Inspection·April 25, 2024

F 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain orders and provide physical therapy services to residents. This failure resulted in a resident with a functional decline (R103) having a delay in receiving physical therapy and taking longer to return to his baseline function. This applies to 3 of 3 residents (R101, R102, and R103) reviewed for therapy services in the sample of 9. Residents Affected - Few The findings include: 1. R103's Medical Record showed R103 was admitted to the facility on [DATE], with multiple diagnoses including hypertensive heart disease, epilepsy, dementia, and nontraumatic subarachnoid hemorrhage. R103's MDS (Minimum Data Set) dated January 28, 2024, showed R103 had moderate cognitive impairment. The MDS continued to show R103 could independently transfer to and from a bed to a chair, toilet transfer, and walk 150 feet. A progress note dated February 26, 2024, at 4:30 AM, by V18 (RN/Registered Nurse) showed, resident awake and alert, verbally responsive. Breathing non labored and with symmetrical chest wall expansion. Observed that resident no longer takes a walk whenever he is awake. Incontinent of bowel and bladder. Tried to get him up and down but resident unable to do task. Conferred with the night CNA (Certified Nursing Assistant) if she noticed the same thing and she reaffirmed nurse observation. Assessment done: temperature 98.3 degrees, blood pressure 144/90, pulse rate 75, respiratory rate 18, oxygen saturation at room air 95% (percent). Facial expression symmetrical, no drooling noted, no numbness, nor muscle weakness, no mental confusion, repaid involuntary eye movement, hand grasp strong and equal, no difficulty speaking nor slurring of speech. Resident with difficulty of mobility, unable to sit upright without assistance. A progress note dated February 29, 2024, at 6:00 PM, by V13 (RN) showed, readmitted a [AGE] year old male from [local hospital] via [ambulance company] up in a wheelchair, extensive assist of two with transfer. On April 22, 2024, at 1:00 PM, V3 (RN/Registered Nurse) said R103 cannot get out of bed and walk. V3 continued to say R103 used to be able to walk independently, but in February, R103 suddenly stopped walking and was sent to the hospital. On April 22, 2024, at 2:58 PM, V13 (RN) said on February 26, 2024, R103 was walking independently and then stopped walking so R103 was sent to the hospital. V13 said she readmitted R103 to the facility on February 29, 2024, and spoke with V11 (Physician). V13 said she did not get an order for physical therapy for R103. V13 continued to say social services will assist in determining if a resident needs physical therapy. V13 said R103 started receiving therapy on March 22, 2024. On April 23, 2024, at 11:09 AM, V12 (Social Services Director) said there was a delay in R103 receiving physical therapy because the facility did not have a therapy company to provide residents with physical therapy. On April 23, 2024, at 9:34 AM, V11 (Physician) said R103 should have been evaluated for therapy when he was readmitted from the hospital on February 29, 2024. V11 said he was not notified of R103's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145825 If continuation sheet Page 2 of 7 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 04/25/2024 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 0825 Level of Harm - Actual harm Residents Affected - Few continued functional decline upon readmission to the facility and was not asked about a physical therapy evaluation. V11 continued to say if he would have been notified of R103's continued functional decline, V11 would have ordered a therapy evaluation. V11 said the facility is having issues with funding and the last therapy department left because of funding issues. V11 said R103 should have received therapy sooner and believes R103 did not receive therapy in a timely manner because the facility did not have therapy services. On April 23, 2024, at 10:36 AM, V5 (Rehab Director) said R103's prior function was supervision, and R103 could ambulate. V5 said R103 was evaluated by physical therapy on March 22, 2024, and the therapist did not walk R103 because R103 could only stand for 10 seconds. V5 continued to say it was a concern R103 was not started on therapy right after being readmitted to the facility on [DATE]. V5 said it will take longer for R103 to get back to his functional baseline because there was a delay in therapy. R103's Physical Therapy Evaluation and Plan of Treatment dated March 22, 2024, by V17 (Physical Therapist) showed, Functional Mobility Assessment: Ambulation: Walk 10 feet = Not attempted due to medical conditions or safety concerns. Gait Pattern/Deviations: Did not ambulate on evaluation; unable to stand greater than 10 seconds with moderate/maximal assist. 2. R102's Medical Record showed R102 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, anxiety, and urinary tract infection. R102's MDS dated [DATE], showed R102 was cognitively intact. The MDS continued to show R102 was dependent on facility staff for transfers to and from a bed to a chair, toilet transfers, and bathing. R102's physician order dated December 23, 2024, showed, Occupational Therapy and Physical Therapy evaluation and treatment order. Physical Therapy clarification order five times a week for 12 weeks. On April 23, 2024, at 1:27 PM, R102 said she had been receiving physical therapy in February with V19 (Physical Therapist), but then R102 went a month without physical therapy. R102 said she started receiving physical therapy again about three weeks ago. R102's Physical Therapy Therapist Progress note by V19, dated February 7, 2024, showed, Remaining Functional Deficits/Underlying Impairments: Patient continues to require skilled therapy due to weakness, balance deficit, poor endurance and poor safety which influence ability to perform activities of choice. R102's Physical Therapy Daily Treatment Note by V19, dated February 16, 2024, showed Patient performed therapeutic exercises to develop strength, endurance, range of motion and flexibility. Effective February 19, 2024, [Rehab Company] will no longer be a therapy provider. The facility did not have documentation to show R102's therapy was discontinued or ending due to R102 meeting her highest practicable level of function. The facility did not have documentation to show R102 received physical therapy between February 16, 2024, and March 22, 2024. On April 23, 2024, at 10:54 AM, V5 said R102 previously received therapy from a different therapy company and when the current rehab company came to the facility on March 22, 2024, R102 was evaluated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145825 If continuation sheet Page 3 of 7 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 04/25/2024 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 0825 so therapy services could resume. Level of Harm - Actual harm On April 23, 2024, at 11:11 AM, V12 (Social Services Director) said R102 was receiving therapy services from the previous therapy company. V12 continued to say R102 was not sent to an outside company to resume therapy services after the previous company stopped services in the facility. V12 said the facility did not send any residents to an outside company for therapy services because the facility thought the new therapy company was starting, but it kept getting delayed. V12 said R102 received therapy when the new company came on March 22, 2024, about a month after the previous therapy company stopped services. Residents Affected - Few 3. R101's Medical Record showed R101 was admitted to the facility on [DATE], with multiple diagnoses including chronic kidney disease, dementia, atrial fibrillation, and anemia. R101's MDS dated [DATE], showed R101 was cognitively intact. The MDS continued to show R101 required maximal assistance of facility staff for bed mobility, transferring to and from a bed to a chair, and toilet transfers. R101's ADL (Activity of Daily Living) care plan initiated on April 13, 2023, showed, Self care deficit-needs supervision and/or assist to complete quality care and/or poorly motivated to completed ADLs . R101's care plan continued to show multiple interventions initiated on April 13, 2023, including IDT (Interdisciplinary Team) to review for need of PT (Physical Therapy) services. R101's Medical Record showed a Physician Order dated January 12, 2024, for Physical Therapy/Occupational Therapy/Speech Therapy evaluation and treatment. Physical Therapy clarification, five times a week for 12 weeks. R101's February 2024 Physician orders showed, Rehabilitation: five times a week times 12 weeks per Plan of Care. R101's Physical Therapy Therapist Progress note dated February 8, 2024, by V19 Patient continues to require skilled physical therapy services to focus on: therapeutic exercise, neuromuscular reeducation, gait training, manual techniques, group therapy, and therapeutic activities. The facility did not have documentation to show R101's therapy was discontinued or ending due to R101 meeting his highest practicable level of function. The facility did not have documentation to show R101 received physical therapy between February 9, 2024, and March 22, 2024. On April 23, 2024, at 9:47 PM, V11 (Physician) said R101's physical therapy should not have been stopped because R101 was not discharged from therapy. V11 continued to say R101 stopped receiving therapy services because the facility did not have a therapy company to provide services. On April 23, 2024, at 11:11 AM, V12 said R101 was receiving therapy services from the previous therapy company. V12 continued to say R101 was not sent to an outside company to resume therapy services after the previous company stopped services in the facility. V12 said the facility did not send any residents to an outside company for therapy services because the facility thought the new therapy company was starting, but it kept getting delayed. V12 said R101 received therapy services when the new therapy company started on March 22, 2024, about a month after the previous therapy company stopped services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145825 If continuation sheet Page 4 of 7 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 04/25/2024 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to employ a licensed administrator to ensure the facility could meet resident needs. The facility administration failed to ensure therapy services were provided to residents. The facility employed a full-time DON, and the administrator failed to ensure the facility employed a part-time Infection Preventionist. The administration also failed to document evidence for plans of correction and evidence of reporting to the QAPI (Quality Assurance Performance Improvement). Residents Affected - Many This applies to all 57 residents residing in the facility. The findings include: The Facility Data Sheet dated April 17, 2024, showed the facility census was 57 residents. The area on the Facility Data Sheet designated for the Administrator's license number was left blank. On April 18, 2024, at 9:24 AM, V1 (Administrator) said she has a temporary nursing home administrator license. On April 18, 2024, at 10:23 AM, V1 said she started working at a different facility and came to work at this facility on March 4, 2024. V1 continued to say her temporary administrator license was completed for the other facility which she started working at on January 8, 2024. The State of Illinois form entitled Application for Licensure and/or Examination for V1, showed Certification of Acceptance. Applicant: To ensure timely receipt of a temporary license, the completed application packet for licensure must be received in the Department of Financial and Professional Regulation at least 60 days prior to the appointment of the individual as a nursing home administrator. Employer: This is to certify that the above-named applicant has been appointed as a full-time nursing home administrator in the facility as follows . The form continued to show another facility listed as V1's employer, not the facility V1 is currently employed at. V16 (Regional Director of Operations) provided her signature dated January 8, 2024, under the statement I do hereby declare that the above-named applicant has been/will be employed as indicated. On April 23, 2024, at 1:37 PM, V16 (Regional Director of Operations) said she signed V1's temporary nursing home administrator license on January 8, 2024. V16 continued to say V1's application was for a different facility than the facility V1 is currently working in. V16 said an administrative change form was submitted to the State of Illinois. On April 23, 2024, at 3:32 PM, V1 said she has provided all the submitted material for her temporary nursing home administrators license that V1 is aware of submitting. On April 23, 2024, at 1:08 PM, V15 (Illinois Department of Financial and Professional Regulation Representative) said the facility written on the temporary nursing home administrator license is the only facility the temporary administrator can work at unless an addendum to the application is submitted. The facility does not have documentation to show an addendum was submitted for V1's temporary nursing home administrator license. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145825 If continuation sheet Page 5 of 7 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 04/25/2024 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 0835 Level of Harm - Minimal harm or potential for actual harm On April 25, 2024, at 11:29 AM, V20 (Senior Representative for Illinois Department of Financial and Professional Regulation) said once a temporary nursing home administrator license number is issued, the individual can submit a request to change the facility the individual will be working in. V20 continued to say the Illinois Department of Public Health form Long-Term Care Facility - Administrator Form is not how to change the facility the temporary nursing home administrator is able to work in. Residents Affected - Many On April 23, 2024, at 9:06 AM, V1 said she does not have evidence to show medication counts were reviewed daily for three months as mandated by the facility's plan of correction for the survey of March 6, 2024 related to missing narcotic medication. In addition, the facility lacked evidence that any of the plan of correction material was submitted to the QAPI committee. V1 continued to say a couple times a week, V1 or a nurse will review the medication sign off sheets. The facility's plan documents, Director of Nursing or designee and QA will review medication counts daily for 1 month and for the next 3 months though the QA process. On April 18, 2024, at 9:24 AM, V1 (Administrator) said the facility does not have a DON. V1 continued to say the facility last had a DON on April 3, 2024. V1 said the facility does not have an interim DON. On April 18, 2024, at 2:17 PM, V9 (Regional Director of Clinical Operations) said she is the IP (Infection Preventionist) nurse until the facility hires a DON (Director of Nursing). V9 said she lives about three hours from the facility. V9 continued to say she tries to come to the facility once a week, but due to health issues V9 has had difficulty coming to the facility once a week. The facility was cited for infection control issues on the March 6, 2024 survey. The facility failed to implement adequate PPE (personal protection equipment) during a COVID outbreak. On April 18, 2024, at 10:23 AM, V1 said the last day the previous rehab company provided rehab services in the facility was February 5, 2024, and the new rehab company started providing services in the facility on March 22, 2024. On April 23, 2024, at 11:11 AM, V12 (Social Services Director) said when the previous rehab company stopped providing rehab services in the facility, no residents were sent to an outside facility or company for rehab services. V12 continued to say rehab services were not provided in the facility after the previous rehab company left and the new rehab company started in the facility on March 22, 2024. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145825 If continuation sheet Page 6 of 7 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 04/25/2024 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 0882 Level of Harm - Minimal harm or potential for actual harm Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on interview and record review, the facility failed to have an Infection Preventionist at least part time at the facility. Residents Affected - Many This applies to all 57 residents residing in the facility. The findings include: The Facility Data Sheet dated April 17, 2024, showed the facility census was 57 residents. On April 18, 2024, at 2:17 PM, V9 (Regional Director of Clinical Operations) said she is the IP (Infection Preventionist) nurse until the facility hires a DON (Director of Nursing). V9 said she lives about three hours from the facility. V9 continued to say she tries to come to the facility once a week, but due to health issues V9 has had difficulty coming to the facility once a week. V9 said when she is able to come to the facility, V9 reviews and updates the infection control logs. V9 continued to say the March 2024 log was incomplete. The Facility Assessment Tool dated March 7, 2024, showed .The facility follows the current CDC (Centers for Disease Control and Prevention) best practices. The facility has an Infections Nurse that oversees the program in its entirety . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145825 If continuation sheet Page 7 of 7