Inspection·May 4, 2023

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Level 1 screen necessitates an in-depth evaluation of the individual by the state-designated authority, known as PASARR Level II, which must be conducted prior to admission to a nursing facility. The facility was asked to provide the PASARR for R11 and R29. On May 2, 2023, the facility provided a PASARR Level I Screen Outcome dated March 10, 2023, that was initiated when R11 was in the hospital. The outcome showed R11 had evidence of a serious mental illness or intellectual/developmental disability, but met the criteria for a 30 day hospital discharge exemption and did not need further PASARR evaluation. The outcome showed, This means you may stay up to thirty days in a Medicaid-certified nursing facility without further PASARR evaluation. The outcome showed, If you or your care provider thinks you need to stay longer than thirty days, a nursing facility staff member must submit a new Level I screen This must be competed by or before the 30th day after your admission to the nursing facility. R11's EHR showed she was hospitalized from [DATE]-March 12, 2023 and April 11, 2023 was R11's 30th day in the facility. On May 2, 2023, V12 (Business Office Manager) stated, R29 did not have a PASARR completed. On May 3, 2023, when asked what the facility process if for getting a Level I/II PASARR screen, V12 stated, the hospital starts that PASARR process, before the resident is admitted to the facility. V12 stated, she reviews the result of the PASARR to see if a Level 2 is needed, enters the information into the PASARR program, and requests an assessment to be done. On May 3, 2023, V1 (Administrator) stated, when she was made aware there was no PASARR for R11 and R29, she looked into the matter. V1 stated, when the PASARR Level I became mandated around 2020, all residents had to be entered into the computer program that tracks PASARRs (Assessment Pro) and a Level I screen requested. V1 stated, when she started on August 1, 2023, she did an audit to make sure all current residents, was entered into the program. V1 stated, all residents were entered by previous staff, but until now, she was not aware that they did not take the next step to request a Level I screen be done. V12 stated, they did another audit and there were 42 residents who did not get a screen, including R7, R11, R29 and R33, so she had V12 request a Level I screen for all of those residents. V1 stated, any new admissions, since her start date, had a Level I screen completed and a Level II, if the resident was suspected of having a mental illness. V1 agreed that since R11 was past the 30 day exemption and indicated to have a mental illness, she should have been re-screened. The facility policy titled PASARR Guideline (Preadmission Screening and Resident Review) (Revised November 2017) showed The objective of the PASARR guideline is to ensure that the individuals with mental illness and intellectual disability received the care and services that they need in the most appropriate setting. Procedure: 1) admission and readmission a) The facility will participate in or complete the Level I screen for all potential admissions, regardless of payer source to determine if the individual meets the criterion for mental disorder, intellectual disability or related condition. b) Based upon the Level I screen, if an individual is determined to meet the above criterion, the facility will not admit an individual, the facility will refer the potential admission to the State PASARR representative for the Level II screening process. c) Upon completion of the Level II screen, the facility will review the screen recommendations and determine the facility's ability to provide the specialized services outlined. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146065 If continuation sheet Page 2 of 12 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 146065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbington Vlge Nrsg & Rhb Ctr 31 West Central Roselle, IL 60172 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide assistance with personal hygiene, grooming and incontinence care to residents identified needing assistance. Residents Affected - Some This applies to 6 of 6 residents (R5, R9, R20, R32, R40 and R305) reviewed for ADL (activities of daily living) in the sample of 16. The findings include: 1. R20 has multiple diagnosis including Parkinson's disease, neurocognitive disorder with Lewy bodies, and chronic obstructive pulmonary disease according to the face sheet. R20's Minimum Data Set (MDS) dated [DATE] shows severe cognitive impairment and requires extensive staff assistance for all ADL's. R20's care plan for ADL's, dated March 14, 2023 stated requires extensive assistance with ADL's including personal hygiene, with the goal to remain clean and neat daily. On May 2, 2023 at 1:50 PM, R20's fingernails on both hands were long with black/brown substance underneath and long facial hair across the upper lip. R20 stated she wanted the upper lip hair removed and the fingernails cut and cleaned. V4, Certified Nursing Assistant (CNA) was present and made aware. 2. R305 was admitted to the facility April 17, 2023, with multiple diagnoses including acute osteomyelitis of the mandible, malignant neoplasm of the lungs, and malignant neoplasm of the pancreatic duct according to the face sheet. R305's MDS of April 20, 2023 indicates moderate cognitive impairment and requires extensive assistance with all ADL's. R305's current care plan for ADLs stated requires extensive assistance with most of his ADL's. On May 1, 2023 at 10:53 AM, R305 was observed with long fingernails on both hands with black/brown substance underneath and facial hair that the resident said was in need of trimming. R305 stated wanted both nail trim, cleaning and shaving. V6 (CNA) was made aware. 4. R40 is 93 years-old who has multiple medical diagnoses such as dementia, chronic kidney disease, reduced mobility, and weakness. R40's Quarterly MDS dated [DATE] showed that R40 is cognitively impaired and requires extensive assistance for toileting and hygiene. On 5/02/23 at 1:30 PM. V6 (Certified Nursing Assistant/CNA) rendered incontinence care to R40 who was heavily saturated with urine which overflowed to her pants. V6 stated that he last changed R40's incontinence brief around 9:15 AM. 5. R32 is 74 years-old who has multiple medical diagnoses which include needing assistance with personal care. R32's admission MDS dated [DATE] showed that R32 is alert and oriented and requires extensive assistance for toileting and hygiene. On 5/02/23 at 1:44 PM, V6 (CNA) rendered incontinence care to R32 who was heavily saturated with urine. R32's urine overflowed to her pad. She stated that her incontinence brief has not been changed since beginning of morning shift. V6 (CNA) who is assigned to R32 stated that this is his first time (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146065 If continuation sheet Page 3 of 12 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 146065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbington Vlge Nrsg & Rhb Ctr 31 West Central Roselle, IL 60172 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some this shift that he will provide incontinence care to R32. V6 did not give reason why he was not able to provide incontinence care to R32 earlier. 6. R5 is 87 years-old who has multiple medical diagnoses which include vascular dementia, weakness, and needing assistance for personal care. R5's quarterly MDS dated [DATE] shows that R5 is cognitively impaired and requires extensive assistance for toileting and hygiene. On 5/02/23 at 2:15 PM, V6 (CNA) rendered incontinence care to R5 who was heavily saturated with urine. V6 stated that it's his first time that he will be changing R5's incontinence brief for this shift, because when he came in the beginning of shift (7 AM), R5 was already changed, and was sitting on her wheelchair. On 5/03/23 at 9:05 AM, V2 (Director of Nursing/DON) stated that staff must check and change resident for incontinence every 2 hours and as needed. This is part of the ADL care. 3. R9 has multiple diagnoses which includes Parkinson's disease and mild dementia with psychotic disturbance, based on the face sheet. R9's significant change in status MDS (minimum data set) dated February 20, 2023 shows that the resident is moderately impaired in cognition and requires extensive assistance from the staff with most of her ADLs (activities of daily living) including personal hygiene. On May 1, 2023 at 11:52 AM, R9 was in bed, alert and verbally responsive. R9's fingernails were long with black substances underneath. R9 stated that she wants the staff to trim and clean her fingernails. V6 (CAN/Certified Nursing Assistant) was made aware of R9's request for nail trimming and cleaning. R9's active care plan initiated on February 23, 2023 shows that the resident requires extensive assistance with most of ADLs. The same care plan shows multiple approaches which includes provision of extensive assistance with personal hygiene. On May 3, 2023 at 9:06 AM, V2 (Director of Nursing) stated that it is part of the nursing service to ensure that resident's needing assistance with fingernails trimming and cleaning are assisted. V2 also stated that it is also part of the nursing service to remove/shave facial hair for female residents and for those residents who wanted to be shaven, to maintain cleanliness and hygiene. On May 3, 2023 at 10:34 AM, R9 was in bed alert and verbally. R9's fingernails remained long and with black substances underneath. R9 stated that she wants the staff to trim and clean her fingernails. V7 (Activity Assistant) was present during the observation and was aware of the resident's request. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146065 If continuation sheet Page 4 of 12 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 146065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbington Vlge Nrsg & Rhb Ctr 31 West Central Roselle, IL 60172 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 change a soiled peripherally inserted central catheter site (PICC) dressing according to the Physician's order. Residents Affected - Few This applies to 1 of 2 residents (R43) reviewed for intravenous catheter care in a sample of 16. The findings include: R43 was readmitted to the facility from the acute care hospital on April 23, 2023 with multiple diagnoses including multiple sclerosis, acute osteomyelitis of the right ankle and foot wound, methiocillian resistant staphylococcus aureus infection of the right heel, and long term use of antibiotics, based on the face sheet. R43's Minimum Data Set (MDS) dated [DATE] shows that the resident is cognitively intact and requires extensive assistance with all activities of daily living (ADLs). R43's physician order sheet (POS) for April 2023 shows R43 was readmitted for intravenous (IV) therapy antibiotics of vancomycin every 12 hours and ceftriaxone daily until June 5, 2023 for treatment of osteomyelitis of the right heel wound. The POS also includes an order for the PICC line dressing to be changed PRN (as needed). On May 1, 2023 at 10:33 AM, R43's right upper arm PICC line dressing was observed with red drainage on gauze, covered with a transparent dressing dated April 26, 2023. R43's April 2023 treatment administration history shows the prior dressing change was documented on April 30, 2023. R43's PICC line dressing was not changed until May 3, 2023 after drainage was noted by survey team on May 1, 2023. The treatment administration record documents under comments, soiled dressing. On May 3 2023 at 12:34 PM V2 (Director of Nursing) stated if a PICC line dressing is soiled it should be changed immediately. The facility's PICC Line Policy, dated July 2022 states Monitor the PICC line area daily for signs of infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146065 If continuation sheet Page 5 of 12 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 146065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbington Vlge Nrsg & Rhb Ctr 31 West Central Roselle, IL 60172 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 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to meet the nutritional needs of residents in accordance to spread sheet or nutrition guidelines. Residents Affected - Many This applies to all 53 residents who are served food in the facility. The findings include: According from the facility census on 5/1/23, there were a total of 54 residents in the facility. On 5/3/23 at around 11:30 AM, V10 (Food Service Supervisor) stated that they only have one resident who was complete NPO (nothing by mouth) in the facility. On 5/1/23 at 12:15 PM, the dietary department served Turkey Pot Pie and Seasoned Broccoli for lunch. The residents were either served 1 Turkey Pot Pie for regular meal order or 2 Turkey Pot Pies for those who had orders for double portions. V10 (Food Service Manager) separated out the turkey portion of the pie. The turkey was separated from the other ingredients. There were small cubes of turkey meat in the pie which weighed a total of 0.5 ounces on the weighing scale. The nutritional label for the pot pie lists the total protein content of the item to be 10 grams, meaning the pot pie only provides a total of 1.4 ounces of protein (this is the total amount of protein and includes other incomplete protein found in the pie). The planned daily menu spread sheet documents the turkey pot pie as containing 3 ounces of protein. On 5/03/23 at 12:24 PM, V9 (Registered Dietitian) stated that the nutritional content depends on the food item being served to the resident. If it is written in the spread sheet 3 ounces of protein in the meal, then there should be 3 ounces of protein the pot pie that was served. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146065 If continuation sheet Page 6 of 12 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 146065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbington Vlge Nrsg & Rhb Ctr 31 West Central Roselle, IL 60172 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 0805 Level of Harm - Minimal harm or potential for actual harm Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview and record review, the facility failed to prepare pureed consistency diet for the lunch meal. Residents Affected - Some This applies to all the 5 residents (R6, R11, R20, R24, R34) who are receiving pureed diet in the facility. The findings include: On 5/1/23 at 11:26 AM, V10 (Food Service Director) pureed Turkey Pot Pie and Seasoned Broccoli in the food blender. After she pureed the food, V10 poured the pureed Broccoli and Pot Pie in a small metal container and covered it with plastic wrap. V10 stated that it's ready to be serve to the residents. V10 did not taste the pureed food prior to placing it in the small metal container. The state surveyor tasted the pureed broccoli and pot pie. Both food items were grainy. On 5/01/23 at 12:45 PM, V11 (Certified Nursing Assistant/CNA) was feeding R34 in the bedroom. R34 was observed eating with good appetite. However, it was noted that she occasionally manipulated food in her mouth then she would spit out a solid food particle. R34 was also observed spitting out a cube of turkey from the pureed pot pie that was fed to her. V11 stated that she regularly feeds R34 during lunch and R34 usually spit out food that was not properly pureed. This is not the first time that it happened. On 5/03/23 at 12:24 PM, V9 (Registered Dietitian) stated the pureed food should be smooth like pudding and mash potatoes consistency. Facility's Guidelines for Pureed Preparation indicates: Policy: The pureed diet provides food with semi-liquid to semi-solid consistency (i.e., pudding-like). Please keep following pointers in mind. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146065 If continuation sheet Page 7 of 12 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 146065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbington Vlge Nrsg & Rhb Ctr 31 West Central Roselle, IL 60172 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 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 prepare pureed food in a sanitary process. Residents Affected - Some This applies to all the 5 residents (R6, R11, R20, R24, R34) who are receiving pureed diet in the facility. The findings include: On 5/1/23 at 11:26 AM, V10 (Food Service Director) pureed Turkey Pot Pie and Seasoned Broccoli in the food blender. V10 wore a pair of gloves while preparing and pureeing the food. She touched other surfaces and equipment with her gloved hands. V10 used her right gloved hand to pour the chicken broth slowly into the food blender to help puree the broccoli. After she completed pureeing the broccoli, she carried the food blender in her left hand, while her right gloved hand carried a small metal container. She placed it on top of a food prep table. V10 proceeded to scoop the pureed broccoli from the blender to the small metal container using her right gloved hand. V10 repeated the same process while pureeing the turkey pot pie. On 5/03/23 at 11:45 AM, V10 stated that it is ok to use a gloved hand to scoop or scrape the pureed food from the blender to a regular container if the staff does not touch anything else aside from the pureed food. Otherwise, the staff must use a spatula. The Facility's Food and Nutrition Services, Sanitation and Food Safety indicates: Policy: Food and nutrition services employees will practice safe food handling to prevent food borne illness. Procedure: Disposable gloves worn to handle ready-to-eat food shall be single-use only for one task. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146065 If continuation sheet Page 8 of 12 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 146065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbington Vlge Nrsg & Rhb Ctr 31 West Central Roselle, IL 60172 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** Based on observation, interview, and record review, the facility failed to follow standard infection control practices related to hand hygiene and gloving during provisions medications and incontinence care. The facility also failed to ensure that the medications and glucometer machine are placed on clean surface. Residents Affected - Some This applies to 6 of 16 residents (R3, R5, R23, R32, R40, R105) observed for infection control in the sample of 16. The findings include: 1. R23 is 87 years-old who has multiple medical diagnoses which include weakness and diabetes mellitus. Minimum Data Set (MDS) dated [DATE] shows that R23 is alert and oriented and requires extensive assistance for grooming and hygiene. On 5/02/23 10:08 AM, V6 (Certified Nursing Assistant/CNA) incontinence care to R23 who was wet with urine and had a bowel movement. V6 cleaned R23 from front to back perineum, he applied barrier cream, and applied incontinence brief. V6 changed gloves in between task, however, he did not perform hand hygiene. After completing incontinence care, V6 removed his gloves and left the room without hand hygiene. 2. R40 is 93 years-old who has multiple medical diagnoses such as dementia, chronic kidney disease, reduced mobility, and weakness. R40's Quarterly MDS dated [DATE] showed that R40 is cognitively impaired and requires extensive assistance for toileting and hygiene. On 5/02/23 at 1:30 PM. V6 rendered incontinence care to R40 who was heavily saturated with urine. V6 cleaned R40's peri-area from front to back, applied new incontinence brief. V6 changed his gloves and without hand hygiene, he applied the barrier cream. V6 changed his gloves and again without hand hygiene to close the incontinence brief and repositioned R40. 3. R32 is 74 years-old who has multiple medical diagnoses which include needing assistance with personal care. R32's admission MDS dated [DATE] showed that R32 is alert and oriented and requires extensive assistance for toileting and hygiene. On 5/02/23 at 1:44 PM, V6 rendered incontinence care to R32 who was heavily saturated with urine and had a small bowel movement. V6 cleaned R32's frontal perineum, he changed gloves without hand hygiene and continued to clean the buttocks. V6 changed gloves again without hand hygiene, then he applied barrier cream, and while wearing same gloves applied incontinence brief. 4. R5 is 87 years-old who has multiple medical diagnoses which include vascular dementia, weakness, and needing assistance for personal care. R5's quarterly MDS dated [DATE] shows that R5 is cognitively impaired and requires extensive assistance for toileting and hygiene. On 5/02/23 at 2:15 PM, V6 rendered incontinence care to R5 who was heavily saturated with urine and had a bowel movement. V6 cleaned R5 from front to back, with same gloves, placed clean incontinence brief underneath R5's buttocks. V6 changed his gloves without hand hygiene, and proceeded to apply barrier cream, closed incontinence brief. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146065 If continuation sheet Page 9 of 12 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 146065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbington Vlge Nrsg & Rhb Ctr 31 West Central Roselle, IL 60172 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 - Some On 5/03/23 at 9:41 AM, V2 (Director of Nursing/DON) stated that the staff should change gloves and perform hand hygiene in between task during incontinence care to prevent cross contamination and infection. 5. During medication pass observation held on May 2, 2023 at 9:01 AM, V5 (Nurse) prepared R105's medications. After preparing R105's medications, V5 went inside the resident room, placed the medication cup containing all of R105's medications and the blood sugar monitoring supplies on top of the resident's overbed table, beside R105's urinal which contained urine. V5 put on a pair of gloves, attempted to get R105's blood sugar to monitor, but was not successful and needed to get extra lancet. V5, still wearing the same gloves went outside of R105's room to the medication cart to get more lancet. V5 turned the door knob, opened the medication cart, got several lancets, closed the medication cart, went back inside R105's room, closed the resident's door by handling the door knob and with the same gloves, continued to take the residents blood sugar. On May 3, 2023 at 9:11 AM, V2 (Director of Nursing) stated that the nurse should have removed the urinal with urine from the overbed table and disinfect the table, before putting the medication cup and blood sugar monitoring supplies to maintain infection control. During the same interview, V2 stated that the nurse should remove her gloves, wash hands or use the alcohol based rub before handling the door knob and opening the medication cart to get more lancets, then again wash hands or use the alcohol based rub, before putting on a new pair of gloves before obtaining R105's blood sugar, to ensure that infection control is maintained. 6. R3's Electronic Health Record (EHR) showed R3 was admitted to the facility on [DATE] and has multiple diagnoses including rheumatoid arthritis, cervicalgia, and scoliosis. R3's Minimum Data Set (MDS) dated [DATE] showed R3 is cognitively intact. R3's Care Plan dated April 28, 2023 showed R3 has chronic cervical pain due to neck fracture and multiple comorbidities impacting pain. Administer Norco (hydrocodone-acetaminophen), as needed for pain relief. R3's Physician Order Sheet (POS) showed an order dated April 19, 2023 for Norco (hydrocodone-acetaminophen) 10-325 mg, give one tablet by mouth every eight hours, as needed for pain. On May 3, 2023 at 11:32 AM, V13 (Licensed Practical Nurse - LPN) did not do hand hygiene before prepared and administered R3's Norco, which V13 held the medication cup to R3's mouth and poured in the tablet. When V13 was made aware that she did not do hand hygiene, she was apologetic and stated, she would make sure to do it going forward. During an earlier interview on May 3, 2023, V13 stated, she did receive infection control training from the facility, which included hand hygiene. The facility policy titled Hand Hygiene Policy Procedure (Revised 2022) showed, Purpose: Effective hand hygiene reduces the incidence of healthcare-associated infections. Procedure: Indications for handwashing and hand rubbing. A3) Handwashing may also be used for routinely decontaminating hands in the following clinical situations:. After contact with a patient's intact skin (e.g., when taking a pulse or blood pressure and lifting a patient); Before and after administering ophthalmic medications, after transdermal patch application, before and after invasive procedures (injections, accuchecks, etc.), after touching an oral medication during administration; After contact with body fluids or excretions, mucous membranes, non-intact skin and wound dressings, event if hands are not visibly soiled; When moving from contaminated body site to a clean body site during patient care; After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient; After removing gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146065 If continuation sheet Page 10 of 12 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 146065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbington Vlge Nrsg & Rhb Ctr 31 West Central Roselle, IL 60172 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0916 Ensure each resident has a room at or above ground level. Level of Harm - Potential for minimal harm Based on observation, interview and record review, the facility failed to ensure resident rooms were located at or above ground level. Residents Affected - Some This applies to 19 residents (R4, R8, R9, R10 R12, R13, R16, R18, R19, R20, R24, R30, R36, R37, R43, R47, R49, R105, R305) reviewed for facility environment. The findings include: On 5/1/23 at 11:55 AM during initial tour of the facility, 19 residents (R4, R8, R9, R10 R12, R13, R16, R18, R19, R20, R24, R30, R36, R37, R43, R47, R49, R105, R305) were observed residing on the first floor in rooms located below ground level. Facility Bed File roster, dated 4/30/23, shows R4, R8, R9, R10 R12, R13, R16, R18, R19, R20, R24, R30, R36, R37, R43, R47, R49, R105, R305 were all residing in rooms on the first floor. Rooms are 102,104, 107,109, 110,112,114,115,201,205,210,214,215,219,222,223 05/03/23 12:51 PM V1 (Administrator) stated she understood in the past the facility received a waiver for the first floor rooms that were located below ground level because the building was out of compliance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146065 If continuation sheet Page 11 of 12 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 146065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbington Vlge Nrsg & Rhb Ctr 31 West Central Roselle, IL 60172 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to have all portions of the call light system functioning to ensure that residents calls are received and answered by the staff. Residents Affected - Some This applies to 35 of 35 residents (R1, R2, R3, R5, R6, R7, R11, R14, R15, R17, R19, R21, R22, R23, R25, R26, R27, R28, R31, R32, R33, R34, R35, R38, R39, R40, R41, R42, R44, R45, R46, R48, R51, R52 and R255) reviewed for functioning call light system on the second floor. The findings include: During the resident council meeting held on May 2, 2023 at 11:00 AM attended by 11 residents (five residents from the first floor) and (six residents from the second floor), a second floor resident complained that call lights are not being answered timely on the second floor unit. During random observations made on May 2, 2023 (10:00 AM, 12:05 PM and 12:44 PM), R32's call light was observed with the light above the room, but no sound could be heard at the nursing station. Review of the resident council from November 2022 through April 2023 showed concerns with regards to timely call light responses. On May 3, 2023 at 12:25 PM, V1 (Administrator) stated that after the State Agency informed her of the resident council meeting concern regarding the call light on May 2, 2023, the facility checked all the call light system on both first and second floors. The facility found out that all the second floor call light system have the light above each resident doors working when the call lights were activated, but not the sound (call light) system at the nursing station. V1 stated that the facility's call light system is both visual (light above the door) and sound (beeping sound on the nursing station) system and should both be functioning at all times to ensure that resident's calls are received and answered by the staff. According to V1, it is possible that resident's call lights are not immediately answered because the staff are not able to hear the call light. V1 stated that the facility does not know when the sound portion of the call light system stopped functioning. The facility presented a signed statement dated May 3, 2023 created by V1 which documented that the facility completed call light system audit of the entire facility (first and second floor). The statement showed, All call lights on the second floor were lighting up but not beeping at the nurses' station. Review of the resident room roster showed that the facility has 35 residents residing in the second floor unit. The residents were R1, R2, R3, R5, R6, R7, R11, R14, R15, R17, R19, R21, R22, R23, R25, R26, R27, R28, R31, R32, R33, R34, R35, R38, R39, R40, R41, R42, R44, R45, R46, R48, R51, R52 and R255. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146065 If continuation sheet Page 12 of 12