Inspection·February 11, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 6. On February 6, 2025 at 9:28 AM, R15 and R16 were sitting in their room. R15 and R16's window was covered by temporary, pleated papers shades. The paper shades were torn in multiple places and did not have plastic clips in place to raise or lower the shades to see outside. 7. On February 6, 2025 at 9:25 AM, R17 and R18 were sitting in their room. R17 and R18's window was covered by a large shade. The window shade was an ivory color. The bottom two feet of the window shade was heavily stained with a dark brownish, red substance. On February 6, 2025 at 11:22 AM, V5 (Maintenance Director) said, They were in the middle of a remodeling update here, but then stopped because of money issues. They are thinking of starting it up in the next six months. V9 (Former Administrator) had started the remodeling, but then never finished it. We had a quote for over $4,000 for window treatments, so he did not go through with it. We had an administration change about six months ago, but we have not restarted the remodeling. V5 continued to say it has been six months or longer that resident rooms have been without permanent window shades. 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 02/11/2025 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 provide timely incontinence care. This applies to 2 of 3 residents (R1 and R4) reviewed for timely incontinence care in the sample of 18. Residents Affected - Few The findings include: 1. On February 10, 2025 at 9:14 AM, R1 was lying in bed in her room. R1 said, My brief is wet. I was changed at 3:00 AM this morning. No one has changed me since they started at 6:00 AM when the next shift got here. I just have to wait my turn because they tell me they have a lot of people to take care of. V10 (CNA/Certified Nursing Assistant) was outside of R1's room. V10 said she was assigned to care for R1. V10 said she was assigned to care for twelve residents. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including rheumatoid arthritis, generalized anxiety disorder, insomnia, restless leg syndrome, major depressive disorder, anemia, and chronic pain syndrome. R1's MDS (Minimum Data Set) dated December 5, 2024 shows R1 has moderate cognitive impairment, requires supervision with eating, partial/moderate assistance with oral and personal hygiene, and is dependent on facility staff for all other ADLs (Activities of Daily Living). R1 is frequently incontinent of urine, and always incontinent of stool. R1's care plan, initiated on May 9, 2024 shows: The resident is at risk for incontinence related to activity intolerance, has current bowel incontinence, has current urinary incontinence, impaired mobility, loss of peritoneal tone, physical limitations. Multiple interventions, initiated May 9, 2024 show: Clean peri-area with each incontinence episode. Check every two hours, upon request, as needed for incontinence . 2. On February 10, 2025 at 9:18 AM, R4 was sitting in his wheelchair by the nurse's station. R4 said he needed to use the restroom. At 9:25 AM, V6 (CNA/Staffing Coordinator) said R4 frequently states he has to use the restroom when his incontinence brief is already wet. V6 pushed R4 in his wheelchair back to his room to transfer R4 back to bed with V11 (CNA). As V6 and V11 lifted R4 from his wheelchair, the back of R4's sweatpants were soaking wet, approximately 12 inches in diameter about R4's buttocks. V6 said, [R1] drank a lot of water at breakfast this morning. V6 and V11 put R4 in his bed and started to remove his wet pants and incontinence brief. A strong odor of urine and stool was present. When V6 and V11 removed R4's incontinence brief, the brief was wet with urine and stool was present. V6 used disposable wipes to clean the stool from R4's buttocks and sacrum. R4 had an area of redness around his rectal area and sacrum, approximately six inches long by four inches wide. R4 said the area was tender when V6 was using disposable wipes to clean the area. V11 (CNA) said she was assigned to care for R4. V11 said she dressed R4 and provided incontinence care to him prior to breakfast. V11 said she was assigned to care for 12 residents, including two residents who required feeding assistance. The EMR shows R4 was admitted to the facility on [DATE]. R4 has multiple diagnoses including ALS (Amyotrophic Lateral Sclerosis), pain, insomnia, lung cancer, depression, and osteoporosis. R4's MDS dated [DATE] shows R4 has moderate cognitive impairment, require partial/moderate assistance with eating, substantial/maximal assistance with bed mobility and transfers between surfaces, and (continued on next page) 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 02/11/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete is dependent on facility staff for all other ADLs (Activities of Daily Living). R4 is always incontinent of bowel and bladder. R4 did not have a pressure ulcer at the time of this MDS assessment. R4's care plan, initiated on March 8, 2024 shows: The resident is at risk for incontinence related to ALS, dementia, immobility. Goal: The resident will remain free from skin breakdown due to incontinence and brief use through the review dated. Interventions: Clean peri-area with each incontinence episode. Check every two hours, upon request, as needed for incontinence. Wash, rinse, and dry perineum. Change clothing PRN (as needed) after incontinence episodes. 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 02/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crescent Care of Elgin 180 South State Street Elgin, IL 60123 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure electrical wires are not left exposed, near a resident's metal bed frame. This applies to 1 of 4 residents (R1) reviewed for safe environment in the sample of 18. The findings include: On February 6, 2025 at 9:15 AM, R1 was lying in bed in her room. The headboard of R1's bed was up against the wall of her room. The wall behind R1's bed had multiple areas of chipped plaster and paint. On the wall behind R1's headboard, approximately 4 inches from the floor, an electrical outlet box appeared damaged. The outlet box was hanging off the wall. The outlet box was open, and electrical wires were hanging outside of the outlet box. The electrical wires had multiple electric wire connectors in place on the ends of the electrical wires. The exposed electric wires were approximately two to four inches from R1's metal bed frame. R1 said, Oh, every time they boost me in the bed, the whole bed moves and bangs into the wall behind my bed. I know they hit that outlet with my bed, because I hear the staff say, Oh darn, we hit that outlet again. R1 continued to say she is dependent on facility staff to reposition her in bed, and remains in her bed at all times, which is her preference. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including rheumatoid arthritis, generalized anxiety disorder, insomnia, restless leg syndrome, major depressive disorder, anemia, and chronic pain syndrome. R1's MDS (Minimum Data Set) dated December 5, 2024 shows R1 has moderate cognitive impairment, requires supervision with eating, partial/moderate assistance with oral and personal hygiene, and is dependent on facility staff for all other ADLs (Activities of Daily Living). R1 is frequently incontinent of urine, and always incontinent of stool. On February 6, 2025 at 11:22 AM, V5 (Maintenance Director) said, I have constant issues with a hanging outlet in [R1's] room. It is behind her bed and the staff keep hitting the outlet with her bed when they boost [R1]. My plan is to shorten that outlet where it won't keep getting knocked off the wall. As long as the box is intact, there is no way she can get electrocuted. The last time it was reported to me was three months ago. During this interview, V5 was made aware of the electrical outlet hanging off the wall with exposed wiring in R1's room by this surveyor. On February 6, 2025 at 2:57 PM, R1 was lying in bed in her room. The broken electrical outlet and exposed wiring continued to be an issue, with no changes noted in the electrical outlet. On February 10, 2025 at 9:37 AM, V5 (Maintenance Director) said he was able to cover the electrical outlet in R1's room. V5 said he had not shortened the outlet or put any interventions in place to ensure the electrical outlet could not become damaged again during repositioning of R1. V5 said, I wouldn't be surprised if that outlet is broken again. 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 02/11/2025 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide sufficient staff to meet the ADL (Activities of Daily Living) needs of the residents in the facility. This applies to all 79 residents residing in the facility. The findings include: The Facility Data Sheet dated February 6, 2025 shows the facility census as 79 residents. 1. On February 10, 2025 at 9:14 AM, R1 was lying in bed in her room. R1 said, My brief is wet. I was changed at 3:00 AM this morning. No one has changed me since they started at 6:00 AM when the next shift got here. I just have to wait my turn because they tell me they have a lot of people to take care of. R1 continued to say she is always sure she has an absorbent under pad to sit on in her bed so when she soaks through her incontinence brief, her bedding does not get soiled. V10 (CNA/Certified Nursing Assistant) was outside of R1's room. V10 said she was assigned to care for R1. V10 said she was assigned to care for twelve residents. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including rheumatoid arthritis, generalized anxiety disorder, insomnia, restless leg syndrome, major depressive disorder, anemia, and chronic pain syndrome. R1's MDS (Minimum Data Set) dated December 5, 2024 shows R1 has moderate cognitive impairment, requires supervision with eating, partial/moderate assistance with oral and personal hygiene, and is dependent on facility staff for all other ADLs (Activities of Daily Living). R1 is frequently incontinent of urine, and always incontinent of stool. R1's care plan, initiated on May 9, 2024 shows: The resident is at risk for incontinence related to activity intolerance, has current bowel incontinence, has current urinary incontinence, impaired mobility, loss of peritoneal tone, physical limitations. Multiple interventions, initiated May 9, 2024 show: Clean peri-area with each incontinence episode. Check every two hours, upon request, as needed for incontinence . 2. On February 10, 2025 at 9:18 AM, R4 was sitting in his wheelchair by the nurse's station. R4 said he needed to use the restroom. At 9:25 AM, V6 (CNA/Staffing Coordinator) said R4 frequently states he has to use the restroom when his incontinence brief is already wet. V6 pushed R4 in his wheelchair back to his room to transfer R4 back to bed with V11 (CNA). As V6 and V11 lifted R4 from his wheelchair, the back of R4's sweatpants were soaking wet, approximately 12 inches in diameter about R4's buttocks. V6 said, [R1] drank a lot of water at breakfast this morning. V6 and V11 put R4 in his bed and started to remove his wet pants and incontinence brief. A strong odor of urine and stool was present. When V6 and V11 removed R4's incontinence brief, the brief was wet with urine and stool was present. V6 used disposable wipes to clean the stool from R4's buttocks and sacrum. R4 had an area of redness around his rectal area and sacrum, approximately six inches long by four inches wide. R4 said the area was tender when V6 was using disposable wipes to clean the area. V11 (CNA) said she was assigned to care for R4. V11 said she dressed R4 and provided incontinence care to him prior to breakfast. V11 said she was assigned to care for 12 residents, including two residents who required feeding assistance. (continued on next page) 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 02/11/2025 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many The EMR shows R4 was admitted to the facility on [DATE]. R4 has multiple diagnoses including ALS (Amyotrophic Lateral Sclerosis), pain, insomnia, lung cancer, depression, and osteoporosis. R4's MDS dated [DATE] shows R4 has moderate cognitive impairment, require partial/moderate assistance with eating, substantial/maximal assistance with bed mobility and transfers between surfaces, and is dependent on facility staff for all other ADLs (Activities of Daily Living). R4 is always incontinent of bowel and bladder. R4 did not have a pressure ulcer at the time of this MDS assessment. R4's care plan, initiated on March 8, 2024 shows: The resident is at risk for incontinence related to ALS, dementia, immobility. Goal: The resident will remain free from skin breakdown due to incontinence and brief use through the review dated. Interventions: Clean peri-area with each incontinence episode. Check every two hours, upon request, as needed for incontinence. Wash, rinse, and dry perineum. Change clothing PRN (as needed) after incontinence episodes. 3. On February 10, 2025 at 12:09 PM, V15 (CNA) was passing meal trays to residents. Multiple call lights were going off, and V15 had to stop passing meal trays to attend to the needs of the residents with requests for assistance. V15 answered the call lights, and each resident asked, Where is my lunch tray? V15 explained to multiple residents she was in the process of passing lunch trays and would bring their trays as soon as possible. V15 said she was assigned to care for 14 residents on her shift. Of the 14 residents, 11 need me to help them with incontinence care and toilet hygiene, two of the residents need mechanical lifts to get out of bed, which means I need to find another CNA to help me, and one of the residents needs to be fed by me. The CNAs are also responsible for passing all meal trays to the residents and picking up the empty meal trays after lunch is finished. It is very difficult to do it all, but I always do my best. On February 6, 2025 at approximately 10:30 AM, V2 (DON/Director of Nursing) provided staffing schedules for the period of January 5, 2025 to March 1, 2025. V2 (DON) said, Our CNAs workday shift from 6:00 AM to 2:00 PM, PM shift from 2:00 PM to 10:00 PM, and night shift from 10:00 PM to 6:00 AM. We staff seven CNAs on day shift; four CNAs on the second floor, and three CNAs on the first floor. We staff six CNAs on PM shift; three CNAs on the second floor, and three CNAs on the first floor. We staff four CNAs on the night shift; two upstairs, and two on the first floor. Nurses workday shift from 7:00 AM to 3:30 PM, with two nurses on the second floor and two nurses on the first floor. PM shift is from 3:00 PM to 11:30 PM with two nurses on the second floor and two nurses on the first floor. Night shift is from 11:00 PM to 7:30 AM and is staffed with two nurses total; one upstairs and one on the first floor. On February 10, 2025 at approximately 10:00 AM and 10:50 AM, V6 (Staffing Coordinator/CNA) reviewed the staffing schedules for the period of January 1, 2025 to January 31, 2025. V6 said, Ideally, we would like to have seven CNAs in the facility for day shift so we can have four CNAs on the second floor where the resident care needs are greater, and three CNAs on the first floor. That just isn't always possible. I use agency staff to fill the gaps to get us up to six CNAs on day shift, but I have not been given permission to use agency staff to get us up to seven CNAs. There are a lot of days where we only have six CNAs for the day shift, and it is hard for the staff. Today we had a call-in, so I was pulled to the floor to work as a CNA so we can have six CNAs on the floor. There are a lot of residents with heavy needs. We do the best we can with what we have. We have to use two facility staff to do a transfer with a mechanical lift. V6 continued to say the facility census on February 6, 2025 was 79 residents and the facility had six CNAs working from 6:00 AM to 2:00 PM. V6 also said the ADL needs of the residents in the facility were the same on February 6 and February 10, 2025. (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 02/11/2025 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 0725 Level of Harm - Minimal harm or potential for actual harm During review of the staffing schedules with V6 (Staffing Coordinator/CNA), multiple day shifts were identified where the facility did not have 7 CNAs. The facility census and staffing numbers were confirmed with V6 (Staffing Coordinator/CNA) present. The staffing schedule shows the following dates/resident census/number of CNAs working from 6:00 AM to 2:00 PM: Residents Affected - Many January 6, 2025 - 79 residents - 6 CNAs January 7, 2025 - 78 residents - 6 CNAs January 8, 2025 - 79 residents - 6 CNAs January 9, 2025 - 79 residents - 6 CNAs January 11, 2025 - 80 residents - 6 CNAs January 12, 2025 - 80 residents - 6 CNAs January 14, 2025 - 79 residents - 6 CNAs January 15, 2025 - 82 residents - 6 CNAs January 16, 2025 - 82 residents - 6 CNAs January 20, 2025 - 81 residents - 6 CNAs January 21, 2025 - 80 residents - 6 CNAs January 22, 2025 - 81 residents - 6 CNAs January 24, 2025 - 80 residents - 6 CNAs January 25, 2025 - 81 residents - 6 CNAs January 27, 2025 - 81 residents - 6 CNAs January 28, 2025 - 80 residents - 6 CNAs January 29, 2025 - 81 residents - 6 CNAs January 30, 2025 - 82 residents - 6 CNAs January 31, 2025 - 81 residents - 6 CNAs February 6, 2025 - 79 residents - 6 CNAs February 10, 2025 - 79 residents - 6 CNAs The facility provided a list of residents requiring feeding assistance, a list of residents requiring the use of a mechanical lift device for transfers between surfaces, a list of residents requiring (continued on next page) 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 02/11/2025 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many substantial/maximal assistance or are dependent on facility staff for toilet hygiene, a facility census, and CNA staffing assignments for February 6, and 10, 2025. The resident census and resident ADL needs were similar on February 6 and 10, 2025. On February 10, 2025 from 6:00 AM to 2:00 PM, V11 (CNA) was assigned to care for 12 residents. Ten of the residents assigned to V11 required staff assistance with toilet hygiene, 4 residents required mechanical lifts for transfers, and 2 residents required feeding assistance. On February 10, 2025 from 6:00 AM to 2:00 PM, V12 (CNA) was assigned to care for 12 residents. Ten of the residents assigned to V12 required staff assistance with toilet hygiene, 3 residents required mechanical lifts for transfers, and 2 residents required feeding assistance. On February 10, 2025 from 6:00 AM to 2:00 PM, V6 (Staffing Coordinator/CNA) was assigned to care for 12 residents. Seven of the residents assigned to V6 required staff assistance with toilet hygiene, and one resident required a mechanical lift device to transfer between surfaces. On February 10, 2025 from 6:00 AM to 2:00 PM, V16 (CNA) was assigned to care for 14 residents. Eleven residents assigned to V16 required staff assistance with toilet hygiene, 4 residents required a mechanical lift device to transfer between surfaces, and 2 residents required feeding assistance. On February 10, 2025 from 6:00 AM to 2:00 PM, V15 (CNA) was assigned to care for 14 residents. Eleven residents assigned to V15 required staff assistance with toilet hygiene, 2 residents required the use a mechanical lift device to transfer between surfaces, and 1 resident required feeding assistance. On February 10, 2025 from 6:00 AM to 2:00 PM, V17 (CNA) was assigned to care for 15 residents. Eight of the residents assigned to V17 were dependent on facility staff for toilet hygiene, 1 resident required a mechanical lift device for transfers between surfaces, and 1 resident required feeding assistance. The Facility Assessment Tool, updated on 09/20/24 and reviewed by the QAA/QAPI (Quality Assessment and Assurance/Quality Assurance Performance Improvement on 12/11/24 shows the average daily census for the facility is 74 to 78 residents. The Facility Assessment Tool continues to show: Staffing Plan: Based on your resident population and their needs for care and support, describe your general approach to staffing to ensure that you have sufficient staff to meet the needs of the residents at any given time. Licensed nurses providing direct care: 10 to 17 total number needed or average or range. Nurse aides: 24 to 26 CNAs. The Facility Assessment Tool continues to show: Describe your general staffing plan to ensure that you have sufficient staff to meet the needs of the residents at any given time. Consider if and how the degree of fluctuation in the census and acuity levels impact staffing needs. For example: Licensed Nurses: Plan: DON full-time days, ADON (Assistant Director of Nursing/Restorative: 1 LPN (Licensed Practical Nurse) Full-time days, MDS: 1 MDS RN (Registered Nurse) full-time days. Wound Care: 1 LPN Full-time days. RN or LPN Charge Nurse: 1 for each shift, 1 nurse per shift is the charge nurse. Staffing ratio 1 LPN or RN for days and evening shift for 20 residents. The Facility Assessment Tool continues to show the staffing ratio of direct care staff (CNAs) to residents is one CNA to ten residents for day and PM shift, and one CNA to 20 residents for night (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 02/11/2025 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 0725 shift. It will be checked against the state requirements as well as evaluated daily based on census and acuity in the facility and per floor. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145004 If continuation sheet Page 10 of 10