Inspection·July 24, 2023

F 0607 2023 shows V13 worked from 1:51 PM to 10:00 PM. Level of Harm - Minimal harm or potential for actual harm On July 18, 2023, at 3:10 PM, V14 (Housekeeper) continued to say, as of July 17, 2023, she had not received abuse training since her date of hire on June 5, 2023. Residents Affected - Many On July 18, 2023, at 3:10 PM, V16 (Maintenance Director) said he is the supervisor for V14 and had been asked multiple times by Human Resources to provide abuse training to V14 (Housekeeper) because V14 does not speak English and requires a translator. V14 said he had been busy and had not been able to provide abuse training to V14 as of July 17, 2023, at 3:10 PM. V16 continued to say, [V14] has worked here for about 90 days, I think. The lady who does our training or orientation does not speak Spanish, so I must do the training. We do not have a Spanish version of the training materials or the employee handbook. [V17] (Administrator in Training) has brought this up to me, that I need to go through the handbook with [V14], but I have not had a chance. On July 20, 2023, at 8:34 AM, V16 (Maintenance Director) said, [V14] (Housekeeper) has worked on all floors of the facility. For the most part, the housekeeping staff are assigned to one floor, but I can tell you she has worked on both floors of the facility. On July 19, 2023, at 12:13 PM, V17 (Administrator in Training) said, Abuse training has to be completed before the staff work on the floor. The Maintenance Director was supposed to train her (V14) (Housekeeper) on abuse. It is our expectation they go through abuse training before they work on the floor. On July 19, 2023, at 12:13 PM, V1 (Administrator) said, [V17] (Administrator in Training) and I are not sure how [V14] (Housekeeper) got through the cracks. On July 20, 2023, at 10:09 AM, V17 (Administrator in Training) said staff sign the abuse training acknowledgement form at the time they receive abuse training. V17 continued to say dietary aides work in the kitchen and leave the kitchen to deliver food carts to the resident floors. V17 also said activity aides work with residents all over the facility. The facility's personnel files show the following facility staff members, their date of hire, and the date of the staff's signed acknowledgement of abuse training: V14 (Housekeeper) - DOH (Date of Hire): June 5, 2023. Abuse Training signed acknowledgement: July 18, 2023. V22 (CNA) DOH: May 23, 2023. Abuse Training signed acknowledgement: June 27, 2023. V23 (CNA/AA-Activity Aide) DOH: June 19, 2023. Abuse Training signed acknowledgement: June 27, 2023. V24 (AA) DOH: June 19, 2023. Abuse Training signed acknowledgement: June 27, 2023. V25 (DA-Dietary Aide) DOH: June 30, 2023. Abuse Training signed acknowledgement: July 19, 2023. V8 (CNA) DOH: March 11, 2023. Abuse Training signed acknowledgement: May 4, 2023. V10 (CNA) DOH: April 10, 2023. Abuse Training signed acknowledgement: April 25, 2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 2 of 11 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 07/24/2023 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 0607 V11 (CNA) DOH: April 11, 2023. Abuse Training signed acknowledgement: April 25, 2023. Level of Harm - Minimal harm or potential for actual harm V26 (DA) DOH: June 17, 2023. Abuse Training signed acknowledgement: June 27, 2023. V27 (Housekeeping) DOH: March 15, 2023. Abuse Training signed acknowledgement: April 25, 2023. Residents Affected - Many V28 (DA) DOH: March 14, 2023. Abuse Training signed acknowledgement: April 27, 2023 V29 (Housekeeping) DOH: March 31, 2023. Abuse Training signed acknowledgement: April 26, 2023. V30 (DA) DOH: March 15, 2023. Abuse Training signed acknowledgement: May 2, 2023. V31 (DA) DOH: March 27, 2023. Abuse Training signed acknowledgement: April 27, 2023. V32 (Housekeeping) DOH: April 1, 2023. Abuse Training signed acknowledgement: May 10, 2023. V33 (LPN-Licensed Practical Nurse) DOH: May 8, 2023. Abuse Training signed acknowledgement: May 29, 2023. Facility timecards for V8, V10, V11, V14, and V22-V33 show those staff members worked in the facility between their date of hire and the date they signed the abuse training acknowledgement form. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 3 of 11 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 07/24/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy to immediately report an allegation of abuse resulting in an employee witnessing alleged abuse of a resident and not reporting the alleged abuse for approximately 17 hours. This failure has the potential to affect all 75 residents residing in the facility. The findings include. The Facility Data Sheet dated July 17, 2023, shows the facility census as 75 residents. On July 19, 2023, at 11:21 AM, R8 was lying in bed in his room. No injuries or bruising were visible on R8. Due to his cognitive status, R8 was unable to recall events from June 27, or 28, 2023. The EMR (Electronic Medical Record) shows R8 was admitted to the facility on [DATE]. R8 has multiple diagnoses including, adult failure to thrive, anemia, rectal cancer, hypertension, lack of coordination, and cognitive communication deficit. R8's MDS (Minimum Data Set) dated February 28, 2023, shows R8 has moderate cognitive impairment, requires extensive assistance with toilet use, limited assistance with personal hygiene, supervision with bed mobility, transfers between surfaces, locomotion, dressing, and eating, and can independently walk in the room. R8 is frequently incontinent of urine and has a colostomy. The facility's undated Abuse Investigation Report shows V17 (Administrator in Training) was notified on June 28, 2023, by V14 (Housekeeper), that V14 observed V13 (CNA-Certified Nursing Assistant) providing care to R8 while V14 was cleaning the hallway. V14 reported [V13] was rough with care. On July 18, 2023, at 3:10 PM, V16 (Maintenance Director) translated for V14 (Housekeeper). V16 said V14 does not speak English. V14 and V16 said V14 had not received abuse training since her date of hire on June 5, 2023. V14 (Housekeeper) said she was working at the facility on June 27, 2023, at approximately 3:00 PM. V14 said she was working in the hallway outside of R8's room and saw V13 (CNA) being rough with the resident while providing care and verbally inappropriate when speaking to R8. V14 said she had direct visual sight of R8 and V13. V14 said, [V13] entered the room and saw the resident being upset because the CNA did not address the situation fast enough. [R8] was upset because he wanted his colostomy bag changed. V14 continued to say she saw the CNA going through R8's room being upset herself, and V13 and R8 had an angry discussion. V14 felt the CNA was being too rough taking the colostomy bag off the resident, and the resident was screaming and got combative with the CNA. V14 said she did not report the alleged abuse to V17 (Administrator in Training) until June 28, 2023, at approximately 8:00 AM. V14 said she was not sure what procedure to follow and spoke to a fellow coworker the following day, on June 28, 2023, who encouraged her to report the alleged abuse. V14 said she was upset after observing the rough handling of the resident, and was scared to report the abuse to anyone, and feared retaliation if she reported V13 (CNA) to administration. Due to the delay in reporting alleged abuse, V13 (CNA) continued to work in the facility and care for residents on June 27, 2023. V13's timecard for June 27, 2023, shows V13 worked from 1:51 PM to 10:00 PM. On July 20, 2023, at 8:34 AM, V16 (Maintenance Director) said, [V14] (Housekeeper) has worked on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 4 of 11 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 07/24/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many all floors of the facility. For the most part, the housekeeping staff are assigned to one floor, but I can tell you she has worked on both floors of the facility. On July 19, 2023, at 12:13 PM, V17 (Administrator in Training) said, It became clear to me, after [V14] (Housekeeper) reported the abuse allegation on June 28, 2023, that she had not reported the abuse allegation immediately, and had reported it late to me. The staff are supposed to report abuse immediately. The facility's undated Internal Reporting Requirements and Identification of Allegations Policy shows: Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer. In the absence of the administrator, reporting can be made to an individual who has been designated to act in the administrator's absence. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 5 of 11 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 07/24/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide and document post (after) fall nursing assessments for a resident who sustained an unwitnessed fall with injury in accordance with their policy. This failure resulted in a delay in obtaining medical treatment for a resident with a displaced fracture of the leg bone and contusion of the forehead and eye orbit. Residents Affected - Few This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 9. The findings include: R1's EMR (Electronic Health Record) showed R1 was re-admitted to the facility on [DATE], and discharged to the local hospital on July 11, 2023. R1 had multiple diagnoses including Dementia with psychotic disturbance, glaucoma, hypertension, atherosclerotic heart disease, repeated falls, and cognitive communication deficit. R1's most recent fall risk assessment dated [DATE], showed R1 was at high risk for falls. R1's MDS (Minimum Data Set) dated April 18, 2023, showed R1 had severe cognitive impairment, required extensive assistance with bed mobility and transfer, did not walk, and was dependent on staff for locomotion. R1 also required extensive assistance of 1 for dressing, personal hygiene and eating. R1 was always incontinent of bowel and bladder. R1's actual fall care plan-initiated December 6, 2022, with goal revised on June 2023, showed interventions included to Monitor/document/report PRN (as needed) x 72 hours to MD for s/sx. (Signs and symptoms) pain, bruises, changes in mental status, new onset confusion, sleepiness, inability to maintain posture, agitation. R1's EMR showed on July 9, 2023, at 6:30 PM, R1 was found lying on the floor with abrasions to the forehead, under eye and right knee. There was no documentation of any range of motion assessment for R1, or an evaluation for possible injuries to the head, neck, spine, and extremities. R1's EMR showed there were no nursing assessment progress notes on July 9, 2023-night shift (11:00 PM-7:30 AM) and July 10, 2023-day shift (7:00 AM-3:30 PM). R1's EMR showed no documentation regarding a range of motion assessment for any extremity at the time of the fall on July 9, 2023, until transfer to the hospital on July 11, 2023. R1's vital signs record showed vital signs were not documented on July 10, day, evening and night shift or July 11, 2023, day shift. On July 20, 2023, at 9:30 AM, V34 (LPN-Licensed Practical Nurse) stated that she worked on July 10, 2023, day shift and was assigned to R1. V34 stated she did not receive a shift report from V7 (LPN) when coming on duty. V34 stated throughout her shift she was not aware of R1's fall the previous evening and did not do a post fall assessment or neuro checklist on R1 during her shift. On July 18, 2023, at 3:36 PM, V33 (LPN) stated she worked on July 10, 2023, on the evening shift (3:00 PM to 11:30 PM) and was assigned to R1. V33 stated she did not receive a shift report from V34 (LPN) when she came on duty and did not know of R1's fall from the previous day. V33 stated R1 slept (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 6 of 11 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 07/24/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few in her bed until around 6:30 PM when V33 woke R1 up to take her medication. V33 then noticed R1 had a black eye and bruising to the right side of her face and V33 checked R1's EMR and discovered that R1 had fallen the day before. V33 stated she did not do neuro checklist form in EMR for her shift. V33 also stated she was unsure of what to do for follow up after a resident had a fall. V33 stated she made a late entry progress note for the shift (July 10, 2023, evening shift) on July 12, 2023, when the Supervisor told her how to do it. On July 17, 2023, at 2:31 PM, V6 (RN-Registered Nurse) stated she became aware that R1 had a femur fracture on July 11, 2023, at 9:00 AM when she took the radiology results from the fax machine. V6 further stated R1's left knee was swollen. On July 17, 2023, at 10:33 AM, V9 (LPN) stated she was with V2 (DON-Director of Nursing) on July 11, 2023, in R1's room prior to R1's transfer to the hospital. V9 stated R1's left knee was really swollen and her leg was in a flexed positioned, and her leg looked as if the bone was out of place. V9 also noted there was a break in the skin on the outside of the left knee and it looked as if the bone was protruding through the skin. On July 18, 2023, at 11:18 AM, V2 (DON) stated, on July 11, 2023, V9 (LPN) informed me regarding the small hole on the side of left knee that was described as a bone protruding through the skin. V2 stated at the time of the fall there was an abrasion to the knee, and it is the left knee, the same leg as the one that was fractured. R1's Emergency Department Physician Report dated July 11, 2023, showed R1 had facial hematoma on the right forehead and right upper eyelid. R1 also had left knee deformity with one centimeter skin opening with bone protrusion. R1's hospital record progress note dated July 11, 2023, by V36 (Physician, orthopedic surgeon) showed R1 had an open left distal femur fracture that likely occurred July 9, 2023, two days prior. V36 recommended urgent I&D (incision and drainage) of open fracture site in OR (operating room) with application of knee spanning external fixator. On July 19, 2023, at 4:51 PM, V21 (R1's Physician) stated he relies on the facility nurses to inform him regarding a resident's injury as the nurses are his eyes and ears. V21 further stated he expects nurses to perform neuro checks and nursing assessments for residents who experience an unwitnessed fall or hit their head. V21 stated he did not receive any information regarding injury to R1 until July 11, 2023, at 3:30 AM, via text and he ordered an X-ray of the left knee due to report of the knee swelling. V21 also stated had he been told that R1 had an unwitnessed fall from her wheelchair onto her face that resulted in facial bruising on July 9, 2023, V21 would have ordered to send R1 to the hospital immediately. On July 19, 2023, at 10:38 AM, V2 (DON) stated the expectation following a fall with injury is for documentation of assessment of the resident for 72 hours. When asked if staff is expected to document the assessment each shift V2 stated I hope so. The facility's document titled Falls:, undated, indicated .9. Follow up 72 Hours Post Fall with Neuro checks, Vitals, changes in ROM (range of motion) or LOC (level of consciousness). The facility's policy titled Falls -Clinical Protocol dated March 2018 indicated in paragraph 2, . the nurse shall assess and document /report the following: a. vital signs, b. Recent injury (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 7 of 11 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 07/24/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete especially fracture or head injury, c. Musculoskeletal function, observing for changes in normal range of motion, weight bearing, etc., d. Change in cognition or level of consciousness e. neurological status f. pain The facility's policy titled Neurological Assessment dated October 2019, indicated under general guidelines section that neurological assessments are to be completed 1. b. following an unwitnessed fall, and 2. When assessing neurological status always include frequent vital signs. Particular attention should be paid to widening pulse pressure (the difference between systolic and diastolic pressures) This may be indicative of increasing intracranial pressure (ICP). Event ID: Facility ID: 145004 If continuation sheet Page 8 of 11 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 07/24/2023 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary supervision to a resident to prevent a fall that resulted in a serious injury. This failure resulted in R1 sustaining a leg fracture because of the fall, that required urgent surgery upon admission to the hospital on July 11, 2023. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 9. The findings include: R1's EMR (Electronic Health Record) showed R1 was re-admitted to the facility on [DATE], and discharged to the local hospital on July 11, 2023. R1 had multiple diagnoses that including Dementia with psychotic disturbance, glaucoma, hypertension, atherosclerotic heart disease, repeated falls, and cognitive communication deficit. R1's most recent fall risk assessment dated [DATE], showed R1 was at high risk for falls. R1's MDS (Minimum Data Set) dated April 18, 2023, showed R1 had severe cognitive impairment, required extensive assistance with bed mobility and transfer, did not walk, was dependent on staff for locomotion. Also required extensive assistance for dressing, personal hygiene and eating. R1's care plan had a fall intervention dated May 1, 2022, that stated Remain in a room near the nurse's station for visual checks. R1 sustained an unwitnessed fall on July 9, 2023, at 6:30 PM, as documented in R1's EMR (Electronic Medical Record). On July 17, 2023, at 4:23 PM, V10 (CNA-Certified Nursing Assistant) stated R1 was noted on the floor, face on the floor, on her knees, in front of her wheelchair on July 9, 2023, at approximately 6:30 PM. On July 20, 2023, at 1:14 PM, V10 (CNA) stated she was passing dinner trays and there was no staff at the nurse's station, when she saw R1 had a fall on July 9, 2023. V10 stated she called for V12 (LPN-Licensed Practical Nurse) who was passing medications in the hall, to assist with R1 after the fall. V10 stated V12 came, and they assisted R1 to a sitting position with R1's legs in front of her and then assisted R1 back into her wheelchair by lifting R1 up. V10 stated that process took about one to two minutes. V10 also stated after R1 was seated in the wheelchair, V10 left the nurses station to return to passing dinner trays and V12 texted V7 (LPN) to let her know that her assigned resident, R1 had a fall because V7 was not in the facility at the time. V7 (LPN) stated on July 17, 2023, at 2:15 PM, that she was R1's assigned nurse on July 9, 2023, on the evening shift and was not in the facility at the time of R1's fall. V7 stated R1 is usually sitting in her wheelchair behind the nurse's station so staff can keep an eye on her. V7 stated around 6:00 PM on July 9, 2023, V7 left the facility to go on break and as she exited the building her coworker V12 (LPN) was already outside the building on break. V8 (CNA) stated on July 17, 2023, at 3:21 PM, that V8 worked the evening shift on July 9, 2023, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 9 of 11 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 07/24/2023 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 - Actual harm Residents Affected - Few saw R1 sitting in her wheelchair, at the nurse's station and noticed bruising on R1's face around 6:30 PM. V8 stated V12 (LPN) told her that R1 just had a fall. V8 also stated she was unaware of the time when V7 went on break and was not asked to supervise R1 during that shift. V11 (CNA) stated on July 17, 2023, at 4:09 PM, that she was assigned to care for R1 on July 9, 2023, during the evening shift. V11 stated around 7:30 PM she was putting R1 to bed and noticed a bruise on R1's face. V11 stated she put R1 back into the wheelchair and took her to the nurse's station to show V7 (LPN) the bruise on R1's face. V11 (CNA) stated V10 (CNA) saw V11 taking R1 to the nurse's station and told V11 that R1 had fallen earlier. V11 further stated she was unaware when V7 (LPN) left the building to go on break and was not asked to watch R1 during that shift. V11 (CNA) had stated to V2, (DON), who provided a written statement on July 19, 2023, that on July 9, 2023, evening shift, V11 had fed R1 dinner between 5:15-5:30 PM at the nurse's station and then went to assist other residents with the dinner meal, leaving R1 in the nurse's station. On July 20, 2023, at 9:15 AM, V35 (CNA) stated she works in the facility full time and knows R1 well. V35 stated staff bring R1 to the nurse's station so all staff can keep an eye on her. V35 demonstrated the usual position of R1 when sitting at the nurse's station. R1 sits in her wheelchair and likes to rock back and forth. V35 stated R1 sits behind the nurse's station, at the counter, and puts both knees flexed, up against the counter, and moves back and forth in a rocking motion. V35 further stated R1 sits next to staff at the counter while staff chart on the computer. V10 (CNA) stated on July 20, 2023, at 1:14 PM that at the time of the fall on July 9, 2023, R1 was sitting away from the counter on the left side of the nurse's station, with no counter in front of her. The wheelchair was upright, and R1 was face down on the floor in a kneeling position on the floor. On July 20, 2023, at 9:30 AM, V34 (LPN) stated she has worked at the facility for eight years and has worked with R1 since her admission to the facility and knows R1 well. V34 stated R1 requires a lot of attention and somebody must keep an eye on her at all times. V34 further stated that R1's routine includes if she is awake, staff keep her at the nurse's station and R1 sits behind the counter with staff while in her wheelchair. V34 also stated that nursing staff know staff are not to take their breaks during resident mealtimes. Staff break times are assigned to occur either before or after resident mealtimes. V34 also stated that nurses cover for each other during staff breaks and don't leave the unit at the same time for breaks. On July 19, 2023, at 4:51 PM, V21 (R1's Physician) stated he relies on the facility nurses to inform him regarding a resident's injury as the nurses are his eyes and ears. V21 stated he did not receive any information regarding injury to R1 until July 11, 2023, at 3:30 AM, via text and he ordered an X-ray of the left knee due to report of the knee swelling. V21 also stated had he been told that R1 had an unwitnessed fall from her wheelchair onto her face that resulted in facial bruising on July 9, 2023, V21 would have ordered to send R1 to the hospital immediately. V21 also stated the cause of the fracture was most definitely the fall on July 9, 2023. R1's hospital record progress note dated July 11, 2023, by V36 (Orthopedic Surgeon) showed R1 had an open left distal femur fracture that likely occurred July 9, 2023, two days prior. V36 recommended urgent I&D (Incision and Drainage) of open fracture site in OR (Operating Room) with application of knee spanning external fixator. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 10 of 11 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 07/24/2023 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 - Actual harm Residents Affected - Few During multiple interviews, between July 17 and July 20, 2023, at various times, staff who worked the evening shift on July 9, 2023, V7(LPN), V10 (CNA), V11(CNA) and V8 (CNA) each stated R1 was at risk for falls and was kept at the nurse's station for visual monitoring. During additional staff interviews, between July 17 and July 20, 2023, at various times, V2 (DON), V35 (CNA), V34 (LPN), V33 (LPN), V9(LPN) and V6 (RN) each stated R1 was at risk for falls and R1 was often positioned behind the nurse's station to provide visual monitoring. The Facility policy Fall and Fall Risk, managing, dated March 2018, showed under the section, Resident-Centered Approaches to Managing Falls and Fall Risk, 1. The staff will implement a resident centered fall prevention plan to reduce the specific risk factor for each resident at risk. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 11 of 11