Inspection·November 16, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm The facility's policy titled Care Plans, Comprehensive Person-Centered showed 8. the comprehensive, person-centered care plan will: b. describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 2 of 20 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 11/16/2023 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 remove a resident's facial hair and failed to provide set up assistance for meals for 2 of 22 residents (R17, R70) reviewed for activities of daily living in the sample of 22. Residents Affected - Few The findings include: 1. On 11/13/23 at 9:52 AM, R17 was sitting up in her wheelchair. R17 had a mustache and facial hair on her chin and neck. R17 stated I don't like this (and rubbed her chin), and I don't like a mustache either. On 11/14/23 at 8:40 AM, R17 was in her room sitting at the bedside, eating breakfast. R17's facial hair and mustache remained. V8 (Certified Nursing Assistant/CNA) said R17 needs help with activities of daily living. V8 said R17 is supposed to get her face shaved during showers. V8 looked at R17 and stated They must not have done it with her shower over the weekend. R17 doesn't like the hair on her face. I will get the electric razor and take care of it. R17's Minimum Data Set, dated [DATE] shows R17 needs extensive assist of one person for personal hygiene. The undated facility's Shaving Male and Female Residents Policy shows Purpose: To provide cleanliness, comfort, and improved morale. Female residents will be assessed weekly, and assistance provided in accordance with the resident's preference. 2. R70's Face sheet printed on 11/15/23 showed he was admitted on [DATE] with diagnoses to include, but not limited to, fall on same level from slipping, tripping, and stumbling, essential hypertension, osteoarthritis, and gout. R70's Minimum Data Set (MDS) dated [DATE] shows R70 has moderate cognitive impairment. Eating with supervision once the food is placed before the resident. R70's Occupational Therapy notes dated 11/14/23-12/24/23 showed eating: set up or clean up assistance. On 11/14/23 at 9:42 AM, R70 said, I need help with eating I can't raise my arms all the way, I can't open my milk and I drop my food. On 11/14/23 at 12:48 PM, R70 was sitting on the side of his bed at his bed side table attempting to eat his meal. R70 used his right hand to cut sliced potatoes, used a spoon for sliced green beans and the mechanical soft meat. Some green beans fell off the plate and onto the tray. Pieces of potatoes were noted on tray. A blue bowl with an unopened lid remained on the table with a food item inside of the bowl. On 11/14/23 at 12:49 PM, R70 said it's too late now I need someone to help me before I start. On 11/14/23 at 12:59 PM, V10 (CNA) said she asked (R70) if he needed help and he said no. He said he was having difficulty, but he said no. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 3 of 20 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 11/16/2023 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 Residents Affected - Few On 11/15/23 at 11:29 AM, V18 (Occupational Therapist/OT) said she is familiar with (R70). We are working with him on both upper extremities. Both shoulders limited with ROM (range of motion), weakness bilateral (both sides). He complains occasionally of pain to his right arm. He has an old fracture to his right hand and the pain is consistent with that. He needs help opening containers and removing the lids from the bowls. On 11/15/23 at 11:40 AM, V21 (CNA) said Yes, I am familiar with (R70). I am taking care of him today. I did pass his trays for him today. If someone does not help him with the lids it could be difficult for him to start eating. He can't get the containers open. The facility's policy titled Assistance with Meals shows residents shall receive assistance with meals in a manner that meets the individual needs of each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 4 of 20 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 11/16/2023 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to have ordered pressure reducing interventions in place to prevent R72's stage 2 sacral pressure wound from deteriorating to a stage 3. R72's pressure wound increased in size and depth and worsened in condition. This applies to 1 of 3 residents (R72) reviewed for pressure wounds in the sample of 22. Residents Affected - Few The findings include: R72's Minimum Data Set Assessment of 9/24/23 shows that R72 was admitted to the facility on [DATE] with diagnoses including Renal Insufficiency, Neurogenic Bladder and Paraplegia. This same assessment shows that R72 had a stage 2 pressure ulcer (wound) present upon admission. On 11/14/23 at 8:45 AM R72 was lying in bed awake. R72 was alert and oriented. R72 stated that he gets up sometimes but really doesn't have any motivation to get out of bed. R72 stated that he walked into the hospital, and they had to wheel him out. He stated that he is unable to walk and usually just prefers to stay in bed. R72's Initial Wound assessment dated [DATE] shows that R72 had a stage 2 sacral pressure wound (a partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. Granulation tissue, slough and eschar are not present) measuring 1.0 x 1.0 x .01 cm. The wound is described as 100% pink or red non-granulating tissue with a scant amount of serous (yellow or transparent) drainage. The treatment is listed as Collagen and foam. On 11/16/23 at 2:30 PM, V11 (Licensed Practical Nurse/Wound Nurse) stated, Wound Rounds must have had a glitch because my assessments were not in there. I have these. V11 provided Surveyor with 2 handwritten wound assessments dated 9/28 and 10/4. Surveyor asked why the first assessment by (V12 Wound Nurse Practitioner) was not done until 10/10/23 and V11 stated, I did not think the wound needed to be seen by (V12) until then. R72's Handwritten Wound Assessment (Without pictures) dated 9/28/23 describes the sacral wound as unstageable (a full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar), measuring 1.0 x 1.0 x 0.01 cm (declined from a stage 2). The treatment is listed as collagen and a bordered foam dressing. R72's Handwritten Wound Assessment (Without Pictures) dated 10/4/23 (16 days after admission) also shows the sacral wound as unstageable, measuring 1.0 x 1.0 x 0.01 cm. The same treatment was continued, collagen and bordered foam. R72's Initial Wound Assessment done by V12 and dated 10/10/23 shows that R72 has an unstageable sacral wound, present on admission. The assessment shows the wound as 1.8 x 1.4 x 0.1 cm, 90% slough (devitalized tissue) and 10% non-granulating red tissue. This assessment also states, The pressure ulcer is to be offloaded using low air loss mattress. On 11/14/23 at 10:09 AM V11 and V12 assessed R72's wound with Surveyor present. R72 was lying on a regular facility mattress, not a low air loss mattress. V11 stated, He had a low air loss mattress but we were having a problem with the pumps-so we had to order him a new one. It may be downstairs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 5 of 20 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 11/16/2023 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 because we got a shipment in today. V11 was unsure how long R72 had been without the low air loss mattress. Level of Harm - Actual harm Residents Affected - Few At 10:20 AM V12 stated, Every resident with a stage 3 should have a low air loss mattress, I noticed that today. I don't recall if he ever had one. R72's undated care plan shows that R72 has a stage 2 pressure ulcer to the coccyx. The interventions include Follow facility policies/protocols for the prevention/treatment of skin breakdown. R72's Physician's Order Sheet dated November 2023 shows an order dated 11/14/23 for a Low Air Loss Mattress. The facility policy entitled Prevention of Pressure Ulcers/Injuries dated July 2017 states, Select appropriate support surfaces based on the resident's mobility, continence, skin moisture and perfusion, body size, weight and overall risk factors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 6 of 20 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 11/16/2023 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 - Immediate jeopardy to resident health or safety Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. There are multiple deficient practice statements. A. Based on observation, interview and record review the facility failed to ensure water temperatures in resident bathrooms were maintained at a safe level to prevent potential resident injury. This failure resulted in the water in five residents' bathrooms measuring 150(+) degrees Fahrenheit, having the potential to cause third degree burns within 1-2 seconds, at 12:40 PM on 11/13/23. This applies to 5 of 5 residents (R16, R17, R38, R53 and R55) reviewed for safety in the sample of 22. B. Based on observation, interview and record review the facility failed to ensure a resident on a mechanically altered diet was safely assisted to eat for 1 of 22 residents (R39) reviewed for safety in the sample of 22. The findings include: A. The Immediate Jeopardy began on 11/13/23 at 12:40 PM when V3 (Maintenance Director) and Surveyor checked the water temperature in 5 residents' bathrooms on the second floor of the facility. Using the facility's thermometer, the temperatures measured 150.1-150.2 degrees Fahrenheit. V1 (Administrator) was notified of the Immediate Jeopardy on 11/15/23 at 10:45 AM. The Surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 11/15/23 at 2:15 PM; however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. On 11/13/23 at 12:40 PM V3 (Maintenance Director) and Surveyor used the facility's thermometer to measure the water temperatures in the bathroom sinks of R16, R17, R38, R53 and R55. R16's water measured 150.1 degrees Fahrenheit, R17's water measured 150.1 degrees Fahrenheit, R38 and R53's water measured 150.2 degrees Fahrenheit and R55's water measured 150.2 degrees Fahrenheit. R16's Physician's Order Sheet (POS) dated November 2023 shows that R16 has diagnoses including Vascular Dementia with Behavioral Disturbance. R16's MDS (Minimum Data Set) of 8/10/23 shows that R16 has severe cognitive impairment. On 11/13/23 and 11/14/23 R16 was observed propelling herself in her wheelchair in her room and in the hallway outside of her room. R17's POS dated November 2023 shows that R17 has diagnoses including Dementia and Anxiety. R17's MDS of 9/17/23 shows that she has Moderate Cognitive Impairment and requires only supervision for locomotion on the unit. R38's POS dated November 2023 shows that R38 has diagnoses including Traumatic Subdural Hemorrhage and Dementia. R38's MDS of 8/17/23 shows that he has moderate cognitive impairment and requires only supervision for locomotion on the unit. R53's POS dated November 2023 shows that R53 has diagnoses including Cognitive Communication Deficit and Lack of Coordination. R53's MDS of 8/29/23 shows that he has Moderate Cognitive Impairment and requires only supervision for locomotion on the unit. R55's POS dated November 2023 shows that R55 has a diagnosis of Dementia. R55's MDS of 9/12/23 shows that he has severe cognitive impairment and requires only supervision for locomotion on the unit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 7 of 20 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 11/16/2023 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 - Immediate jeopardy to resident health or safety Residents Affected - Some On 11/13/23 at 12:40 PM V3 (Maintenance Director) stated, Oh wow, that is too hot. I do random room checks every day- just random rooms throughout the building. I've been getting 98-110 degrees Fahrenheit every day. The mixing valve is reading about 105-108 degrees Fahrenheit. We had a problem about 4-5 months ago that upstairs was not getting enough hot water and we had the mixing valve replaced. I will need to call the vendor and have them come out and take a look. On 11/13/23 at 12:55 PM V3 and Surveyor went to the basement mechanical room and observed the mixing valve dial on the hot water boiler system. The mixing valve dial showed the water temperature at approximately 108 degrees Fahrenheit. On 11/13/23 at 1:56 PM V3 stated, I ran the shower upstairs for about 10 minutes and it dumped all that hot water. This is an old building. I don't know what the problem is. I still have to call the plumber to come out and take a look. This has never happened before. We had issues with the mixing valve but that was replaced. The water temperatures are good now. On 11/13/23 at 3:53 PM V1 (Administrator) stated, This is an old building. This is not something that happens all the time. We can have (Vendor) come back out and look at it. The staff use the sinks all the time. I have never heard any complaints about it before. I can try to get someone here tomorrow to look at it. Since they came out and did the work (9/28/23), we haven't had a problem. I understand that it has to be treated in a special way. We can check the water temps throughout the building in the meantime while we are waiting for plumber to come. On 11/14/23 at 8:19 AM V7 (Certified Nursing Assistant/CNA) stated, If you turn it on and let it run like early in the morning it sometimes, like once or twice, has gotten really hot. I can't even touch it. But then you can adjust it by turning on the cold. On 11/14/23 at 8:43 AM V8 (CNA) stated, We can run it sometimes it takes 15-20 minutes to heat up. Once in a blue moon it gets too hot, depending on how many showers we have. The more showers the better it gets because it is constantly running. It is an old building. Sometimes it won't get hot at all. On 11/14/23 at 9:10 AM V9 (CNA) stated, (The water) can get too warm, if you turn it too much, too hot or too cold, it gets pretty hot. (I) have to finesse it to get it to the right temperature. Not sure if it is the plumbing, it is an old building. We couldn't give showers because it was too hot a while ago. I told maintenance and I filled out a form. On 11/14/23 at 9:14 AM V10 (CNA) stated, On my second day working, the shower room was not working, there was no handle. The hot was too hot. I had to mix with cold water. On 11/14/23 at 12:20 PM V5 (Plumber), V3 (Maintenance Director) and Surveyor checked the water temperatures in R17's and R55's rooms. The temperatures measured 105 degrees Fahrenheit and 104 degrees Fahrenheit. V3 then stated, We did have a power outage on Friday, and I had to reset the breakers yesterday. I did that around 1:00 PM, after we checked the water. (After the hot water temperatures measured 150(+) degrees Fahrenheit.) V5 stated, It is possible that something got caught in the Leonard Valve (mixing valve). That can be very touchy, and this could be very difficult to figure out where the problem is. V5 observed the dial on the mixing valve that showed the water temperature at just below 110 degrees Fahrenheit. V5 stated that the boiler is at 140 degrees Fahrenheit. V5 stated, I am at a loss. Without being here (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 8 of 20 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 11/16/2023 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 - Immediate jeopardy to resident health or safety Residents Affected - Some when it happened, I just don't know. Everything seems to be working fine. V3 was asked if he had done any water temperature checks today. V3 stated, I have checked the water twice so far today- I have not documented it yet. V3 was asked for any maintenance requests or a maintenance log. V3 stated, I am not logging the maintenance stuff. I just get texts or notes and then I complete the work. I will start doing that now. On 11/15/23 at 2:15 PM, after assessing the facility water system, V22 (HVAC/Mechanical Contractor) stated, The issue seemed to be purely a mechanical issue. I balanced the system. It is very touchy, and we were getting it up to almost 120 degrees Fahrenheit. Surveyor asked V22 if the power outage over the weekend and the need to reset the breakers on Monday could have anything to do with the water getting too hot. Surveyor explained to V22 that the water temperatures measured 150 degrees Fahrenheit. V22 stated, Oh, that is laundry temperature. That is the pump. If there was a power outage and the pump was not running at all you would be getting pure hot water from the return water pump, or the hot water would be backed up into the pipes. If that were the case, the rooms at the furthest and highest points would be affected by the hot water. (Surveyor explained to V22 that the rooms affected were at the furthest and highest point from the boiler). V22 stated, Then the pump could be going out- it is not a bronze pump, and they can fail. It sounds like the return loop was the problem with the hot water just sitting there. The facility water temperature logs for August, September, October, and November 2023 show daily water temperatures taken in random rooms and areas throughout the facility. There are no documented temperatures outside the expected range of 100-110 degrees Fahrenheit. The log for November 13, 2023, shows temperatures between 99.8- and 105.2-degrees Fahrenheit. (The elevated temperatures found at 12:40 PM are not documented on the log). The log for November 14, 2023, shows only one documented temperature reading. (V3 stated he had checked the temperatures twice before 12:30 PM on 11/14/23). The undated facility policy (revised on 11/15/23 as part of abatement plan) states, Tap water in the facility shall be kept within a temperature range to prevent scalding of residents. Hot water systems that service resident rooms, bathrooms, common areas and tub/shower areas shall be set to temperature of no more than 110 degrees Fahrenheit or 43.3 degrees Celsius or the maximum allowable temperature per state regulations. The Immediate Jeopardy that began on 11/13/23 was removed and on 11/15/23 when the facility took the following actions to remove the immediacy: The facility has taken immediate corrective action to assure no serious injury, harm, impairment, or death occurred or would occur due to the presence of hot water beyond the maximum temperature of 110 degrees Fahrenheit allowed in the facility. Upon the identification of the hot water temperatures at resident areas the facility took the following steps: *Notified nursing staff to prevent any resident from using the faucets unassisted. *Contractor from (Local Mechanical Company) identified, on 11/15/23, the problem as being an imbalance between the high flow and low flow mixing valves which, in a building of this size, tends to raise the temperature as the water goes through the return loop. The problem was fixed by recalibrating the high flow and low flow mixing valves and keep testing the water temperatures at the furthest point in the building to assure that the water temperatures are in a range between 100- and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 9 of 20 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 11/16/2023 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 110-degrees Fahrenheit at resident use areas. Level of Harm - Immediate jeopardy to resident health or safety *Additional temperatures were taken throughout the building at faucets in sinks and shower areas after the identification and adjustment of the mixing valve issue. Residents Affected - Some *Contacted Facility plumbing contractor on 11/14/23 to come to the facility and inspect and run additional calibrations. *Facility has reviewed and revised its policies and procedures on testing hot water, identifying issues and assuring the safety of residents while corrective actions were taken. *In-services have been and will continue to be held with all facility staff, including any new hires and temporary staff assigned to the facility. In-services have been conducted by the Administrator and/or his designee and have begun on 11/15/23 and are ongoing. Staff who were not present were in-service via telephone. All staff are in-service prior to the start of their next shift. In-services included the following: *A review of the requirement to maintain safe water temperatures throughout the resident areas of the facility. *A review of the facility policies and procedures, as revised, of steps to be taken if hot water temperatures are identified, which include, but are not exhaustive, of the following. alert all nursing staff, post signs at water use areas, notify maintenance, plumbing contractors, maintain safety of residents until all issues are resolved. *Going forward, daily water temperatures will be taken by maintenance and/or designee at 10 randomly selected faucets and a log is kept. Whenever a temperature exceeds the maximum allowed amount of 110 degrees Fahrenheit, the facility's revised policies and procedures will be followed. *Any trends of noncompliance will be addressed immediately and noted on the Quality Assurance Report. Any trends of noncompliance will be reported at the next QAPI meeting. Administrator is responsible for overall compliance. Administrator and /or designee will monitor logs to ensure overall compliance. B. On 11/13/23 at 12:26 PM, R39 was in bed with her lunch tray on the bedside table on the right side of R39's bed. R17 (R39's roommate) was on R39's left side and was feeding R39 her lunch. R17 was repeatedly feeding R39 bite after bite of food with no drink given in between bites. R17 stated She almost ate all of it. That's my buddy, I feed her a lot. R39 had a mouthful of food and was swallowing very slowly. On 11/14/23 at 8:40 AM, V8 (Certified Nursing Assistant/CNA) said R39 is on a pureed diet and needs someone to feed her, she tires out easily and eats slowly. On 11/15/23 at 9:07 AM, V14 (Director of Rehab/Speech Therapy) said she is seeing R39 for tolerance of her current diet. V14 said R39 is slow to initiate eating and has difficulty managing her utensils. V14 said R39 needs staff to feed her. V14 said CNAs and/or Nursing should be feeding residents with mechanically altered diet. V14 said it is not safe for residents to feed other residents. R39's Speech Therapy Progress Report and Updated Therapy Plan dated 9/12/23 shows R39 has diagnoses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 10 of 20 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 11/16/2023 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 - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete of Alzheimer's, dementia, dysphagia, and cognitive communication deficit and requires variable verbal/visual/tactile instructions due to slow responses and initiation at times and nursing is aware of patient's need for feeding assist. R39's Care Plan shows I have dx (diagnosis) of late onset Alzheimer's dementia. Monitor and document intake every meal, provide cues and supervision with all meals and fluids, Monitor, document, report and s/sx (signs and symptoms) of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth. refusing to eat, appears concerned at meals. Notify MD if Speech therapy screen indicated, Registered dietician to evaluate and make recommendations as indicated, Monitor and report to MD s/sx malnutrition: emaciation (cachexia), muscle wasting, significant weight loss of 3lb in 1 week, 5% in 1 month, 7.5% in 3 months, or 10% in 6 months. Event ID: Facility ID: 145004 If continuation sheet Page 11 of 20 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 11/16/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the catheter tubing for an indwelling urinary catheter was kept below the level of the bladder for 1 of 2 residents (R65) reviewed for urinary catheters in the sample of 22. The findings include: R65's Face Sheet printed on 11/14/23 showed he was admitted on [DATE] with diagnoses to include, but not limited to, retention of urine, hypertension, low back pain, and benign prostatic hyperplasia with lower urinary tract symptoms. R65's Physicians order sheet printed on 11/14/23 showed Foley (indwelling urinary catheter) catheter care every shift, monitor urine output via Foley every shift. R65's Minimum Data Set (MDS) dated [DATE] shows R65 is cognitively intact, bed mobility required limited assistance, transfer and toileting required supervision with one-person physical assist for all three. The assessment shows R65 has an indwelling catheter. R65's care plan printed 11/14/23 showed catheter care every shift and as needed. On 11/13/23 at 11:20 AM, R65's catheter bag was hanging on the arm rest of his wheeled seated walker and was above the level of the resident's bladder. Yellow urine was visible inside the tubing along its length. On 11/13/23 at 11:21 AM, R65 said, Look, I have to have it here because it is pulling on my penis, and it may come out. I need it glued to my leg. On 11/15/23 at 09:17 AM, V2 (Director of Nursing) said the urinary catheter should be secured. It should be secured to keep it in place. On 11/16/23 at 11:54 AM, V15 (Registered Nurse) said there is no (backflow prevention) valve on the drainage bags, and you need to keep them below the bladder to keep the urine from going into the bladder. The facility's policy titled Catheter Care, Urinary showed, 3. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Changing catheters 2. Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: catheter tubing should be strapped to the resident's inner thigh.) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 12 of 20 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 11/16/2023 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 0692 Provide enough food/fluids to maintain a resident's health. 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 put interventions in place for a resident with significant weight loss. The facility also failed to provide ordered nutritional supplements for residents at risk for weight loss. This applies to 3 of 3 resident (R72, R39 and R46) reviewed for weight loss in the sample of 22. Residents Affected - Some The findings include: 1. R72's Minimum Data Set Assessment of 9/24/23 shows that R72 was admitted to the facility on [DATE] with diagnoses including Renal Insufficiency, Neurogenic Bladder and Paraplegia. R72's Weights and Vitals Summary printed on 11/16/23 shows R72's admission weight on 9/18/23 as 139 lbs. (pounds). On 10/26/23 R72's weight was recorded as 128 lbs. (7.91% weight loss in 38 days). R72's Nutrition/Dietary Note written by V13 and dated 10/11/23 states, Increased protein needs related to wound healing as evidenced by stage 2 pressure injury to sacrum. Continue to follow with RD (Registered Dietician) available for consult PRN. The next Nutrition/Dietary Notes was not until 11/8/23 (1 month later) and shows that R72 had a 5.4 % (Significant) weight loss x 1 month. On 11/15/23 at 8:52 AM V13 (Dietician) stated, The weights came in last week, so I was going to see him today. He told me the food is not like home, we got a list of his preferences. He is on (supplements) now. I didn't see him last week because of the COVID outbreak here at the facility but I reviewed his weights and recommended the (supplement) daily. I put a note in on 11/8/23 (2 weeks after the weight loss was found). No one notified me of the weight loss on 10/26. They don't ever notify me. I see them when I come in. I see anyone that triggers for weight loss/gain or any unusual conditions. On 11/15/23 at 9:18 AM V6 (Registered Nurse/RN) stated, We do monthly weights. We notify hospice if the resident is on hospice. V2 (Director of Nursing) lets us know if we need a reweigh. The CNAs (Certified Nursing Assistants) will let me know if a resident is eating less. I don't notify the Dietician directly. We turn in all the weights to the DON or ADON and then they take it from there. On 11/15/23 at 9:29 AM V2 (Director of Nursing) stated, The Staff do the weights monthly. If they need a weekly weight, then they are put in as an order. All monthly weights must be done by the 7th of the month. The Dietician is here every week, and she looks at everything. She has complete access to everything. I don't need to notify her of anything. The facility policy entitled Weights and dated 11/14/12 states, Undesired or unanticipated weight gains/loss of 5%, in 30 days, 7.5% in 3 months or 10% in 6 months shall be reported to the physician, dietician and or dietary manager as appropriate. 2. On 11/13/23 at 12:26 PM, R39's lunch tray was served. R39's lunch tray did not contain milk, pudding, or yogurt. R39 was being assisted to eat and consumed 90% of the meal. R39's meal ticket on the tray showed whole milk with every meal, pudding with meals, yogurt with breakfast and lunch. On 11/14/23 at 8:40 AM, V8 (Certified Nursing Assistant/CNA) was feeding R39 breakfast. There was no yogurt or pudding provided on the meal tray. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 13 of 20 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 11/16/2023 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 11/14/23 at 12:02 PM, R39 was sitting up feeding herself a few bites of lunch. There was no milk, pudding, or yogurt provided. On 11/15/23 at 9:00 AM, V13 (Dietician) said R39 is supposed to get (fortified cereal) at breakfast, whole milk with meals, pudding at lunch, yogurt at breakfast and lunch, and offered a snack at bedtime. V13 said R39's BMI (Body Mass Index) is 15.5 (underweight) and these supplements are to promote weight gain. V13 said dietary is to provide the supplements and it should be on her meal ticket. R39's Care Plan shows I have diagnosis of late onset Alzheimer's dementia. I consume about 50-75% of meals: I will maintain my weight +/- 5 lbs. by next review, Provide supplements as ordered, Provide diet as ordered, Monitor and document intake every meal, Registered dietician to evaluate and make recommendations as indicated, Monitor and report to MD s/sx (signs/symptoms) malnutrition: emaciation (cachexia), muscle wasting, significant weight loss of 3lb in 1 week, 5% in 1 month, 7.5% in 3 months, or 10% in 6 months. R39's Dietary: Oral/Dehydration/Nutritional assessment dated [DATE] shows gaining weight desired related to underweight Body Mass Index. Current Plan of Care: pudding with meals, yogurt at breakfast and lunch, whole milk at meals. 3. On 11/13/23 at 12:16 PM, R46 was finishing eating lunch. R46 was assisted by staff to eat and had consumed all his pureed meal. There was no pudding provided on the tray. On 11/14/23 at 12:28 PM, R46 was in bed feeding himself lunch. There was no pudding provided on R46's lunch tray. R46's dietary meal ticket showed double portions and pudding tid (three time per day). On 11/15/23 at 9:00 AM, V13 said the goal for R46 is to promote weight gain so he is supposed to get (fortified cereal) at breakfast, pudding with all meals, double portions, (supplement) 4 x day given by the nurse. V13 said R46 is underweight his BMI is 17.1. V13 said the expectation is that the residents should receive these supplements. R46's Dietary: Oral/Dehydration/Nutritional assessment dated [DATE] shows significant weight loss x 3 and 6 months. On (fortified cereal) at breakfast, pudding with meals and double portions. Current nutrition Plan of Care offers kcals and protein to promote weight gain. R46's Care Plan shows provide supplements as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 14 of 20 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 11/16/2023 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 interview and record review, the facility failed to test and record the wash and rinse temperatures of their high temperature dishwasher three times a day. This failure has the potential to affect all 68 residents residing in the facility. The findings include: The facility CMS 671 dated 11/13/23 shows there are 68 residents in the facility. During the initial tour of the kitchen on 11/13/23 at 9:33 AM, the facility's Dish Machine Log-High Temp was reviewed for November 2023. No wash or rinse temperatures were recorded under Supper on 11/10/23, 11/11/23, or 11/12/23. On 11/15/23 at 10:05 AM, V17 (Dietary Manager) said she checks the dishwasher temperatures in the morning when she first arrives and before dishes from each meal service are washed. V17 said she will run an empty load first before proceeding to wash dishes in order to verify the temperature is in the correct temperature range. The Dish Machine Log-High Temp dated November 2023 shows, Instructions: Record wash and rinse temperature, and provide initials, three times per day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 15 of 20 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 11/16/2023 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** 4. R51's Physician's Order Sheet dated November 2023 shows that R51 has a diagnosis of Dementia and Alzheimer's Disease. This same form shows that R51 was placed on contact/droplet isolation precautions (for COVID 19) on 11/10/23. Residents Affected - Many On 11/13/23 at 12:09 PM R51 was seen ambulating down the hallway on the second floor. R51's mask was on but down around her chin. R51 was approached by several staff and assisted to pull her mask up but R51 became very agitated and aggressive and would immediately pull the mask back down. R51 was assisted back to her room by the staff, shown where her snacks were in the room and then the door was shut to try to keep R51 in the room. Within 2 minutes R51 was back at the doorway with the door open, then in the hallway and messing with the PPE on the cart outside of her room, then standing in the doorway of the room across the hall from hers. On 11/13/23 at 12:16 PM V11 (LPN/Wound Nurse) stated to Surveyor, We can't restrain her, and she just doesn't understand. Do you have any suggestions for what we can do with her? On 11/13/23 at 1:00 PM R51 was up and out of her room again. Again, messing with the PPE on the cart outside her room. R1 continued walking up and down the hall, stopping to touch carts, other resident wheelchairs and approached 2 Surveyors, attempting to touch the safety glasses of one of the Surveyors. R51 was again approached by staff multiple times and asked to pull her mask up, but then R51 pulls it down again, gets agitated and pulls away from staff. The facility policy entitled Infection Prevention and Control Interim Guideline for Suspected or confirmed Coronavirus dated 6/14/23 states, Place a patient with suspected or confirmed SARS-CoV2 infection in a single- person room. The door should be kept closed (if safe to do so). 5. On 11/13/23 the facility reported that there were 5 residents positive for COVID residing on the second floor of the facility. The residents included R51, R58, R2, R15 and R7. On 11/13/23 at 9:00 AM, all 5 residents' rooms on the second floor had signs posted showing Contact Isolation. There were no Droplet Isolation signs observed on the doors. Around 10:00 AM V2 (Director of Nursing) was observed posting Droplet Isolation signs on the doors. V2 stated, I wasn't here last week so I am just getting the signs up now. All 5 residents on the second floor came up positive for COVID on 11/9/23. The facility policy entitled Infection Prevention and Control Interim Guideline for Suspected or Confirmed Coronavirus dated 6/14/23 states, Post signs on the door or wall outside of the resident room to clearly describe the type of precaution needed and required PPE. 2. On 11/13/23 at 11:15 AM, R4 stated Thursday (11/2/23) night my roommate (R68) got sick and was sent out to hospital. When he came back, he was Covid positive and put back in the room with me. They did move him over the weekend, but they should not have put him in the same room with me when he came back from the hospital. I was not tested until Monday and then I tested positive. On 11/16/23 at 08:52 AM, V23 (Licensed Practical Nurse) stated I worked the evening of 11/2/23 when R68 was admitted back from the hospital. He went back into his old room. He came really late that night. R68 was still in his room when I finished my shift in the morning. I spoke to V2 (Director of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 16 of 20 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 11/16/2023 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 Nursing) and informed her he was admitted back Covid positive. I was not instructed to do anything. Level of Harm - Minimal harm or potential for actual harm R4's Census List shows R4 is and has been in room YYY-B. R68's Census List shows R68 was in room YYY-A until 11/3/23 at 1:41 PM. Residents Affected - Many R4's Minimum Data Set, dated [DATE] shows R4 is cognitively intact. R4's Progress Note dated 11/6/23 at 2:50 PM (Monday) shows R4 tested Covid-19 positive. R68's Progress Note dated 11/2/23 at 11:40 PM shows R68 returned from the hospital positive for Covid-19. The facility's Infection Prevention and Control Interim Guideline for Suspected or Confirmed Coronavirus (COVID-19) Policy dated 6/14/23 shows Place a patient with suspected or confirmed Sars-Cov-2 infection in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom. If cohorting, only patients with the same respiratory pathogen should be housed in the same room. Based on observation, interview and record review facility failed to ensure sure staff doffed PPE (personal protective equipment) in a manner to prevent cross-contamination after caring for COVID-19 positive residents. The facility failed to ensure 5 residents (R51, R58, R2, R15, R7) on contact/droplet transmission-based precautions had the required isolation signage outside of their rooms. The facility failed to have an effective system in place to test staff and 5 residents (R68, R48, R61, R23, R60) for COVID-19 during a facility outbreak. The facility failed to ensure COVID negative residents were not exposed to 3 residents (R68, R4, R51) who were COVID positive. These failures resulted in a facility outbreak of COVID-19 which, as of 11/13/23, included twenty-nine positive residents and sixteen positive staff. These failures have the potential to affect all 68 residents residing in the facility. The findings include: The facility CMS-671 dated 11/13/23 shows there are 68 residents residing in the facility. 1. On 11/14/23 at 3:21 PM, V2 (Director of Nursing/DON/Infection Preventionist) said that on Friday, 11/3/23, three residents (R68, R48, and R61) started having a cough and lethargy. V2 said they tested the three residents on 11/3/23 and all three were COVID positive, thus beginning their COVID outbreak. V2 said the three residents were all friends who resided on the first floor. V2 said they did not test staff who cared for R68, R48, and R61 on 11/3/23. V2 said a definitive source was not identified through contact tracing for the COVID outbreak, but speculated the three residents got it from their church group the previous Sunday (10/29/23). V2 said she became ill over the weekend of 11/4/23 and 11/5/23 and tested positive for COVID on 11/6/23. V2 said the nurses tested all residents and staff on the first floor for COVID on 11/6/23. V2 said she told V28 (Assistant DON) to put up contact/droplet isolation signs on the doors of the residents being isolated for COVID-19 but was not in the facility to make sure it was done until Monday, 11/13/23. V2 said V1 (Administrator) who was her back-up during her absence, did not implement any COVID testing when she was out with COVID over the weekend of 11/4/23 or 11/5/23. On 11/16/23 at 8:28 AM, V2 said she could not remember testing staff or residents on 11/3/23, but (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 17 of 20 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 11/16/2023 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 Residents Affected - Many all staff that worked on the first floor within the previous five days of identifying the COVID outbreak on 11/3/23 and all residents on the first floor were tested on [DATE]. V2 said she did not write out COVID tests on 11/3/23, she just checked the residents off on a printed roster. On 11/16/23 at 10:39 AM, V29 (Licensed Practical Nurse/LPN) said R23 and R60 both reside on the first floor. V29 said R23 was at an appointment on 11/3/23 and R60 was out on pass on 11/3/23, so she knows they were not tested on [DATE]. V29 said she only tested two staff members on 11/3/23. V29 said she does not have copies of the tests she performed; she had a resident census sheet she used to check mark. On 11/16/23 at 8:41 AM, V24 (Receptionist) said she always works at the reception desk on the first floor. V24 said she was tested for COVID on the Monday (11/6/23) after she returned to work from the weekend following the identification of the COVID positive residents. V24 said she was not tested for COVID on 11/3/23. On 11/16/23 at 8:57 AM, V15 (Registered Nurse/RN) said she worked on the first floor on 11/2/23 and was the nurse assigned to R68, R48, and R61. V15 said she was not tested for COVID on 11/3/23 and no one contacted her over the weekend. V15 said she came in Monday, 11/6/23, and tested herself for COVID. On 11/16/23 at 9:18 AM, V25 (Housekeeping Director) said he works in the facility Monday through Friday. V25 said he works all over the building and is everywhere helping his staff. V25 said he was not tested for COVID on 11/3/23 but was sick over the weekend (of 11/4/23 and 11/5/23) and that is why he came into the facility on Monday 11/6/23 and got tested for COVID, for which, he was positive. A document titled Second Floor (undated) was provided by the facility and shows what V2 said are the COVID-19 positive residents as of 11/13/23 on the first floor. It lists five residents. A document titled First Floor (undated) was provided by the facility and shows what V2 said are the COVID-19 positive residents as of 11/13/23 on the first floor. It lists 24 residents. A document with the handwritten title Employees (undated) was provided by the facility and shows what V2 said are the COVID-19 positive employees as of 11/13/23 in the facility. It lists 16 staff members. No proof of COVID-19 testing for residents or staff was provided by the facility for 11/3/23. The facility's Infection Prevention and Control Interim Guideline for Suspected or Confirmed Coronavirus (COVID-19) Policy (last revised 6/16/23) shows a broad-based approach to an outbreak is preferred if all potential contacts cannot be identified with contact tracing. The facility's Interim COVID-19 Testing-Residents and Staff Policy provided by the facility (last revised 5/12/23) shows the facility should perform testing for all residents and health care providers identified as close contacts or on the affected unit(s) if using a broad-based approach. The above referenced Policy also shows under Documentation of Testing: Upon identification of a new COVID-19 case in the facility (i.e., outbreak), document the date the case was identified, the date that all other residents and staff are tested, the dates that staff and residents who tested negative are retested, and the results of all tests. 3. On 11/13/23 at 10:01 AM, V19 (RN) came out of an isolation room that had signs on the door for contact/droplet precaution. She was donned in her isolation gown, gloves, and mask. She removed the gown and gloves on the outside of room door and took them down the hall. V19 did not wash her hands (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 18 of 20 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 11/16/2023 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 nor sanitize them. She threw the gown and gloves away in her trash on her medication cart. Level of Harm - Minimal harm or potential for actual harm On 11/13/23 at 10:05 AM, V19 said I did not see a trash can inside the room, so I put it here. Residents Affected - Many On 11/16/23 at 8:33 AM, V2 (Director of Nursing) DON said they should dispose of Personal Protective Equipment (PPE) at the door before they come out the room. It is an infection control issue. 11/16/23 at 9:16 AM, V1 (Administrator) said The PPE should be disposed of in the room just before they exit the rooms. That also is potential exposure to others if they touch someone. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 19 of 20 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 11/16/2023 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 ensure all residents were offered and/or received a pneumococcal immunization for 1 of 5 residents (R51) reviewed for immunizations in the sample of 22. Residents Affected - Few The findings include: R51's admission Record dated 11/16/23 shows she was originally admitted to the facility on [DATE] and is [AGE] years of age. R51's Immunization Report dated 11/16/23 shows she last received a Pneumococcal Conjugate Vaccine (PCV13) on 3/23/22. Per current Centers for Disease Control and Prevention (CDC) guidelines, R51 was eligible and recommended for a Pneumococcal Vaccine (PCV20) one year after receiving the PCV13. On 11/14/23 at 2:54 PM, V2 (Director of Nursing/Infection Preventionist) said a resident's vaccination status is assessed on admission and annually. V2 said they offer the Pneumococcal 20 vaccination (PCV20). V2 said she just started reviewing residents' Pneumococcal status. The facility's Influenza and Pneumococcal Immunizations Policy (effective 11/28/12) shows each resident is offered a pneumococcal immunization per CDC recommendations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 20 of 20