Health inspection·November 1, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 10/30/24 at 9:00 AM, R37 had no call light. R37 stated, he doesn't know how he would call for assistance. On 10/31/24 at 12:09 PM, V13 (RN) verified, R37's call light was behind the dresser, and he is able to use call light appropriately. R37's MDS dated [DATE] showed he had no cognitive impairment and needs extensive assist for ADLs. 5. On 10/29/24 at 11:31 AM, R67 was lying in her bed. R67's call light was lying under the bed. R67 stated she did not know where her call light was. On 10/30/24 at 9:40 AM, observed R67's call light was lying under her bed. On 10/31/24 at 12:19 PM, V12 (RN) verified R67's call light was lying under her bed. R67's MDS dated [DATE] showed she had no cognitive impairment and needs moderate assist for ADLs. Progress Notes dated 08/09/2024 at 04:28 PM showed R67 can communicate her needs to staff and is able to use call lights for staff assistance. On 10/31/24 at 01:15 PM, V2 (DON-Director of Nursing) stated everyone should have a call light to ensure they have access to help. Policy on 'Answering the Call Light' revised on August 2008 showed, ' Call lights must be accessible to residents from their bed, bathroom, shower or other position accommodations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145715 If continuation sheet Page 2 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2024 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident/resident's representative of the reason for the discharge in writing. The facility also failed to send a copy of the notice to the Ombudsman. This applies to 2 of 2 (R51, R73) residents reviewed for discharge in a sample of 23. The findings include: 1. R73's Face Sheet documents R73 was admitted to facility on 9/16/2024. Diagnoses includes spinal stenosis, Alzheimer's Disease, Type II Diabetes Mellitus, chronic kidney disease, atrial fibrillation, and benign prostatic hyperplasia. R73's Progress Notes dated 10/27/2024 at 3:08 PM documented R73 was observed to be very weak, not responding to verbal stimuli and had a sudden change of mental status. Progress Notes dated 10/27/2024 at 3:29 PM documented R73 was sent to a local hospital in an ambulance. Progress Notes written on 10/27/2024 at 9:48 PM documented R73 was admitted for diagnoses of dehydration and urinary tract infection. On 10/30/2024 at 11:40 AM, V1 (Administrator) said facility does not notify the resident and resident's representative in writing of the reason for the transfer/discharge to the hospital. V1 said they also do not send a copy of the notice to the ombudsman. No notification of discharge with reason for discharge was found in R73's medical records. Facility was not able to show proof the Ombudsman was notified of R73's discharge during the duration of the survey. The facility does not have a policy addressing written discharge notification for resident/resident representative and informing ombudsman of the discharge. 2. The Electronic Medical Records (EMR) records of R51 showed diagnoses included end-stage renal failure dependent on dialysis, chronic anemia, moderate protein-calorie malnutrition, cirrhosis of the liver, and hypertensive cardiac diseases. The current Minimum Data Set, dated [DATE] indicated R51 is cognitively intact. On 10/30/2024at 1:30 PM, R51 said she went to the hospital multiple times and doesn't recall receiving a notice during transfer to the hospital. The progress report review for R51 showed R1 had multiple hospitalizations related to chronic anemia and received blood transfusions, the most recent ones being on 10/02/2024 and 10/23/2024. The clinical records did not provide a copy of the notice in writing to R51 and the Ombudsman. On 10/31/2024 at 11:30 AM, V1(Administrator) and V2 (Director of Nursing) said the facility does not practice providing a copy of the notice in writing to residents, family, and the Ombudsman. The facility policy titled Discharge Summary and Plan with no date did not address notice before discharge to resident, representative and informing the Ombudsman after discharge to the hospital. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145715 If continuation sheet Page 3 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2024 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide bed hold policy in writing to resident/resident's representative upon their transfer to the hospital. This applies to 2 of 2 (R51, R73) residents reviewed for discharge in a sample of 23. The findings include: 1. R73's Face Sheet documents R73 was admitted to facility on 9/16/2024. Diagnoses includes spinal stenosis, Alzheimer's Disease, Type II Diabetes Mellitus, chronic kidney disease, atrial fibrillation, and benign prostatic hyperplasia. R73's Progress Notes dated 10/27/2024 at 3:08 PM documented R73 was observed to be very weak, not responding to verbal stimuli and had a sudden change of mental status. Progress Notes dated 10/27/2024 at 3:29 PM documented R73 was sent to a local hospital in an ambulance. Progress Notes written on 10/27/2024 at 9:48 PM documented R73 was admitted for diagnoses of dehydration and urinary tract infection. On 10/31/2024 at 1:00 PM, V2 (DON-Director of Nursing) said the facility forgot to give R73's representative the bed hold notice upon his discharge to the hospital. V2 said he is aware bed hold notice should be given to residents/resident representatives when they are transferred to the hospital. No documentation of bed hold notice being given to R73 or his representative prior to his transfer to hospital on [DATE] was found in his medical records. Facility's Bed Hold and readmission Policy dated November 2016 stated the following: .Standards: 1. Residents or their designated representative, shall be informed of this policy at the time of admission and at the time of transfer to a hospital, or for therapeutic leave which extends beyond 24 hours. The facility provides written notification at the time of transfer as included in the designated state form. The notice to the resident or their representative will specify the facility's policy, the duration of the state hold policy and the reserve bed payment policy. 2. The clinical records of R51 showed diagnoses included end-stage renal failure dependent on dialysis, chronic anemia, moderate protein-calorie malnutrition, cirrhosis of the liver, and hypertensive cardiac diseases. The current Minimum Data Set, dated [DATE] indicated R51 is cognitively intact. On 10/30/2024at 1:30 PM, R51 said she went to the hospital multiple times and didn't recall receiving a notice upon discharge to the hospital. The progress report review for R51 showed R1 had multiple hospitalizations related to chronic anemia and received blood transfusions, the most recent ones being on 10/02/2024 and 10/23/2024. The clinical records lacked the documentation of providing R51 and the Ombudsman with written notice to be aware of a facility's bed-hold and reserve bed payment policy to R51 before and Ombudsman upon transfer to a hospital. On 10/31/2024 at 11:30 AM, V1(Administrator) and V2 (Director of Nursing) said the facility does not practice providing a copy of the notice in writing to residents, family, and the Ombudsman. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145715 If continuation sheet Page 4 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2024 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 0625 The policy titled bed hold and readmission policy, dated 11/2026 in parts standards #1, states the facility provides written notification to the resident or their representative at the time of the transfer. 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 5 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2024 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide nail care for residents dependent on staff. This applies to 2 of 2 residents (R71, R107) reviewed for ADL (Activities of Daily Living) care in a sample of 23. Residents Affected - Few The findings include: 1. On October 29, 2024 at 10:35 AM, R71 had nails on his hands that were about a quarter of an inch long and jagged. R71 said he had been asking the staff to cut his nails for months and they had not done it, saying they would get back to him, but never did. R71 said he had arthritis, and it was hard to cut them and was the reason he asked for help from the staff. On October 31, 2024 at 10:46 AM, R71 said he had never had his nails cut since being admitted to the facility. R71 said he would see other residents have their nails cut and would ask why it was not done for him. R71 said it was not easy for him to cut his nails and he needed help. R71's face sheet showed he was admitted to the facility with diagnoses including chronic pain, rheumatoid arthritis, chronic gout, and primary osteoarthritis. R71's MDS (Minimum Data Set) dated October 11, 2024 showed R71 was cognitively intact needed substantial assistance for personal hygiene. R71's care plan dated March 8, 2024 showed R71 is limited in ability to groom self [related to] decreased mobility and endurance and requires a restorative grooming program. 2. On October 29, 2024 at 10:28 AM, R107 had fingernails on both hands which were one inch long. R107 said she had arthritis in both her hands. On October 31, 2024 at 10:55 AM, R107's fingernails were still one inch long. R107 said she did not like the length of her nails and preferred them shorter. R107 said she needed help to cut her nails since she had arthritis and was unable to do it herself. R107 said she could not remember the last time the staff had cut her nails. R107's face sheet showed she was admitted to the facility with diagnoses including schizoaffective disorder, depression, unilateral primary osteoarthritis, and anxiety disorder. R107's MDS dated [DATE] showed R107 was cognitively intact and needed substantial assistance from staff for personal hygiene. On October 31, 2024 at 12:47 PM, V11 (CNA/Certified Nurse Assistant) said she was the CNA for R71 and R107 and had never done nail care for either resident. V11 said the residents' nails should be short to prevent them from being dirty and reduced the risk of infection. On October 31, 2024 at 12:52 PM, V10 (CNA) said R71 and R107 both needed help with personal hygiene and were unable to cut their own nails. V10 said the CNAs are the ones who cut the residents' nails on shower days. V10 said the staff should cut their nails if they see the nails are long or if the resident asked. V10 said if a resident refused to have their nails cut, the CNA should notify the nurse so they can document accordingly. On October 31, 2024 at 12:57 PM, V12 (RN/Registered Nurse) said the CNAs usually cut the residents' nails and if they are unable to, would let the nurses know. V12 said the nails should be cut short as it could grow fungus, have infections, or collect dirt. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145715 If continuation sheet Page 6 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On October 31, 2024 at 1:33 PM, V2 (DON/Director of Nursing) said the CNAs were responsible for cutting the residents' nails. V2 said nail care was done as needed, typically on shower or spa days. V2 said nails should be cut short to prevent scratching, inadvertently hurting themselves, and could also accumulate dirt under them. The facility's Nail Care Guideline policy dated February 2023 showed nail care includes routine cleaning and regular trimming. Proper nail care can aid in the prevention of skin problems around the nail bed. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. The facility's undated Activities of Daily Living policy showed A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145715 If continuation sheet Page 7 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, Interview and Record Review the facility failed to ensure resident received respiratory care and services in accordance with professional standards of practice for 3 of 3 residents (R2, R33 and R95) reviewed for respiratory therapy in the sample of 23. Residents Affected - Few Findings include: 1. On 10/29/24 at 11:59 AM, R2 was sitting on his wheelchair next to his bed. Using Oxygen at 4 lpm (Liters per minute) via nasal cannula. On 10/30/24 at 9:47 AM, R2's nasal cannula was noted on the floor near the bathroom and R2 was not in the room. The floor in R2's room was dirty, dusty and was noted with used tissue paper and food debris lying around. On 10/30/24 at 10:25 AM, observed R2 wheeled himself into the room on his wheelchair, pick up the nasal cannula from the floor and apply it into his nostrils. On 10/31/24 at 12:17 PM, V12 (RN) stated, R2 has an order for oxygen at 2 lpm as needed, but he is using it all the time. V12 (RN) stated, he witnessed multiple times that R2 leaves the nasal cannula on the bed when not in use. V12 (RN) stated, he should have educated R2 that the canula must be bagged when not in use. The cannula should not be re-used once it has fallen on the floor as the floor is not clean and will cause infection. V12 (RN) stated, when not in use, nasal cannula must be placed in a plastic bag. R2's face-sheet showed R2 was admitted on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease and Schizoaffective Disorder. R2's Physicians orders for October 2024 showed, 'May administer 2-5 liters oxygen via nasal cannula as needed to titrate SPO2 >90%. R2's Care Plan dated 10/16/24 addressed his need for oxygen. 2. On 10/29/24 at 11:45 AM, R33 had a CPAP (Continuous Positive Airway Pressure) machine on her bedside table and the oxygen tubing was located on the floor under her bed. R33 stated, she uses the machine every night and demonstrated how. The floor in R33's room was dirty, dusty and had old food debris. R33's face-sheet showed R33 was admitted on [DATE] with diagnoses to include Dementia, Obstructive Sleep Apnea and Diabetes Mellitus. R33's Physicians orders for October 2024 included using CPAP at bedtime and remove in the morning. Care Plan dated 8/29/24 addressed R33's Sleep Apnea and use of CPAP machine. 3. On 10/29/24 at12:12 PM R95 stated, she uses CPAP at night. R95 pulled out her CPAP machine from the dresser drawer from among her clothing with the mask not bagged. On 10/31/24 at 12:35 PM, V12 (RN) verified that R95's CPAP machine, tubing and mask were located in R95's dresser along with her clothing. The mask was noted to be unbagged. V12 (RN) stated it was not right to leave the CPAP mask unbagged among her clothes in the dresser as it will catch dust and fiber particles. R95's Face-sheet showed R95 was admitted on [DATE] with diagnoses to include Asthma, Heart Failure, Depression and Obstructive Sleep Apnea. R95's Physicians orders for October 2024 included using CPAP at bedtime and remove in the morning, as needed. Care Plan dated 10/08/24 addressed R33's Sleep (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145715 If continuation sheet Page 8 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2024 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 Apnea and use of CPAP machine. Level of Harm - Minimal harm or potential for actual harm On 10/31/24 at 01:06 PM V2 (DON-Director of Nursing) stated, ideally nasal cannula should be bagged in a plastic bag when not in use. If the RN sees the canula on the floor, she should replace it. If the CNA (Certified Nursing Assistant) sees it on the floor, she should notify the nurse about it. Cannulas, masks & tubing for respiratory treatments should be bagged when not in use to prevent contamination and potential infection. Residents Affected - Few Policy on Oxygen Administration revised March 2004 did not include it's 'infection control' aspect. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145715 If continuation sheet Page 9 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to properly store medications for residents who were not assessed or had orders to self-medicate or store medications at the bedside. This applies to 5 of 5 residents (R65, R94, R98, R14, R44) reviewed for medication storage in a sample of 23. The findings include: 1. On October 30, 2024 at 9:43 AM, R65's dresser had a medication cup with her name written on it and a pale, orange pill inside the cup. The pill had the letters TEVA- 5728, which was Famotidine 20 mg (Milligrams). R65 was not in the room, but her roommate was. R65's face sheet showed she was admitted to the facility with diagnoses including rheumatoid arthritis, paranoid schizophrenia, arthritis, anxiety disorder, borderline personality disorder, and heart disease. R65's POS (Physician Order Sheet) showed an order for Famotidine 20 mg once a day at 6 AM. R65's POS did not show an order to keep medications at bedside. R65's MDS (Minimum Data Set) dated January 11, 2024 showed R65 was cognitively intact. The facility was unable to provide an assessment form to show R65 was evaluated to self-administer medications or to store medications at bedside. 2. On October 29, 2024 at 11:33 AM, during initial tour, R94's bedside table had three bottles of Flonase 50 mcg (Micrograms). On October 30, 2024 at 9:41 AM, R94 still had three bottles of Flonase on her bedside table. R94 said she had been taking the Flonase every morning by administering one spray in each nostril. R94's face sheet showed she was admitted to the facility with diagnoses including bipolar disorder, major depressive disorder, anxiety disorder, tremor, borderline personality disorder, carpal tunnel syndrome in bilateral upper limbs, chronic pain syndrome, chronic rhinitis, and abnormalities of gait and mobility. R94's MDS dated [DATE] showed R94 was cognitively intact. The facility was unable to provide an assessment form to show R65 was evaluated to self-administer medications or to store medications at bedside. R94's POS shows an order for Flonase Allergy Relief 50 mcg/actuation; 1 spray in each nostril once a day 8 AM, which started on April 5, 2024 and was discontinued on October 30, 2024 (during the survey). The POS showed a new order, which was started October 30, 2024 for Flonase Allergy Relief 50 mcg/actuation; May keep at bedside and self-administer. R94's care plan dated October 31, 2024 showed [R94] can self-administer medication: Flonase. Resident wants to self-administer medication. R94's care plan dated July 15, 2024 showed Upon admission, hospital record indicates that family believes [R94] would intentionally and unintentionally take the wrong medications. [R94] does not recall such events. On October 31, 2024 at 10:59 AM, V13 (RN/Registered Nurse) said she worked on October 30, 2024 starting from 6:30 AM. V13 said the night shift pulled the 6 AM medications, and the nurse who worked on October 30, 2024 until 6 AM was an agency nurse. V13 said she had not seen the pill on the side dresser, as R65 had come to the medication cart for her morning medications and was not sure if R65 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145715 If continuation sheet Page 10 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some took her medication or not. V13 said she went to R65's room around lunchtime, and the medication was not there. V13 said R65 was not allowed to have medications at the bedside. V13 said when the nurses were doing medication administration, they had to make sure the resident takes all the medication and to assess if they swallowed the medication or not. At 11:28 AM, V13 said R94 was allowed to keep her Flonase at bedside as of October 30, 2024 (during the survey). V13 said the medications should be locked as there was a potential for another resident walking in and grabbing the medications. On October 31, 2024 at 11:08 AM, V12 (RN) said none of the residents should have medications left at the bedside. V12 said the nurses should watch the resident take and swallow the medications, as some of the residents were known to pocket the medications. V12 said the medications should be kept locked in the medication cart. V12 said the residents were allowed to administer their medications themselves but had to be supervised by the nurse. On October 31, 2024 at 11:10 AM, V9 (RN) said some of the residents were allowed to self-administer medications, but an observation with an assessment needed to be completed first. V9 said the doctor needed to put an order in. V9 said both these steps needed to be done prior to the resident being allowed to self-administer or store the medications at bedside. V9 said the nurses never keep the pills at the bedside when they passed medications. V9 said the staff should make sure the residents swallow the pill as there are residents who pocket their pills. V9 said they do tongue checks if the resident was known to pocket their pills. On October 31, 2024 at 12:29 PM, V2 (DON/Director of Nursing) said if a resident expressed that they wanted to keep their medications at bedside, they needed a doctor's order and an assessment to evaluate if the resident was cognitively able to keep medications at bedside. V2 said the assessment form would evaluate whether they were able to self-administer, as well as store medications. V2 said if the resident was allowed to store their medications at bedside, it should ideally be locked up or inside a drawer. V2 said if it was left out, another unattended resident could come and take the medications. V2 said if a resident was allowed to keep medications at bedside, they also would not need to have multiple containers/bottles of the same medication. V2 said it was his expectation the nurses made sure the resident took their medications by asking them and staying to watch the resident take the medication. V2 said if the nurse left the medication unattended, another resident could see a pill and take it. 3. On 10/29/24 at 12:35 PM, R98 was noted with Breztri 160mcg (micrograms)/9mcg/4.8mcg inhaler on his bedside table. R98 said he takes two puffs every morning and if he is having a bad day he will use the inhaler again at night. R98's MDS (Minimum Data Set) dated 9/19/24 shows his cognition is intact. R98's POS (Physician Order Set) shows an order dated 2/23/24 Breztri Aerosphere aerosol inhaler 160-9-4.8 mcg/actuation 2 puffs twice a day at 8AM and 4PM. R98's POS does not show a physician order that he can self-administer medications or store medications at his bedside. R98's Care Plan dated 1/4/24 shows he has potential for impaired gas exchange secondary to diagnosis of COPD (Chronic Obstructive Pulmonary Disease) and interventions include provide inhalation meds and/or inhalation treatment as ordered. R98's Care Plan does not say he self-administer medications or store medications at his bedside. 4. On 10/29/24 at 12:28 PM, a tube of prescription ketoconazole cream was seen on the bedside table of R14. On 10/31/24 at 11:14 AM, the tube of ketoconazole cream was again seen on the bedside table of R14. R14 was not in her room, and at 11:17 AM, R14 was found sleeping with her head down on the table in the dining room of the basement. Staff woke up R14, but surveyor was unable to interview (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145715 If continuation sheet Page 11 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2024 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 0761 R14 about the ketoconazole cream before she fell right back to sleep. Level of Harm - Minimal harm or potential for actual harm R14's POS shows an order dated 8/14/24 ketoconazole cream 2% thin layer topical to lips as needed for flare. R14's POS does not show a physician order that she can self-administer medications or store medications at her bedside. R14's Care Plan does not say she can self-administer medications or store medications at her bedside. Residents Affected - Some On 10/31/24 at 11:19 AM, V8 (LPN/Licensed Practical Nurse) said none of the residents can keep their medications at their bedside, and the nurses have to give all residents their medications. V8 said the ketoconazole cream should not be kept at the bedside of R14. V8 said the ketoconazole cream should be given to R14 in a small cup when she requests it, and she should be observed when she puts it on her lips. V8 said all medications should be kept in the nurse's locked medication cart for resident safety because they have a lot of wandering residents and residents with dementia that it is unsafe to keep medications out in the open. V8 said R98 can administer his inhalers himself in the presence of the nurse. V8 said R98's inhalers need to be kept locked in the nurse's medication cart and not at his bedside, for the safety of all residents. On 10/31/24 at 2:17 PM, V2 (DON) said both R98 and R14 are not able to have medications stored at their bedside. 5. On 10/29/24 at 10:554 AM, 10/30/24 at 9:30 AM and 10/31/24 at 9:20 AM, there was Nystatin Powder on R44's nightstand. The Nystatin Powder was labeled and showed to apply to abdominal folds once a day on Monday, Wednesday, and Fridays. The Nystatin Powder did not have a cap on and was uncovered. R44 said she applies the powder on her abdominal fold whenever she feels itchy. R44 said she uses the powder multiple times in a day. An unlabeled eye drop named Polyethylene Glycol 400%; Tetrahydrozoline Hydrochloride 0.05 % lubricant was observed on her bed side table. R44 said she administers the eye drop herself twice a day. She said facility provides the eye drops. On 10/31/24 at 9:20 AM, V9 (RN) said R44 does not have an order for medications to stay at her bedside or to self-administer medication. V9 said it is important to make sure that medication is properly stored because it can pose as danger to the resident and/or her roommate. She said powder might spill on the floor and resident might slip and fall. The powder was also uncovered, she said it is an infection control issue. On 10/31/24 at 1:00 PM, V2 (DON-Director of Nursing) said if medication is left at the bedside and not stored properly, there will be a safety concern especially if resident is not able to manage medication appropriately. R44 was admitted to the facility on [DATE]. R44's face Sheet documents diagnoses of schizoaffective disorder, hypertensive heart disease, Type II Diabetes Mellitus, morbid obesity, and hyperlipidemia. MDS (Minimum Data Sheet) dated 9/13/24 documents she requires partial/moderate assist with personal hygiene and shower/bathe self. Review of R44's POS (Physician Order Sheet) showed there was no order for R44 to have medication by the bedside and to self-administer medication. During survey, on 10/31/2024 at 9:57 AM, facility obtained order for eye drop to stay at the bedside and may self-administer with supervision. Facility's Policy on Self-Administration of Medications dated 10/25/2014 stated the following: Procedures: A. If the resident desires to self-administer medications, an assessment is conducted by the Interdisciplinary team of the resident's cognitive (including orientation to time), physical and visual ability to carry out this responsibility during the care planning process.C.5) The resident is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145715 If continuation sheet Page 12 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some asked to complete a bedside record indicating the administration of the medication (if bedside storage is to be used). E. If the resident demonstrates the ability to safely self-administer medications, a further assessment of the safety of bedside medication storage is conducted. F. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into rooms of, or room with, residents who self-administer. Conditions outlined in ID3: BEDSIDE MEDICATION STORAGE are met for bedside storage to occur. Facility's Policy on Bedside Medication Storage dated 10/25/2014 stated the following: .Policy: Bedside medication storage is permitted for residents who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate in the judgement of the facility's interdisciplinary resident assessment team.Procedures: A. A written order for the bedside storage of medication is present in the resident's medical record. B. Bedside storage of medications is indicated on the resident medication administration record (MAR) and in the care plan for the appropriate medications.C.1) The manner of storage prevents access by other residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145715 If continuation sheet Page 13 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2024 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 properly label/date/store/discard items, ensure the dishwasher was functioning, dispose of garbage, and maintain proper levels of chlorine in the dishwasher and quaternary in sanitizer buckets. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 10/29/24 documents that the total census was 110 residents. On 10/29/24 at 11:16 AM, V4 (Dietary Manager) said all residents eat from the facility kitchen; there are no NPO (Nothing by Mouth) residents. On 10/29/24 starting at 9:59 AM, the facility kitchen was toured in the presence of V4 (Dietary Manager) and the following was observed: Kitchen low temperature dishwasher: 1. On 10/29/24 at 10:35 AM, V4 tested the chlorine level of the low temperature dishwasher with strip that showed low reading between 10-50ppm (parts per million). During this time, V5 (Dietary Aide/Dish washer) was using the dishwasher to wash dishes. V4 did not tell V5 to stop washing dishes. At 10:44 AM, V5 (Dietary Aide) pointed out to V4 (Dietary Manager) the red tube coming from the dishwasher labeled detergent was broken/split/completely detached from the dishwasher. At 10:47 AM, V5 (Dietary Aide) said he noticed the red tubing to the dishwasher was broken earlier in the day. At 10/29/24 at 11:07 AM, V5 was observed still using the dishwasher to clean dishes in the kitchen. At 11:10 AM, while surveyor and V4 (Dietary Manager) were leaving the kitchen together, V5 was still using the dishwasher to clean dishes. At this time, surveyor asked V4 (Dietary Manager) if V5 (Dietary Aide) should still be using the dishwasher to clean dishes with the detergent line not functioning and the chlorine level measuring low. V4 said, No. V4 instructed V5 to use the 3 compartment sink to wash the dishes. 2. On 10/29/24 at 10:48 AM, V4 tested with strip the quaternary level of V6's (Cook) sanitizer bucket in the kitchen and received a low reading between 0-100ppm. V6 said she had been using the sanitizer bucket to clean in the kitchen. 3. On 10/29/24 at 10:28 AM, the thermometer on the outside of the milk cooler showed a reading of 49 degrees Fahrenheit (F). There was a numerous amount of 4 ounce cartons of milk inside the cooler and no thermometer inside the cooler. V4 (Dietary Manager) then removed a 4 ounce 2% milk and tested the temperature with digital thermometer. First 2% milk tested showed a reading of 45 degrees F. A second 2% milk was tested with digital thermometer and showed reading of 43.8 degrees F. V4 said, It is warm in the kitchen, this building is pretty old, it gets to be hot. 4. 8-2 pound cartons of thawed frozen egg product not dated. 5. 11 tomatoes that appear to be rotten/soft with black spots on them. 6. First in, first out method not used to store 2% 5 pound cottage cheese containers. 5 containers (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145715 If continuation sheet Page 14 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2024 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 with a December expiration date were placed in front of 2 containers with November expiration date. Level of Harm - Minimal harm or potential for actual harm 7. 3-32 ounce bags of raisins expired, with best by date of 10/5/24, bags were noted to be dusty with a white powder on them. Residents Affected - Many 8. A box of 10- 16 ounce bags of sweetened coconut with sell by date of 8/17/24 and delivery date on box of 10/13/23. Bags are sticky and dusty. V4 said these bags need to be discarded and cannot be served to the residents. 9. On 10/29/24 at 10:40 AM 2 large garbage cans were seen uncovered near the dishwasher with visible food debris in cans, appeared to be scrambled eggs. Again, on 10/30/24 upon return to the kitchen at 11:28 AM, 2 large garbage cans were seen uncovered in dishwasher room with food debris inside the cans and on the outer rim of the garbage bag. 10. On 10/30/24 at 11:12 AM, clean plates were stacked in preparation for lunch service and set up on a tray right next to/pushed up against the handwashing sink within splash distance. 11. On 10/31/24 at 11:13 AM small black flies were seen flying in hallway immediately outside the kitchen. On 10/31/24 at 11:02 AM, V4 (Dietary Manager) said all food items in the kitchen are supposed to be labeled and dated to know when they were received, opened, and when the items should be used and/or discarded by. V4 said labeling and dating is important for food safety to prevent food borne illness of the residents. V4 said expired food items should be disposed of by their expiration date to make sure the items are not served to the residents with the potential to cause food borne illness. V4 said food items are supposed to be stored using the first in- first out method to make sure residents are not served expired foods, they are receiving fresh items, and the facility is not wasting food. V4 said the refrigerators/coolers should be holding cold foods at or below 40 degrees F. V4 said hold cold food items stored above 40 degrees can spoil and cause food borne illness of the residents. V4 said V5 (Dietary Aide) should not have been using the dishwasher on 10/29/24 once it was discovered that the detergent tubing was not connected, and the chlorine strips were not showing safe levels. V4 said the dishwasher did not have detergent so the dishwasher was not properly washing the dishes or sanitizing the dishes with the chlorine. V4 said the garbage cans should be covered with lids to prevent flies and food debris from coming out of the garbage cans. V4 said the chlorine strip reading should show 100ppm and the quaternary strips should show 200ppm. The facility provided undated policy titled, Labeling and Dating Foods states, Policy: Prepared and packaged foods will be labeled and rotated to decrease the risk of food borne illnesses, provide the highest quality product for the residents and minimize waste . The facility's policy titled, Labeling and Dating Foods last revised 2017 states, Policy: To decrease the risk of food borne illness and to provide the highest quality, foods is labeled with the date received, the date opened and the date by which the item should be discarded .Procedure: Refrigerated Food: .Refrigerated Potentially Hazardous Food (PHF) or Time/Temperature Controlled for Safety (TCS) foods are labeled with the date received and if not opened, are discarded by the manufacturer's expiration date . The facility provided undated policy titled, Dishwashing Procedure states, Policy: To prevent food (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145715 If continuation sheet Page 15 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2024 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 borne illness, all dish wares will be cleaned in the dish machine. Policy Specifications: .2. Check chemicals to determine adequate supply. If not, replace .Test strips are available through the food service supervisor. Before dishes are washed, the sanitation temperature or level of chemical sanitizer in the dish machine should be tested with the correct test strip .For chemical sanitizing machines: .The test strip should turn the appropriate color to indicate 50ppm for chlorine. If the test strip does not turn the appropriate color, the above procedure should be repeated. If the test strip does not turn the appropriate color on the second attempt, the dish machine should be evaluated for proper functioning before the dishes are washed . The facility provided undated policy titled, Sanitizing Solution states, Policy: TO prevent food borne illness through cross contamination, sanitizing solution will be made and strategically located throughout the kitchen. Policy specifications: 4. Wiping cloths should be stored in a sanitizing bucket with the following concentrations: Chlorine- 50-100ppm, . Quaternary- 150-400ppm. The facility provided undated policy titled, First In- First Out states, Policy: .Stock not used by the expiration date will be discarded. Policy Specifications: 1. New supplies are placed on the shelf behind the supplies on hand. Products with the earliest expiration date are stored in the front of products with later dates so that the older food is used first. 2. Cans or boxes will be labeled with the delivery date before being placed on shelves. The facility provided undated policy titled, Storage Temperatures states, Policies: Temperatures of food storage areas are monitored, and action is taken to maintain temperatures within ranges recommended by licensing and surveying agencies . Refrigerated Storage: 41 degrees F or below .Each mechanically refrigerated unit storing potentially hazardous food shall be provided with a numerically scaled indicating thermometer . The facility provided undated policy titled, Garbage Disposal states, Policy: Dispose of garbage and refuse properly. Purpose: To prevent odors, minimize breeding places for insects and rodents, and keep service areas clean. Procedure: .3. Use garbage cans that are leak proof, non-absorbent and have tight fitting lids . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145715 If continuation sheet Page 16 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2024 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 0912 Level of Harm - Potential for minimal harm Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation, interviews, and record review, the facility failed to provide at least 80 square feet for residents for 12 of 48 resident rooms. Residents Affected - Some This applies to rooms A18, A19, A22, A24, A26, A28, A30, A31, A33, A34, B7 and B8. The findings include: Historical room documentation determined rooms A22, A24, A26, A28, A30, A31, A33, and A34 are set up to provide occupancy for three resident beds each and are undersized, providing 74 square feet. Rooms A18, A19, B7, and B8 are set to provide four residents each have 78 square feet per resident respectively. The facility provided residents with a daily roster dated 10/29/2024, showing undersized rooms occupy 35 of 110 residents. On 10/31/2024 at 11:00 AM, V1(Administrator) said that since its inception, the facility has had the same structure and room sizes, and the facility receives the deficiency during the annual survey every year. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145715 If continuation sheet Page 17 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2024 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 - Potential for minimal harm Based on observations and interviews, the facility failed to have the floor of the resident rooms at the garden or above the ground level. This applies to 36 of the 36 (R1, R4, R6, R7, R11, R14, R15, R16, R18, R26, R29, R31, R34, R36, R39, R42, R43, R45, R46, R47, R52, R53, R66, R67, R68, R76, R87, R91, R98, R99, R101, R102, R103, R104, R108) residents reviewed for physical environment. Residents Affected - Some The findings include: Residents rooms B1, B2, B3, B4, B5, B6, B7, B8, B9, B10, B11, B12, B13, and B14 are below the below the garden or ground level. On 10/31/2024 AT 11:00 AM, V1 (Administrator) said since its inception, the facility has had the same structure, and every year, the facility receives the deficiency during the annual survey. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145715 If continuation sheet Page 18 of 18