Health inspection·April 24, 2025

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few frequently. V2 was asked to provide documentation of refusals and provided one shower sheet dated April 3, 2025, that showed R75 refused a shower but had a bed bath instead. There were no other refusals documented. On April 23, 2025, at 1:18 PM, V14 (CNA) said on shower days she will wash the resident's hair unless they refuse to get hair wet, wash their body, apply lotion or Vaseline, check toenails, notify social services to put resident on list to see podiatrist list, get resident dressed, and get resident up out of bed or back to bed if they refuse to stay up. V14 said she showered R75 on Monday afternoon. Facility provided their revised policy dates January 31, 2018, titled Shower and Tub Bath. The policy showed the purpose was to ensure resident's cleanliness to maintain proper hygiene and dignity .Equipment: . shampoo . Facility provided undated policy titled, Shaving Male and Female Residents. The policy showed the Purpose: To provide cleanliness, comfort, and improved morale . Important Information on Frequency and Method of Shaving 1. male residents will be assessed for daily shaving .2. Female residents will be asked regarding preference to give consent for the method of removing facial hair such as clipping with scissors, electric razor or safety razor, and information added to the plan of care. 3. Female residents will be assessed weekly, and assistance provided in accordance with the resident's preference. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145740 If continuation sheet Page 2 of 14 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 145740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Elgin 134 North McLean Boulevard Elgin, IL 60121 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy to quarterly assess a resident's nutritional status. Residents Affected - Few This applies to 1 of 4 residents (R63) reviewed for nutrition in the sample of 18. The findings include: The EMR (Electronic Medical Record) showed R63 was admitted to the facility on [DATE], with multiple diagnoses including polyosteoarthritis, legal blindness, vitamin D deficiency, chronic gastritis, and nicotine dependence. R63's MDS (Minimum Data Set) dated April 8, 2025, showed R63 was cognitively intact. R63's nutrition care plan dated November 3, 2023, showed I have a nutritional problem or potential nutritional problem secondary to HIV (Human Immunodeficiency Virus), cannabis dependence, legally blind, vitamin D deficiency, hypertension, history or COVID-19, and medications which may affect appetite and/or weight. The care plan continued to show a goal revised on October 21, 2024, I will maintain stable weight plus/minus 5% (percent) through next review. On April 21, 2025, at 9:46 AM, R63 said he is blind. R63 said he thinks he has been losing weight. On April 21, 2025, at 12:13 PM, R63 was sitting in the dining room eating lunch. R63 was eating unassisted and was dropping food onto his lap, on the table, and on his meal tray. R63 was not assisted by facility staff. R63 got up from the lunch table and left the dining room. R63's Weights and Vitals Summary dated April 23, 2025, showed the following weights for R63: On November 5, 2024, 151.8 pounds; On December 3, 2024, 151.4 pounds; On January 2, 2025, 148.8 pounds; On February 3, 2024, 146.3 pounds; On March 1, 2025, 144 pounds and; On April 3, 2025, 140.8 pounds. On April 23, 2025, at 1:14 PM, V3 (Dietary Manager) said he performs quarterly nutrition assessments on residents who are not being seen by the dietitian. V3 continued to say he documents his assessments in the EMR. The EMR showed V3 documented a nutrition assessment for R63 on October 29, 2024. As of April 23, 2025, at 1:00 PM, the EMR does not show R63 had a nutrition assessment since October 29, 2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145740 If continuation sheet Page 3 of 14 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 145740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Elgin 134 North McLean Boulevard Elgin, IL 60121 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On April 23, 2025, at 1:18 PM, V2 (DON/Director of Nursing) said V11 (Dietitian) does not evaluate a resident unless the resident has a significant weight loss. V2 continued to say V11 told V2 she did not need to see R63 because he did not have significant weight loss. On April 23, 2025, at 2:51 PM, V2 said R63's nutrition assessment by V3 was on October 29, 2024, and R63's last nutritional assessment by V11 was on August 1, 2024. On April 23, 2025, at 3:24 PM, V1 (Administrator) said residents should have a nutritional assessment completed at least quarterly. The facility's policy titled Routine Nutritional Documentation and Assessment dated 2020, showed Guideline: After admission the resident is assessed and monitored in accordance with the MDS schedule and evaluation of need determined at admission. High-Risk residents at admission are placed on the high-risk roster and followed as indicated. Residents at nutritional risk or with current nutritional concerns are referred to the Registered Dietician for a comprehensive nutritional assessment. The MDS schedule will screen for nutritional triggers which may indicated a nutritional problem or opportunity for improvement. Nutrition screening may also be used to monitor for nutritional risk. Ongoing comprehensive nutritional assessments are updated as needed by the Registered Dietitian for residents screened or trigger on the MDS with nutritional concerns. Some communities choose to complete a baseline nutritional assessment on each resident annually. Procedure: 1. The MDS schedule is used to define the time frame for documentation. The Dining Service Manager is responsible for observing the resident at meal times, reviewing the MDS, completing section K of the MDS, and signing the MDS . 3. Progress notes will be used by the Dining Services Manager and Registered Dietitian as needed to record observations, progress towards nutritional goals, and incidental information related to the nutritional care of the resident. A progress note will be entered into the health record by the Dining Services Manager in accordance with the MDS schedule, no [NAME] than quarterly. In circumstances where the resident is being followed by the Registered Dietitian due to a nutritional risk, the quarterly note by the Dining Services Manager may be deemed unnecessary. 4. The care plan will be updated as changes are made to individualized nutritional interventions and reviewed at least quarterly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145740 If continuation sheet Page 4 of 14 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 145740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Elgin 134 North McLean Boulevard Elgin, IL 60121 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 0694 Provide for the safe, appropriate administration of IV fluids 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 monitor and care for a midline peripheral intravenous catheter. This applies to 1 of 1 residents (R48) reviewed for intravenous catheters in the sample of 18. Residents Affected - Few The findings include: R48's electronic medical record showed R48 was admitted to the facility on [DATE] with diagnoses that included stable burst fracture of second lumbar vertebra, subsequent encounter for fracture with routine healing, dependence on renal dialysis, gait abnormalities, and need for assistance with personal care. On April 21, 2025 at 10:10 AM, R48 stated that she is receiving intravenous antibiotics. R48 showed the surveyor, her right arm intravenous catheter which had a transparent dressing that was dated April 14, 2025. Underneath R48's transparent dressing, there was a gauze dressing which was stained with dried blood and was covering the insertion site. On April 21, 2025 at 1:24 PM with V2 (Director of Nursing/DON), observed R48 right upper arm intravenous catheter and V2 confirmed that there was a gauze dressing underneath the transparent dressing that had dried blood on it and was covering the insertion site. R48 had the following order dated April 6, 2025: Insertion of midline catheter. Sent for imaging on April 6, 2025 at 10:01 AM. R48's progress note dated April 6, 2025 showed the following: A vascular nurse was in the facility at approximately 8 PM to open vascular access to right midline catheter. R48's medication administration record showed administrations of Ceftriaxone Sodium (Antibiotic) Reconstituted 1 Gram for 6 days starting on April 6, 2025 through April 11, 2025. On April 23, at 2:00 PM, V2 stated when central or midline intravenous catheters are placed, she expects the nurses to check for signs and symptoms of infection and bleeding every shift. V2 stated nurses are supposed to chart their assessments in the resident's progress notes. V2 stated that from the moment the midline is inserted, there should be monitoring every shift for infection, redness and warmth, bleeding, and swelling and the nurses should also be monitoring every shift the circumference of the resident's arm where the catheter line is inserted. V2 stated she expects the nurse to change midline intravenous dressing after the first 24 hours of insertion. V2 stated with a gauze dressing, the dressing should be changed every 2 days. V2 stated she believes R48 midline catheter was inserted on April 6, 2025, therefore R48's dressing should have been changed on April 8, 2025, as needed, and weekly. As of April 23, 2025 at 11:15 AM, the facility did not have a care plan for the care of R48's midline intravenous line. There was also no documentation to show that the circumference of the R48's right arm was being measured. Prior to April 20, 2025 there was no documentation in the MAR (Medication Administration Record) or the TAR (Treatment Administration Record) that the midline intravenous line was being flushed or monitored every shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145740 If continuation sheet Page 5 of 14 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 145740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Elgin 134 North McLean Boulevard Elgin, IL 60121 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 0694 Level of Harm - Minimal harm or potential for actual harm The facility's Intravenous Access Line Maintenance Protocol policy dated February 7, 2020 showed the following: Site Maintenance: Transparent dressing changes should be done on admission or 24 hours post insertion, then weekly and as needed. Measure upper arm circumference and exterior catheter length with each dressing change and as needed. Gauze dressing changes should only be used if patients are sensitive to clear transparent dressings and must be changed every 2 days. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145740 If continuation sheet Page 6 of 14 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 145740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Elgin 134 North McLean Boulevard Elgin, IL 60121 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 follow sanitary practices in the facility kitchen and during meal service in the dining room. This applies to all 84 residents that received foods prepared in the facility kitchen. The findings include: Facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated April 21, 2025 showed that the facility census was 86 residents. Facility provided information that two residents are NPO (nothing by mouth) status. On April 21, 2025 at 09:19 AM, the initial tour of facility kitchen was done in presence of V3 (Dietary Manager). V5 (Dietary Aide) was washing dishes at a low temperature dish machine. On request, V5 ran a test strip through the dish machine and the tip turned from white to orange showing 200 ppm (parts per million) per instructions for chlorine test strip guidance on the dispenser bottle. When asked, V5 stated that he did not test the dish machine earlier with test strips and that the sanitizer range should be 100-200 ppm. Guidance for chlorine test strips posted on the wall showed the ppm should range between 50-100 ppm. Facility was requested for policy guidance for chlorine test strips. On April 22, 2025 at 12:20 PM, V3 stated that V5 misspoke and that the chlorine should be 50-100 ppm as posted on guidance poster near the dish machine. V3 stated that the dish machine servicing contractor was notified that morning as the test strips continued to show 200 ppm. V3 added that the dish machine service representative came in that morning and replaced something in the dish machine and stated that they will be back. V3 added that the facility has two different kind of chlorine test strips from two dish service companies and the current dish service contractor told him that it is okay to use both test strips. On April 22, 2025 at 3:43 PM, V1 (Administrator) stated that the dish machine servicing company is coming back to the facility later this evening to install a part into the dish machine as the cycle (to turn off water) would not stop running. On April 23, 2025 at 1:50 PM, V12 (Dish machine Service Representative) stated that he replaced two contactors as one of them was sticky and the other one looked old. V2 stated that the contactors are control components that turn the wash or rinse pump on. V12 stated that if he does not change the contactors, the machine will not work well and only intermittently. V12 also added that he does not know what test strips that the facility was using to test the chlorine sanitizer and that they should use the test strips that turns from white to light purple (registering between 50-100 ppm). Customer Service Report dated April 22, 2025 for dish machine included that two bad (single pole) contactors were replaced. Facility policy and procedure titled Dishwashing: Machine Operation included as follows: Guideline: The Dining Services staff shall maintain the operation of the dishwashing machine according to established procedure and manufacturer guidelines posted or contained in this guideline to ensure effective cleaning and sanitizing of all tableware and equipment used in the preparation and service of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145740 If continuation sheet Page 7 of 14 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 145740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Elgin 134 North McLean Boulevard Elgin, IL 60121 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 food. Level of Harm - Minimal harm or potential for actual harm Procedure: 2. Check the dishwashing machine before first use. If the dishwashing machine has not been used for several hours, it is generally recommended to allow the dishwashing machine to cycle for one or two cycles to allow dishwashing machine to come up to proper function. 4. If the machine is found to be out of the acceptable range for either final rinse temperature or proper chemical sanitizing concentration, do not proceed to wash dishes. Manufacturer's chlorine sanitizer test procedure showed as follows: Remove a 1.5 inch strip of clean, dry test paper from container below. At the end of the rinse cycle, dip strip of test paper into the final rinse water from the dish machine. Chlorine papers are dip, blot and read at once. Immediately compare test paper strip to the color chart on the test strip dispenser. Test range must be in the range shown below: test paper reading 50-100 ppm. Residents Affected - Many 2. On April 21, 2025 at 12:27 PM, room meal service was observed in the D-wing of the facility. The resident meal trays were placed on free standing cart in the D-wing with uncovered juice and water cups. These room trays were platted in the main dining room (located in another area) from the steam table and placed on the cart. This cart was then wheeled to the unit and meal trays passed out to the residents in their room by staff. Visitors, staff, and residents were seen in transit in hallway where the cart with meal trays were stationed. When V6 (Social Service Designee) who was assisting in passing room trays, was asked why the juices and water are not covered, V6 responded that she doesn't know why and that she works in social services. R30, R44, R56, R80, and R385 received room trays with the juice and water uncovered. Facility policy and procedure titled 'In-Room Dinning for Infection Control (2020) included as follows: Guideline: In order to control the spread of infectious disease, it may be necessary to implement in-room dining operations. Procedure: 3. All foods should be covered during transport. 3. On April 22, 2025 at 12:23 PM, V4 (Cook), was platting food at the steam table and noted to have her gloves soiled and dripping with pureed Brussels sprouts and gravy. V4 proceeded to take a hamburger bun from a plastic bag with the same gloves and added a slice of hamburger patty with tongs on one side of the bun and added lettuce and tomato on top with the same soiled gloves. This meal was prepared for R50 who had placed an order for a substitute meal. V3, who was in the vicinity, and V4 were notified of the unsanitary practices. Facility menu for Week 1 Tuesday lunch meal included oven roasted turkey with gravy and Brussels sprouts. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145740 If continuation sheet Page 8 of 14 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 145740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Elgin 134 North McLean Boulevard Elgin, IL 60121 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. On April 22, 2025, at 8:33 A.M., V7 (Licensed Practical Nurse) retrieved a blood pressure monitoring device from the top of the medication cart and brought it into R48's room to check R48's blood pressure. Upon completing the blood pressure check, V7 returned the device to the top of the medication cart and proceeded to retrieve multiple medications from the cart for administration. At this time, the blood pressure device remained on top of the cart, posing a risk of cross-contamination with medication cards and other supplies being used for medication administration. Residents Affected - Many V7 failed to disinfect the blood pressure device both prior to and following its use. Additionally, V7 did not perform hand hygiene after assessing R48's blood pressure and before preparing or administering medications. V7 continued with the medication pass to other residents without disinfecting the blood pressure device. Review of the Physician Order Sheet (POS) for April 2025 indicated a medical order dated March 31, 2025, specifying that R48 is on Enhanced Barrier Precautions (EBP) due to the presence of a peritoneal dialysis catheter. R48 was also receiving intravenous antibiotics for treatment of leukocytosis. The care plan dated April 1, 2025, reaffirmed that EBP measures must be maintained for R48. 6. On April 22, 2025, at 9:00 A.M., V8 (Registered Nurse) utilized a blood pressure monitoring device to check the blood pressure of R20. Following the assessment, V8 returned the device to the top of the medication cart and retrieved multiple medications from the cart, while the device remained on the cart, risking cross contamination of the medication cards and supplies. V8 did not disinfect the blood pressure device before or after use and continued the medication administration process without cleaning the equipment. V8 subsequently used the same contaminated blood pressure device to assess the blood pressure of R6 without performing any disinfection in between uses. Review of the Electronic Medical Record (EMR) for R20, an [AGE] year-old resident, showed diagnoses including cellulitis of the left lower limb, pruritus, edema, and urinary tract infection (UTI). The EMR for R6 documented diagnoses including emphysema, asthma, dysuria, disorders of skin and subcutaneous tissue, spontaneous ecchymoses, dementia, and bipolar disorder. On April 22, 2025 at 11:26 A.M., V2 (Director of Nursing) stated that facility protocol requires blood pressure monitoring devices to be disinfected with bleach wipes between uses on different residents, regardless of whether residents are under Enhanced Barrier Precautions or Standard Precautions. Review of the facility's Infection Control Policy dated November 28, 2012, states: Handwashing/hand hygiene is the single most important precaution to prevent contamination of infection from one person to another. Wash hands before and after each resident contact and contact with resident belongings and equipment . When use of common medical equipment or items is unavoidable, then adequately clean and disinfect them before use for another resident. 3. R53's had multiple diagnoses on face sheet including sepsis, unspecified organism, urinary tract infection, site not specified, flaccid hemiplegia affecting left nondominant side, unsteadiness on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145740 If continuation sheet Page 9 of 14 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 145740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Elgin 134 North McLean Boulevard Elgin, IL 60121 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 feet, unspecified abnormalities of gait and mobility, cellulitis of right lower limb, need for assistance with personal care. R53's quarterly MDS (minimum data set) dated March 31, 2025 showed that R53 was cognitively intact and was frequently incontinent of urine. Residents Affected - Many R53's POS (physician order summary) showed Macrobid Oral Capsule 100 mg (milligram), Give 100 mg by mouth two times a day for UTI (urinary tract infection) for 7 Days (start date April 21, 2025 5:00 PM). R53's POS also showed Contact Isolation for ESBL (extended spectrum beta-lactamases) in urine until resolved (start date April 21, 2025). On April 22, 2025 at 9:30 AM, R53 was lying in bed and stated that he ate breakfast in the dining room and plans to go for therapy in the therapy room. R53's door had a posting for contact isolation. On April 22, 2025 at 9:58 AM, R53 was seen self controlling his motorized wheelchair to the reception desk where he placed an order for his lunch with V17 (Receptionist). On April 22, 2025 at 10:30 AM, R53 was seated at a table with R29 and R41 in the main dining room and was drinking coffee. R4, R6, R25, R44, and R386 were also seated in close proximity to R53. R53 remained in the dining room to participate in bingo during activities. On April 22, 2025 at 10:36 AM, V2 (Director of Nursing) stated that R53 is on contact isolation for ESBL urine and as long as it is contained, he can go outside his room. V2 stated that R53 uses the urinal by himself. On April 23, 2025 at 9:18 AM, R53 was in his motorized wheelchair and was seen entering the therapy room by touching the door handle and opening the door. Within a few minutes, R385 was seen coming into the therapy room by touching the same door handle. R80, who was already in the therapy room riding the bicycle, also touched the same door handle when she left the therapy room. Both R80 and R385 were ambulatory and R80 used a walker. R53 was participating in therapy with V9 (Physical Therapy) and was handling common weights and a walker that were used by other residents. V9 was seen touching R53's back and walker during therapy. V9 was not wearing gloves and gown. On April 23, at 9:22 AM, V2, who had come to the vicinity, was asked if R53 is allowed to participate in therapy in a common room with other residents and whether V9 should be wearing any gloves or gown. V2 stated that as long as V9 washes hands in between patients, V9 does not have to wear any gowns or gloves. V2 stated They (V9) are not touching the source. On April 23, 2025 at 9:50 PM, V9 stated that she did not know that R53 was on contact isolation. When asked how she knows whether a resident is on contact isolation or not, V9 stated that normally she gets the residents for therapy from their room and will see the signage of contact precautions on the door. V9 stated that R53 brought himself into therapy so she was unaware that he was on contact precautions. V9 stated that therapy is done in the resident's room for residents with contact precautions and wearing gown and gloves. R53's care plan initiated on April 21, 2025 showed that R53 is on antibiotic therapy related to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145740 If continuation sheet Page 10 of 14 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 145740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Elgin 134 North McLean Boulevard Elgin, IL 60121 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 ESBL in urine. Interventions for the same included contact isolation for ESBL in urine until resolved. Level of Harm - Minimal harm or potential for actual harm Facility's infection precaution policy and procedure revised on May 15, 2023, shows as follows: It is the policy of this facility to, when necessary, prevent the transmission of infections within the facility through the use of Isolation Precautions. The 2007 Centers for Disease Control and Prevention (CDC) Guidelines for Isolation Precautions will be utilized in this facility with some modifications Residents Affected - Many Transmission-based precautions: 3. Contact Precautions: In addition to Standard Precautions, use Contact Precautions for residents known or suspected to be infected with microorganisms that can be easily transmitted by direct or indirect contact, such as handling environmental surfaces or resident-care items. In some instances, residents colonized with these organisms may also require Contact Precautions, for example, when a draining wound cannot be contained, when a resident exhibits noncompliant behaviors with stool or other body fluids, or when a resident has very poor perianal hygiene, etc.[etcetera] . Points to remember: -Handwashing (hand hygiene) is the single most important precaution to prevent the transmission of infection from one of person to another. Wash hands with soap and water before and after each resident contact, and after contact with resident belongings and equipment -In general, contact precautions are not required in the LTC [long term care] setting for MDRO's [multi drug resistant organism] if the source of the infection can be contained or if the infection is colonized. Examples include wounds infections where the drainage is contained by dressings, urinary infections that are contained by a catheter that does not leak, infections of the blood stream, etc. -All faucets and handles are considered to be contaminated, as are sinks and hoppers. -Gather all equipment and supplies needed before going into the room. Only take needed supplies into the room. When possible dedicate the use of noncritical resident-care equipment to a single resident or cohort of residents infected or colonized with the pathogen requiring precautions. When use of common equipment or items is unavoidable, then adequately clean and disinfect them before use for another resident . 4. On April 21 2025 at 10:41 AM, R3 stated to the nurse-on-duty she needed to be changed because she had been having diarrhea since last night. R3 stated her medication was making her sick. After the nurse left the room, R3 vomited into the garbage can and onto the floor. V13 (CNA/Certified Nursing Assistant) came into the room with an incontinence brief and wipes to assist R3 with incontinence care. V13 put on gloves and helped R3 onto her back and cleaned her from the front to the back with wet wipes. V13 then helped R3 onto her right side and cleaned the stool she had on her bottom. V13 then removed his gloves and without performing hand hygiene started going through R3's personal drawers looking for barrier cream. R3 stated I don't have any cream. V13 left the room without performing hand hygiene and went into the clean utility room to get some barrier cream. V13 came back with the barrier cream, he went into the bathroom and washed his hands with soap and water. He put on gloves, and started to place barrier cream on R3's buttocks. While V13 was applying the white barrier cream. R3 stated, I'm going again. Loose stool began to pour out of R3. V13 started cleaning R3 and then (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145740 If continuation sheet Page 11 of 14 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 145740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Elgin 134 North McLean Boulevard Elgin, IL 60121 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 stopped, V13 then took off his gloves, and put on new gloves. V13 did not perform hand hygiene. V13 waited and then started cleaning R3 once she had finished having a bowel movement. Once R3 was clean, V13 took the gloves off and put on new gloves without performing hand hygiene. V13 applied barrier cream to R3's buttocks. V13 removed his gloves and put on new gloves without performing hand hygiene. V13 helped R3 onto her left side by holding R3's torso and buttocks to the side while he pulled the right side of the incontinent brief around to R3's right side. After V13 finished cleaning R3 up, V13 started cleaning the vomit off of the floor next to R3's bed. V13 stated he needed to get some disinfectant for the floor. V13 removed the gloves he had just cleaned the vomit with and opened R3's door without performing hand hygiene. V13 then went down the hall to the housekeeper's cart and grabbed a can of disinfectant. V13 then put on a pair of new gloves, again without performing hand hygiene. V13 sprayed the disinfectant on the floor and wiped it up. V13 grabbed the garbage bag that had the soiled incontinence brief in it and put it on the floor next to R3's room door and went out of the room and rolled the linen cart down the hall to R3's room. V13 removed his gloves and donned new gloves without performing hand hygiene and put the dirty linens in the linen cart. R3 took the gloves off, and without performing hand hygiene, grabbed R3's wheelchair and put it closer to her bedside. V13 put some additional linens in the linen cart then took the trash he had by the entry, left the room with it, and threw it away in the hallway trash cart. On April 23, 2025 at 2:00 PM, V2 (Director of Nursing) stated staff should wash hands before providing care, after providing care, after removing gloves, and before touching other surfaces. V2 stated staff should perform hand hygiene to prevent transmission of infection. The facility's Hand hygiene/handwashing policy revised July 30, 2024 showed the following; when to perform hand hygiene: at room entry, before exiting the room, before and after having direct contact with a patient's intact skin, after contact with blood, body fluids, or excretions, mucous membranes, non-intact skin or wound dressings, after contact with inanimate objects in the immediate vicinity of the patient, if hands will be moving from a contaminated-body site to a clean-body site during patient care, and after glove removal. Based on observation, interview, and record review, the facility failed to follow their Water Management Plan for Legionella. The facility also failed to follow their policies for handling soiled laundry, contact isolation, hand hygiene during provisions of care, and cleaning medical devices between residents. This applies to all 86 residents residing in the facility. The findings include: The facility's Long-term Care Application for Medicare and Medicaid dated April 21, 2025, showed the facility's census was 86 residents. 1. On April 22, 2025, at 4:00 PM, V10 (Maintenance Director) said for the facility's Water Management Plan for Legionella, V10 does not do anything because there is no risk for Legionella in the facility. V10 said there is one eye wash station in the facility, in the kitchen, and V10 activates the eye wash station once a month. V10 demonstrated activating the eye wash station, V10 turned the eye wash station on, the water pushed the eye wash covers off, and V10 immediately turned off the eye wash station water. V10 said once a week V10 obtains water temperatures in five resident rooms and the shower rooms. V10 said he does not obtain any other water temperatures in the facility. V10 said he does not document the hot water tanks temperature. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145740 If continuation sheet Page 12 of 14 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 145740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Elgin 134 North McLean Boulevard Elgin, IL 60121 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 On April 23, 2025, at 1:20 PM, V1 (Administrator) said the facility does not have documentation to show V10 was monitoring water temperatures prior to April 16, 2025. On April 23, 2025, at 2:20 PM, V16 (Regional Consultant) said V10 should be following the facility's Water Management Plan for Legionella and documenting the control measure monitoring. Residents Affected - Many The facility's policy titled Water Management Program Guidelines revised on March 24, 2025, showed, Purpose: To identify and reduce the risk of Legionella and other opportunistic pathogens growth and spread in the facility water system. Guidelines The facility shall develop and implement a facility water management program plan to identify potential hazards and reduce the risk of growth and spread of Legionella and other opportunistic pathogens in the facility water system in accordance with current recommendations from ASHRAE (American Society of Heating, Refrigerating, and Air-Conditioning Engineers) standard 514: .Control Measures- Determine locations where control measures shall be applied and maintained to stay within established control limits. Monitoring/Corrective Actions- Establish procedures for monitoring whether control measures are operating within established limits and if not, take corrective actions. ConfirmationEstablish procedures to confirm the following: program is being implemented as designed- verification; Program controls the hazardous conditions throughout the building water systems- validation. Documentation- Establish documentation and communication procedures for all activities of the program . Environmental Services shall be responsible for monitoring the identified areas of risk per and implementing corrective action as indicated and established by the water management program/plan. The facility will perform an assessment of their water system to identify risk areas and determine corrective actions to be taken when control measures are identified to be outside of the parameters established by the facility . Examples of internal factors that increase the risk of Legionella growth: .Water temperature fluctuations: Provide conditions where Legionella grows best (77 degrees Fahrenheit to 113 degrees Fahrenheit); Legionella can still grow outside this range. Many things can cause the hot water temperature to drop into the range where Legionella can grow, including low settings on water heaters, heat loss as water travels through long popes away from the heat source, mixing cold and hot water within the plumbing system, heat transfer (when cold and hot water pipes are too close together), or heat loss due to water stagnation. In hot weather, cold water in pipes can heat up into this range . The facility's Water System Assessment for Legionella Risk dated January 3, 2025, showed .2. Cold Water Distribution: Eyewash stations- List all locations: Kitchen and Utility Room . Comments: Any areas of risk identified such as potential stagnation, dead legs, etc.? If yes please describe below: Eye was stations: Potential stagnation due to infrequent use. Intervention: flush weekly for five minutes . Heating: Water Heaters- List location of each water heater: East boiler room and [NAME] boiler room . Potential risk for improper temperature settings. Intervention: Temperature settings of water heater and/or storage tank (if applicable) will be checked weekly and logged to confirm temperature is set between 140 to 160 degrees Fahrenheit . Hazard Analysis: .Processing Step: 2. Hot Water Tank Heater and/or Hot Water Storage, Mixing Valve. Potential Hazard: Potential growth of microorganisms in heating system. Scalding potential if temperatures are greater than 100 degrees Fahrenheit at the fixture. Risk: Yes. Risk Basis: High Risk: There is potential for microbiological growth at the heating step. This is reduced at temperatures greater than 124 degrees Fahrenheit. Elevated temperature targets also present a noticeable scalding hazard. There factors provide further reason why maintenance of the target temperatures are an essential control measure. Control Measures: 1. Adjust temperature to provide further microbiological control and prevent scalding . Processing Step: 6. Emergency Eye Wash Stations. Potential Hazard: Potential growth of microorganisms which could be propagated and transmitted via cold water distribution piping system and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145740 If continuation sheet Page 13 of 14 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 145740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Elgin 134 North McLean Boulevard Elgin, IL 60121 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 aerosolized. Risk: Yes. Risk Basis Medium Risk: The Emergency Eye Wash and Showers are usually classified as medium risk due to the rarity of their use and the specific situation when they are used. Control Measures: 1. Weekly testing, flushing and cleaning of Emergency Eye Washes . Control Limits and Monitoring: Processing Step: Hot Water Heater and Storage: Domestic Hot Water Tanks, Kitchen Hot Water Tank. Critical Control Limit: Water Heater/Storage Tank set to not less than 140 degrees Fahrenheit (recommended 140 to 160 degrees Fahrenheit. Monitoring: Verify temperature settings of water heater(s)/storage tanks. Frequency: Weekly . Processing Step: Cold Water Distribution: Check disinfectant level (chlorine or chloramine), temperature, and pH (potential of Hydrogen). Critical Control Limit: Potable Water: Cold Water temperature less than 68 degrees Fahrenheit; Residual chlorine of chloramine 0.2 to 0.4 ppm (parts per million); pH 6.5 to 8.5. Monitoring: Check cold water critical control limit in at least three locations: sample a point closest to entry point of water into the facility and at least two fixtures located in areas of the facility most distal from water entry point. Frequency: Weekly. Limit Deviation Corrective Action Suggestion: Contact municipal water department . Processing Step: Plumbed Eye Wash Stations. Critical Control Limit: Preventative maintenance, flushing and cleaning. Monitoring Flush all plumbed eye was stations for five minutes and clean nozzles and equipment. Frequency: Weekly . The facility does not have documentation to show Control Measures were being monitored as shown in the Water Management Plan for Legionella. 2. On April 23, 2025, at 1:24 PM, during a tour of the facility's laundry with V1 and V15 (Housekeeping), V15 said she receives the facility's soiled laundry through a laundry chute and brings the bags of soiled laundry to the washing machine. V15 said when she loads the soiled laundry into the washing machine, V15 wears gloves. V15 continued to say she does not wear a gown or apron when handling the soiled laundry. No apron or gown was observed in the laundry room. On April 23, 2025, at 1:51 PM, V1 said V15 should be wearing an apron when handling soiled laundry. The facility's policy titled Linen Handling- Laundry Department revised on January 11, 2018, showed Purpose: To ensure the proper handling, storage, processing, and transport of all linens and laundry in accordance with accepted national standards in order to produce hygienically clean laundry and prevent the spread of infection to the extent possible. Guidelines: The facility staff should handle all used laundry as potentially contaminated and use standard precautions (i.e., gloves) . 6. Laundry personnel shall wear aprons and utility or non-sterile gloves when handling linens soiled with blood or body fluids . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145740 If continuation sheet Page 14 of 14