Health inspection·November 2, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few same documents inside the advance directive binder. V6 reviewed the said two documents and acknowledged the POLST declination form was made because R91 was cognitively impaired and cannot sign the POLST form. V6 stated R91's POLST declination form meant the resident was a full code, however the surrogate decision-making forms documented withholding the CPR which meant R91 was a DNR. V6 stated there was no signed DNR form available as indicated in the surrogate decision-making forms. During the same interview V6 acknowledged R91's code status in case of a medical emergency was confusing for the nursing staff because it does not provide the specific medical order/direction to follow. V6 further stated the facility did not follow up to obtain a signed DNR for R91. On [DATE] at 9:31 AM, V2 (Director of Nursing) stated with regards to the advance directives or code status of the residents, there should be always consistent documentation, so as not to confuse the nursing staff in case of a medical emergency. The facility's advance directives policy and procedure revised in [DATE] showed in-part under policy specifications, 7. Social Service and/or the interdisciplinary care plan team will review the resident's advance directive status as documented in the resident's record at the time of the initial care plan conference and reconfirm no changes in status are desired. The team will also conduct such reviews and reconfirmations at the time of every scheduled care plan conference. 8. If the resident's assessed decision-making capacity is altered, the resident representative will be contacted to act on the resident's behalf. If changes or revisions are required, the care plan team will initiate the necessary process to modify the status changes in the resident's record, including contact of the resident's attending physician so appropriate orders to reflect these status changes are secured. 9. Resident's advanced directive form is maintained on the nursing unit on top of the facility's crash cart and is available to staff members for reference to and consideration of in rendering care and services to residents to whom they are assigned for duty. 10. Social Service Director or designee will be responsible for maintaining/updating advance directive binder on each unit or floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145715 If continuation sheet Page 2 of 21 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 145715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wheaton Village Nrsg & Rhb Ctr 1325 Manchester Road Wheaton, IL 60187 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure resident rooms were maintained free of water damage and in good repair. This applies to 7 of 7 residents (R32, R37, R50, R51, R56, R72, and R93) reviewed for homelike environment. The findings include: 1. On 10/30/23 at 10:54 AM R72's pointed to the ceiling above her bathroom sink just above the light fixture and stated, It just collapsed and it has taken a long time to get attention to it. R72 stated approximately four days ago, water began coming down through the ceiling tiles in the bathroom above the sink and light fixture above the sink. There was a large brown stain on the tile, the tile was bowed down toward the floor and there was a crack at the bottom the bowed tile. There were pieces missing from the bowed tile and one piece was resting on top of the light fixture attached to the wall above the mirror located above the sink. R51 and R93 also stated the water ran from the ceiling into the bathroom and no repair had been completed. 2. On 10/30/23 at 11:06 AM, R37 stated water had leaked through the room's ceiling into the closet of the room. R37 stated, It was just leaking everywhere. My clothes got wet. We put a bucket in the closet to catch the water! That's why our clothes in the closet are all in bags. There was a blue bucket on the floor on the left side of the closet and clothes were stored in clear plastic bags which were tied. The ceiling tiles in the closet and the bathroom were stained brown and bowed down toward the floor. R50 and R56 stated water had come from the ceiling into the bathroom and closet and caused items in the closet to get wet. On 10/31/23 at 1:00 PM with V7 (Director of Maintenance), observed clothes on the top shelf of the closet were still in clear plastic bags which were tied shut. There were magazines and paper notebooks on the top shelf of the closet which were dry but showed signs of having previously been wet and later dried as the pages were wavy. V7 stated he was not aware of the closet having had water leaking through the ceiling. V7 stated he was aware of the need to replace the ceiling tiles in the bathroom but not aware tiles in the closet needed to be replaced. On 10/31/23 at 10:00 AM, V7 (Director of Maintenance) stated the water falling into the resident rooms in the lower level were the result of residents on the upper level of the building putting paper towels into the toilets and clogging the toilets. V7 stated the residents then continue to flush the toilets and the residual water over flows and seeps down through the floor and then through the ceiling of lower-level rooms. At 12:10, V7 was repairing a toilet and stated the flush valve in the toilet needed to be replaced. V7 stated he bought a new toilet on Friday and was going to install the new toilet later in the day. V7 stated the flush valve which needed repair caused toilet tissue or paper towels to become stuck and the toilet to overflow. There was a sign in the bathroom, undated, which showed, Please hold down handle to complete flush will fix tomorrow. V7 stated some of the upper level rooms had newer toilets and any water leaking below would be the result of toilet paper or paper towels clogging the toilets. 3. Review of R32's face sheet documents a [AGE] year-old female with diagnoses includes Type 2 diabetes mellitus, hypertensive heart disease without heart failure, and history of falling. R32's Minimum Data Set (MDS) section C dated 8/22/23 showed R32's cognitive status to be intact. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145715 If continuation sheet Page 3 of 21 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 145715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wheaton Village Nrsg & Rhb Ctr 1325 Manchester Road Wheaton, IL 60187 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 10/30/23 10:41 AM R32 stated she has had pipes dripping and sinks or toilets over flowing from above into her room. R32 pointed out the ceiling area just outside of her closet and another area of the ceiling in her closet that both have brown water like staining and black mold-like staining. R32 stated she must move her clothes to the side in her closet so they don't get wet. R32's clothes were pushed to the side clearing the area in the ceiling is stained. R32 stated she told maintenance about the leaks. R32 stated maintenance came to look at the leaks each time. R32 stated maintenance does not come back to do any repairs. On 10/31/23 12:25 PM, V7 (Maintenance Director) and surveyor went to R32's room. The ceiling tile just outside of R32's closet is a 12x12 inch white tile is almost completely black with thick mold like stains extend into the plaster of the edge of the ceiling/wall. In R32's closet there is another tile that is black similarly and some brown areas. V7 said, It look like it could be mold, and they need to be replaced. There is 3rd larger ceiling tile just past the entrance that has a large roundish brown stain about the size of a cantaloupe with some black bumpy looking spores around one edge of the brown stain. R32 was in her bed and said the last time it leaked was last week. V7 stated he has talked to R32 about the leaks in her room before. V7 stated it was his plan to open the area behind the tiles to see where water was coming from. V7 stated he is the only maintenance personnel. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145715 If continuation sheet Page 4 of 21 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 145715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wheaton Village Nrsg & Rhb Ctr 1325 Manchester Road Wheaton, IL 60187 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 Based on observation, interview and record review, the facility failed to provide a comprehensive eye assessment for an eye injury sustained after a fall. This applies to 1 of 3 (R89) residents reviewed for falls in the sample of 29. Residents Affected - Few The findings include: R89's face sheet showed R89 with multiple diagnoses including schizoaffective disorder, bipolar type, fracture of fifth metacarpal bone left hand, subsequent encounter for fracture with routine healing, benign prostatic hyperplasia, dementia, extrapyramidal movement disorder, anxiety disorder, hypertensive heart disease, primary osteoarthritis left shoulder and repeated falls. R89's MDS (Minimum Data Set) dated 10/18/23, showed R89 with moderate cognitive impairment, and requires assistance with toileting, bathing, dressing, and ambulates with a walker. On 10/30/23 at 10:52 AM, R89 was observed in his room. R89's right eye sclera was completely red with little white tissue evident, and the area surrounding the right eye was discolored and appeared swollen. R89 stated he had fallen while out at a local restaurant with his wife and had hit his head on the floor. R89 stated he had not seen an eye doctor since the fall. The facility reported an incident to Illinois Department of Public Health on 10/23/23 that R89 had a fall on 10/21/23 at 3:30 PM while in the community at a local restaurant. The report showed while R89 was attempting to stand, he fell forward to the floor. The report indicated the Physician had been notified of the fall on 10/21/23 at 3:30 PM, and that ice had been applied to the area. A review of the progress notes of 10/20/23 through 10/31/23 at 3:09 PM, does not show R89's Physician had been notified of the condition of the right eye or the intervention of ice being applied to the right eye. There are no progress notes documented on 10/21/23 in R89's health record. The first progress note following R89's fall on 10/21/23 is documented at 10/22/23 at 2:33 AM, and showed the right eye was discolored, swollen, and the sclera was reddened, and there was a wound above the right eye had a dressing that was changed earlier due to being saturated with blood. On 10/23/23 at 12:17 PM the progress note showed there was one adhesive strip present on a wound above the right eye and R89 complained of generalized pain. The progress note of 10/27/23 at 2:30 PM, written by V18 (RN) showed R89's right eye sclera remained with redness and R89 reported a complaint of the right eye being itchy, which was not reported to the Physician. On 11/1/23 at 2:37 PM, V2 (DON) stated R89's right eye had not been examined by either an optometrist, ophthalmologist, or Physician since his right eye sclera became reddened, swollen and discolored after the fall on 10/21/23. V2 stated R89's vision is not impaired because he asked the resident to close his left eye (non-injured eye) and asked R89 if he could see V2's two fingers he was holding up with his right eye only. V2 concluded that since R89 responded he could see V2's fingers, R89's vision was not impaired. V2 stated he did not know if there was bleeding inside the eye or what type (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145715 If continuation sheet Page 5 of 21 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 145715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wheaton Village Nrsg & Rhb Ctr 1325 Manchester Road Wheaton, IL 60187 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 FORM CMS-2567 (02/99) Previous Versions Obsolete of injury or illness was causing the continued severe redness of the sclera of R89's right eye or why the redness was not resolving. The facility's policy title Falls-Clinical Protocol showed under the Monitoring and follow up section, 1. The staff with the Physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma has been ruled out or resolved. a. delayed complications such as late fractures and major bruising may occur hours or several days after a fall . Event ID: Facility ID: 145715 If continuation sheet Page 6 of 21 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 145715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wheaton Village Nrsg & Rhb Ctr 1325 Manchester Road Wheaton, IL 60187 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to follow physician's order with regards to administration of continuous oxygen and labeling of the oxygen tubing. The facility also failed to use of the oxygen humidity bottle per policy and procedure. This applies to 1 of 1 resident (R7) reviewed for oxygen therapy in the sample of 29. Residents Affected - Few The findings include: R7 had multiple diagnoses including Parkinsonism, dementia without behavioral disturbance and chronic respiratory failure with hypoxia, based on the face sheet. R7's quarterly MDS (minimum data set) dated 9/19/23 showed the resident was cognitively intact and required extensive assistance from the staff with most of his ADLs (activities of daily living). On 10/30/23 at 10:58 AM, R7 was in bed, alert and verbally responsive. R7 had the ongoing continuous oxygen at 3 liters per minute using oxygen concentrator. R7's oxygen tubing had no label to determine when the oxygen tubing was last changed. R7 stated the inside of his nose was dry. R7's oxygen concentrator had no humidity bottle in place. On 10/31/23 at 10:57 AM, R7 was inside the unit main dining room. R7 was sitting in his wheelchair, alert and verbally responsive. R7 had ongoing oxygen at 3 liters per minute via nasal cannula using a portable oxygen tank. At 11:15 AM, V4 (Registered Nurse) stated he was the assigned nurse that morning for R7. V4 stated he changed and applied the oxygen setting of R7's oxygen from the concentrator to portable tank. During the same interview while observing R7, V4 acknowledged R7's continuous oxygen via nasal cannula was set at 3 liters per minute using the portable oxygen tank. R7's Physician order report dated 5/2/23 showed an order for, Oxygen: At 4 liters per nasal cannula continuous. The same order report showed an order dated 5/2/23 for, Oxygen: Change tubing and mask weekly and PRN. (label). Once a day on [Sunday]. R7's active care plan initiated on 4/6/23 showed the resident, requires oxygen therapy to relieve hypoxia. He has diagnosis of respiratory failure. The same care plan showed multiple approaches including, Administer oxygen as ordered. On 11/1/23 at 9:28 AM, V2 (Director of Nursing) stated the nurses should follow the physician's order for oxygen administration because oxygen therapy is considered as medication. V2 stated humidity bottle should also be used during oxygen therapy to reduce the dryness inside the nose. V2 further stated the oxygen tubing should be labeled to make sure it was replaced on a weekly basis. The facility's oxygen administration policy and procedure last revised in March 2004 showed, The purpose of this procedure is to provide guidelines for safe oxygen administration. The policy and procedure showed in-part under preparation, 1. Verify there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Under equipment and supplies it showed in-part, The following equipment and supplies will be necessary when performing this procedure 3. Humidifier bottle. The same policy and procedure showed in-part under steps in the procedure, 5. Start the flow of oxygen as ordered 7. Adjust the oxygen delivery device so it is comfortable for the resident and the proper flow of oxygen is being administered 9. Check the mask, tank, humidifying jar etc. (et cetera) to be sure they are in good working order and securely fastened. Be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145715 If continuation sheet Page 7 of 21 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 145715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wheaton Village Nrsg & Rhb Ctr 1325 Manchester Road Wheaton, IL 60187 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 0695 sure there is water in the humidifying jar and the water level is high enough the water bubbles as oxygen flows through. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145715 If continuation sheet Page 8 of 21 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 145715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wheaton Village Nrsg & Rhb Ctr 1325 Manchester Road Wheaton, IL 60187 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to comprehensively assess/evaluate and inform the physician of the residents complaint of pain to help manage existing pain and/or prevent pain. This applies to 2 of 6 residents (R38 and R105) reviewed for pain management in the sample of 29. Residents Affected - Few This failure resulted in R38 verbalizing complaint of worsening pain for two consecutive days (10/30/23 and 10/31/23). R38's frequent pain level of eight, documented in the resident's October 2023 medication flowsheet pain scale. The findings include: 1. R38 had multiple diagnoses including COPD, dementia without behavioral disturbance, type 2 diabetes mellitus with diabetic cataract and generalized osteoarthritis, based on the face sheet. R38's significant change in status MDS (minimum data set) dated 9/27/2023 showed the resident was moderately impaired with cognition and required extensive to total assistance from the staff with most of his ADLs (activities of daily living). On 10/30/23 at 10:58 AM, R38 was sitting in his reclined wheelchair inside his room. R38 was alert and verbally responsive. R38 complained of pain all over his body. V4 (Registered Nurse) was present and asked R38 to express his pain level scoring between zero to ten (0-10), ten being the worst possible pain. R38 responded his pain level was ten. V4 stated R38 received his ordered Tramadol medication at around 9:30 AM for chronic pain. On 10/31/23 at 10:51 AM, R38 was sitting in his reclined wheelchair, inside his room. R38 was alert and verbally responsive. R38 complained of pain all over his body and when V4 asked R38 for his pain level, the R38 responded 10/10 (10 being the worst). V4 stated R38 received his ordered Tramadol medication at around 8:00 AM for chronic pain. V4 offered R38 his ordered topical analgesic heat rub to be applied, R38 agreed and stated to apply the said topical analgesic on his body specifically on his back. R38's active Physician order report showed an order dated 6/14/23 for, Tramadol 50 mg, 1 tablet for pain, neck and back pain, twice a day (8:00 AM, 4:00 PM). Further review of R38's order report showed an order dated 11/2/22 for, Bengay ultra strength cream 4-30-10%, small amount topical, apply to neck and knees, may apply patch, every shift (Shift 1, Shift 2, Shift 3). R38's October 2023 medication flowsheet showed the R38's Tramadol 50 mg was administered on 10/30/23 and 10/31/23 at 8:00 AM. The same October 2023 medication flowsheet showed the resident's Bengay ultra strength cream was applied on 10/30/23 and 10/31/23 on all the three shifts. There was no documentation with regards to the effectiveness of the Tramadol medications and the topical analgesic cream. Further review of R38's October 2023 medication flowsheet showed the resident's pain scale was being assessed every shift (shift 1, shift 2 and shift 3). The pain scale assessment showed evidence R38's pain scale was scored eight, 19 times during shift 1 (6:30 AM-2:30 PM), on 10/2, 10/3, 10/6, 10/7, 10/8, 10/9, 10/11, 10/12, 10/13, 10/14, 10/16, 10/17, 10/20, 10/21, 10/22, 10/23, 10/26, 10/27 and 10/28/23. The same pain scale assessment showed evidence R38's pain scale was scored eight, 19 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145715 If continuation sheet Page 9 of 21 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 145715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wheaton Village Nrsg & Rhb Ctr 1325 Manchester Road Wheaton, IL 60187 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 0697 Level of Harm - Actual harm times during the shift 2 (2:30 PM-10:30 PM), on 10/2, 10/3, 10/6, 10/7, 10/8, 10/9, 10/10, 10/12, 10/13, 10/14, 10/16, 10/17, 10/20, 10/21, 10/22, 10/23, 10/26, 10/27 and 10/28/23. Further review of R38's pain scale for 10/30/23 during shift 1 and shift 2 showed the pain score of eight (on both times). On 10/31/23 during shift 1, R38's pain score was nine and during shift 2, R38's pain score was eight. Residents Affected - Few R38's active Physician order report from 10/1/23 through 11/1/23 showed no other breakthrough pain medication was ordered. R38's medication flowsheet showed no documentation what pharmacological intervention was provided to the resident on 10/30/23 and 10/31/23, after the resident complained to V4 of all over body pain with pain level of 10 (10 being the worst). Review of R38's progress notes for the entire month of October 2023 showed no documentation the physician was notified of R38's frequent pain scale of eight as documented in the resident's October 2023 medication flowsheet. The same progress notes showed no documentation and evidence the physician was notified of R38's all over body pain, which according to the resident's pain scale was ten on 10/30/23 and 10/31/23. R38's most recent pain observation for cognitive aware evaluation dated 9/27/23 showed a pain scale of 3 described as aching pain comes and goes. It was documented R38 had a scheduled Tramadol 50 mg, 1 tablet twice a day for neck pain and back pain. The same evaluation showed the Tramadol was always effective, the pain was less than daily (highest level of pain in the last 7 days), and the pain was mild (highest level of pain in the last 7 days). The was no other comprehensive pain assessment/evaluation for R38 in the month of October 2023 to evaluate the resident's pain score of eight to further determine the location, duration, quantity, quality and the effectiveness of the Tramadol medication, and the need to inform the physician for other pain management options. R38's active care plan initiated on 9/30/23 showed the resident had complained of back pain, left hip pain and knee related to severe DJD (degenerative joint disease), history of fracture (thoracic spine) T-12, spinal stenosis, and knee replacement. The same care plan showed multiple approaches including, Evaluate effectiveness of pain management interventions. Adjust if ineffective or adverse side effects emerge. Monitor and record any complaint of pain, its location, duration, quantity, quality, alleviating factors, aggravating factors. On 11/1/23 at 12:05 PM, V2 (Director of Nursing) stated if R38 had multiple documented pain scale level between eight and nine for the month of October 2023, a comprehensive pain assessment/evaluation should be performed to assess the pain and the effectiveness of the pain medication being administered. V2 stated the nurses should call the physician and inform of R38's high pain scale rating (documented between eight and nine) to obtain any other appropriate pain medication for the resident to attempt to control his pain. R38's progress notes dated 11/1/23 (1:06 PM) created by V2 showed, Discussed residents Pain with him. Asked him he could determine the difference between pain of 1 and a pain of score of 10. He reported I don't know what that means. I asked him how long he has been in pain that is unbearable. He said every day since he was [AGE] years old to now. He is 63 (R38 is 81). Always been in pain and won't go away till he dies and goes to Heaven. He indicated nothing relieves the pain. It is always 10 or like 10. When asked whether medicine was effective, he said Bengay and medication help him feel better. But he always had a 10. Introduced him to face scale for pain as it may be more effective tool for monitoring effectiveness of interventions. Informed MD (Medical Doctor) of recent breakthrough pain. Added Norco 5/325 for breakthrough pain for one week. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145715 If continuation sheet Page 10 of 21 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 145715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wheaton Village Nrsg & Rhb Ctr 1325 Manchester Road Wheaton, IL 60187 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 0697 Level of Harm - Actual harm Residents Affected - Few R38's prescription order dated 11/1/23 (created at 1:28 PM) showed an order for hydrocodone-acetaminophen 5-325 mg, 1 tablet every 6 hours as needed for breakthrough pain, until 11/8/23. On 11/1/23 at 1:46 PM, V16 (Physician) stated he had been R38's physician for the past 15 years. V16 stated R38 had diagnoses of dementia with behavior. V16 stated it is the protocol for the facility to call and inform the physician of a resident's complaint of pain, especially if it was documented/scored at eight or nine to determine appropriate action, such as prescription of pain medication or breakthrough pain medication to address and/or relieve the resident's of pain. V16 stated he only received a call from the facility that day about R38's pain and he ordered Norco 5-325 mg, 1 tablet every 6 hours as needed for pain. 2. R105's face sheet showed R105 with multiple diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left non dominant side, vascular dementia with other behavioral disturbance, chronic respiratory failure unspecified, gastric ulcer, hypertensive heart disease, general anxiety disorder and polyneuropathy. R105's MDS dated [DATE], showed R105 is cognitively intact and requires extensive assistance from staff for bed mobility, toileting, dressing, bathing and transfer activities of daily living. On 10/31/23 at 10:54 AM the resident was observed lying in bed with the bed covers over her head. V17 (CNA) stated R105 did not want to get out of bed and was not feeling good. R105 was having too much pain and she had reported this to the nurse. On 10/31/23 at 2:10 PM, R105 was still in bed. V17 stated R105 was not feeling well and remained in bed all day. On October 31, 2023, at 6:38 PM, R105 was transferred to the local hospital emergency room for complaint of left hip pain. According to R105's hospital visit documentation dated 10/31/23 at 6:44 PM, R105 arrived in the emergency room crying related to complaint of pain and was administered opioid medication with subsequent pain relief. On 11/1/23 at 09:30 AM, R105 was observed lying across the bed, with her glasses on her face sleeping. On 11/1/2023 at 1:03 PM, R105 stated her pain occurs on the left side of her body and described the pain as a stabbing nerve pain that occurs daily. R105's MAR (Medication Administration Record) for September 2023 showed R105's pain scores for the day shift as follows: A pain score of 6/10 on 9/1, 9/3, and 9/11/23. A pain score of 9/10 on 9/2, 9/5 and 9/22/23. A pain score of 7/10 on 9/7, 9/10, and 9/20/23. A pain score of 8/10 was recorded for all the remaining days of the month. R105's Lidocaine 4% analgesic patch ordered to be administered daily at 6:00 AM, is not documented (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145715 If continuation sheet Page 11 of 21 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 145715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wheaton Village Nrsg & Rhb Ctr 1325 Manchester Road Wheaton, IL 60187 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 0697 Level of Harm - Actual harm Residents Affected - Few as administered on 9/1, 9/4, 9/6, 9/7, 9/8, 9/10, 9/29 and 9/30. The September MAR also shows documentation of the Lidocaine 4% patch not available on 9/2, 9/5, 9/9, 9/11, 9/12, 9/13, 9/14, 9/15, 9/16, and 9/17/23. The documentation showed R105's pain score remained above 6/10 every day and the Lidocaine 4% topical analgesic was not administered as ordered 18 of 30 days for the month of September 2023. R105's MAR for October 2023 showed R105's pain scores documented for the dayshift as follows: A pain score of 7/10 on 10/17, 10/18, 10/19, 10/20, 10/21, 10/23,10/24,10/25, 10/26 and 10/28. A pain score of 8/10 on 10/4, 10/5, 10/6, 10/7, 10/10, 10/12, 10/22, 10/27, 10/30 and 10/31. The Lidocaine 4% topical analgesic patch, ordered to be administered daily was documented as not administered 19 days. On 11/01/23 at 12:35 PM, V2 (DON) stated R105 has pain related to her previous stoke and that it is neuropathic pain. V2 stated R105 seeks pain relief from opioid medications. R105 is prescribed opioid medication scheduled three times a day and as needed up to four times per day. R105's pain assessment dated [DATE] does not accurately reflect the resident's daily day shift pain score as being greater than 6. The assessment question, Is the resident expressing pain? is answered no. V2 stated on 11/10/23 at 12:35 PM the question on the assessment was answered incorrectly. R105's progress note dated 9/21/23 at 4:30 PM showed V16 (Physician) referred R105 for consultation with pain management physician. There was no documentation regarding the results of the pain management consultation in the progress notes reviewed from 9/22/23 through 10/31/23. Those progress notes do not include documentation of non-pharmacological interventions attempted to relieve pain. There was also no documentation regarding informing the Physician of unrelieved pain in those progress notes. The progress note of 10/20/23 at 5:00 PM states R105 was examined by V16 with no mention if review of pain management was assessed and no new orders given. The facility's Pain Management policy dated July 2019, showed the purpose of the pain management program is To establish a program with a multi-level approach to pain management to assist the facility in delivering safe, individualized pain care. The facility's policy further showed the purpose of this policy is to accomplish the goals through an effective pain management program. The definition of the policy showed The facility will utilize a consistent pain assessment. The resident's descriptive words regarding the quality, duration, and location of pain will be used to evaluate the pain and to identify any changes in the pain. When the resident is unable to describe pain, physical signs such as grimacing, body posturing/protecting, vital sign changes and changes in behavior and mood will be used to determine the presence of pain. The policy showed components of the Pain Management Program includes .Accurate and complete documentation of pain assessment and monitoring .Informed resident participation in care decisions including managing pain .medication for the control or relief of anxiety. Also included in the facility's policy are standards, 1. Pain assessment protocol may be initiated under any of the following situations: .Resident received routine pain medication and/or pain is not controlled .A significant increase in the need for use of PRN use of pain medication .A change in pain identification related to behavior, cognition, or mood and 6. A provision of pain treatment that includes pharmacological and non-pharmacological interventions will be included in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145715 If continuation sheet Page 12 of 21 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 145715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wheaton Village Nrsg & Rhb Ctr 1325 Manchester Road Wheaton, IL 60187 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 0697 care plan and 12. The resident's physician will be notified of the resident's complaint of pain which are not relieved by comfort measures including pain medications. Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145715 If continuation sheet Page 13 of 21 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 145715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wheaton Village Nrsg & Rhb Ctr 1325 Manchester Road Wheaton, IL 60187 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 Residents Affected - Many 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to serve food portion sizes to residents as planned on the facility menu. This applies to all 111 residents receiving oral diets at the facility The Long-Term Care Facility Application for Medicare and Medicaid form, dated 10/31/23, shows the facility census was 111 residents. Facility Order Report by Category, dated 9/30/23 to 10/3023, shows 19 residents had diet orders of mechanical soft or pureed diets and all other residents had diet orders of Regular/No Added Salt/No Added Sweets or Double Portions. Facility document, dated 10/30/23, shows the facility had zero residents who had physician orders of NPO (Nothing By Mouth). Facility Daily Spreadsheet Week 3 Monday shows residents with Regular, No Concentrated Sweets, and No Added Salt diets were to be served two #8 scoops (1 cup total) of the Chicken Broccoli Casserole. The spreadsheet shows residents with double portions were to receive four #8 scoops (2 cups total) of the entrée. During the facility Resident Council Meeting, 10/31/23 at 2:00 PM , residents complained the portions of food are not enough as served. R4 complained the portions were too small. Resident council meeting minutes, dated 10/10/23, 9/12/23, and 8/823 all show Residents stated the portions are too small - ongoing. Inservice titled Portion Sizes, dated 10/30/23, shows staff should follow the recipe as laid out in the food service binders, follow the spreadsheets to ensure adequate portions are being served for each diet, and ask the dietitian or food service supervisor if staff have questions. Facility Policy/Procedure Serving Portions, dated 2017, shows Food will be served in portions indicated on the cycle menu and on the standardized recipes. 1. On 10/30/23 at 12:19 PM, R20's tray ticket showed he was to receive double portions of the casserole at lunch. R20 was served only 2 #8 scoops (1 cup total) of the casserole. 2. On 10/30/23 at 11:49 AM, the lunch meal was observed in the basement dining room. The plates of food included one scoop of chicken and broccoli casserole, a cup of mixed fruit, and 3 to 5 steak style potatoes fries. R15 stated, they brought me 3 french fries. They don't give enough food here. Review of R15's face sheet documents a [AGE] year old male with diagnoses that include Type 2 diabetes mellitus, long term use of insulin, and hypertensive heart disease without heart failure. R15's MDS (Minimum Data Set) assessment dated [DATE] showed R15 cognitive status to be intact. 3. On 10/30/23 at 11:54 AM, R29 during lunch service. R29 sitting at one of the tables. R29 is a large tall male. R29 was served the same meal of one small scoop of chicken and broccoli casserole, 4 steak fries, and a cup of mixed fruit. R29 ate the casserole and fries within a couple minutes. R29 stated, this is not enough food for me. 4. On 10/30/23 during lunch service in the garden level dining room, portions of Chicken Broccoli Casserole were served to residents on regular, no concentrated sweets, and no added salt diets. The portions of Chicken Broccoli Casserole appeared to be served in approximately 1/2 cup portions. V15 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145715 If continuation sheet Page 14 of 21 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 145715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wheaton Village Nrsg & Rhb Ctr 1325 Manchester Road Wheaton, IL 60187 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 Residents Affected - Many (Food Service Director) examined the portions on the plate and stated the residents had not been served two #8 scoops of casserole but only one instead. V15 examined the spread sheet and stated the residents should have been served two #8 scoops (1 cup total) on each plate. V15 stated residents with double portions of the casserole were supposed to be served four #8 scoops (2 cups total) of the casserole. V14 (Dietitian) also examined the portions served on residents plates as well as the diet spread sheet and stated the entrees served were not served in the correct portion sizes. 5. Facility Turkey ala King recipe, dated 9/19/23, shows the total serving size of Turkey ala King was 6 ounces which was equivalent to 2 ounces of protein. The recipe shows, Serve 6 ounces using a 6 ounce ladle or spoodle or #6 scoop. Facility Daily Spreadsheet Week 3 Wednesday, undated, shows Turkey ala King was to be served at lunch using a 6 ounce portion to provide 2 ounces of protein. The spreadsheet shows all facility diets were served 6 ounces of the turkey ala king for lunch except those with diets of double portions who received 12 ounces of the recipe. On 11/01/23 at 11:50 PM staff were plating the Turkey ala King on resident plates using a #6 scoop. Plates of Turkey ala King were served to R8, R32, R37, R43, R59, R97, and R51 and appeared to have only a small amount of turkey in the serving. A sample portion of the entree was placed on a plate and the turkey meat was weighed on a tarred scale. The total weight of the turkey from the portion served weighed only 1.25 ounces. Facility Menu and Diet Guidelines document, dated 2022, shows, The following guidelines were used to ensure nutritional adequacy when planning the menus: Daily Menu Requirements: 6 Ounces of Edible Protein - one once is equivalent to cooked meat FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145715 If continuation sheet Page 15 of 21 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 145715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wheaton Village Nrsg & Rhb Ctr 1325 Manchester Road Wheaton, IL 60187 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 safely store refrigerated potentially hazardous foods and failed to maintain kitchen equipment, floors, and walls in clean and sanitary conditions. This applies to all residents receiving oral diets in the facility. The findings include: The Long-Term Care Facility Application for Medicare and Medicaid form, dated 10/31/23, shows the facility census was 111 residents. Facility Order Report by Category, dated 9/30/23 to 10/3023, shows 19 residents had diet orders of mechanical soft or pureed diets and all other residents had diet orders of Regular/No Added Salt/No Added Sweets. Facility document, dated 10/30/23, shows the facility had zero residents who had physician orders of NPO (Nothing by Mouth). 1. On 11/1/23 at 11:01 AM, there were three boxes of uncooked pork sausage stored above an open box of fresh limes and a box of fresh cauliflower in the refrigerator of the cooking area. V15 (Food Service Director) stated the uncooked pork sausage should not be stored above the fresh produce and replaced the three boxes of uncooked pork sausage on the bottom of the reach in refrigerator. Facility Policy/Procedure Storage of Refrigerated Foods, dated 2021, shows, Refrigerated food is stored in a manner that ensures food safety and preservation of nutritive value and quality . Raw food is stored below cooked food or ready to eat food. 2. On 10/30/23 at 10:21 AM during initial tour of the kitchen with V15 (Food Service Director), the air vent directly above the dish machine had a large amount of debris and dust buildup with a potential of debris to be blown on clean dishes exiting the dish machine. The wall below the dish machine had black, mold-like substance on the wall. There was also paint chipping directly above the dish machine conveyor causing a risk of physical contamination of paint chips. The ceiling tiles had dark brown circle spots in differing sizes above the dish machine. Above the oven/stove, the hood vent slats had a large amount of grease and dust build up that was directly over the stovetop burners creating a physical and biological risk of contamination to food. Droplets of condensed grease were forming on the edge of the hood directly above the cooking area of the stovetop. Below the sink built into the prep island adjacent to the stove/oven was a large amount of dark debris buildup on the floor in the areas of missing floor tile. The area missing tile was located below the sink and in an area difficult to reach/clean. V15 stated the maintenance department was responsible for cleaning and repairing the areas of concern in the dish room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145715 If continuation sheet Page 16 of 21 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 145715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wheaton Village Nrsg & Rhb Ctr 1325 Manchester Road Wheaton, IL 60187 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 Based on observation, interview, and record review the facility failed to follow their policy and ensure there was an assessment conducted that identified where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water system. The facility also failed to ensure they identified, implemented, and documented any preventative measures for waterborne pathogens. Residents Affected - Many This applies to all 111 residents that reside in the facility. The findings include: The facilities Water Management Program policy dated 10/1/2017 shows the following: In the event of an outbreak, or a suspicion of a possible outbreak, or as directed by Public Health Officials, it is the policy of this facility to establish procedures to reduce risk of Legionella and other opportunistic pathogens (e.g., Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, Nontuberculous mycobacteria, and fungi) in the facility's water system. Policy Explanation and Compliance Guidelines. 1). The maintenance Director will maintain documentation that describes the facility's water system. 2). A risk assessment of water system components will be conducted to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water system. 4). Examples of water system components include: m. Eyewash stations n. Ice machines. 7). Testing Protocols and acceptable ranges (control limits) will be established for each control measure. a. Individuals responsible for testing or visual inspections will document findings. b. When control limits are not maintained, corrective actions will be taken and documented accordingly. On 10/30/23 12:12 PM, observed an eye wash station in the laundry room. The eye wash station has a long tan tube (about 4-5 feet) attached to each eye hose. Each eye facet and the entire apparatus is very dirty, with white and brown grime. The cap that goes over the right eye fixture is missing. On 10/31/23 12:23 PM, V7 (Director of Maintenance) stated the facility has 3 eye wash stations. V7 stated they do not document any temperatures or flushing of eye wash stations. V7 also stated, staff does not clean the ice machine, it is outsourced quarterly. On 10/31/23 at 12:47 PM, with V7 in the laundry room at the eye was station, V7 confirmed the cap (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145715 If continuation sheet Page 17 of 21 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 145715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wheaton Village Nrsg & Rhb Ctr 1325 Manchester Road Wheaton, IL 60187 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many is missing on right eye wash fixture. V7 stated, This is the dirtiest one I have ever seen. V7 stated he is going to replace it. V7 stated he had not noticed the eye wash station was so dirty before. On 11/01/23 11:22 AM, V7 stated he does not document or record the temperatures of the boilers. V7 stated he is not taking any temperatures of the water. V7 stated he only checks the temperature of the water if there is an issue, for instance if someone says they are not getting hot water. V7 stated he is not aware of any other assessment other than the Environmental Assessment of the Water Systems that was provided to the surveyor on 10/31/2023. V7 stated he is not aware of any documentation that shows what staff should do to prevent waterborne pathogens or what areas of the water system should be monitored. On 10/31/2023 at 10:45 AM, Review of the facility's Environmental Assessment of the Water Systems (EA) dated 6/22/2023 is incomplete as it refers to tables that document the physical/chemical characteristics of the potable water system that are not included. The EA does not list specific components of the facility's water system, for instance, the ice maker and eye wash stations that may be vulnerable to the growth of water borne pathogens. Page 3 of the EA shows the following: because Legionella amplifies in warm (25-42 °C), stagnant water, it is useful to document temperatures, Chlorine residuals, and Ph in hot potable water. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145715 If continuation sheet Page 18 of 21 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 145715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wheaton Village Nrsg & Rhb Ctr 1325 Manchester Road Wheaton, IL 60187 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 0916 Ensure each resident has a room at or above ground level. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, facility failed to have the floor of the residents' rooms in the garden level at or above ground. Residents Affected - Some This applies to 37 of 37 residents (R1, R4, R6, R8, R12, R15, R16, R17, R18, R25, R29, R27, R30, R31, R32, R37, R40, R43, R46, R47, R49, R50, R51, R56, R57, R59, R66, R72, R80, R92, R93, R97, R101, R104, R107, R109, and R110) reviewed for rooms below ground. The findings include: On 10/30/23 during initial tour of the facility, all rooms in the garden level were located below the ground level. Resident Bed List Report, dated 10/30/23, shows R1, R4, R6, R8, R12, R15, R16, R17, R18, R25, R29, R27, R30, R31, R32, R37, R40, R43, R46, R47, R49, R50, R51, R56, R57, R59, R66, R72, R80, R92, R93, R97, R101, R104, R107, R109, and R110 resided on the garden unit on the lower level in the above mentioned rooms. All the rooms are Medicaid and Medicare certified. On 11/1/23 at 2:00 PM, V1 (Administrator) stated the residents residing in the rooms on the ground floor are all located below ground and have windows. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145715 If continuation sheet Page 19 of 21 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 145715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wheaton Village Nrsg & Rhb Ctr 1325 Manchester Road Wheaton, IL 60187 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. 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 inspect, and identify an infestation of insects, and mitigate the source of the infestation into a resident's room for at least 2 days. This applies to one of one residents (R31) reviewed for insect infestation in a sample of 29. Residents Affected - Few The finding include: Review of R31's face sheet documents a [AGE] year-old male with diagnoses including hypertensive heart disease without heart failure, generalized anxiety disorder, Major depressive disorder, and repeated falls. R31's Minimum Data Set (MDS) section C dated 9/6/23 showed R31's cognitive status to be intact. On 10/30/23 at 10:52 AM, R31 was sitting in a chair in his room. R31's bed is approximately 4-6 inches away from the air conditioning (AC) unit and window. The bed is parallel to the window. There are brown oblong or oval shaped insects with long legs crawling on R31's window outside and inside the window, on R31's curtains, on R31's bed, on the window seal, on the AC unit, and on the wall between the window seal and the AC unit. R31 stated he noticed all the insects yesterday and the facility needs to do something about it. Surveyor informed V10 (LPN) and V7 (Maintenance Director) them of the issue. V7 said it is more of a housekeeping issue. V10 went to R31's room, saw the insects and said she would call housekeeping. On 10/30/23 at 11:46 AM, the same brown insects were observed crawling on the wall below the window seal and above air conditioning unit in R31's room. On 10/30/23 at 04:01 PM, two insects observed on the wall below the window. One insect was crawling up the wall toward the window and fell into the a/c unit. On 10/31/23 at 9:21 AM, observed insects crawling up R31's' bedroom curtain. R31's bed is still right next to the window. R31 is in his room sitting in chair. On 10/31/23 at 9:23 AM, V9 (Restorative nurse) came over and saw insects crawling on the curtain and stated she was going to move the resident to another room. On 10/31/23 at 9:45 AM, V9 stated she transferred R31 for his safety. V9 stated she has just learned of the insects, otherwise she would have transferred R31 earlier. On 10/31/23 at 10:59 AM, V2 (DON) stated it is hard to deal with the insects because it is coming from outside. V2 states normally the facility will try to seal any gaps, call the exterminator, and try to find area they are coming in. On 10/30/23 at 11:42 AM, V19 (Housekeeping/laundry Director) said they are short staffed and the basement level is not cleaned every day. V19 stated they concentrate on the first floor for cleaning. V19 stated they are short staffed 4 housekeepers (3 full time and one part-time). V19 stated she saw the insects in R31's room, and she cleaned the room but it looks like the insects are coming from the outside. On 10/31/23 at 12: 55 PM, V7 (Maintenance Director) stated today he looked at R31's window and it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145715 If continuation sheet Page 20 of 21 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 145715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wheaton Village Nrsg & Rhb Ctr 1325 Manchester Road Wheaton, IL 60187 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 0925 wasn't closing properly so he removed residual caulk, cleaned window seal and track. Level of Harm - Minimal harm or potential for actual harm On 11/01/23 at 9:27 AM, R31 observed sitting in a chair back in his original room. R31's bed is against the AC unit. R31 stated there are still insects in his room and one of the staff ladies took some out. R31 stated he wants his bed to be moved away from the window. The same kind of insect mentioned previously observed on the headboard of R31's bed above his pillow. The insect started crawling towards R31's pillow. R31 jumped up, noticeably perturbed about the insect, and said someone must remove the insect. Residents Affected - Few On 11/2/2023 at 1:15 PM, V20 (General Manager of Pest Control Company) stated they were out at the facility today and were called in for box elder insects. V20 stated, to keep the insects out of the facility, the windows need to be tightly caulked and have screens on them. 11/2/203 at 1:45 PM, V20 called again and stated his technician is still at the facility and found more box elder insects he removed in R31's room. V20 stated his technician said there is a screen on the window, but it is ripped, and the window was not closed properly and they would let the management know. The facility's Pest Control Policy dated 1/21 shows the following: Purpose: To keep building free of any possible infestation of insects and rodents by eliminating site of breeding and harborage inside and outside the building. The steps will be taken to reduce infestation of insects and rodents. 2) The facility will be inspected on a regular basis to identify any possible insect or rodent infestations, potential sites of harborage or breeding, potential sites of entry not covered with appropriate screening and breaks in construction. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145715 If continuation sheet Page 21 of 21