Inspection·July 17, 2023

F 0609 E. Immediate reporting of suspected abuse or a crime . Level of Harm - Minimal harm or potential for actual harm iii. Any reasonable suspicion of a crime against a resident should be reported to the State Survey Agency and the police. Serious bodily injury should be reported immediately but no later than two hours after forming the suspicion. If there is no serious bodily injury not later than 24 hours. Residents Affected - Few iv. Examples of crimes that must be reported (not limited to the below): .sexual abuse . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145606 If continuation sheet Page 2 of 12 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 145606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covenant Living - Windsor Park 110 Windsor Park Drive Carol Stream, IL 60188 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 0610 Respond appropriately to all alleged violations. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect residents from further abuse by allowing an alleged perpetrator of sexual abuse to continue to work and care for residents in the facility for at least four and a half hours after the allegation was reported to the administrator. Residents Affected - Many This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on July 6, 2023, when R263 reported to V4 (Speech Therapist) on July 6, 2023, during R263's speech therapy session that V3 (CNA/Certified Nursing Assistant) sexually abused her. V1 (Administrator) was notified of the alleged abuse on July 6, 2023, between 10:30 AM and 11:00 AM. Following V1's notification, V3 continued to remain in the facility and care for residents. V3 was not suspended from work until July 6, 2023, at 3:38 PM. V1 (Administrator) and V2 (DON/Director of Nursing) were notified of the Immediate Jeopardy on July 12, 2023, at 12:15 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on July 12, 2023, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. This has the ability to affect all 52 residents in the facility. The findings include: The Resident Census and Conditions of Residents report dated July 11, 2023, shows the facility census was 52 residents. On July 10, 2023, at 11:46 AM, R263 said a male employee sexually abused her. R263 continued to say he got on top of her and had sex with her. On July 10, 2023, at 12:12 PM, V8 (R263's Family) said R263 has a hard time talking about the sexual abuse. V8 continued to say R263 can be confused at times, but on July 6, 2023, when R263 was telling V8 about V3 sexually abusing her, R263 was lucid. On July 10, 2023, at 4:40 PM, V4 (Speech Therapist) said during her therapy session with R263, R263 reported to V4 a male CNA sexually abused her. V4 continued to say V4 reported R263's sexual abuse allegation to V5 (Director of Rehab) immediately after her speech therapy session with R263, and they reported to V1 (Administrator). V4 said since R263 was first admitted to the facility she has been able to communicate better and has been more alert. On July 11, 2023, at 10:50 AM, V1 said on July 6, 2023, between 10:30 AM and 11:00 AM, V5 notified V1 of R263's sexual abuse allegation regarding V3. V1 continued to say V4 told V1, during R263's speech therapy session, R263 pointed to V3 walking in the hallway and R263 said he is dangerous, he will sexually assault you. V1 said R263 told V4 she had been sexually assaulted by V3. V1 said she went to speak with R263, but she was sleeping. V1 continued to say V3 is the only CNA who fits R263's description, he is the only male CNA. V1 said on July 6, 2023, after R263's allegation was reported to her, V3 told V1 he was not currently providing care to R263 but had been providing care earlier in the morning and the previous day. V1 said she told V3 to make sure he does not see R263 anymore today and if there is an emergency in R263's room, to make sure he is not in her room alone. V1 said R263's nurse performed a head-to-toe assessment and did not see anything on R263's external genitalia. V1 continued to say R263's physician was notified of R263's allegation and the facility's nurse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145606 If continuation sheet Page 3 of 12 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 145606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covenant Living - Windsor Park 110 Windsor Park Drive Carol Stream, IL 60188 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 0610 Level of Harm - Immediate jeopardy to resident health or safety practitioner was asked to examine R263, but the nurse practitioner was no longer in the facility on July 6, 2023. V1 said the nurse practitioner assessed R263 on July 7, 2023, and the nurse practitioner reported R263 told her the CNA put his fingers inside her vagina. V3's timecard showed on July 6, 2023, V3 started his shift on July 6, 2023, at 6:43 AM and clocked out on July 6, 2023, at 3:38 PM. Residents Affected - Many On July 11, 2023, at 3:25 PM, V1 said she did not suspend V3 immediately because she was waiting to interview R263. V1 continued to say she also did not immediately suspend V3 because V1 spoke with V7 (R263's Family) and V7 told V1 he did not have a problem with V3, he just didn't want V3 providing incontinence care to R263. V1 continued to say V7 called back later in the day and reported to V1 that V3 inserted his fist into R263's vagina, and V1 then suspended V3 at 3:38 PM. V1 said she also did not suspend V3 because the head-to-toe assessment completed on R263 did not show any external trauma. On July 13, 2023, at 11:11 AM, V2 (DON) said she was working on July 6, 2023, and V3 continued to provide care to residents after R263 made the sexual abuse allegation against V3. On July 13, 2023, at 10:02 AM, V14 (RN) said she worked on July 6, 2023, with V3 and was caring for some of the residents in R263's hallway. V14 continued to say V3 provided care to residents until he went home on July 6, 2023. V14 said V3 also assisted residents in the dining room during lunch on July 6, 2023. V14 continued to say in the afternoon on July 6, 2023, she saw V3 sitting in a chair in the hallway across from R263's room. V14 said she was unaware of R263's allegation against V3 until V2 told us V3 was getting sent home, then the staff knew something was going on. A progress note dated July 6, 2023, at 8:46 PM, by V15 (RN/Registered Nurse) showed, .Approximately 3:45 PM, thorough body check done, nothing unusual, with old bruises on both arms, left posterior hand and abdomen with various stages of healing; excoriation on peri area and buttocks . A progress note dated July 7, 2023, at 3:09 PM, by V6 (Nurse Practitioner) showed on July 7, 2023, the DON requested V6 to see R263 due to R263's sexual abuse allegation. The documentation continued to show V6 only assessed R263's external genitalia, and R263 was oriented times two to three. Facility documentation showed on July 6, 2023, at 5:19 PM, V19 (Regional Human Resources Director) interviewed V3 and V3 stated That morning, after feeding her, she said 'Don't touch me. Someone else has to change me.' She didn't want me to change her. I did what the nurse said. I called my coworker like the nurse told me. I was beside my coworker when she was doing it. Facility documentation showed on July 7, 2023, at 10:00 AM, V19 interviewed V15 (RN) and V15 said, I remember in the morning I was doing medication pass because my cart was [adjacent to R263's room] and [V3] was in [R263's room] and he told me 'Can you talk to the resident?' So I went in there and asked the resident, 'What's going on?' [R263] said, 'I don't want him.' I asked, 'Why?' [R263] said, 'I don't want him.' I say to her, 'Let me get another care giver because I'm passing medication.' [R263] said, 'No I want you to clean me.' I said, 'Ma'am I can't do that right now, but I can get another CNA to do that; I can get [V20 (CNA)].' And so I went out and I don't know if I was holding something and I went to the cart and [V20] came out. I told [V3] also before I left the room that [R263] will exchange to [V20]. So I told [V20] that [V3] will have an exchange resident with you because [R263] doesn't want [V3]. Later on, I was in [R263's room] now when [V1] approached and said 'We have an allegation of abuse. For the meantime, don't have [V3] handle [R263].' I said, 'Ok.' She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145606 If continuation sheet Page 4 of 12 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 145606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covenant Living - Windsor Park 110 Windsor Park Drive Carol Stream, IL 60188 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 0610 mentioned two persons should go in there all the time. So I told that to [V20] and I told to [V3]. Level of Harm - Immediate jeopardy to resident health or safety The EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including nontraumatic subarachnoid hemorrhage, aphasia, dysphagia, and diabetes. Residents Affected - Many R1's MDS (Minimum Data Set) dated June 27, 2023, showed R1 had severe cognitive impairment. The MDS continued to show R1 required extensive assistance from facility staff for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. The facility's policy titled, Abuse Prevention Program, dated October 15, 2022, showed, Policy: The policy of [the facility] is zero tolerance of any form of abuse, neglect, or exploitation . F. Investigation . iii. Protect the resident or residents involved in a case of suspected abuse from potential additional harm during the investigation. If an employee is the alleged perpetrator, the administrator will take appropriate action, including suspending the employee pending investigation . The facility presented a removal plan to remove the immediacy on July 12, 2023, at 2:19 PM. The survey team reviewed the removal plan and was unable to accept the plan to remove the immediacy. The removal plan was returned to the facility for revisions. The facility presented a revised removal plan on July 12, 2023, at 3:29 PM, and the survey team reviewed the removal plan and was unable to accept the plan to remove the immediacy. The facility presented a revised removal plan on July 12, 2023, at 4:19 PM, and the survey team accepted the removal plan on July 12, 2023, at 4:41 PM. The Immediate Jeopardy that began on July 6, 2023, was removed on July 12, 2023, when the facility took the following actions to remove the Immediacy. Corrective Action: 1. Education of abuse policy with immediate removal of an alleged perpetrator from the property once an abuse allegation is made. This education was provided to the Executive Director, V1, and V2 by the facility's Associate [NAME] President on July 12, 2023. 2. Education regarding reporting abuse and facility abuse policy with skilled facility staff which includes: nursing, nursing agency, social services, dining, housekeeping, transportation, therapy, maintenance, laundry, activities, and administrative staff that are on schedule was completed on July 12, 2023. Skilled Facility staff not on duty (including agency) will be educated prior to their first scheduled shift. This in-service will be completed by the HCA (Healthcare Administrator)/DON/ or a [Facility] leadership team member. 3. Ad-hoc QAPI (Quality Assurance and Performance Improvement) meeting was held on July 12, 2023. This included a review of the removal plan and the abuse policy. Immediate Change to Facility Systems: 1. Staff members named in an allegation will be removed immediately from the property and schedule. They will be placed on administrative leave pending investigation. 2. HCA and ED (Executive Director) will review the Abuse Policy. Monitoring: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145606 If continuation sheet Page 5 of 12 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 145606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covenant Living - Windsor Park 110 Windsor Park Drive Carol Stream, IL 60188 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 0610 Level of Harm - Immediate jeopardy to resident health or safety The Executive Director will be informed immediately of allegations of abuse and suspension of employees. The Executive Director will ensure that any employee involved in alleged allegation is suspended immediately. Allegations of abuse will be reviewed during the IDT (Interdisciplinary Team) meeting that occurs Monday through Friday. Residents Affected - Many All allegations of Abuse will be reviewed monthly during QAPI to ensure that employee suspensions were immediate, and investigations completed timely to ensure the protection of all residents. This will be done for a period of three months, then quarterly for 3 months, then as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145606 If continuation sheet Page 6 of 12 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 145606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covenant Living - Windsor Park 110 Windsor Park Drive Carol Stream, IL 60188 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 implement pressure relieving interventions for a resident with pressure injuries. Residents Affected - Few This applies to 1 of 2 residents (R15) reviewed for pressure ulcers in a sample of 14. The findings include: Face Sheet, dated July 11, 2023, shows R15's diagnoses included unstageable pressure ulcer of left heel, pressure ulcer of right heel, pressure ulcer of other site stage 4, atherosclerosis of right leg arteries with ulcer, Alzheimer's disease, dementia with psychotic disturbances, psychosis, and protein calorie malnutrition. MDS (Minimum Data Set), dated June 8, 2023, shows R15 was severely cognitively impaired, required two staff assistance for bed mobility, transfers, and toilet use, and required one staff assistance for dressing and personal hygiene. Wound Evaluation and Management Summary, dated June 27, 2023, shows R15 had several wounds including the following: 1. Unstageable (due to necrosis) pressure wound of the left heel with necrosis measuring 1.7 cm (centimeters) x 1.5 cm. Plan of care recommendations included sponge boot and off-load wound. 2. Stage 4 pressure wound of the right heel with 30% tendon/fascia/muscle visible, 20% black necrotic tissue, 10% thick adherent black necrotic tissue, and 40% granulation measuring 12 cm x 4.2 cm x 0.3 cm. Plan of care recommendations included sponge boot. 3. Stage 4 pressure wound of the right first toe with 80% thick adherent black necrotic tissue and 20% thick adherent devitalized necrotic tissue visible which measured 3.5 cm x 4.5 cm x 0.4 cm. Plan of care recommendations included sponge boot. Care plan, printed July 11, 2023, shows R15 was at risk for skin breakdown, had an unavoidable, unstageable, facility-acquired pressure ulcer of the left heel, a stage 4 pressure ulcer of the 1st right toe, and arterial wounds on the right 5th toe and right medial 1st toe. Pressure ulcer interventions included the use of pressure relieving heel boots. Urinary Continence care plan interventions include, Use pillows, pads, or wedges to reduce pressure on heels and pressure points. R15's Range of Motion care plan interventions included, Please use devices and measures to prevent skin break down. On July 10, 2023 at 10:56 AM, R15 was sitting in her wheelchair in her room with her legs extended straight in front of her. R15 had both wheelchair leg rests extended parallel to the floor causing her legs to be parallel to the floor and to be extended straight in front of her from her hips to her heels. Both of the metal flaps of the foot rests were unfolded. R15's heels/feet extend beyond the foot plate causing the back of both heels to rest on the top edges of both foot plates. R15 had plastic gray inflatable foot protectors on both feet. The heel flaps of both inflatable foot protectors were open exposing both heel/achilles areas. R15's exposed heel/achilles areas were resting on top of edge of the metal foot plates of the leg rests. R15 had a large wedge cushion placed on the calf rests of the extended leg rests and the backs of both of R15's knees/calves/thigh areas were above the cushion. R15 was able to slightly adjust her sitting position using elbows on arm rests of chairs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145606 If continuation sheet Page 7 of 12 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 145606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covenant Living - Windsor Park 110 Windsor Park Drive Carol Stream, IL 60188 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 Level of Harm - Minimal harm or potential for actual harm and minimally scoot on the seat of her chair which caused her feet to shift slightly but remain on top edges of the metal foot plates. On July 10, 2023 at 11:17 AM, R15's heels continued to rest on edges of the metal foot plates of her foot rests. R15's right great toe was very dark. Residents Affected - Few On July 10, 2023 at 11:27 AM with V16 (Registered Nurse) and V18 (Hospice Certified Nursing Assistant), both of R15's heels continued to rest on the top edge of her metal foot plates. R15 was shifting in her chair using both elbows and her left heel slid past the edge of foot plate resulting in her heel sliding further past the top edge of the metal foot plate and her achilles area resting on the top edge of the metal foot plate. R15's right heel was still resting on the top edge of her foot plate. V16 unwrapped R15's protective boots and pulled out a washcloth from both boots which was placed between her heels and the insides of both protective boots. R15 began crying out Owww V16 then refastened the boots but did not reposition R15's feet leaving R15's heels/achilles areas to continue to rest on the top edges of her metal foot plates. R15 continued to use her elbows to shift her seat in her wheelchair. V16 stated R15 had wounds on back of her heels that extended up her achilles areas. On July 10, 2023 at 11:45 PM in the room with R15, V17 (Restorative Nurse) examined R15's heels which continued to be resting on the edges of her metal foot plates and stated it was her expectation that the back of R15's heels/achilles were not be touching the edges of the metal foot plates. V17 also stated it was her expectation that there were no wash cloths placed between resident heels and the insides of their protective boots. V17 folded R15's metal foot plates toward the extended leg rests and out of the way of resident heels/legs. R15's heels sunk down approximately 3 inches and the backs of R15's legs came to rest on the wedge cushion positioned on the calf rests of the extended leg rests. On July 11, 2023 at 11:37 AM, V13 (Wound Physician) stated it was his expectation that R15's feet/achilles/legs were not resting on the edges of her metal foot plates of her foot rests. V13 stated only the planter parts of R15's feet should be resting on the flat part of the foot rests. V13 stated there should be no washcloths placed inside R15's boots. V13 stated R15 had very poor circulation and advanced arterial disease. Facility Pressure Injury Risk Assessment, dated March 2020, shows, Develop the resident-centered care plan and interventions base on the risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition, and the resident's stated wishes and goals. Facility Prevention of Pressure Injuries, dated April 2020, shows, Prevention- Support Surfaces and Pressure Redistribution 1. Select appropriate support surfaces based [on] the resident's risk factors, in accordance with current clinical practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145606 If continuation sheet Page 8 of 12 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 145606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covenant Living - Windsor Park 110 Windsor Park Drive Carol Stream, IL 60188 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 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review, the facility failed to plan pureed menus to include the required number of grain/cereal servings per facility policy. Residents Affected - Some This applies to all 5 residents (R9, R28, R39, R114, R213) reviewed for pureed diets. The findings include: Facility Pureed Diet List, dated July 12, 2023, shows 5 residents (R9, R28, R39, R114, R213) all received pureed diets. On July 11, 2023 at 10:51 AM, V21 (Cook) was pureeing lunch items for pureed diets. Review of diet extension sheet, Tuesday Week 3, showed residents receiving regular diets were offered a grain/cereal choice of wild rice blend however pureed diet residents were offered a vegetable of mashed potatoes instead of the rice grain/cereal. V21 stated she had no orders for pureed rice for lunch. On July 11, 2023 at 11:09 AM with V10 (Dietitian) and V12 (Food Service Manager), V11 Food Service Worker) stated if residents on pureed diets were unable to select their own menus for meals, V11 served them a main entree, mashed potatoes and a vegetable for lunch. V11 stated that day three residents on the 2 [NAME] unit were unable to select their menus for the lunch meal (R9, R28, and R39) and she would serve them the chicken, mashed potatoes, and a vegetable at the meal. V10 (Dietitian) stated any residents on pureed diets who were unable to select their meals would receive the chicken, mashed pot and wax beans but no grain/cereal item was offered. V10 stated residents on pureed diets did not receive pureed rice at meals if rice was served on the regular menus but only received mashed potatoes instead. V10 stated she planned the facility menus. Review of facility menu extension sheets, Week 3 Days Mon-Sat and Week 4 Days Sun-Sat, show the pureed diets were not offered pureed rice when regular diets were served rice at a meal. The menus showed the rice was replaced with a vegetable (mashed potato) on pureed diets instead of a grain/cereal menu item. The menus show the pureed diets failed to have a total of 5-6 daily servings of grains/cereals planned throughout the day on 10 of the 13 days reviewed. The menus showed the pureed diet residents were menued to receive mashed potatoes on 21 of the 26 lunches/dinners reviewed. Facility Policy and Procedure Manual Section 2 - Diets & Menus: Menu Planning Guidelines, dated January 2017, shows, To properly plan and develop nutritionally balanced menus and meet resident preferences and needs that will meet regulatory agencies' requirements 8. The Dietitian is responsible for ensuring menu meet nutritional adequacy In the absence of a nutritional analysis, the following guide may be used to help meet menu standards Menus should offer the following nutrition composition each day: .5 servings of fruits and/or vegetables, 5-6 servings of grains/cereals FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145606 If continuation sheet Page 9 of 12 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 145606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covenant Living - Windsor Park 110 Windsor Park Drive Carol Stream, IL 60188 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the administrator was aware of the potential sexual abuse and allowed the alleged perpetrator to remain on duty with access to all residents. The administrator also failed to follow their abuse policy and notify the local law enforcement agency of an allegation of sexual abuse in a timely manner. Residents Affected - Many This has the ability to affect all 52 residents in the facility. The findings include: The Resident Census and Conditions of Residents report dated July 11, 2023, shows the facility census was 52 residents. On July 11, 2023, at 12:06 PM, V1 said I am the abuse coordinator. On July 11, 2023, at 10:50 AM, V1 said on July 6, 2023, between 10:30 AM and 11:00 AM, V5 (Director of Rehab) notified V1 of R263's sexual abuse allegation regarding V3 (CNA/Certified Nursing Assistant). V1 continued to say V4 (Speech Therapist) told V1, during R263's speech therapy session, R263 pointed to V3 walking in the hallway and R263 said he is dangerous, he will sexually assault you. V1 said R263 told V4 she had been sexually assaulted by V3. V1 said she went to speak with R263, but she was sleeping. V1 continued to say V3 is the only CNA who person who fits R263's description, he is the only male CNA. V1 said V3 told V1 he was not currently providing care to R263 but had been providing care earlier in the morning and the previous day. V1 said she told V3 to make sure he does not see R263 anymore today and if there is an emergency in R263's room, to make sure he is not in her room alone. V1 said R263's nurse performed a head-to-toe assessment and did not see anything on R263's external genitalia. V1 continued to say R263's physician was notified of R263's allegation and the facility's nurse practitioner was asked to examine R263, but the nurse practitioner was no longer in the facility. V1 said the nurse practitioner assessed R263 on July 7, 2023, and the nurse practitioner reported R263 told her the CNA put his fingers inside her vagina. V1 continued to say the police were not notified of R263's sexual abuse allegation on July 6, 2023. V3's timecard showed on July 6, 2023, V3 started his shift on July 6, 2023, at 6:43 AM and clocked out on July 6, 2023, at 3:38 PM. On July 11, 2023, at 3:25 PM, V1 said she did not suspend V3 immediately because she was waiting to interview R263. V1 continued to say she also did not immediately suspend V3 because V1 spoke with V7 (R263's Family) and V7 told V1 he did not have a problem with V3, he just didn't want V3 providing incontinence care to R263. V1 continued to say V7 called back later in the day and reported to V1 that V3 inserted his fist into R263's vagina, and V1 then suspended V3 at 3:38 PM. V1 said she also did not suspend V3 because the head-to-toe assessment completed on R263 did not show any external trauma. The facility's policy titled, Abuse Prevention Program, dated October 15, 2022, showed, Policy: The policy of [the facility] is zero tolerance of any form of abuse, neglect, or exploitation . E. Immediate reporting of suspected abuse or a crime . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145606 If continuation sheet Page 10 of 12 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 145606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covenant Living - Windsor Park 110 Windsor Park Drive Carol Stream, IL 60188 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 0835 Level of Harm - Minimal harm or potential for actual harm iii. Any reasonable suspicion of a crime against a resident should be reported to the State Survey Agency and the police. Serious bodily injury should be reported immediately but no later than two hours after forming the suspicion. If there is no serious bodily injury not later than 24 hours. iv. Examples of crimes that must be reported (not limited to the below): .sexual abuse . Residents Affected - Many F. Investigation . iii. Protect the resident or residents involved in a case of suspected abuse from potential additional harm during the investigation. If an employee is the alleged perpetrator, the administrator will take appropriate action, including suspending the employee pending investigation . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145606 If continuation sheet Page 11 of 12 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 145606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covenant Living - Windsor Park 110 Windsor Park Drive Carol Stream, IL 60188 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 Pneumococcal Vaccine policy. Residents Affected - Few This applies to 3 of 5 residents (R18, R26, and R41) reviewed for Pneumococcal Vaccine in the sample of 14. The finding include: 1. R18's EMR (Electronic Medical Record) showed R18 was over [AGE] years old and was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, multi-system degeneration of the autonomic nervous system, and sarcoidosis of the lung. Facility documentation showed the facility failed to offer the pneumococcal vaccine within 30 days of admission. 2. R26's EMR showed R26 was over [AGE] years old and was admitted to the facility on [DATE] with diagnoses that included unspecified urinary incontinence, iron deficiency anemia, and hypertension. Facility documentation showed the facility failed to administer the pneumococcal vaccine within 30 days of admission. 3. R41's EMR showed R41 was over [AGE] years old and was admitted to the facility on [DATE] with diagnoses that included lobular pneumonia, Alzheimer's disease, seasonal allergies, and generalized muscle weakness. There was no documentation to show the facility offered or administered pneumococcal vaccine within 30 days of admission. On July 13, 2023, 10:32 AM, V2 (DON/Director of Nursing) said the expectation is to for the facility to follow the policy and offer residents the pneumococcal vaccine as stated in the policy. Facility provided their policy titled Pneumococcal Vaccine with a revision date of March 2022. Their policy showed all residents are to be offered the pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. The Policy and Interpretation and Implementation 1. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within 30 days of admission . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145606 If continuation sheet Page 12 of 12