Inspection·March 6, 2024

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few C3 (controlled substance) to C5 (controlled substance) medications in the back medication cart was missing. (V3) reported it to her boss and she also reported it to me. Myself and the other 2 nurses were the second eyes of the search. We looked everywhere in the back and front stations, medication and treatment carts and the medication room. We could not find it. I called my boss (V4) and let her know. She made an incident report for the facility's missing emergency medication box. She had me fill out some questionnaires and interview the nurses. She reported it to IDPH (Illinois Department of Public Health) and she told me to report it to the police department. On 2/21/24, V8 (Police Officer) from the local police department came and interviewed me and (V3) in my office. The emergency box was replaced on 3/1/24 by pharmacy. Yes, I believe making sure the emergency box is there should be part of the check. Staff need to do a physical check to make sure it's really there. We also need to make sure it's intact and not tampered with. On 3/5/24 at 10:02 AM, V6 stated, A couple of weeks on 2/9 or 2/10, we were missing (R1) and (R2's) narcotic medications. We also were missing their pink sheets which has the name of the medications. I believe (V7) took them because I started to notice a trend or pattern in resident's medication missing. It was my process of deduction. I just didn't trust (V7) because she would want to leave early on her shift before the night nurse would come, so she could avoid counting the narcotics. On 2/21/24, (V3-Pharmacist) and I were doing the narcotic count in my medication cart which is the back cart. (V3) then asked to see the emergency medication box. What I thought was the emergency box turned out to be a box with an IV infusion pump kit. It was covered in a thick plastic similar to what the emergency box was wrapped in. I never had to open the emergency box except to clean the dust bunnies. I received the new box on 2/6/24. That was the last interchange where pharmacy puts a new emergency box in our medication cart. Oh God no, I didn't take the emergency box. I think maybe (V7) who is no longer with us took it because we think she allegedly took some narcotic medications (which belonged to R1 and R2). Anyway, we searched all over and we couldn't find it. We never had to check or verify the emergency box was there on the log sheet. We started doing that after the incident. On 3/5/24 at 10:54 AM, telephone interview was conducted with V4 (Regional Director of Operations/RN). V4 stated, Yes, on 2/11/24, (V2) called me and told me that two residents' narcotic medications were missing. I don't remember who the residents were, and the name of the medications. She thought they were missing. (V2) couldn't really pinpoint if (V7) took the medications. There was no proof. On 2/21/24, (V2) again called me and told me that (V3-Pharmacist) came to do the monthly review in the facility and could not find the emergency box for the back side. I instructed her to call the police. I did an incident report for the facility's emergency medication box and (V2) helped me interview the nurses, we also called the police. On 3/5/24 at 11:10 AM, telephone interview was conducted with V3 (Pharmacist) in the presence of V2. V3 stated she was not aware of R1 and R2's medications missing. V3 said, On 2/21/24, I was in the nursing home doing an audit like how I do every time I'm there. I checked the front medication cart and saw the emergency box was there. Then I checked the back medication cart while V6 (RN-Registered Nurse) was manning it. We could not find the emergency box which is kept in the narcotic box. Instead, we found a box that had an IV (Intravenous) pump. We did a search and were looking in the front medication cart and medication room. We couldn't find it. The police were notified and (V8) came and interviewed me and (V2). I notified my general manager and he notified DEA (Drug Enforcement Association). We replaced the emergency box on 3/1/24. On 3/5/24 at 1:05 PM, telephone interview was done with V10 (LPN). V10 stated, I work part time and I work nights. (R1) and (R2's) Norco was delivered on 2/9/24 at around 2:30 AM when I was working. That evening (V7) was working. She called me at home and told me that she needed to leave early. I (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145825 If continuation sheet Page 2 of 13 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 145825 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Elgin Living & Rehab Center 746 West Spring Street South Elgin, IL 60177 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few told her that's okay, but that she would have to do the narcotic count with (V11) who was working in the front section and leave the keys for the medication with her as well. When I came to the facility, I saw the keys were just left inside the narcotic binder which was lying on top of the medication cart. (V7) never endorsed it to (V11). On 2/10/24 on the night shift, I noticed (R1) and (R2's) medication cards for the Norco and pink slips (narcotic count/signout sheets) were missing. I called (V7) at home and asked her if she gave them their medications. She said no. Then I called (V2) at 6:30 AM on a Sunday and told her I'm missing (R1) and (R2's) medication cards and pink slips. On 3/5/24 at 2:42 PM, telephone interview was conducted with V8 (Police Officer). V8 stated, (V2) called me as soon as she found out that the emergency medication box was missing. I came to the nursing home and interviewed (V2) and (V3) in (V2's) office. They told me they suspect (V7-LPN) because she was terminated for allegedly stealing some residents' medications earlier in the month. I made an incident report (#24-001913) and reported it to the investigations department. On 3/5/24 at 10:36 AM, V2 submitted a list of controlled substances that were in the back emergency box that was found to be missing by the facility on 2/21/24. Those controlled substances include the following: Acetaminophen-Codeine #3 300 MG (Milligrams)-30 MG tablet, Clonazepam 0.5 MG tablet, Tramadol HCL 50 MG tablet, Zolpidem Tartrate 5 MG tablet, Alprazolam 0.5 MG tablet, Alprazolam 0.25 MG, Lorazepam 1 MG tablet, Diazepam 5 MG tablet, Temazepam 15 MG capsule, and Lorazepam 0.5 MG tablet. Facility's initial report dated 2/21/24 regarding the missing emergency kit box shows: It was reported to (V4-Director of Clinical Operations), that while Pharmacist was on site and conducting review, the emergency control box could not be located. Investigation initiated interventions for remaining emergency control boxes put in place. Proper notifications made. At this time, the investigation is ongoing. No residents were affected by the loss of the control box. Will continue to follow protocol, and notify appropriate authorities of any changes. Facility's final report dated 2/26/24 shows: Missing EKIT (Emergency Kit) C3-C5 Time Line. Date noticed missing: 2/21/24. Who reporting missing: (V3-Pharmacist) onsite to do monthly pharmacy review. Last time EKIT was accounted for: delivered on 2/6/24 at 6:56 PM, signed for by (V6-RN) and confirmed by her. Where was the EKIT stored once it was received by the nurse: (V6) placed it inside the narcotic section of the medication cart. When was the last time anyone can recall seeing the EKIT: 1. (V10-LPN/Licensed Practical Nurse) said she remembered seeing the EKIT inside the narcotic section when she worked night shift on 2/9/24. 2. (V11-RN) said on 2/10/24 (evening shift) between 9 PM to 10 PM (she was assigned at the front nurse station), the nurse at the back station (V7-LPN) called her attention and showed her the EKIT. (V7) told her this is where the other nurse (V6) should get the narcotics. (V7) left her post at the end of the shift without waiting for the night shift nurse. She left the keys in the narcotic binder. Statements from each nurse who between the dates of 2/6/24 and 2/21/24: 1. (V6) saw the EKIT on 2/6/24. She didn't notice it until it was discovered by the pharmacist that it was missing. Somebody placed the IV infusion pump inside the narcotic section and she thought it was the EKIT. Police report filed and initial report sent to IDPH (Illinois Department of Public Health) on 2/21/24. On 2/26/24, V4 followed up with V8 (Police officer). At this time, the EKIT has still not been located. R1's face sheet shows an admission date of 1/11/24. R1's POS (Physician Order Sheet) for February 2023 shows an order for Hydrocodone-Acetaminophen (Norco) 5-325 MG (Milligrams)-1 tablet by mouth every 6 hours as needed. R1's delivery receipt it shows that her Norco (6 tablets) was delivered on 2/9/24. V10 signed for it and wrote the following in ink: I received this medication last night on 2/10/24 at 3 AM together with the Norco for (R2). I also didn't give any tablets to (R1) and (R2). Both (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145825 If continuation sheet Page 3 of 13 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 145825 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Elgin Living & Rehab Center 746 West Spring Street South Elgin, IL 60177 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 0602 Level of Harm - Minimal harm or potential for actual harm their Bingo cards for the Norco and the pink form to be signed by the nurse are both missing now. When I counted, I didn't notice that it's missing because the Bingo Cards in the narcotic box and the pink forms are matching. I noticed it when another narcotic medication-the Ativan for (R2) was delivered at 2:30 AM. And I noticed that the Norco of (R2) was all gone when I checked the pink form. It's not in the book also. I checked the Norco for (R1) and it was not there also. Residents Affected - Few R2's face sheet shows an admission date of 12/28/23. R2's March 2023 POS shows an order for Hydrocodone-Acetaminophen 5-325 MG (Milligrams)-1 tablet by mouth every 6 hours as needed. It was ordered on 12/29/23. R2's delivery receipt shows that her Norco (6 tablets) was delivered on 2/9/24. V10 signed for it and wrote the following in ink: Received last night on 2/10/24 at 3:00 AM. Didn't give any to resident yet and nurse to nurse counted in morning. Still 6 tablets still in narcotic box. Now, I counted the narcotic meds and missing the whole Bingo car and the pink form. No endorsement done because the pm nurse (V7) left already. I came at 10:20 Pm in the facility. I told the nurse if she wants to leave early, she has to endorse to the front nurse and leave the keys with her. But she didn't do it. Facility was unable to provide an incident report regarding R1 and R2's medications missing. Pharmacy's policy titled Loss or Theft of Medications (1/1/24) shows: If controlled substances are missing from the emergency medication supply (1.e., emergency kit, emergency box, e-kit, etc,) Facility staff should notify pharmacy immediately for appropriate action. Facility's policy titled Controlled Substances (11/6/18) shows: The schedule II cabinet must remain locked and charge nurse shall have the key in her possession at all times. Only Licensed nurses will have access to controlled substances. 7. The drugs in schedule II (and those in other schedules which have been restricted and stored in the Controlled Substance cabinet) will be counted and reconciled by the nurse coming on duty with the nurse thats going off duty. 9. Discrepancies must be reported immediately to the Director of Nursing who shall investigate as described in the missing controlled substance policy. When loss, suspected theft or an error in the administration of regulated drug occurs, a report will be filed with the pharmacist and the administrator. Facility's policy titled Missing Controlled Substance (11/6/18) shows: It is the policy of this facility to prevent the loss of controlled substances and vigorously investigate incorrect inventory of controlled drugs, medications or pharmaceuticals reported by pharmacists, physicians or licensed nurses. 1. All controlled drugs will be counted by the oncoming and outgoing nurse at the change of each shift as per the Controlled Drug policy and procedure. 3. The oncoming and outgoing Licensed Nurse will sign the controlled substance inventory sheet each change of shift to signify the count was completed and is accurate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145825 If continuation sheet Page 4 of 13 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 145825 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Elgin Living & Rehab Center 746 West Spring Street South Elgin, IL 60177 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to complete an incident report and notify the state agency about theft of resident property. This applies to 2 of 2 residents (R1, R2) reviewed for narcotic medications in a sample of 2. The finding include: On 3/5/24 at 10:02 AM, V6 (RN-Registered Nurse) stated, A couple of weeks on 2/9 or 2/10, we were missing (R1) and (R2's) narcotic medications. We also were missing their pink sheets which has the name of the medications. I believe (V7-LPN/Licensed Practical Nurse) took them because I started to notice a trend or pattern in resident's medication missing. It was my process of deduction. I just didn't trust (V7) because she would want to leave early on her shift before the night nurse would come, so she could avoid counting the narcotics. On 3/5/24 at 10:15 AM, V2 (DON-Director of Nursing) stated, On 2/9/24, (V10-LPN) was working the night shift and she received a delivery of (R1) and (R2's) Norco. It was around 2 AM. On 2/10/24 in the morning, (V6) came and relieved (V10). They both did the count together. (R1) and (R2's) medications were there. Then, in the evening shift, (V7) started her shift and counted the narcotics with (V6) who was the off going. Again, (R1) and (R2's) medications were there. I heard from (V10) that (V7) called her at home and said she had to leave early due to her family emergency. (V10) told (V7) to endorse the keys and narcotics sheet binder to (V11-LPN) who works in the front area. When (V10) came that night to start her shift, she found the narcotic keys inside the narcotic medication binder on top of the medication cart. (V7) never endorsed it to (V11). I was made aware by (V10) on 2/11/24, that she couldn't find (R1) and (R2's) medication cards and pink sheets. She said it was there on 2/9/24 because she got the delivery on her shift. On 2/11/24, I notified (V4-Regional Director of Operations/RN) via phone of what happened. That was a Sunday. On 2/12/24, (V4) came to the facility and I told her what happened. I don't have an incident report for what happened. I'm not sure if Public Health was notified. You would have to talk to (V4). Also on 2/12/24, I asked (V7) to come to the facility so I could talk to her about something important. She was scheduled to be off on 2/12 and 2/13. In the presence of (V12 - RN/MDS-Minimum Data Set Coordinator), I interviewed (V7). (V7) denied stealing (R1) and (R2's) medications. I also told her that she can't just leave the narcotic keys in the narcotic binder and leave her shift. We don't have proof that she stole the medications, but they were there at the start of her shift, because she signed off for them with (V6). (V7) was upset and stated she was feeding her family and needed money. On 3/5/24 at 10:54 AM, telephone interview was conducted with V4 (Regional Director of Operations/RN). V4 stated, Yes, (V2) called me and told me that two residents' narcotic medications were missing. I don't remember who the residents were, and the name of the medications. She thought they were missing. (V2) couldn't really pinpoint if (V7) took the medications. There was no proof. So, that's why I didn't do an incident report because the nurse just thought the medications were missing. She wasn't sure and the patients didn't go without medications. If I knew for sure, I would have completed an incident report and reported it to IDPH (Illinois Department of Public Health). On 3/5/24 at 11:44 PM, V12 (MDS Coordinator) stated that on 2/12/24, V2 asked her to be a witness when they questioned V7 about R1 and R2's missing medications and when they terminated her. V12 stated that V7 denied all the allegations. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145825 If continuation sheet Page 5 of 13 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 145825 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Elgin Living & Rehab Center 746 West Spring Street South Elgin, IL 60177 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 3/5/24 at 11:10 AM, telephone interview was done V3 (Pharmacist). V3 stated she was not aware of R1 and R2's medications missing. On 3/5/24 at 1:05 PM, telephone interview was done with V10 (LPN). V10 stated, I work part time and I work nights. (R1) and (R2's) Norco was delivered on 2/9/24 at around 2:30 AM when I was working. That evening (V7) was working. She called me at home and told me that she needed to leave early. I told her that's okay, but that she would have to do the narcotic count with (V11) who was working in the front section and leave the keys for the medication with her as well. When I came to the facility, I saw the keys were just left inside the narcotic binder which was lying on top of the medication cart. (V7) never endorsed it to (V11). On 2/10/24 on the night shift, I noticed (R1) and (R2's) medication cards for the Norco and pink slips (narcotic count/signout sheets) were missing. I called (V7) at home and asked her if she gave them their medications. She said no. Then I called (V2) at 6:30 AM on a Sunday and told her I'm missing R1 and R2's medication cards and pink slips. R1's face sheet shows an admission date of 1/11/24. R1's POS (Physician Order Sheet) for February 2023 shows an order for Hydrocodone-Acetaminophen (Norco) 5-325 MG (Milligrams)-1 tablet by mouth every 6 hours as needed. R1's delivery receipt it shows that her Norco (6 tablets) was delivered on 2/9/24. V10 signed for it and wrote the following in ink: I received this medication last night on 2/10/24 at 3 AM together with the Norco for (R2). I also didn't give any tablets to (R1) and (R2). Both their Bingo cards for the Norco and the pink form to be signed by the nurse are both missing now. When I counted, I didn't notice that it's missing because the Bingo Cards in the narcotic box and the pink forms are matching. I noticed it when another narcotic medication-the Ativan for (R2) was delivered at 2:30 AM. And I noticed that the Norco of (R2) was all gone when I checked the pink form. It's not in the book also. I checked the Norco for (R1) and it was not there also. R2's face sheet shows an admission date of 12/28/23. R2's March 2023 POS shows an order for Hydrocodone-Acetaminophen 5-325 MG (Milligrams)-1 tablet by mouth every 6 hours as needed. It was ordered on 12/29/23. R2's delivery receipt shows that her Norco (6 tablets) was delivered on 2/9/24. V10 signed for it and wrote the following in ink: Received last night on 2/10/24 at 3:00 AM. Didn't give any to resident yet and nurse to nurse counted in morning. Still 6 tablets still in narcotic box. Now, I counted the narcotic meds and missing the whole Bingo car and the pink form. No endorsement done because the pm nurse (V7) left already. I came at 10:20 Pm in the facility. I told the nurse if she wants to leave early, she has to endorse to the front nurse and leave the keys with her. But she didn't do it. Facility was unable to provide an incident report regarding R1 and R2's medications missing. Facility's abuse policy titled Abuse Prevention Program (11/28/16) documents: Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. 5. Final Investigation Report. The investigator will report the conclusions of the investigation in writing to the administrator or designee within five working days of the reported incident. The final investigation report shall contain the following: Name, age, diagnosis and mental status of the resident allegedly abused or neglected; The original allegation (note day, time, location, the specific allegation, by whom, witnesses to the occurrence, circumstances surrounding the occurrence and any noted injuries; Facts determined during the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145825 If continuation sheet Page 6 of 13 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 145825 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Elgin Living & Rehab Center 746 West Spring Street South Elgin, IL 60177 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few process of the investigation, review of medical record and interview of witnesses; Conclusion of the investigation based on known facts; If there is a police report, attach the police report; If the allegation is determined to be valid and the perpetrator is an employee, include on a separate sheet the employee's name, address, phone number, title, date of hire, copies of previous disciplinary actions, and current status (still working, suspended or terminated); and Attach a summary of all interviews conducted, with the names, addresses, phone numbers and willingness to testify of all witnesses. The administrator or designee will review the report. The administrator or designee is then responsible for forwarding a final written report of the results of the investigation and of any corrective action taken to the Department of Public Health within five working days of the reported incident. The administrator or designee is also responsible for informing the resident or their representative of the results of the investigation and of any corrective action taken. 1. Initial Reporting of Allegations. The facility must ensure that all alleged violations involving mistreatment, exploitation, neglect or abuse, including injuries of unknown source, misappropriation of resident property, and reasonable suspicion of a crime, are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures. If the events that cause the reasonable suspicion result in serious bodily injury or suspected criminal sexual abuse, the report shall be made to at least one law enforcement agency of jurisdiction and IDPH immediately after forming the suspicion (but not later than two hours after forming the suspicion), Otherwise, the report must be made not later than 24 hours after forming the suspicion. 2. A written report shall be sent to the Department of Public Health. The written report should contain the following information, if known at the time of the report; 3. Name, age, diagnosis and mental status of the resident allegedly abused or neglected; 4. Type of abuse reported (physical, sexual, theft, neglect, exploitation, verbal or mental abuse); 5. Date, time, location and circumstances of the alleged incident; 6. Any obvious injuries or complaints of injury; and, 7. Steps the facility has taken to protect the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145825 If continuation sheet Page 7 of 13 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 145825 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Elgin Living & Rehab Center 746 West Spring Street South Elgin, IL 60177 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 0609 8. Level of Harm - Minimal harm or potential for actual harm The administrator or designee will also inform the resident or resident's representative of the report of an occurrence of potential mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property and that an investigation is being conducted. Residents Affected - Few 9. Five-day Final Investigation Report. Within five working days after the report of the occurrence a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health. The Public Health requirements for a final investigation report are detailed in paragraph 5 of the Internal Investigations section of this procedure. For the protection of all individuals involved, copies of any internal reports, interviews and witness statements during the course of the investigation shall be released only with the permission of the administrator or the facility attorney. 10. Informing the Resident's Representative. The administrator or designee will inform the resident or resident's representative of the conclusions of the investigation. 11. Informing Law Enforcement Authorities. If there is clear evidence of abuse by an employee, the Department of Public Health will notify the Health Care Worker Registry or the Department of Financial and Professional Regulation. The Department of Public Health will also notify the State Police for further investigation of the employee. If there is any reasonable suspicion of a crime, as defined by local law, the administrator shall immediately (not later than two hours after forming the suspicion in the event of serious bodily injury or suspected criminal sexual abuse) notify local law enforcement as soon as possible but no later than 24 hours in accordance with 300.695 (b). The pharmacy's policy titled Loss or Theft of Medications (1/1/24) shows: Procedure: 1. Where facility staff suspect theft or loss of medications, facility staff should take such actions as required by applicable law and facility policy. Appropriate actions may include, without limitation: 1.1. Immediately report suspected theft or loss of drugs to a supervisor/manager or the director of nursing for appropriate investigation and follow-up and 1.3 Notifying the appropriate facility administrator of controlled substance discrepancies and if such discrepancies are not reconciled, notifying the appropriate law enforcement agencies according to applicable law and facility policy 4.1 If there is suspected misuse or theft of a resident's medications, the facility must notify the appropriate regulatory agency within 2 hours. 5. The Director of Nursing (DON) will direct and investigation into the incident including a full accounting of controlled substances. The investigation will be conducted with the assistance of human resources and will be completed within 48 hours of the incident's discovery. 6. Report must include: 6.1. Identity and quantity of medication involved. 6.2 Identity of employee reporting theft or loss. 6.3 Name of any state or regulatory agency involved in investigation. 6.4 How suspected theft or loss was discovered. 6.5 Date of suspected theft or loss. 6.6 Detailed written description of the investigation conducted. 6.7 Results of the investigation and 6.8 Performance improvement measures taken to ensure theft or loss does not reoccur 8. The administrator will (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145825 If continuation sheet Page 8 of 13 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 145825 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Elgin Living & Rehab Center 746 West Spring Street South Elgin, IL 60177 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 0609 determine which, if any, agencies need to be notified of the incident. Level of Harm - Minimal harm or potential for actual harm Facility's policy titled Controlled Substances (11/6/18) shows 9. Discrepancies must be reported immediately to the Director of Nursing who shall investigate as described in the missing controlled substance policy. When loss, suspected theft or an error in the administration of regulated drug occurs, a report will be filed with the pharmacist and the administrator. Residents Affected - Few Facility's policy titled Missing Controlled Substances (11/6/18) shows 8. The Administrator will be responsible for notifying the police, regulatory agencies as relevant and the regional director of any findings of the investigation suggestive of misappropriation of controlled substances. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145825 If continuation sheet Page 9 of 13 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 145825 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Elgin Living & Rehab Center 746 West Spring Street South Elgin, IL 60177 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 - Many 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 interview and record review, the facility failed to safeguard resident's individual narcotic medications and failed to secure the facility's emergency control medication box, which resulted in the disappearance of these medications. This applies to 2 of 2 residents (R1, R2) for missing individual prescriptions and has the potential to affect the remaining 55 residents in the facility reviewed for prescription medications. The findings include: On 3/5/24 at 9:15 AM, V1 (Administrator) submitted to surveyor the facility resident roster which shows there is a current census of 57 residents. On 3/5/24 at 9:16 AM, V1 stated she just started yesterday and was unaware of any incidents regarding the missing emergency medication box with controlled substances. On 3/5/24 at 9:22 AM, V2 (DON-Director of Nursing) stated, On 2/9/24, (V10-LPN) was working the night shift and she received a delivery of (R1) and (R2's) Norco. It was around 2 AM. On 2/10/24 in the morning, (V6) came and relieved (V10). They both did the count together. (R1) and (R2's) medications were there. Then, in the evening shift, (V7) started her shift and counted the narcotics with (V6) who was the off going. Again, (R1) and (R2's) medications were there. I heard from (V10) that (V7) called her at home and said she to leave early due to her family emergency. (V10) told (V7) to endorse the keys and narcotics sheet binder to (V11-LPN) who works in the front area. When (V10) came that night to start her shift, she [NAME] the narcotic keys inside the narcotic medication binder on top of the medication cart. (V7) never endorsed it to V11. I was made aware by (V10) on 2/11/24, that she couldn't find (R1) and (R2's) medication cards and pink sheets. She said it was there on 2/9/24 because she got the delivery on her shift. On 2/11/24, I notified (V4-Regional Director of Operations/RN) via phone of what happened. That was a Sunday. On 2/12/24, came to the facility and I told her what happened. I don't have an incident report for what happened. Also on 2/12/24, I asked (V7) to come to the facility so I could talk to her about something important. She was scheduled to be off on 2/12 and 2/13. In the presence of (V12 - RN/MDS-Minimum Data Set Coordinator), I interviewed (V7). (V7) denied stealing (R1) and (R2's) medications. I also told her that she can't just leave the narcotic keys in the narcotic binder and leave her shift. We don't have proof that she stole the medications, but they were there at the start of her shift, because she signed off for them with (V6). (V7) was upset and stated she was feeding her family and needed money. V2, DON continued to say that the facility has two locations for the emergency medication box and keep one in the front medication cart and the other emergency box is kept in the back medication cart. Like in other facilities, we don't keep the emergency box in the medication room. The front station consists of rooms 300 to 400 and the back stations consists of rooms 100 to 200. On 2/21/24, our regular pharmacist (V3) came to the facility to do her regular monthly audits. She was checking the medication carts both front and back. She visibly noted that the emergency box that contained the C3 (controlled substance) to C5 (controlled substance) medications in the back medication cart was missing. (V3) reported it to her boss and she also reported it to me. Myself and the other 2 nurses were the second eyes of the search. We looked everywhere in the back and front stations, medication and treatment carts and the medication room. We could not find it. I called my boss (V4 - Regional (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145825 If continuation sheet Page 10 of 13 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 145825 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Elgin Living & Rehab Center 746 West Spring Street South Elgin, IL 60177 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 - Many Clinical Director of Operations) and let her know. She made an incident report fpr the facilitys missing emergency medication box. She had me fill out some questionnaires and interview the nurses. She reported it to IDPH (Illinois Department of Public Health) and she told me to report it to the police department. On 2/21/24, (V8 - Police Officer) from the local police department came and interviewed me and (V3) in my office. The emergency box was replaced on 3/1/24 by pharmacy. Yes, I believe making sure the emergency box is there should be part of the check. Staff need to do a physical check to make sure it's really there. We also to make sure it's intact and not tampered with. On 3/5/24 at 10:02 AM, V6 (RN-Registered Nurse) stated, A couple of weeks on 2/9 or 2/10, we were missing (R1) and (R2's) narcotic medications. We also were missing their pink sheets which has the name of the medications. I believe (V7-LPN/Licensed Practical Nurse) took them because I started to notice a trend or pattern in resident's medication missing. It was my process of deduction. I just didn't trust (V7) because she would want to leave early on her shift before the night nurse would come, so she could avoid counting the narcotics. On 2/21/24, (V3-Pharmacist) and I were doing the narcotic count in my medication cart which is the back cart. (V3) then asked to see the emergency medication box. What I thought was the emergency box turned out to be a box with an IV infusion pump kit. It was covered in a thick plastic similar to what the emergency box was wrapped in. I never had to open the emergency box except to clean the dust bunnies. I received the new box on 2/6/24. That was the last interchange where pharmacy puts a new emergency box in our medication cart. Oh God no, I didn't take the emergency box. I think maybe (V7) who is no longer with us took it because we think she allegedly took some narcotic medications (which belonged to R1 and R2). Anyway, we searched all over and we couldn't find it. We never had to check or verify the emergency box was there on the log sheet. We started doing that after the incident. On 3/5/24 at 10:54 AM, telephone interview was conducted with V4 (Regional Director of Operations/RN). V4 stated, Yes, on 2/11/24, (V2) called me and told me that two residents' narcotic medications were missing. I don't remember who the residents were, and the name of the medications. She thought they were missing. (V2) couldn't really pinpoint if (V7) took the medications. There was no proof. On 2/21/24, (V2) again called me and told me that (V3-Pharmacist) came to do the monthly review in the facility and could not find the emergency box for the back side. I instructed her to call the police. I did an incident report for the facility's emergency medication box and (V2) helped me interview the nurses, the police were also called. On 3/5/24 at 11:10 AM, telephone interview was conducted with V3 (Pharmacist) in the presence of V2. V3 stated she was not aware of R1 and R2's medications missing. V3 said, On 2/21/24, I was in the nursing home doing an audit like how I do every time I'm there. I checked the front medication cart and saw the emergency box was there. Then I checked the back medication cart while (V6 - RN-Registered Nurse) was manning it. We could not find the emergency box which is kept in the narcotic box. Instead, we found a box that had an IV (Intravenous) pump. We did a search and were looking in the front medication cart and medication room. We couldn't find it. The police were notified and (V8) came and interviewed me and (V2). I notified my general manager and he notified DEA (Drug Enforcement Association). We replaced the emergency box on 3/1/24. On 3/5/24 at 1:05 PM, telephone interview was done with V10 (LPN). V10 stated, I work part time and I work nights. (R1) and (R2's) Norco was delivered on 2/9/24 at around 2:30 AM when I was working. That evening (V7) was working. She called me at home and told me that she needed to leave early. I told her that's okay, but that she would have to do the narcotic count with (V11) who was working in the front section and leave the keys for the medication with her as well. When I came to the facility, I saw the keys were just left inside the narcotic binder which was lying on top of the medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145825 If continuation sheet Page 11 of 13 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 145825 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Elgin Living & Rehab Center 746 West Spring Street South Elgin, IL 60177 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 - Many cart. (V7) never endorsed it to (V11). On 2/10/24 on the night shift, I noticed (R1) and (R2's) medication cards for the Norco and pink slips (narcotic count/signout sheets) were missing. I called (V7) at home and asked her if she gave them their medications. She said no. Then I called (V2) at 6:30 AM on a Sunday and told her I'm missing R1 and R2's medication cards and pink slips. On 3/5/24 at 2:42 PM, telephone interview was conducted with V8 (Police Officer). V8 stated, (V2) called me as soon as she found out that the emergency medication box was missing. I came to the nursing home and interviewed (V2) and (V3) in (V2's) office. They told me they suspect (V7-LPN) because she was terminated for allegedly stealing some residents' medications earlier in the month. I made an incident report (#24-001913) and reported it to the investigations department. On 3/5/24 at 10:36 AM, V2 submitted a list of controlled substances that were in the back emergency box that was found to be missing by the facility on 2/21/24. Those controlled substances include the following: Acetaminophen-Codeine #3 300 MG (Milligrams)-30 MG tablet, Clonazepam 0.5 MG tablet, Tramadol HCL 50 MG tablet, Zolpidem Tartrate 5 MG tablet, Alprazolam 0.5 MG tablet, Alprazolam 0.25 MG, Lorazepam 1 MG tablet, Diazepam 5 MG tablet, Temazepam 15 MG capsule, and Lorazepam 0.5 MG tablet. Facility's initial report dated 2/21/24 regarding the missing emergency kit box shows: It was reported to (V4-Director of Clinical Operations), that while Pharmacist was on site and conducting review, the emergency control box could not be located. Investigation initiated interventions for remaining emergency control boxes put in place. Proper notifications made. At this time, the investigation is ongoing. No residents were affected by the loss of the control box. Will continue to follow protocol, and notify appropriate authorities of any changes. Facility's final report dated 2/26/24 shows: Missing EKIT (Emergency Kit) C3-C5 Time Line. Date noticed missing: 2/21/24. Who reporting missing: (V3-Pharmacist) onsite to do monthly pharmacy review. Last time EKIT was accounted for: delivered on 2/6/24 at 6:56 PM, signed for by (V6-RN) and confirmed by her. Where was the EKIT stored once it was received by the nurse: (V6) placed it inside the narcotic section of the medication cart. When was the last time anyone can recall seeing the EKIT: 1. (V10-LPN/Licensed Practical Nurse) said she remembered seeing the EKIT inside the narcotic section when she worked night shift on 2/9/24. 2. (V11-RN) said on 2/10/24 (evening shift) between 9 PM to 10 PM (she was assigned at the front nurse station), the nurse at the back station (V7-LPN) called her attention and showed her the EKIT. (V7) told her this is where the other nurse (V6) should get the narcotics. (V7) left her post at the end of the shift without waiting for the night shift nurse. She left the keys in the narcotic binder. Statements from each nurse who between the dates of 2/6/24 and 2/21/24: 1. (V6) saw the EKIT on 2/6/24. She didn't notice it until it was discovered by the pharmacist that it was missing. Somebody placed the IV infusion pump inside the narcotic section and she thought it was the EKIT. Police report filed and initial report sent to IDPH (Illinois Department of Public Health) on 2/21/24. On 2/26/24, V4 followed up with V8 (Police officer). At this time, the EKIT has still not been located. R1's face sheet shows an admission date of 1/11/24. R1's POS (Physician Order Sheet) for February 2023 shows an order for Hydrocodone-Acetaminophen (Norco) 5-325 MG (Milligrams)-1 tablet by mouth every 6 hours as needed. R1's delivery receipt it shows that her Norco (6 tablets) was delivered on 2/9/24. V10 signed for it and wrote the following in ink: I received this medication last night on 2/10/24 at 3 AM together with the Norco for (R2). I also didn't give any tablets to (R1) and (R2). Both their Bingo cards for the Norco and the pink form to be signed by the nurse are both missing now. When I counted, I didn't notice that it's missing because the Bingo Cards in the narcotic box and the pink forms are matching. I noticed it when another narcotic medication-the Ativan for (R2) was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145825 If continuation sheet Page 12 of 13 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 145825 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Elgin Living & Rehab Center 746 West Spring Street South Elgin, IL 60177 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 - Many delivered at 2:30 AM. And I noticed that the Norco of (R2) was all gone when I checked the pink form. It's not in the book also. I checked the Norco for (R1) and it was not there also. R2's face sheet shows an admission date of 12/28/23. R2's March 2023 POS shows an order for Hydrocodone-Acetaminophen 5-325 MG (Milligrams)-1 tablet by mouth every 6 hours as needed. It was ordered on 12/29/23. R2's delivery receipt shows that her Norco (6 tablets) was delivered on 2/9/24. V10 signed for it and wrote the following in ink: Received last night on 2/10/24 at 3:00 AM. Didn't give any to resident yet and nurse to nurse counted in morning. Still 6 tablets still in narcotic box. Now, I counted the narcotic meds and missing the whole Bingo car and the pink form. No endorsement done because the pm nurse (V7) left already. I came at 10:20 Pm in the facility. I told the nurse if she wants to leave early, she has to endorse to the front nurse and leave the keys with her. But she didn't do it. Facility was unable to provide an incident report regarding R1 and R2's medications missing. Pharmacy's policy titled Loss or Theft of Medications (1/1/24) shows: If controlled substances are missing from the emergency medication supply (1.e., emergency kit, emergency box, e-kit, etc,) Facility staff should notify pharmacy immediately for appropriate action. Facility's policy titled Controlled Substances (11/6/18) shows: The schedule II cabinet must remain locked and charge nurse shall have the key in her possession at all times. Only Licensed nurses will have access to controlled substances. 7. The drugs in schedule II (and those in other schedules which have been restricted and stored in the Controlled Substance cabinet) will be counted and reconciled by the nurse coming on duty with the nurse that going off duty. 9. Discrepancies must be reported immediately to the Director of Nursing who shall investigate as described in the missing controlled substance policy. When loss, suspected theft or an error in the administration of regulated drug occurs, a report will be filed with the pharmacist and the administrator. Facility's policy titled Missing Controlled Substance (11/6/18) shows: It is the policy of this facility to prevent the loss of controlled substances and vigorously investigate incorrect inventory of controlled drugs, medications or pharmaceuticals reported by pharmacists, physicians or licensed nurses. 1. All controlled drugs will be counted by the oncoming and outgoing nurse at the change of each shift as per the Controlled Drug policy and procedure. 3. The oncoming and outgoing Licensed Nurse will sign the controlled substance inventory sheet each change of shift to signify the count was completed and is accurate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145825 If continuation sheet Page 13 of 13