Inspection·June 13, 2024

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4. On 6/8/24 at 11:38 AM, R7 stated, Sometimes there is activities and sometimes not. I have not seen them in a long time, especially on the weekends. I would like to play Bingo and cards. R7's face sheet shows he was admitted on [DATE]. R7's face sheet shows diagnoses of unspecified psychosis not due to a substance or know physiological condition, major depressive disorder, vascular dementia, unspecified severity, with anxiety, depressive and anxiety disorders. Facility did not provide a MDS. 5. On 6/8/24 at 11:41 AM, R8 stated, There are really no activities here on the weekend. I wish there were some. When there's nothing to do, it's boring, man. R8's face sheet shows he was admitted on [DATE]. R8's face sheet shows diagnoses of schizophrenia and bipolar disorder. R8's MDS dated [DATE] shows a BIMS score of 14 which means she is cognitively intact. 6. On 6/8/24 at 1:10 PM, R9 and R10 were lying in bed in their room. Both of them stated that they never have activities on the weekend. They said, It's boring! R9's face sheet shows he was admitted to the facility on [DATE]. R9's face sheet shows diagnoses of major depressive disorder, severe with psychotic features, anxiety disorder, and schizoaffective disorder. R9's MDS dated [DATE] shows a BIMS score of 12, which means moderate impairment in cognition. R10's face sheet shows an admission date of 8/26/2014. R10's face sheet shows a diagnosis of personal history of traumatic brain injury. R10's MDS dated [DATE] shows a BIMS score of 12, which means moderate impairment in cognition. On 6/8/24 at 11:33 AM, V9 (CNA--Certified Nursing Assistant) stated, I don't know what happened this time. Usually there's activities. On 6/8/24 at 1:05 PM, V1 (Administrator) stated, I will talk to the activity director. We are in the process of revising our activity schedules. Activities should be provided 7 days a week for the residents. On the weekends, if the activity aides are not working, then they should leave the activities like games, puzzles, and/or sheets on the table in the dining room for the residents. It's the MOD (Manager on Duty) and nurse's jobs to administer those activities during the weekend. On 6/11/24 at 12:40 PM, V11 (Activity Aide) stated, There's supposed to be someone on the weekends to do the activities. If the activity aides are not working on the weekend, someone is supposed to leave the activity on the table for the resident. That ain't good if no one didn't leave anything for the residents on Saturday. They will get bored. They always need something to do. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145825 If continuation sheet Page 2 of 5 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 06/13/2024 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 0679 Facility was unable to provide a policy on activities for residents. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145825 If continuation sheet Page 3 of 5 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 06/13/2024 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on observation, interview, and record review, the facility failed to have a Director of Nursing on a full-time basis. This has the potential to affect all 60 residents who reside in the facility. Residents Affected - Many Findings include: On 6/8/24 at 2:52 PM, V1 (Administrator) submitted a resident roster and facility data sheet that showed 60 residents were in the facility. On 6/8/24 at 10:49 AM, surveyor asked V5 (RN-Registered Nurse) that if she can let the DON (Director of Nursing) know that surveyor is in the building. V5 stated, We don't have a DON. It's been some time now. The administrator is on her way. We used to have an ADON (Assistant Director of Nursing), but she is no longer with us. Someone from corporate is helping us. On 6/8/24 at 11:08 AM, V6 (LPN-Licensed Practical Nurse) stated, We don't have a DON here. But we have a regional lady and we have someone from our sister facility that is helping us. On 6/11/24 at 9:15 AM, V1 stated, (V13--Former DON--Director of Nursing) resigned on 3/29/24. Then (V14--2nd Former DON) took over on 3/30/24. (V14) then worked for a couple of weeks. Then we had both (V3--Regional Director of Clinical) and (V2--Acting DON) cover as DON. (V3) covers for 3 days and (V2) covers for 2 days. (V2) also covers as DON at our sister facility for 3 days. (V3) was not here last week because she has something personal going on and had appointments. (V2) was here last Tuesday but was not here Wednesday to Friday because she was sick. On 6/11/24 at 9:20 AM, V3 (Regional Director of Clinical) stated, I was just diagnosed with [medical condition] during the facility's annual survey (5/28-5/31). I try to come here 3 times a week, but I have other homes that I'm responsible for. (V2) who works in our sister facility also helps out 2 days a week here. There are times when I couldn't come here because I had doctor appointments. I've been assisting, but mainly (V2) is the one doing the job as DON. Surveyor asked V3 if the facility was meeting the federal regulations of having a full time DON. V3 stated, Honestly, not at 100%. We don't have someone here full time to do the duties of a DON the whole time. We are hiring a DON and ADON (Assistant Director of Nursing). I believe they will take the position today. On 6/11/24 at 9:47 AM, V2 (Acting DON) stated, I'm the full time DON at our sister facility. (V3) told me I have to work 20 hours here as well. I started here approximately May 15, 2024. Intermittently, I would go to both places. When I came here, we didn't have a structured clinical meeting on what my job duties were to be. They told me to focus on infection control. On 6/11/24 at 11:55 AM, telephone interview was done with V12 (Health Department Communicable Disease Supervisor). V12 stated, (V2) is the DON for two sister facilities. This shouldn't be happening. She shouldn't be dividing her time. She has to focus on infection control and the outbreaks at this facility. On 6/11/24 at 12:12 PM, V2 (Acting DON) stated, When I do my required 2 days a week here, I work 10 hours a day. This morning, I stopped the by the sister facility for a few hours and now I'm here. I don't have a ADON (Assitant Director of Nursing) here to help me. I know some changes had to happen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145825 If continuation sheet Page 4 of 5 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 06/13/2024 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete when I walked in the door. I knew it was going to be challenging. It's unfortunate that we got all the tags that happened during our annual. Facility's job description of Director of Nursing (Unknown Date) shows the following: Job Summary: To plan, organize, develop, and direct the overall operation of our nursing service department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility and as may be directed by the Administrator and the Medical Director to ensure that the highest degree of quality care is maintained at all times. 7. Must possess the ability to plan, organize, develop, implement and interpret the programs, goals, objectives, policies and procedures, etc., that are necessary for providing quality care. 8. Make daily rounds of the nursing service departments to ensure that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards. 9. Schedule daily rounds to observe residents and to determine if nursing needs are being met in accordance with the resident's needs. 10. Monitor medication passes and treatment schedules to ensure that medications are being administered as ordered and that treatments are provided as scheduled. Event ID: Facility ID: 145825 If continuation sheet Page 5 of 5