Health inspection·September 12, 2024

F 0690 trauma and to maintain comfort of the resident. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 2 of 10 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 09/12/2024 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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Potential for minimal harm Based on interview and record reviews, the facility's most recent arbitration agreements failed to include language that stated signing the agreement was not a condition/requirement to admission or receiving care at the facility. The facility also failed to update previously signed arbitration agreements which did not include language that: 1. The arbitration agreement could be rescinded in 30 days. 2. An arbitrator and meeting location would be mutually decided between parties. This applies to all 70 residents residing in the facility. Residents Affected - Many The findings include: Facility Long-Term Care Facility Application for Medicare and Medicaid form, dated September 9, 2024, shows the facility census was 70 residents. On September 10, 2024 at 9:54 AM, V12 (Admissions Coordinator) stated the arbitration agreement is offered to every resident upon admission to the facility as a part of the admission contract. On September 10, 2024 at 9:57 AM, V1 (Acting Administrator) stated the facility arbitration agreement was imbedded in the facility admission contract. V1 stated the facility updated their contracts to include language that allows a resident to rescind the arbitration agreement within 30 days of signing as well as included language that an arbitrator and meeting location would be mutually decided between parties. V1 reviewed the updated facility arbitration agreement and stated the contract did not include language that signing the agreement was not a condition/requirement for admission or receiving care at the facility. Review of R65's signed arbitration agreement, dated September 10, 2024, showed the agreement failed to include language that signing the agreement was not a condition/requirement to admission or receiving care at the facility. Review of R26's signed arbitration agreement, dated June 25, 2022, and R51's signed arbitration agreement, dated September 26, 2022, showed the arbitration agreements failed to include the following language in the agreements: 1. Signing the agreement was not a condition/requirement to admission or receiving care at the facility 2. The agreement could be rescinded in 30 days 3. An arbitrator and meeting location would be mutually decided between parties. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 3 of 10 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 09/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crescent Care of Elgin 180 South State Street Elgin, IL 60123 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their water management plan. The facility also failed to follow their policy regarding catheter care to prevent infection and to follow Enhanced Barrier Precautions. The facility also failed to perform hand hygiene and glove changes during provisions of care. This applies to all 70 residents residing in the facility. Residents Affected - Many The findings include: 1. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated September 9, 2024, showed the facility census was 70 residents. The facility's Water Management Program for Prevention of Legionella Growth dated June 27, 2023, showed Purpose: To identify and reduce the risk of Legionella growth and spread . Preventative maintenance will be performed as applicable: The following will be verified and documented at least once weekly: -The domestic hot water boiler/storage tanks verified to be set between 140 to degrees Fahrenheit. -Thermostat indicating the temperature of water entering the circulating system at the mixing valve is 120 Fahrenheit or above. -Eye wash stations will be inspected and flushed weekly. -Ice machines will be inspected and cleaned internally at least monthly and as needed for leakages or contamination. -Cooling tower (if applicable) will be inspected at least weekly to ensure proper functioning and chemical distribution. -Weekly sanitizing of medical devices such as CPAP (Continuous Positive Airway Pressure), hydrotherapy, etc. Environmental Services will monitor the identified areas of risk per guidelines above and implement corrective action as indicated . On September 10, 2024, at 2:56 PM, V10 (Maintenance Director) said he does not perform weekly checks and record the temperatures of the hot water boiler/storage tank. V10 continued to say he doesn't flush the eye wash stations weekly. V10 said he checks the flow of the eye wash stations once a month. V1 continued to say he cleans the ice machine every one to two months. V10 said he inspects the cooling tower monthly. The facility does not have documentation to show the temperatures of the hot water boiler/storage tanks and thermostat at the mixing valve was checks at least once weekly. On September 10, 2024, at 3:38 PM, V1 (Administrator) said V10 should be following the facility's water management program for Legionella, including documenting the water temperatures weekly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 4 of 10 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 09/12/2024 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 2. R48's EMR (Electronic Medical Record) showed R48 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, dementia, depression, anxiety disorder, arthropathy, and generalized muscle weakness. R48's MDS (Minimum Data Set) dated June 29, 2024 showed R48 had moderately impaired cognition, was always incontinent of bowel and bladder and was dependent on staff for incontinence care. R48's care plan showed R48 was at risk for incontinence related to inactivity, Alzheimer's disease, confusion, and dementia. The interventions included check and change every two hours and as needed. Staff were to wash, rinse, and dry perineum with each incontinence episode. On September 11, 2024, at 9:15 AM, V4 (Certified Nursing Assistant/CNA) and V5 (CNA) were in the room of R48 and R22 making their beds wearing gloves. R48 was brought back into her room from breakfast. V4 removed her gloves, grabbed a new pair of gloves, and without hand hygiene put on the gloves. V5 finished making V22's bed, removed her gloves, grabbed new gloves, and put on gloves without hand hygiene. V4 placed a gait belt around R48 and V4 and V5 transferred R48 back to bed. R48's pants were removed, and incontinence brief was opened. V5 explained to R48 that she was going to clean her up and change her incontinence brief. V5 used disposable wipes and cleaned all areas of the front perineal area. V5 helped R48 turn onto her left side facing V4 and it was noted she had a small bowel movement. V4 wearing the same gloves used to clean the front perineal area, used disposable wipes to clean the buttocks area. V5 removed her gloves, went to the bathroom, and washed her hands and put on new gloves to apply barrier cream to R48's buttocks. With the same glove used to apply barrier cream, V5 grabbed the clean brief and pulled the brief up in between R48's legs, V4 fastened the brief, V5 removed her gloves and without hand hygiene put on new gloves and fixed R48's covers on the bed. V5 removed her gloves and took the garbage out. V5 came back to the room with a bag for the soiled linen that was laying on the floor. V4 had removed her gloves and set them on the top of a box of gloves, V5 asked V4 to pick up the soiled linen and put in the bag. V4 picked up her gloves off the top of the box of gloves and put them on. V4 then picked up the soiled linen off the floor and placed them into the bag that V5 was holding. V4 removed her gloves and gathered supplies to provide incontinence care to R48's roommate, R22. 3. R22's EMR showed R22's most recent admission date to the facility was May 15, 2021. R22's diagnoses included epilepsy, generalized muscle weakness, overactive bladder, cognitive communication deficit, major depression, and abnormalities of gait and mobility. R22's MDS dated [DATE] showed R22 had moderately impaired cognition, was always incontinent of bladder, frequently incontinent of bowel, and was dependent on staff for incontinence care. R22's care plan showed R22 had the potential for skin impairment related to fragile skin, immobility, and incontinence. Interventions included keep skin clean and dry, use lotion on dry skin. On September 11, 2024 at 9:49 AM, V4 (CNA) and V5 (CNA) had just finished providing incontinence care to roommate R48 and now had prepared to check and change R22. V5 closed the blinds and pulled the curtain in between the two beds. V4 put on gloves, no hand hygiene, placed gait belt on R22 and explained to her what they were going to do. Once R22 was laid down bed, her pants were removed. V4 used disposable wipes and cleaned all area of the front perineal area. V4 turned R22 onto her left side, and without removing her gloves or performing hand hygiene, cleaned the buttocks, wiping from front to back. After cleaning her buttocks V4 removed her gloves, and said she was going to wash her hands in the bathroom. V4 put on new gloves and applied barrier cream to R22's buttocks. V5 grabbed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 5 of 10 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 09/12/2024 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 R22's pants and put them on R22 while V4 removed her gloves and without hand hygiene, put on new gloves. V4 helped V5 pull up R22's pants, pull R22 up higher in the bed, and then covered her with her blankets. 4. The EMR (Electronic Medical Record) showed that R64, a [AGE] year-old with diagnoses that includes but not limited to type 2 diabetes mellitus, malignant neoplasm of the prostate, history of urine infection with identified ESBL (Extended Beta Lactamase Spectrum) microorganism, osteoarthritis, congestive heart failure, anemia, diabetic neuropathy, lack of coordination, and abnormalities of gait and mobility. R64 was admitted to the facility on [DATE]. The EMR also showed that R64 was on EBP (Enhanced Barrier Precautions). The MDS (Minimum Data Set) dated August 2,2024 showed that R64 was cognitively intact. On September 9, 2024 at 9:35AM, V7 (CNA) assisted R64 to stand up. While R64 was in a standing position, V7 pulled down R64 pants to check for soiling. V7 assisted R64 back to seating position and said she will get V6 (CNA assigned to R64) to clean R64. V7 did not perform hand hygiene prior to leaving the room and touching R64. V6 came and took R64 to the bathroom. V6 removed the urinary drainage bag from the privacy bag that was hanging behind R64's wheelchair. V6 placed the urinary drainage bag on the floor, and she assisted R64 to get up from his wheelchair and R64 positioned standing behind the toilet seat. V6 wiped R64's penile area with moistened wipes. V6 then left R64's room without performing hand hygiene and V8 (Registered Nurse) returned 5 minutes later. V8 came back to R64's room. V8 then applied an ointment to R64's private area. V8 did not perform hand hygiene. V6 was then noted to step on the urinary drainage bag that was still located on the floor. On September 11, 2024 at 9:30 A.M., V3 (Assistant Director of Nursing) said that R64 was on Enhance Barrier Precaution due to indwelling urinary catheter, history of ESBL and a wound on R64's great toe. V3 said that a gown must be used when V6 and V8 had provided direct care to R64. V3 also said that to prevent infection, it is the facility's practice not to placed urinary catheter drainage bag on the floor. V3 added that staff should have done handwashing/hand hygiene in between providing resident's care, in between care task, task, touching dirty to clean areas and in between gloves changing. 5. On September 9, 2024 at 10:15 A.M., R4 was lying in bed. V6 and V7 (CNAs) were observed providing incontinence care to R4. R4's incontinence brief was soaked with urine. V7 wiped R4's groins, and midline opening of labial folds. V6 wiped R4's rectal area; apply skin barrier, put on a clean brief, fastened the brief; did not changed gloves after the incontinence care and prior to putting clean brief and skin barrier. R4 was then transferred from bed to wheelchair with used of mechanical transfer lift device. V6 and V7 have both removed their gloves, no hand hygiene, then put on a pair of gloves without hand hygiene prior to transferring R4 to the wheelchair. The EMR showed that R4, an [AGE] year-old female with diagnoses of type 2 diabetes mellitus, dementia, and anemia. The undated facility's policy and procedure for urinary catheter care showed that urinary indwelling catheter drainage bag should be off the floor to prevent cross contamination and infection. The undated policy for hand washing/hand hygiene showed hand hygiene be implemented including but not limited to before and after direct contact with residents; before and after handling invasive device such as urinary catheter, and before donning on gloves. The undated policy for Enhanced Barrier Precautions showed to wear PPE (such as gown, gloves, mask) when providing resident's care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 6 of 10 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 09/12/2024 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 follow their policy to offer and administer pneumococcal vaccines in accordance with CDC (Centers for Disease Control and Prevention) guidelines. This applies to 3 of 5 residents (R1, R22, and R32) reviewed for vaccinations in the sample of 18. Residents Affected - Few The findings include: 1. The EMR (Electronic Medical Record) showed R1 was a [AGE] year-old resident, admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, asthma, alcoholic cirrhosis of the liver, heart failure, and type 2 diabetes mellitus. R1's Informed Consent for Vaccinations dated January 16, 2021, showed R1 consented to receive pneumococcal vaccinations. R1's Immunization Report showed R1 received the PPSV23 (23-valent Pneumococcal Polysaccharide Vaccine) on January 18, 2021. On September 11, 2024, at 1:37 PM, V11 (Nurse Consultant) said the facility follows CDC guidelines for pneumococcal vaccine timing and R1 should have been offered a second pneumococcal vaccine after receiving the PPSV23. The facility does not have documentation to show R1 was offered or received another pneumococcal vaccine. 2. The EMR showed R22 was a [AGE] year-old resident, admitted to the facility on [DATE], with multiple diagnoses including epilepsy, anemia, hyperlipidemia, atherosclerotic heart disease, transient ischemic attack, and cerebral infarction. R22's Informed Consent for Vaccinations dated October 18, 2020, showed R22's Resident Representative consented for R22 to receive the pneumococcal vaccinations. R22's Immunization Report showed R22 received the PPSV23 on December 15, 2020. On September 11, 2024, at 1:37 PM, V11 said R22 should have been offered a second pneumococcal vaccine after receiving the PPSV23. The facility does not have documentation to show R22 was offered or received another pneumococcal vaccine. 3. The EMR showed R32 was a [AGE] year-old resident, admitted to the facility on [DATE], with multiple diagnoses including rheumatoid arthritis, long term use of systemic steroids, type 2 diabetes mellitus, and hypertension. R32's Pneumococcal Vaccine Information and Consent dated October 2, 2023, showed R32 consented to receiving the pneumococcal vaccine. R32's Immunization Report showed R32 received the PCV13 (13-valent Pneumococcal Conjugate Vaccine) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 7 of 10 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 09/12/2024 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 on June 15, 2012. Level of Harm - Minimal harm or potential for actual harm On September 11, 2024, at 1:37 PM, V11 said R32 should have received a second pneumococcal vaccine since she consented to receiving the vaccine. Residents Affected - Few The facility does not have documentation to show R32 received a second pneumococcal vaccine. The facility's policy titled Pneumococcal Vaccine dated April 2022, showed Policy Statement: All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Policy Interpretation and Implementation: .7. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. The CDC's Pneumococcal Vaccine Timing for Adults dated April 1, 2022, showed For those who previously received PPSV23 but who have not received any pneumococcal conjugate vaccine (e.g., PCV13, PCV15 (15- valent Pneumococcal Conjugate Vaccine), PCV20 (20-valent Pneumococcal Conjugate Vaccine)). You may administer one dose of PCV15 or PCV20. Regardless of which vaccine is used (PCV15 or PCV20): the minimum interval is at least one year. Their pneumococcal vaccinations are complete . Pneumococcal vaccine timing for adults who previously received PCV14 but who have not received all recommend doses of PPSV23 . Adults 65 years or older without an immunocompromising condition, cerebrospinal fluid leak, or cochlear implant: CDC recommends one dose of PPSV23 at age [AGE] years or older. Administer a single dose of PPSV23 at least one year after PCV13 was received. Their pneumococcal vaccinations are complete . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 8 of 10 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 09/12/2024 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy to offer and administer the COVID-19 vaccine to residents. This applies to 4 of 5 residents (R1, R22, R32, and R39) reviewed for vaccinations in the sample of 18. The findings include: 1. The EMR (Electronic Medical Record) showed R1 was a [AGE] year-old resident, admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, asthma, alcoholic cirrhosis of the liver, heart failure, and type 2 diabetes mellitus. R1's Immunization Report showed R1's most recent COVID-19 vaccine was received on September 27, 2022. On September 11, 2024, at 1:37 PM, V11 (Nurse Consultant) said the facility follows CDC (Centers for Disease Control and Prevention) recommendations for COVID-19 vaccinations. V11 continued to say R1 should have been offered the 2023-2024 COVID-19 vaccine. The facility does not have documentation to show R1 was offered the 2023-2024 updated COVID-19 vaccine. 2. The EMR showed R22 was a [AGE] year-old resident, admitted to the facility on [DATE], with multiple diagnoses including epilepsy, anemia, hyperlipidemia, atherosclerotic heart disease, transient ischemic attack, and cerebral infarction. R22's Immunization Report showed R22's most recent COVID-19 vaccine was received on October 27, 2022. On September 11, 2024, at 1:37 PM, V11 said R22 should have been offered the 2023-2024 COVID-19 vaccine. The facility does not have documentation to show R22 was offered the 2023-2024 updated COVID-19 vaccine. 3. The EMR showed R32 was a [AGE] year-old resident, admitted to the facility on [DATE], with multiple diagnoses including rheumatoid arthritis, long term use of systemic steroids, type 2 diabetes mellitus, and hypertension. R32's Immunization Report showed R32's most recent COVID-19 vaccine was the COVID-19 bivalent booster on January 19, 2023. On September 11, 2024, at 1:37 PM, V11 said R32 should have been offered the 2023-2024 COVID-19 vaccine. The facility does not have documentation to show R32 was offered the 2023-2024 updated COVID-19 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 9 of 10 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 09/12/2024 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 0887 vaccine. Level of Harm - Minimal harm or potential for actual harm 4. The EMR showed R39 was a [AGE] year-old resident, admitted to the facility on [DATE], with multiple diagnoses including type 2 diabetes, chronic kidney disease, and peripheral vascular disease. Residents Affected - Some R39's Immunization Report showed R39's most recent COVID-19 vaccination was received on February 18, 2022. On September 11, 2024, at 1:37 PM, V11 said R39 should have been offered the 2023-2024 COVID-19 vaccine. The facility does not have documentation to show R39 was offered the 2023-2024 updated COVID-19 vaccine. The facility's policy titled COVID-19 Vaccine Policy dated October 2023, showed Policy: All residents and employees who have no medical contraindications to the vaccine will be offered the vaccine/booster annually to discourage and promote the benefits associated with vaccinations against COVID-19. The facility shall provide pertinent information about the significant risks and benefits of vaccines to staff and residents (residents' legal representatives); for example, risk factors that have been identified with specific age groups or individuals with risk factors such as allergies or pregnancy. Facility will encourage the COVID-18 vaccinations as per guidelines. Procedure: 1. The vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated, or the resident or employee has already been immunized . 7. Administration of the vaccine will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination . The CDC's COVID-1 Vaccine Information Statement dated October 19, 2023, showed .COVID-19 Vaccine: Updated (2023-2024 Formula) COVID-19 vaccine is recommended for everyone six months of age and older . Everyone 12 years and older should get one dose of an FDA (Food and Drug Administration) approved, updated 2023-2024 COVID-19 vaccine. If you have received a COVID-19 vaccine recently, you should wait at least eight weeks after you most recent dose to get the updated 2023-2024 COVID-19 vaccine . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 10 of 10