Inspection·September 28, 2023

F 0550 signature, at the bottom of the page. Level of Harm - Minimal harm or potential for actual harm The Illinois Department on Aging, Resident's Rights for People in Long-term Care Facilities showed, As a long-term care facility resident in Illinois, you are guaranteed certain privileges according to rights, protections, and State and Federal law. You have the right to safety and good care. Your facility must provide services to keep your physical and mental health, and sense of satisfaction . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145433 If continuation sheet Page 2 of 18 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 145433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of St Charles 611 Allen Lane Saint Charles, IL 60174 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 offer and provide activities of daily living (ADL) care for a dependent resident (R17), and failed to provide showers for a resident (R395). These failures apply to 2 of 3 residents reviewed for ADL care in the sample of 18. Residents Affected - Few The findings include: 1) R17's electronic face sheet printed on 9/28/23 showed R17 has diagnoses including but not limited to unilateral post-traumatic osteoarthritis right hip, generalized anxiety disorder, schizophrenia, major depressive disorder, and history of falls. R17's facility assessment dated [DATE] showed R17 has moderate cognitive impairment and requires 1 staff assist for personal hygiene. R17's care plan dated 12/8/21 showed, (R17) has an ADL self-care performance deficit related to impaired ability with dressing and grooming such as: putting on or taking off clothing .unable to groom self satisfactorily, unable to complete task with personal hygiene, unable to bathe and groom self independently related to confusion and impaired balance. R17's care plan dated 3/10/21 showed, (R17) has bladder incontinence requiring assistance with toileting related to: physical limitations, muscle weakness .incontinence: I would like the staff to check me for incontinence episode as needed. I would also need assistance to wash, rinse and dry my perineum. On 9/27/23 at 9:22AM, R17 was lying in her bed with her incontinence brief lying on the floor next to her bed. V10 and V11 (Certified Nursing Assistants-CNA's) entered R17's room to assist R17 with getting ready for the day. V10 stated R17's incontinence brief was not soiled; therefore, they did not need to provide perineal care to R17. V11 placed a dry incontinence brief on R17 and R17's perineal area was red. A strong urine odor was noted coming from R17. Surveyor requested V10 to show her the incontinence brief that was lying on R17's floor. V10 removed the soiled incontinence brief from R17's garbage can and the inside of the brief was bright yellow and saturated. V10 stated, I told you it was wet earlier, that's why we put cream on her. V11 and V10 then transferred R17 to her chair in her room and gave her a breakfast tray. V11 and V10 did not provide any incontinence care, oral care or toileting assistance to R17. V10 stated they put cream on R17 so that is enough for her incontinence care. V10 stated R17 probably wouldn't have let them take her to the toilet or brush her teeth so he didn't even bother asking her. V10 stated that is all supposed to be part of every resident's morning care. On 9/28/23 at 11:05AM, V2 (Director of Nursing) stated, Morning cares for every resident consists of incontinence care (when resident is incontinent), changing resident clothes, oral care, brush hair, and all other grooming. Every resident should be offered to sit on the toilet for more complete evacuation of bowel and bladder. There is no reason why a resident would not get incontinence care or morning cares for that matter. (R17) can be difficult to manage but she should still be offered the same cares as all other residents because she is unable to do them on her own. She is completely dependent on staff for hygiene needs. The facility's policy titled, Incontinent and Perineal Care with a review date of 7/28/23 showed, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145433 If continuation sheet Page 3 of 18 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 145433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of St Charles 611 Allen Lane Saint Charles, IL 60174 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 It is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's skin condition .Procedures: 6. Wash the perineal area and gently dry after the procedure. The facility's policy titled, Mouth Care with a review date of 1/14/17 showed, The facility shall administer proper oral care to its residents in order to keep the lips and oral tissues moist, to cleanse and freshen the resident's mouth and to prevent mouth infection. 2) R395's electronic face sheet printed on 9/28/23 showed R395 has diagnoses including but not limited to malignant neoplasm of prostate, Parkinson's disease, schizoaffective disorder, and generalized anxiety disorder. R395's facility assessment dated [DATE] showed R395 has no cognitive impairment and requires 1 staff assist for personal hygiene. On 9/26/23 at 9:56AM, R395 stated he was admitted over a week ago and has not received a shower at the facility. R395's hair was disheveled and had a greasy appearance. On 9/28/23 at 9:00AM, R395 stated he still has not received a shower and is feeling pretty gross. R395's shower documentation showed R395 refused a shower on 9/21/23. No further documentation was presented by the facility as of 9/28/23. As of surveyor exit on 9/28/23, R395 had still not received a shower in the 12 days since his admission to the facility. On 9/27/23 at 9:43AM, V10 stated all residents receive one shower each week unless they want more. V10 stated personally he does all his assigned showers when he gets residents up for the day and is unsure of when R395's shower day is. On 9/28/23 at 11:05AM, V2 (Director of Nursing) stated, I'm not sure if (R395) has had his shower yet since he got here but he's been here over a week so he should have had one. All residents get one shower per week for cleanliness and can get more showers if they request more. If a resident refuses their shower, then the next shift should try and if they continue to refuse then the nurse should be notified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145433 If continuation sheet Page 4 of 18 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 145433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of St Charles 611 Allen Lane Saint Charles, IL 60174 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to obtain accurate weights as ordered by the doctor for residents at high risk for nutritional decline for 2 of 3 residents (R23, R75) reviewed for weights in the sample of 18. Residents Affected - Few The findings include: 1. On 9/26/23 at 12:13 PM, R23 was sitting up in her wheelchair, visiting with her husband. R23 said she still had a feeding tube but was trying food now. R23's husband said the plan was to leave the tube in to make sure she was able to eat okay and take her medications. R23's husband said prior to admission to the facility, she was receiving her feeding and medications through the feeding tube. R23's Facesheet dated 9/28/23 showed she was admitted [DATE] and had diagnoses to include, but not limited to: traumatic subdural hemorrhage, diabetes, dementia, anxiety, gastrostomy tube, lack of coordination, feeding difficulties, epilepsy, and morbid obesity. R23's Physician Order Sheet (POS) dated 9/28/23 showed orders for a consistent carbohydrate diet; 3-day calorie count; flush gastrostomy (G-tube) with 200 ml water every shift; and weight upon admission, weekly for 4 weeks, and then monthly. R23's Weights showed she had weights documented on 8/21/23 (Admission) and 9/11/23. (Weekly weights are missing for 8/28, 9/4, and 9/18). R23's Care Plan imitated 8/25/23 showed she was increased risk for nutritional decline. This care plan showed an intervention to obtain weights as ordered. On 9/28/23 at 9:28 AM, V2 (DON) said weights are done by the Restorative Aide, written on a paper form, and entered by the Restorative Nurse. V2 said weights are done more frequently upon admission or readmission to watch for an fluctuations in the resident's weights. V2 said R23 was increased risk for nutritional issues because she was a new admission and had from tube feeding to oral intake. The surveyor asked V2 to look at R23's weights. V2 said R23 only had two weights entered and was missing weekly weights. V2 stated, I expect the staff to follow the weight orders. It is important that accurate weights are documented in the EMR, so the nurse and Dietician are able to track any trends and implement needed interventions. On 9/28/23 at 1:29 PM, V18 (Dietician) said the weights are obtained and entered into the EMR by the Restorative department. V18 said the weights are ordered more frequently after admission to get to know the resident. V18 stated, It could allow us to catch something quickly, especially for residents that are already at risk for nutritional deficit (like R23). V18 said if weights are not entered then the facility will not have an accurate picture of R23's nutritional status. The facility's Weights Policy revised 7/28/23 showed, It is the facility's policy to obtain resident's monthly weight unless otherwise ordered differently by the physician . 2. On 9/26/23 at 9:41 AM, R75 was sitting in her wheelchair, preparing to leave the facility for a doctor's appointment. R75 appeared thin and frail. R75 said she was heading out for an Oncology (cancer) appointment and was unsure when she would be back. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145433 If continuation sheet Page 5 of 18 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 145433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of St Charles 611 Allen Lane Saint Charles, IL 60174 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 9/28/23 at 10:34 AM, R75 was sitting on the side of her bed, eating peanut M&Ms. R75 said the facility just finished weighing her and she was so glad to hear that she had gained some weight. R75 said her weight had got down to 105 pounds and her Oncologist was concerned. R23 said he told me that I needed to gain some weight. R75 said, They've weighed me before, but I couldn't tell you how many times. I cut my lip and it was hard for me to eat for a while because I had stitches. I had to have different food and it wasn't my favorite, but now I'm healed and I hope I can do what the doctor asked. R75's Face Sheet dated 9/28/23 showed she was admitted [DATE] and had diagnoses to include, but no limited to: multiple left rib fractures; severe protein-calorie malnutrition; muscled wasting and atrophy; difficulty walking; cognitive communication deficit; breast cancer; diabetes; chronic kidney disease; and multiple myeloma. R75's Care Plan initiated 8/26/23 showed she was at risk for nutritional discharge due to fluctuating appetite, missing teeth, receiving chemotherapy, and the need for a therapeutic diet order. This care plan showed an intervention to obtain weights as ordered. R75's POS dated 9/28/23 showed weights should be completed upon admission/readmission; weekly for 4 weeks; and then monthly. This POS showed that R75 was receiving chemotherapy type medications (medications with side effects that can affect appetite and weight). R75's weights were documented as 109 pounds on 8 different dates, from 8/28/23 to 9/18/23, and the facility used different scales including the following: standing, mechanical lift, and chair scales. (This is a very unlikely occurrence to get the exact same weight on various days with different scales). R75's facility assessment dated [DATE] showed she had moderate cognitive impairment and required extensive assistance from staff for most ADLs. R75's Nursing admission dated 8/22/23 showed R75 fell at home and was admitted to the hospital due to multiple rib fractures. This document showed R75 was on a high calorie, high protein diet. R75's Dietary Evaluation dated 8/26/23 showed R75's admission weight (8/22/23) was 114.8 pounds, using the wheelchair scale. On 9/28/23 at 9:28 AM, V2 (DON) said weights are done by the Restorative Aide, written on a paper form, and entered by the Restorative Nurse. V2 said weights are done more frequently upon admission or readmission to watch for an fluctuations in the resident's weights. V2 said R75 was increased risk for nutritional issues because she had cancer; recently injured her lip, requiring stitches; and was a new admission. The surveyor asked V2 to look at R75's weights in the EMR. V2 replied, They are all 109. How can that be? As a nurse I would question that. Someone should have re-weighed R75. It is important that accurate weights are documented in the EMR, so the nurse and Dietician are able to track any trends and implement needed interventions. On 9/28/23 at 1:29 PM, V18 (Dietician) said the weights are obtained and entered into the EMR by the Restorative department. V18 said the weights are ordered more frequently after admission to get to know the resident. V18 stated, It could allow us to catch something quickly, especially for residents that are already at risk for nutritional deficit (like R75). It is very unlikely that R75 weighed the exact same weight, on different scales, and various days. That should have resulted in R75 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145433 If continuation sheet Page 6 of 18 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 145433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of St Charles 611 Allen Lane Saint Charles, IL 60174 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm being re-weighed. It is important that accurate weights are entered into computer. V18 said the weights need to be accurate to trigger weight loss or weight gain in the EMR. V18 said if significant weight loss or gain occurs, the EMR will create an alert for the Dietician to review. V18 said inaccurate weights would prevent this trigger from working. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145433 If continuation sheet Page 7 of 18 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 145433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of St Charles 611 Allen Lane Saint Charles, IL 60174 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure pressure injury prevention interventions were in place for a resident with a history of pressure injuries. This applies to 1 of 5 (R40) residents reviewed for pressure injuries in the sample of 18. Residents Affected - Few The findings include: R40's admission Record (Face Sheet) showed an original admission date of 7/2/22 with diagnoses to include paraplegia (paralyzed from chest down), lack of coordination, and borderline personality disorder. R40's 7/8/23 Minimum Data Set (MDS) showed she was cognitively intact with a brief interview for mental status score of 15 out of 15. R40's MDS showed she required extensive assistance of two people for bed mobility, and she was totally dependent upon two staff for transfers. On 9/26/23 at 1:00 PM, R40 was in bed and her heels were in direct contact with her mattress. R40 was in a private room; at the foot of her bed, in a bin, was a pair of off-loading heel protectors. On 9/27/23 at 10:47 AM, V6 and V7 Certified Nursing Assistants (CNAs) entered R40's room to provide perineal and catheter care. R40's heels were in direct contact with the mattress and her heel protectors were in a bin at the foot of the bed. Prior to starting this care, R40's catheter tubing was under her left thigh. When V6 and V7 rolled R40 to her left side, there was an indentation in R40's skin where the catheter tubing had been. Above R40's buttocks was a pressure injury with a dressing in place. At the conclusion of care, V6 and V7 did not offer to off load R40's heels. On 9/28/23 at 8:47 AM, R40 said, They are not good about putting the heel boots on me. I don't refuse them, it doesn't bother me to wear them, I'm wearing them now . That catheter tubing was under me all night. It shouldn't have been like that it. It could cause a pressure wound. On 9/28/23 at 8:50 AM, V5 Wound Care Nurse stated, .She (R40) wears the heel protectors to prevent a pressure wound to the heels. At times she does refuse care. She should not lay on top of catheter tubing it can cause a pressure wound. She is paraplegic so she would not be able to feel the catheter tubing. R40's Care Plan focus area, from 7/2/22, showed she is at high risk of pressure ulcer due to a history of ulcers, immobility, paraplegia, morbid obesity, diabetes, and high blood pressure. The care plan showed an intervention to off load both heels when in bed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145433 If continuation sheet Page 8 of 18 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 145433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of St Charles 611 Allen Lane Saint Charles, IL 60174 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to apply an arm splint, enter an order for a splint, and initiate a restorative program for R83's arm splint for 1 of 2 residents (R83) reviewed for limited range of motion in the sample of 18. The findings include: On 9/26/23 at 9:46 AM, R83 was sitting in a reclining wheelchair in the common area across from the nurses' station. R83's left arm was resting in her lap, on top of her blankets. R83 was not using her left arm. R83's fingers were curled up toward the palm of her hand. R83 did not have a left arm splint in place. At 12:43 PM, R83 was in the dining room during the noon meal. V4 (LPN - Licensed Practical Nurse) was feeding R83 lunch. R83's left arm resting in her lap. R83 was able to make movements with her right arm but was not moving her left arm. There was no left arm splint in place. On 9/27/23 at 10:18 AM, R83 was sitting in the TV area with a blue splint on her left arm. The splint extended from below her left below to the knuckles of her left hand. R83's brace had an opening for her thumb and a curvature to the wrist area. On 9/28/23 at 9:00 AM, R83 was in her room with V6 (CNA - Certified Nursing Assistant). R83 had the new blue splint to her left arm. R83 said she had been at the facility for a while. R83 said she is supposed to wear the splint every day because her 3 fingers (pointing to her left middle finger, pinky, and ring finger) are curling up and they hurt. The surveyor asked how long R83 had been wearing the left arm splint. R83 replied, They just put it on me, the last few days. R83 denied refusing the splint on Tuesday (9/26/23) and said, No one tried to put it on me. (R83 pointed to V6 (CNA), as she walked out of the room) That lady put in on me. R83 said they used to do exercises with me, but they haven't in a while. R83 stated, It's hard, because I used to be able to take care of myself, but since the fall I need help with just about everything. My legs don't work and my left arm doesn't work much either. My fingers have been getting tighter and hurt me. They are curling in. R83's Face Sheet dated 9/28/23 showed diagnoses to include, but not limited to: quadriplegia, morbid obesity, depression, anxiety, critical illness myopathy, lack of coordination, abnormal posture, diabetes, and history of a neck fracture. R83's facility assessment dated [DATE] showed she was cognitively intact; had no rejection of care; required extensive assistance from staff to totally dependent on staff for most ADLs; last received OT (Occupational Therapy) 6/2/23 - 6/29/23; and had zero days of splint or brace assistance for Restorative Nursing Programs. R83's Therapy Recommendation for Restorative Programs form dated 6/29 showed, left hand resting splint. The splint should be on during the day as tolerated and off at bedtime. This handwritten form was signed by V17 (OT - Occupational Therapist). R83's Physician Order Sheet dated 9/28/23 did not contain an order for a left arm splint. R83's EMR (Electronic Medical Record) was reviewed and there was not a Restorative Program for R83's left arm splint. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145433 If continuation sheet Page 9 of 18 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 145433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of St Charles 611 Allen Lane Saint Charles, IL 60174 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R83's Restorative assessment dated [DATE] showed R83 required extensive to total assistance with ADLs (Activities of Daily Living). R83's left arm splint was not mentioned in this document. R83's Care Plan did not contain a Restorative Program for the left arm splint/brace. R83's Provider Note dated 9/17/23 showed R83 was at the facility for mobility and ADL dysfunction due to cervical stenosis of the spine, after a fall and spinal surgery. The document showed R83 had functional quadriplegia with weakness. This document showed R83 is at risk for developing contractures. On 9/28/23 at 8:52 AM, V16 (RN - Registered Nurse) said she was responsible for R83's hall assignment. The surveyor asked V16 about R83's left arm splint and she looked back blankly. V16 said R83 fell and had come to the facility after due to the quadriplegia. V16 said R83 has been at the facility approximately six months. V16 said R83 was receiving therapy the first few months but didn't think she had seen therapy in a while. V16 did not think R83 had contractures and was unaware of R83's left arm splint/brace. V16 stated, I'd have to go look at it, I'm not sure. On 9/28/23 at 9:08 AM, V6 (CNA) said she hadn't worked with R83 prior to this week, so she is unsure if R83's left arm splint/brace was new. V6 said she worked 9/27/23 and 9/28/23. V6 said she placed R83's sling on during morning cares each day because she saw it in her room. V6 stated, I assume the brace is for contractures in her fingers. I think she's supposed to wear it most of the day. On 9/28/23 at 9:10 AM, V15 (Restorative Nurse) said she had been in the position for three months. V15 said she coordinates with therapy to ensure residents are skills and abilities are maintained. V15 said therapy will provide recommendations for the residents and the Restorative Nursing Program should carry out those recommendations. V15 said residents at risk for contractures include those that lack sensation, are quadriplegic, and are not moving often. V15 said R83 would be a high risk for developing contractures (tightness or curling of joints). V15 said splints are one of the interventions that therapy will put in place to either prevent a contracture from developing or prevent continued decline of a contracture that already exists. V15 said R83 had a splint when she first came to the facility. V15 stated, I think it's her splint. The surveyor asked V15 if there should be an order and Restorative Program for R83's arm splint. V15 replied, Yes, there should be an order for the splint and a program. I'm a little shaky on why there isn't an order or if it was discontinued. [R83's] splint helps prevent contractures (to her fingers, hands) and wrist drop. On 9/28/23 at 9:28 AM, V2 (DON - Director of Nursing) said splints are usually a recommendation from therapy. V2 said there should be an order for R83's splint, but I don't see one in her orders. V2 stated, I've seen a splint, but I'm unsure about the details. She (R83) should have a Restorative Plan in place for that splint. V2 said placing the order and initiating the Restorative Program are important to alert the staff what is being done for R83. V2 said she was not aware if R83 had contractures. On 9/28/23 at 11:34 AM, V17 (OT) said R83 was dependent on staff for most ADLs, but she had not seen R83 for months. V17 said R83 had a contracture to her hand, her fingers were curling tighter. V17 said that is why she recommended the arm brace for her. V17 said she completed the recommendation form, ordered the brace, and provided staff education on the proper use of R83's splint. V17 said that is common practice to provide the in-service, so the staff know how to use the splints properly. They will be the ones placing them on every day. V17 said she makes the recommendations and the Restorative Nursing Program is responsible for entering the order and developing the programs for R83. V17 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145433 If continuation sheet Page 10 of 18 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 145433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of St Charles 611 Allen Lane Saint Charles, IL 60174 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete stated, I recommended the resting hand brace for her because her fingers were closing and getting pretty tight. When I was seeing her, I worked on stretching her hand, wrist and fingers. The splint was recommended to prevent further decline in R83's contracture. She should wear the splint during the day and remove at bedtime. The facility's Restorative Nursing Program revised 7/28/23 showed, .Procedures: .2. Appropriate nursing and restorative services consistent to the resident's functional needs must be provided. If the assessment shows the resident needs therapy, then therapy should be provided. 3. Nursing and Restorative Services may include the following: .c. Contracture Prevention and Management: i. PROM/AROM (Passive Range of Motion and Active ROM) exercises. ii. Splint/Orthotic Management . 4. Nursing and restorative services shall be reflected in the resident's individualized care plan consistent to the completion of the resident comprehensive assessment. 5. Evaluation as to the need of adaptive equipment/enabling devices to help accommodate the resident's needs, promote optimal functioning and self-sufficiency in ADLs may be referred to the Therapy Department (either physical and/or occupational therapy) for the most appropriate device/s recommendations. 6. Restorative Programs shall be reflected and indicated in the resident's electronic restorative log in order to document the provision of services and the frequency by the nurses, CNAs and/or restorative aides . Event ID: Facility ID: 145433 If continuation sheet Page 11 of 18 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 145433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of St Charles 611 Allen Lane Saint Charles, IL 60174 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure fall prevention measures were in place for a resident (R17), failed to supervise a resident (R17) on aspiration precautions during meal times, and failed to transfer a resident (R395) with a gait belt. These failures apply to 2 of 11 residents reviewed for safety in the sample of 18. The findings include: 1) R17's electronic face sheet printed on 9/28/23 showed R17 has diagnoses including but not limited to unilateral post-traumatic osteoarthritis right hip, generalized anxiety disorder, schizophrenia, major depressive disorder, and history of falls. R17's facility assessment dated [DATE] showed R17 has moderate cognitive impairment. R17's fall risk assessment dated [DATE] showed R17 is a high fall risk. R17's physician's orders dated 5/11/23 showed, Regular diet, finger foods, think liquids, pleasure feed as tolerated, aspiration precautions. R17's care plan dated 3/10/21 showed, (R17) is at a high risk for falls related to difficulty maintaining standing position, muscle weakness, unsteady gait, limited mobility, poor sense of safety awareness, diagnosis of Schizophrenia. Interventions: provide floor mat next to bed when resident is lying in bed .please make sure my call light is within reach and encourage me to use it for assistance as needed. R17's dietary evaluation dated 6/26/23 showed, Residents vision is very poor. She is unable to determine what items are on her meal tray and has difficulties with self-feeding. Resident can use a spoon but does better with finger foods .Continue encouragement from staff at mealtimes. On 9/26/23 at 12:55PM, V9 (Certified Nursing Assistant) delivered R17's lunch tray to her room, opened the main meal plate and left the room. V9 stated, She won't let you help her eat. We've tried. She doesn't need supervision during meal times anyway so she can stay in her room by herself and eat. R17's diet card on her lunch tray showed, finger foods, no restrictions. R17 had a whole orange, hot coffee, whole piece of ham, potatoes, beets, and a dinner roll on her plate and was feeding herself. On 9/27/23 at 9:22AM, R17's call light was on and she was requesting assistance with getting up for the day. R17's floor mat was folded up and wedged between her dresser and table across the room. V10 and V11 (Certified Nursing Assistants) entered the room and provided cares and transferred R17 to her chair in her room. V10 put R17's over the bed table in front of her with her breakfast and left the room. V10 stated R17 does not need assistance or supervision during meal times. On 9/28/23 at 11:05AM, V2 (Director of Nursing) stated, I don't know of any swallowing difficulty with (R17). She doesn't have an order or anything for aspiration precautions so staff don't need to monitor her. Residents with aspiration precautions should be monitored at meals to prevent choking. (Surveyor then reviewed R17's physician's orders with V2 who was unaware that R17 had an order for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145433 If continuation sheet Page 12 of 18 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 145433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of St Charles 611 Allen Lane Saint Charles, IL 60174 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 aspiration precautions). V2 then stated, I think that was from our previous dietician, she's not here anymore and I don't know why she ordered that. The facility's policy titled, Fall Occurrence with a review date of 7/17/23 showed, It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised as necessary .2. Those identified as high risk for falls will be provided fall interventions . The facility's policy titled, Dysphagia and Aspiration dated 7/17/23 showed, 1. The staff and physician will monitor the progress of individuals with swallowing difficulties. 2) R395's electronic face sheet printed on 9/28/23 showed R395 has diagnoses including but not limited to malignant neoplasm of prostate, Parkinson's disease, schizoaffective disorder, and generalized anxiety disorder. R395's facility assessment dated [DATE] showed R395 has no cognitive impairment and requires 1 staff assist for transfers and toilet use. R395's fall care plan was unavailable due to R395 being a new admission to the facility. R395's nursing admission evaluation dated 9/21/23 showed R395 sustained a fall in his home prior to admission and was taken to the hospital which prompted a nursing home admission. On 9/27/23 at 9:43AM, V10 (Certified Nursing Assistant) provided toileting and transfer assistance to R395. V10 assisted R395 to stand up by grabbing underneath of his right arm and pulling up forcefully. R395 then attempted to grab a loose towel bar in the bathroom and leaned forward against the fall with his hand. R395 became weak and shaky during care and had to sit back down on the toilet. After 3 minutes, R395 was then again assisted to stand by V10 by grabbing underneath of his right arm. V10 assisted R395 from the toilet to his wheelchair by grabbing his arms and pants a series of times before R395 made it into his wheelchair. V10 stated he has not worked with R395 yet and thought he would be able to stand better. V10 stated he did not use a gait belt because R395 only requires one staff member to assist him so he did not need a gait belt. On 9/28/23 at 11:05AM, V2 (Director of Nursing) stated, A gait belt is to be used for all residents who require any type of staff assistance for transferring. It is an extra safety measure to ensure that staff are able to stabilize a weak resident and to hopefully prevent falls so they can hold the gait belt and stand the resident up if they begin to fall. A gait belt policy was requested and never received from the facility as of 9/28/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145433 If continuation sheet Page 13 of 18 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 145433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of St Charles 611 Allen Lane Saint Charles, IL 60174 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 provide catheter care in a manner to prevent infections for 1 of 2 residents (R395) reviewed for urinary catheters in the sample of 18. The findings include: R395's electronic face sheet printed on 9/28/23 showed R395 has diagnoses including but not limited to malignant neoplasm of prostate, Parkinson's disease, unspecified urethral stricture, schizoaffective disorder, and generalized anxiety disorder. R395's facility assessment dated [DATE] showed R395 has no cognitive impairment, utilizes an indwelling catheter and requires 1 staff assist with personal hygiene. R395's care plan dated 9/18/23 showed, (R395) has an indwelling Foley catheter due to acute urethral stricture. On 9/27/23 at 9:43AM, V10 (Certified Nursing Assistant) provided catheter care and perineal care to R395. V10 stated catheter care is done every time they check and change residents. R395's catheter tubing was not secured and had blood-tinged urine in the tubing. V10 applied gloves and then cleansed R395's buttocks after a bowel movement. V10 went to the front of R395, wiped his perineal area, and then cleaned R395's catheter tubing with the same wipe from his groin area. V10 did not use a new wipe or change his gloves prior to giving R395 catheter care after cleaning R395's feces off his buttocks. R395 removed his gloves after giving R395 cares and left the room without performing hand hygiene. V10 stated he will wash his hands when they are soiled and did not know he needed to change his gloves between cleaning feces and a urinary catheter. On 9/28/23 at 11:05AM, V2 (Director of Nursing) stated, when staff are providing catheter care they should be using different sides of the wipe or washcloth or a new one due to the concerns for cross contamination if using the same side of the washcloth and then cleaning the catheter insertion site. The facility was unable to provide a policy regarding catheter care as of 9/28/23. Multiple requests were made on 9/27/23 and 9/28/23 for this policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145433 If continuation sheet Page 14 of 18 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 145433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of St Charles 611 Allen Lane Saint Charles, IL 60174 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure food was prepared and served in a manner to prevent cross-contamination and food-borne illness. The facility also failed to ensure the chemical sanitation level testing for the chemical dishwasher was performed and documented. These failures have the potential to affect all the residents in the facility. The findings include: The Resident Census and Conditions of Residents, CMS 672 form, dated 9/28/23 showed 79 residents resided in the facility. On 9/28/23 at 12:15 PM, V2 (Director of Nursing) said there are 2 residents in the facility who have feeding tubes/g-tubes. V2 said both residents receive food by mouth. On 9/26/23 at 9:10 AM, V19 (Dietary Manager-DM) said the lunch menu for the day was ham, steamed cabbage, and seasoned potato wedges. V19 said chicken, beef, BLTs, and other sandwiches are the substitutes available for residents that do not want the ham. At 9:35 AM, V22 (Dietary Aide) tested the chemical sanitation level for the chemical dishwasher. V22 said the testing should be done during every meal service. V22 said after the dietary staff test the chemical sanitation for the dishwasher, they document the results on the clipboard that was located on a shelf by the entrance to the dishwashing area (V22 pointed to the clipboard). This surveyor reviewed the documents on the clipboard. The documents showed no results were entered for the following meals: 9/3/23 for the breakfast and lunch meals; 9/16/23 for the breakfast and lunch meals; 9/17/23 for the breakfast and lunch meals; 9/23/23 for the breakfast and lunch meals; and 9/24/23 for the breakfast and lunch meals. On 9/26/23 at 10:25 AM, V20 (Dietary Cook) took a large pan containing sliced ham out of the oven and measured the temperature of the ham. V20 did not disinfect or clean the thermometer probe prior to sticking the probe into the ham slices for temping. V20 removed 10 pieces of sliced ham from the large pan and placed them into the food processor. V20 added some glaze for the ham and began processing the ham for the residents who received pureed diets. During this time, there was a baking sheet with cooked hamburgers on it, a dish with cooked bacon in it, and the large pan with the sliced ham in it (for the residents who received regular and mechanical soft diets) sitting on the prep table. All these foods were uncovered. At 10:44 AM, V20 finished making the pureed ham, placed it in a small pan and put the pureed ham back in the oven. At 10:47 AM, V20 was asked to take the temperature of the burgers that were sitting on the prep table. V20 placed the thermometer probe into the burgers without disinfecting or cleaning the probe. While V20 was temping the burgers, V19 (DM) said something to V19 in Spanish, then V19 covered the large pan of sliced ham, and a small pan containing the glaze. V19 placed the large pan and the pan with glaze back in the oven. At 10:59 AM, this surveyor observed a baking sheet with cooked chicken on it that was sitting on top of a skillet, on a shelf, uncovered. The baking sheet with the cooked chicken had been sitting there uncovered since before this surveyor began watching V20 make the pureed items for the lunch service. At 11:07 AM, V20 put all but 2 of the burgers in a metal pan and placed them in the oven. At 11:15 AM, the 2 burgers, and the dish containing the cooked bacon were still sitting uncovered on the prep table. The baking pan with the cooked chicken was still sitting uncovered on the shelf. At 11:20 AM, V20 placed a used baking sheet directly on top of the cooked chicken that was on the shelf. At 11:25 AM, this surveyor asked V20 if the chicken was for the substitute for the lunch meal. V20 said yes and placed the pieces of chicken in a smaller, deeper pan and placed the chicken in the oven. At 11:56 AM, the temperatures (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145433 If continuation sheet Page 15 of 18 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 145433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of St Charles 611 Allen Lane Saint Charles, IL 60174 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 of the foods on the steam table, that were being served for the lunch meal were obtained. the temperature of the chicken was 123.8 degrees Fahrenheit. The temperature of the burgers was 120.3 degrees Fahrenheit. On 9/26/23 At 12:09 PM, V21 (Dietary Aide) was standing by the food line. V21 had gloves on and put both of his gloved hands in his pants pockets. V21 pulled his gloved hands out of his pant pockets and touched several of the insulated plate bottoms and covers (used to help keep individual plates warm until served). At 12:22 PM, V21 was holding an insulated plate lid up against his shirt while waiting for V20 to plate food for the cart he was filling. V20 handed V21 the filled plate and he placed the cover over the plate and put it in the cart. V21 picked up another insulated plate cover and did the same thing, holding the plate cover directly against his shirt while waiting for the filled plate. V21 covered the filled plate with the contaminated cover and placed it in the food cart. On 9/27/23 at 10:56 AM, V23 (Regional Director of Operations for Dietary) said V20 should not have left the food sit out uncovered. V23 said after the food has been cooked, the bottom oven is set up to keep food warm, until it is ready to be processed or served. V23 said the food temperature can drop down into the danger zone where bacteria grows and it causes food- borne illnesses. At 11:04 AM, V23 said they are going to in-service staff about changing gloves and not allowing the food covers to touch your clothing. Because you are carrying germs and cross-contaminate onto the covers. V23 said the food temperatures on the steam table should be 135 degrees Fahrenheit and above to keep foods out of the danger zone. On 9/27/23 at 11:15 AM, V22 said testing the dish machine with the test strips is how the dietary staff monitor to ensure the equipment is working properly. On 9/28/23 at 8:38 AM, V23 said the thermometer should be cleaned/disinfected between uses for infection control. V23 said they ensure proper sanitation of dishes by testing the dishwasher with the chlorine strips. V23 said the machine should be tested at every meal service. V23 said the facility did not have a specific policy regarding sanitizing the thermometer or keeping the dishes away from clothing, adding, It is just general infection control standards. The facility's policy titled Food: Preparation, dated October 2019, showed Definitions: Time/Temperature Control for Safety Food (formally known as potentially hazardous food) means a food that requires time/temperature controls for safety (TCS) to limit pathogenic organism growth or toxin formation . The policy showed Action Steps: 1. The Dining Services Director ensures that all staff practice proper hand washing technique and practice proper glove use. 2. the Dining Services Director or Cook(s) are responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination . The policy showed 11. The Cook(s) ensures that all foods are held at appropriate temperatures, greater than 135 degrees Fahrenheit (or as state regulation requires) for hot holding, and less than 41 degrees Fahrenheit for cold food holding . 13. All staff will use serving utensils appropriately to prevent cross-contamination. The facility's policy and procedure titled Ware Washing, dated October 2019, showed it is the center's policy that all dishware and service ware will be cleaned and sanitized after each use. The policy showed 1.The Dining Services Director ensures that the nutritional service staff is knowledgeable in proper technique for processing dirty dish ware to clean through the dish machine and proper handling of sanitized dish ware. The policy showed 3. The Dining Services Director is responsible for ensuring appropriate completion of temperature and/or sanitizer concentration logs as appropriate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145433 If continuation sheet Page 16 of 18 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 145433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of St Charles 611 Allen Lane Saint Charles, IL 60174 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** 3. R53's admission Record, printed by the facility on 9/27/23, showed she had diagnoses including type II diabetes mellitus with ketoacidosis (a serious diabetes complication in which the body produces excess blood acids-ketones. This condition occurs when there is not enough insulin in the body), and long-term use of insulin. Residents Affected - Few On 9/26/23 at 12:49 PM, V13 (Licensed Practical Nurse-LPN) was preparing R53's insulin medication. V13 removed the cap to R53's Lispro Kwik Pen (a pen-type injector to administer insulin) and attached the needle to the pen without disinfecting the rubber stopper on the pen. V13 dialed the Kwik Pen to 12 units of insulin and went into R53's room. V13 administered the insulin in R53's left upper abdomen. At 12:57 PM, V13 said she should have disinfected the rubber stopper with alcohol, prior to attaching the needle, for infection control. On 9/27/23 at 8:52 AM, V2 (Director of Nursing) said she expects the nurses to alcohol the rubber tip of the Kwik Pen prior to attaching the needle. The facility's policy and procedure titled Medication Pass, with a revision date of 7/28/23, did not address disinfecting the rubber stopper prior to attaching the needle. On 9/27/23 at 1:56 PM, V2 said the facility does not have a policy specifically for insulin administration. V2 said the nurse should alcohol the rubber top of the Kwik Pen prior to attaching the needle for infection control, so it will be clean. R53's Order Summary Report, printed by the facility on 9/27/23, showed R53 had orders for Lispro insulin 6 units with meals, in addition to sliding scale Lispro insulin with meals, based on the results of her blood glucose checks. Based on observation, interview, and record review, the facility failed to wear personal protective equipment per their policy for 2 residents (R17, R395) on enhanced barrier precautions, failed to disinfect an insulin pen prior to needle application and insulin administration for a resident (R53). These failures apply to 3 of 3 residents reviewed for infection control in the sample of 18. The findings include: 1. R17's electronic face sheet printed on 9/28/23 showed R17 has diagnoses including but not limited to unilateral post-traumatic osteoarthritis right hip, generalized anxiety disorder, schizophrenia, major depressive disorder, and history of falls. R17's care plan dated 5/17/23 showed, Resident is on enhanced barrier precaution due to wound management .ensure that gown and gloves are used during high-contact resident care activities (dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting. Device care or use for those with central line, urinary catheter, feeding tube, and wound care) that provide opportunities for transfer of multi-drug resistant organisms (MDROs) to staff hands and clothing. On 9/27/23 at 9:22AM, R17's doorway had a sign showing, Enhanced Barrier Precautions. Clean hands before entering & when leaving the room. Wear gloves & gown for dressing, bathing/showering, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145433 If continuation sheet Page 17 of 18 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 145433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of St Charles 611 Allen Lane Saint Charles, IL 60174 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 transferring, changing linens, providing hygiene, toileting. V10 and V11 (Certified Nursing Assistants) walked into R17's room and provided morning cares to R17. Staff provided incontinence brief changing, transfer, dressing assistance, and linen changes to R17. V10 and V11 had gloves on but no gowns were being worn by either staff member during all R17's morning cares. V11 stated so many residents are on precautions for no reason the staff don't always wear the gowns. Residents Affected - Few On 9/28/23 at 11:08AM, V2 (Director of Nursing) stated, We are utilizing enhanced barrier precautions for all residents that are at risk of obtaining an infection. The residents most likely to obtain an infection would be those with intravenous lines, catheters, open wounds, gastrostomy tubes, etc. We need to ensure our staff are wearing gowns and gloves for all cares with these residents to keep them safe and ensure our staff are not carrying bacteria into these rooms. It is the expectation that all staff follow the enhanced barrier precautions as stated on those specific resident doorways. The facility's policy titled, Enhanced Barrier Precautions with a revision date of 7/14/22 showed, The facility will use enhanced barrier precautions (EBP) to reduce transmission of infectious organisms. EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities .3. The EBP requires the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing. 2. R395's electronic face sheet printed on 9/28/23 showed R395 has diagnoses including but not limited to malignant neoplasm of prostate, Parkinson's disease, unspecified urethral stricture, schizoaffective disorder, and generalized anxiety disorder. R395's facility assessment dated [DATE] showed R395 has an indwelling urinary catheter. R395's care plan dated 9/22/23 showed, Resident is on Enhanced Barrier Precaution due to right upper extremity peripherally inserted central catheter line, indwelling Foley catheter, and wound management. On 9/27/23 at 9:43AM, V10 (Certified Nursing Assistant) entered R395's room to provide perineal and incontinence care. V10 had on a pair of gloves but no gown on upon entering R395's room and throughout all R395's cares. V10 stated he does not need a gown in R395's room because the precautions are a suggestion, not a rule. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145433 If continuation sheet Page 18 of 18