident rooms and he requires close observation to redirect him away from this behavior. V5 said both R7 and R38 are alert and oriented. On 2/9/2023 at 9:35 AM, V6 Social Service said R72's behaviors include wandering in the halls in his wheel chair. R72 was trying all the doors on the halls and entering other residents rooms. On 2/9/2023 at 9:50 AM, V2 Director of Nursing (DON) said he needs close supervision due to his wandering, and needs redirection if seen entering a residents room to prevent an altercation between the residents. The undated care plan for R72 shows cognitive short term and long term memory problems with an intervention to provide him with the level of supervision that he requires and provide him with assistance in decision making tasks and use task segmentation to support his short term memory deficits . The undated care plan for wandering for R72 shows he wanders aimlessly, significantly intrudes on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 6 of 14 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 145004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crescent Care of Elgin 180 South State Street Elgin, IL 60123 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 privacy of activities. Resident wanders into other resident rooms causing disruption. The interventions for this problem include only: assess for fall risk, distraction from wandering, monitor for weight loss and fatigue and provide structured activities. The facility policy for wandering, unsafe resident dated August 2014 shows the facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents. 3. The residents care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan will be included. 2. On 2/7/23 at 9:37 AM, R34 was sitting in her wheelchair, looking at the floor. R34's overbed table was sitting in front of her with a cup of thickened water. R34 stated, I stay in my room for meals. I don't like my water like this, but they say that I have to because I'm not swallowing right. I love to drink water, but not like this. It's disgusting. But, I do what they tell me to. They don't help me eat. Someone just brings in my tray and drops it off. At 12:20 PM, R34 was sitting up in her wheelchair with her lunch tray in front of her. R34 was eating pumpkin pie with her fork. There were no staff members in R34's room while she was eating. There was a veal steak with gravy, green beans, and dressing with a slice of bread under the insulated lid. R34 stated, I guess we'll see how this tastes later. This pie is really good. After finishing her pie, R34 used her spoon to eat the veal steak. R34 coughed several times while she was eating. As of 12:30 PM, none of the nursing staff assisted R34 with dining or observed her eating. V4 (CNA) and V12 (CNA) were answering call lights and assisting other residents. V10 (LPN) and V9 (RN) were passing medications and documenting in the EMR (Electronic Medical Record). On 2/8/23 at 12:43 PM, R34 was sitting in her room drinking thickened water. R34 stated, The lunch was actually pretty good today. I ate most of it. I always eat in my room. The staff doesn't come in here when I eat. They just bring me the food and come back later to pick up my tray. They never stay in the room with me, while I eat. I know I had my swallowing checked, but I don't remember exactly when. That's why I have to have these thick liquids, because I have a swallowing problem. I had to have a test this morning. The doctor wanted a CT of my chest because I keep coughing when I eat. The doctor seems to think that I still have pneumonia. I feel okay, other than the coughing when I eat or drink. I didn't get my results today, so I guess we'll see what the doctor says when I get the results. On 2/9/23 at 8:40 AM, R34 was sitting in her wheelchair, eating breakfast. R34's plate had scraps of sausage and smears of syrup on it. I just had some delicious pancakes and sausage. I don't like the oatmeal because they never bring me milk. I like milk in my oatmeal. There was not staff present in R34's room. V8 (CNA) and V9 (RN) were in the hallway talking to each other. R34's Facehseet dated 2/8/23 showed diagnoses to include, but not limited to: encephalopathy; CHF (congestive heart failure); diabetes; hypertension; GERD (Gastroesophageal Reflux Disease); unspecified mood disorder; pneumonia; dysphagia (difficulty swallowing); lack of coordination; abnormal posture; and cognitive communication deficit. R34's facility assessment dated [DATE] showed R34 was cognitively intact; had no behaviors; required limited assistance of one staff member for eating; and received a mechanically altered diet. R34's Physician Order Sheet showed, Diet: General/Regular diet - Mechanical soft consistency ., nectar mildly thick consistency (liquids) . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 7 of 14 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 145004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crescent Care of Elgin 180 South State Street Elgin, IL 60123 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 R34's Hospital Therapy Notes dated 1/9/23 showed, Speech Language Pathology Daily Note . SLP Diagnosis: Dysphagia, Oropharyngeal phase . Diet Recommendations: Dysphagia - Advanced/soft to chew. Liquid consistency recommendations: Nectar thick liquids. Support strategies recommendations: Alternating solids/liquids, Small bites/drinks, No straws, slow rate, Upright 90 degrees (1:1 supervision when alert) . Assessment: . Throughout session, pt with delayed swallow initiation. Suspect delayed bolus formation. Pt also observed with need for use of multiple swallows per bolus. Suspect pharyngeal residue present . Recommend pt remain on NDD3/NTL (soft to chew food and nectar thickened liquids) with 1:1 feed and above listed swallow strategies . R34's Hospital After Visit Summary dated 1/11/23 showed R34 was hospitalized from [DATE] - 1/11/23 for multifocal pneumonia. This document showed, Speech Feeding & Diet Consistency Recommendations: .Diet: Dysphagia - Mechanically altered ground (NDD2) . Nectar thick liquids . Alternating solids/liquids, Small bites/drinks, no straws, slow rate, upright 90 degrees . 1:1 supervision . R34's undated Care Plan showed, My name is (R34). I am on a mechanical diet and nectar thick liquid . Interventions: Provide diet as ordered . Provide set-up with meals and fluids only. OR Provide cues and supervision with all meals and fluids. OR Provide assistance as needed for meals and fluids. OR Requires total care with food and fluid intake (The facility should have chose the appropriate option for R34. The care plan is not resident specific) . Monitor, document and report signs/symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth. Refusing to eat, appears concerned at meals . Registered dietician to evaluate and make recommendations as indicated . R34's Speech Therapy SLP Evaluation and Plan of Treatment dated 1/12/23 - 1/25/23 showed R34 had dysphagia. This document showed, .Reason for referral: . (R34) was resident at ALF (Assisted Living Facility), brought to hospital s/p (after) altered mental status and increased weakness. Patient was diagnosed in hospital with metabolic encephalopathy and possible multifocal pneumonia due to aspiration . (1/9/23 VFSS (Video Fluoroscopic Swallowing Study) at the hospital with results recommending mechanical soft and nectar thick liquid diet. Deep penetration noted with thin liquids and no aspiration noted t/o study with any consistencies tested.) . Clinical Impressions/Reason for Skilled Services: Patient presents with moderate/mild oropharyngeal dysphagia which necessitates skilled SLP services for dysphagia to restore oral/pharyngeal function, reduce signs and symptoms of aspiration and develop and instruct in compensatory strategies in order to improve ability to safely swallow without signs/symptoms of aspiration, meet primary nutrition/hydration needs and use strategies/compensatory techniques. Due to documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient is at risk for: aspiration, compromised general health, pneumonia, and malnutrition . R34's SLP Recert, Progress Report & Updated Therapy Plan dated 1/26/23 - 2/8/23 showed, .Patient presents with decreased swallowing function/strength which necessitates skilled SLP services for dysphagia to restore oral/pharyngeal function, reduce signs and symptoms of aspiration and assess/evaluate for safest level of oral intake in order to improve ability to safely swallow without signs/symptoms of aspiration, safely consume highest level of oral intake and use strategies/compensatory techniques . On 2/8/23 at 12:43 PM, V20 (Speech Language Pathologist - SLP) said R34 came from the hospital with multifocal pneumonia related to aspiration. R34 had a video swallow study at the hospital, but has not had a video swallow study at the facility. V20 stated, I do see R34 for Speech Therapy. Initially R34 was seen 5 times a week, beginning 1/12/23. I even did a re-certification for her, so she is still on my services. I spoke with her daughter and she hopes R34 can return to an ALF. R34 is on a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 8 of 14 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 145004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crescent Care of Elgin 180 South State Street Elgin, IL 60123 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 mechanical soft diet with nectar thick liquids. She eats in dependently, but staff should be supervising here. She usually eats pretty slow on her own, but she does need verbal cues and reminders. She had a repeat chest X-ray here and she still has pneumonia. I think she's having a CT scan soon. V20 said she has not advanced R34's altered diet since she was admitted to the facility. V20 said R34 still needs more therapy. On 2/8/22 at 1:50 PM, V19 (Dietician) said the speech therapist would be responsible for determining the appropriate diet/liquid texture for a resident. V19 stated, I would expect residents that can't safely feed themselves to get assistance with meals. If a resident had a history of aspiration pneumonia, still had dysphagia, and was on an altered diet, then I would expect the resident to be supervised and/or assisted with meals. On 2/9/23 at 12:28 AM, V2 (DON) said before COVID, most of the residents went to the dining room. It is easier for the staff to supervise the meal, when the residents are in the dining room. Many residents are still leery of going to the dining rooms. We just started opening up the dining rooms for lunch. Everyone still eats breakfast in their rooms. A resident assessed for the need for feeding assistance on admission. Therapy will see them and provide recommendations. There is a list of resident's that need feeding assistance at the nurses' station. V2 stated, If a resident in coughing during meals, then the nurse should assess the resident, notify the doctor, and inform Speech Therapy. If a resident has a history of aspiration pneumonia, then they would need a Swallow Study and we would follow the recommendations. Speech Therapy takes over and follows-up with the resident to determine if it is appropriate to advance a diet. If a resident is coughing at meals and they have dysphagia, that's not good. The food could have gone down the wrong pipe. V2 said the facility did not have a policy for resident's with swallowing precautions. The facility's Assisting the Impaired Resident with In-Room Meals Policy (revised 2013) showed, The purpose of this procedure is to provide the appropriate support for residents who need assistance with eating. Preparation: 1. Review the resident's care plan and provide for any special needs of the resident . 3. On 2/7/23 at 12:44 PM, R65 was sitting in the dining room being fed by facility staff. R65 had a divided plate with pureed food. On 2/8/23 at 9:01 AM, R65 was in her room feeding herself breakfast. R65 was shoveling pureed eggs into her mouth with shaking hands. V8 (CNA) and V9 (RN) were in the hallway talking. There was no staff supervising R65 eat. After the surveyor looked into R65's room, V8 (CNA) stopped into R65's room and asked her if she needed any help. R65 denied the need for help and V8 promptly left the room, leaving R65 to finish her pureed breakfast alone. R65's Facesheet dated 2/9/23 showed diagnoses to include, but not limited to: Alzheimer's Disease, dementia, generalized muscle weakness, depression, and dysphagia (difficulty swallowing). R65's facility assessment dated [DATE] showed R65 had severe cognitive impairment; required extensive assistance from one staff member; and was on a mechanically altered diet. R65's Physician Order Sheet dated 2/9/23 showed, .Diet . General/Regular diet. Pureed consistency texture, Regular (Thin) consistency (liquids). Give magic cup/mighty shake at breakfast per resident and POA preference . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 9 of 14 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 145004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crescent Care of Elgin 180 South State Street Elgin, IL 60123 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 On 2/8/23 at 12:48 PM, V20 (SLP) said she does not see R65 for Speech Therapy. Level of Harm - Minimal harm or potential for actual harm On 2/9/23 at 8:56 AM, V10 (LPN) R65 requires feeding assistance. The staff have to help her because she's getting more and more shaky. R65 is on a pureed diet because the family requested it. R65 needs a mechanical soft diet because it's hard for her to eat chewier foods, but the family just decided pureed was better for her. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 10 of 14 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 145004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crescent Care of Elgin 180 South State Street Elgin, IL 60123 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 Residents Affected - Many 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 ensure meal trays were delivered in a manner to prevent cross-contamination. This has the potential to affect all the residents residing in the facility. This findings include: The facility's CMS 672 form dated 2/7/23 showed there are 74 residents residing in the facility. On 2/7/23 from 12:09 PM to 12: 20 PM, the surveyor observed lunch, room tray service on the first floor. Two hot carts were parked and plugged in near the nurses' station. The first floor nurses' station is located at the bend in the hallways, with a resident halls extending from the side and rear of the nurses' station. V4 and V12 (CNAs - Certified Nursing Assistants) were obtaining trays from the hot box, stopping at the beverage cart, and proceeding to the resident rooms with the lunch trays. The slice of pumpkin pie was uncovered on all the resident trays. V12's hair was down and resting on her shoulders and upper back. V4 and V12 (CNAs) walked from the hot boxes (a central location) to deliver room trays down each hall. While walking down the hall the pumpkin pie was open to air and they were passing other staff and residents in the hallway. V4 was delivering room trays to residents on the shorter hallway and V12 was delivering meals to the residents on the longer hallway. At one point, V12 was standing in front of the hot box with the door open. V12 was holding the tray with the pumpkin pie uncovered, when V4 walked up behind her and reached directly over the pumpkin pie, to get pull another tray. On 2/7/23 from 12:18 PM to 12:40 PM, the surveyor observed lunch, room tray service on the second floor. V15 (CNA) and V16 (LPN) were obtaining trays from the hot box and taking them to the residents' rooms. The pumpkin pie was uncovered, as they passed through the hallways with other staff and residents in the hallways. On 2/7/23 at 1:36 PM, V7 (Dietary Manager) said the facility just started re-opening the dining room. So, essentially all the residents still received room trays. V7 denied any residents being on tube feeding. V7 said the dietary department delivers the hot box to the units and the nursing staff passes the trays to the residents. V7 said the food is placed in the hot box, in the kitchen. V7 stated, All the food should be in the dome. We've never covered the desserts before. I'm newer here and we are working on new procedures. The nursing staff should be taking the hot box from room to room, so the tray doesn't travel from one end of the hall to the other. The surveyor described the above observations and V7 replied, It shouldn't be happening that way. The food is at risk for cross-contamination. I will see if we have a policy on that. On 2/9/23 at 11:53 AM, V7 (Dietary Manager) said the facility does not have a food handling or food distribution policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 11 of 14 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 145004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crescent Care of Elgin 180 South State Street Elgin, IL 60123 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 provide wound care in a manner to prevent cross-contamination for 1 of 4 residents (R12) reviewed for infection control in the sample of 22. Residents Affected - Few The findings include: R12's admission Record, printed by the facility on 2/8/23, showed he had diagnoses including hemiplegia and hemiparesis (paralysis and weakness) following cerebrovascular disease (conditions that affect the blood flow and blood vessels in the brain) affecting his left non-dominant side, other abnormalities of gait and mobility, and lumbago with sciatica (pain and/or numbness and tingling radiating from the lower back (lumbar spine) thighs and buttocks, and may radiate into the legs and feet). R12's Order Summary Report, provided by the facility on 2/9/23, showed the following order: Wound care sacrum-Cleanse with saline, pat dry, apply skin prep, cover with hydrocolloid (a dressing that provides an insulated environment to promote wound healing) in the evening every other day and as needed for wound care. R12's most recent Wound Assessment Details Report dated 2/3/23 showed MASD (moisture-associated skin damage) due to incontinence that measured 3.6 cm (centimeters) x 4.5 cm x 0.01 cm. R12's facility assessment dated [DATE] showed he was cognitively intact and required extensive assistance of two staff members for bed mobility and toileting. The assessment showed R12 required extensive assistance of one staff member for personal hygiene and was dependent on one staff member for bathing. The assessment showed R12 had a limitation in range of motion on one side of his upper and lower extremities. The assessment showed R12 was occasionally incontinent of urine and always incontinent of bowels. The assessment also showed R12 had moisture associated skin damage. R12's care plan, printed 2/8/23 by the facility, showed he is dependent on staff for meeting emotional, intellectual, physical and social needs related to immobility and physical limitations. The care plans showed R12 has an actual ADL (activities of daily living) self-care performance deficit related to impaired mobility associated with left-sided hemiplegia from cerebrovascular disease, and generalized muscle weakness with poor trunk control. The care plan showed R12 required the extensive assistance of one staff member to meet his toileting and incontinence needs. On 2/07/23 at 10:23 AM, V3 (Wound Nurse) said R12 has had a wound on his buttocks off and on since she started a year and 2 months ago. V3 had the supplies in her hand and walked into R12's room. V3 did not wash her hands upon entering R12's room. V3 put on clean gloves and rolled R12 over onto his left side. V3 removed the old dressing. R12 had been incontinent of stool V3 cleaned the stool from R12, then changed gloves. V3 did not wash her hands or perform hand hygiene when she changed the gloves. V3 cleaned the wound on R12's sacral area with saline, then changed gloves again without performing any hand hygiene. V3 applied triad paste (a zinc oxide based paste used in wound care) and a dressing ( (a dressing that provides an insulated environment to promote wound healing). with the gloves still on, V3 touched the remote to R12's bed, R12's covers, picked up R12's urinal and emptied the urinal, V3 then removed the gloves and grabbed her supplies and the bag from the waste can and went to the soiled linen room, touching R12's door knob and the door knob to the soiled linen room. V3 then washed her hands. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 12 of 14 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 145004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crescent Care of Elgin 180 South State Street Elgin, IL 60123 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 2/07/23 at 10:38 AM, V3 said she should clean her hands before performing wound care and anytime she changes her gloves to prevent cross-contamination. On 2/08/23 at 2:03 PM, V3 said It is important to make sure you keep an area with only superficial skin clean and prevent cross-contamination to help with healing. Residents Affected - Few The facility's policy and procedure titled Wound Care, with a revision date of October 2010, showed Steps in the Procedure: 1. Use disposable cloth (paper towel is adequate) to establish a clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly. 3. Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. Put on exam glove. Loosen tape and remove dressing. 5. Pull [NAME] over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 16. Discard disposable items into the designated container. Discard all soiled laundry, linen, towels and washcloths into the soiled laundry container. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly. 17. Reposition the bed covers. Make the resident comfortable. The facility's policy and procedure titled Handwashing/Hand Hygiene, with a revision date of August 2015, showed This facility considers hand hygiene the primary means to prevent the spread of infections. The policy showed Procedure. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors 7. Use an alcohol-based hand rub containing at east 62% alcohol, or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: a. Before and after coming on duty. b. Before and after direct contact with residents .d. Before performing any non-surgical invasive procedures .g. Before handling clean or soiled dressings, gauze pads, etc. After contact with a resident's intact skin. After contact with blood or bodily fluids. After handling used dressings, contaminated equipment, etc. After removing gloves. the policy showed 9. the use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. The policy also showed Applying and Removing Gloves: 1. Perform hand hygiene before applying non-sterile gloves. 3. When removing gloves, pinch the glove at the wrist and peel away from the hand, turning the glove inside out. 4. Hold the removed glove in the gloved hand and remove the other glove by rolling it down the hand and folding it into the first glove. 5. Perform hand hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 13 of 14 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 145004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crescent Care of Elgin 180 South State Street Elgin, IL 60123 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure water temperatures were in a consistent and comfortable range. This applies to all 74 residents residing in the facility. The findings include: The facility census and condition of residents from the #672 dated 2/7/23, shows there are 74 residents residing in the facility. On 2/7/23 at 10:10 AM, in room [ROOM NUMBER] and 152, the water in the bathroom sink was too hot for this surveyor to keep his hand under the stream without discomfort, with just the hot water turned on. On 2/07/23 at 10:10 AM, R55 said, try turning the water on for a minute and sticking your hand in it. R55 said, the water in the bath room is so hot he makes his instant coffee with it. R55 said the coffee he makes is hotter than the coffee the serve at the meals. On 2/07/23 at 10:15 AM, R60 said, when the CNA's (Certified Nursing Assistants) gives him a shower sometimes the water is too hot or too cold, and he'll have to tell the CNA's to adjust it. On 2/7/23 at 10:35 AM, V2 DON (Director of Nursing) was asked to send V13 (Maintenance Director) to the conference room for an interview. V13 came to the conference room with a thermometer (even though a thermometer was not requested) and told this surveyor he was in the process of testing resident water temperatures when he dropped the thermometer in water and now it's not working. V13 said, he will go to the local hardware store to purchase another thermometer. On 2/7/23 at 1:08 PM, V13 said, the water temperature fluctuates based on the time of day, where the room is located, and how long the water has been running. V13 tries to adjust the mixing valve based on what the residents or CNA's are telling him, or based on his weekly water test. On 2/9/23 at 10:00 AM, V8 CNA said, the water temperatures vary widely and he is not sure why. V8 said he has told V13 about it. V8 said, it's important to test the shower water with his hand so the resident is comfortable. On 2/9/23 at 2:40 PM, V2 said, V13 said, it could be a mixing valve issue. R55's 12/8/22 MDS (Minimum Data Set) shows he scored a 15 on his brief interview for mental status, indicating he is cognitively intact. R60's 1/15/23 MDS (Minimum Data Set) shows he scored a 13 on his brief interview for mental status, indicating he is cognitively intact. The same document shows he is totally dependant on the facility staff for bathing. A Policy and Procedure for water temperatures was requested but not received. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 14 of 14