Inspection·March 8, 2024

F 0554 left at the bedside or self-administered unless specifically ordered for self-administration. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146065 If continuation sheet Page 2 of 19 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 03/08/2024 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 0578 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on interview and record review, the facility failed to maintain accurate advanced directives for 2 residents' (R31 & R256) medical records in a sample of 24. Residents Affected - Few Findings include: 1. On 03/06/24 at 10:25 AM the facility's Advance Directive Binder showed R31' s POLST (Uniform Practitioner Orders for Life-Sustaining Treatment) form dated 1/30/20 with a DNR (Do Not Resuscitate) status, and R31's EHR (Electronic Health Record) showed she was a full code (if a person's heart stops beating or they stop breathing all resuscitation procedures will be provided to keep them alive). 03/07/24 12:18 PM V1 (Administrator) said that the POLST should be the same as the EHR, so the staff knows how to proceed in an emergency. 2. R256's Face Sheet dated 3/06/2024, showed an admission date of 2/08/2024 and there were no advanced directives selected. On 3/06/2024 V6 (Registered Nurse/RN) and V7 (RN) both searched in R256's EMR (Electronic Medical Record) and said there was no code status or uploaded advanced directive documents. They said that if there was no code status in a resident's EMR they treat the patient as a full code. They continued to say V4 (Social Worker) uploads a copy of the advance directive documents into the resident's EMR and places another copy in the unit's advanced directive binder located at the nursing station. On 3/6/2024 at 2:53 PM, V4 said she verifies the residents' code status then enters an alert with their code status in their EMR and if available uploads a copy of their advance directive form in their EMRs. V4 said she also places a copy of the advance directives in the unit's advanced directive binder. V4 continued to say the residents' EMRs code status should match with the unit's advanced directive binder. V4 said R256 was recently admitted to the facility and had an advance directive form indicating she was DNR (Do Not Attempt Resuscitation) with comfort-focused treatment. V4 said she forgot to upload R256's advanced directive form and enter a code status alert into R256's EMR but placed it inside the unit's advanced directive binder located at the nursing station. R256's Practitioner Order for Life-sustaining Treatment (POLST) Form dated 2/15/2024 showed advanced directive selections for DNR and Comfort-Focused Treatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146065 If continuation sheet Page 3 of 19 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 03/08/2024 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain a functional privacy curtain/curtain track. Residents Affected - Few This applies to 1 resident (R16) reviewed for privacy in a sample of 24. The findings include: On 3/5/24 at 12:00 PM, the surveyor hit her head on a white TV cable hanging from R16's ceiling. V17 (CNA/Certified Nurse Assistant) said R16 told her on 3/4/24 that she wanted the hanging cord fixed and V17 told R16 that she could not fix it. V17 (CNA) said she got busy and forgot to notify V10 (Maintenance Director) of the hanging cable. On 3/5/24 at 12:01 PM, R16 said she did not remember when the white cable first fell, but the way the cord was hanging down was blocking her from being able to pull her privacy curtain closed. R16 said she wanted to be able to close her privacy curtain. It was then noticed that there were two TV cables, a white and a black, that were hanging off the ceiling and blocking the curtain track, preventing the curtain from closing the last 5 feet by the foot of R16's bed. The next day, on 3/6/24 at 1:06 PM, R16 said the curtain not closing is a concern to me, I like to be covered up a little bit for privacy. It was then noticed that the white TV cable had been removed, but the black cable was still hanging off the ceiling, preventing R16 from being able to close her privacy curtain the last 2-3 feet. R16 is in a room with 2 other roommates, one roommate's bed is adjacent to R16's bed to her left and the other roommate's bed is located against the opposite wall across the room. The roommate whose bed is located on the opposite wall can visualize R16's space at any time due to the privacy curtain being blocked from closing all the way. On 3/7/24 at 12:55 PM, V1 (Administrator) went with surveyor into R16's room to inspect the privacy curtain. V1 tried to close R16's curtain and was unable to close the curtain the last 2-3 feet. V1 agreed that R16's roommate on the opposite wall could see past R16's privacy curtain at any time because the curtain did not close all the way. V1 said V10 (Maintenance Director) was in R16's room on 3/6/24 and removed the white TV cable, but he did not resolve the black TV cable that is still blocking the privacy curtain track and preventing the curtain from being able to close completely. V1 said R16's curtain needs to be fixed so that it can close all the way for privacy. The facility's undated policy titled, Dignity and Respect Policy states, Policy: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality with appropriate accommodations for confidentiality and personal privacy . Procedures: .9. e. Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures .delivery of personal resident care which is provided behind closed curtains with the room door closed, including, but not limited to physician/nurse practitioner/nurse examination, changing an incontinent product, delivery of wound care or other intimate, personal care delivery . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146065 If continuation sheet Page 4 of 19 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 03/08/2024 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 0584 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview, and record review the facility failed to provide a safe, warm, home-like environment for 1 resident (R49) in a sample of 24. Residents Affected - Few Findings include: On 03/05/24 at 10:15 AM, R49 was in her bed. A thin sheet of plastic covered her upper window where the glass would have been. No glass or plexiglass covered the window above the window air conditioner, and the opening was approximately 2' X 3'. R49 said that the window lets air blow in all the time, and she doesn't like it. On 03/06/24 at 12:46 PM R49 said her room was cold and would like it to be warmer. The plastic above the air conditioner unit was observed being blown from the wind. On 03/06/24 at 12:14 PM R49 was in bed asleep with 2 blankets on. The window was observed still with only a plastic sheeting over the opening. On 03/07/24 at 09:10 AM V10 (Maintenance Director) checked the temperature in R49's room while R49 was in bed asleep, and the temperature was 66° Fahrenheit. V10 said that about a week and a half ago, during a storm, the Visqueen (plastic sheeting) above the air conditioner in R49's room was blown open, so he tore the rest out and then put a clear plastic weather sheeting over the whole window, including the air conditioner. On 03/07/24 at 11:54 AM V1 (Administrator) said that the temperature's in the resident's rooms should be between 71° to 81°. V1 said that a temperature of 66° is not acceptable it should be higher. V1 said that R49's window should not have plastic on it. V1 said that the plastic and the air conditioner unit should have been removed, and the window closed, or the facility should have put plexiglass above the air conditioner unit. The facility's maintenance log showed: 2/28/24 R49's window plastic came out, room is too cold. - date completed (check mark) The facility's Environment of Care policy (no date) shows it is the policy of the facility to provide an environment of care for the residents which is safe, functional, effective and as near a homelike environment as possible. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146065 If continuation sheet Page 5 of 19 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 03/08/2024 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 Based on observation, interview, and record review, the facility failed to ensure residents dependent upon staff for ADLs (activities of daily living) received nail grooming. Residents Affected - Some This applies to 4 residents (R49, R35, R54, & R18) of 24 residents were reviewed for ADLs in the sample of 24. Findings include: 1. On 03/05/24 at 10:30 AM, R35 was observed with long jagged nails. R35 said that she would like her nails shorter, and it had been about a month or two since she hand them trimmed. On 03/06/24 at 12:15 PM, R35 was observed with long jagged nails. R35 said she had gotten a shower, but staff still has not cut and filed her nails. R35's 10/17/23 care plan showed Problem: ADL : requires assistance with ADL task performance as follows: Substantial/Maximal assistance with personal Hygiene. R35 had diagnose including Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side which has impacted her ability to perform/participate with ADLs. 2. On 03/05/24 at 10:15 AM, R49 was observed with long jagged nails, with brown substances under the nails. R49 said that staff hasn't helped her with her nail care since she has been admitted , including not leaving a nail file for her to do her nails. R49 said it would be nice if the staff would help her with her nail hygiene. On 03/06/24 at 12:46 PM, V14 (Nurse) went into R49's room and observed R49's nails. V14 said that R49's nails should not be long and jagged with substances under them. V14 said that the CNAs (Certified Nurses' Assistants) should be cutting and filing them when they are long and jagged. V14 said any one of the CNAs and nurses can clean the residents' nails. R49's 2/1/24 care plan showed, Problem: ADLs: R49 requires Partial/Moderate assistance with her personal Hygiene ADLs, and staff is to provides assistance needed to meet her needs daily. 3. On 03/05/24 at 10:45 AM, R18 was observed with long, jagged nails. On 03/06/24 at 12:25 PM, R18's nails were observed long, jagged and sharp. R18's 2/7/24 care plan showed that R18 has an ADL deficit and needs Substantial/Maximal to Dependent assistance with ADLS . personal hygiene . On 03/06/24 at 03:01 PM a review of R18's progress notes for the last 30 days did not show any documentation regarding refusal of patient care. A review of R18's last 30 days of POC (point of care) under Responses to ADL care, showed, no data found. 4. On 03/05/24 at 10:35 AM, R54 was observed with jagged nails with brown substances under the nails. The next day on 03/06/24 at 12:19 PM, R54 was observed with jagged nails with brown substances under the nails. R54's 6/8/23 care plan showed, Problem: ADL: R54 requires Partial/Moderate assistance for ADLS. On 03/07/24 at 12:05 PM, V1 (Administrator) said that staff should provide the residents with nail care every day. V1 said that if someone refuses nail care the staff will document it and then try to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146065 If continuation sheet Page 6 of 19 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 03/08/2024 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 FORM CMS-2567 (02/99) Previous Versions Obsolete provide nail care again and continue to try. V1 said that staff is to provide assistance with ADLs even if they are a minimum assistance, set up or verbal prompts. V1 said that nail hygiene/care should be done for safety reasons, or scratching. V1 said it is an infection control measure to prevent the spread of bacteria. The facility's Personal Care Services (ADL Care) policy (7/22) showed, each resident shall receive nursing care and supervision based on individual needs. Residents' fingernails and toenails will be kept clean and trimmed. Event ID: Facility ID: 146065 If continuation sheet Page 7 of 19 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 03/08/2024 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide meaningful activities for a resident. Residents Affected - Few This applies to 1 of 24 residents (R31) in a sample of 24. Findings include: On 03/05/24 at 10:43 AM, R31 was observed in her bed, awake, with the window curtains closed and no TV on or any stimuli in her room, including books, magazines, or word search puzzles. On 03/06/24 at 12:22 PM, R31 was observed in her bed awake, window closed, lights off, TV off, and no music or any stimuli on in her room, including books, magazines, or word puzzles. On 3/07/24 at 10:19 AM, R31 was observed in her bed asleep. No word search puzzles, or magazines present at that time. On 03/07/24 at 10:24 AM V9 (Activities Director) said that there is only herself and one assistant in the activities department and her assistant has been out for 2 weeks. V9 said she doesn't know when her assistant will be returning to work. V9 said that R31 had not received any activities on 3/4/24 - 3/7/24 since her assistant is the only person who provides R31's activities. V9 said that there was no one to provide activities on Monday because she is off on Mondays. On 03/07/24 at 12:02 PM V1 (Administrator) said that staff should have provided R31 with activities every day to keep her mind active and for R31's mental health. R31's 11/15/23 care plan showed, Problem: Activities: Limited participation: R31 has limited participation in recreation programs. Goal - R31 will respond to reading stimuli at least 15 minutes as evidenced by visiting and bringing independent activities for as long as R31 needs. Activity staff will visit R31 and give her independent activities to keep her busy when R31 chooses not to attend scheduled activity groups. We check in on her daily while doing morning rounds and encourage and or leave magazines, word search and books. The facility's Activities policy (no date) showed that it is the facility's policy to provide an activity program to the residents which is appropriate to their needs and interest and capacity to participate and benefit. Activities are designed to stimulate physical and mental capabilities in order to obtain the optimal social, physical and emotional state. Activity programming will include daily activities including weekends and at least two evenings per week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146065 If continuation sheet Page 8 of 19 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 03/08/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, facility failed to ensure residents return their smoking materials back to the receptionist for safe-keeping after smoking. This applies to 2 (R1, R26) of 6 residents reviewed for smoking in the sample of 24. Findings include: 1) On 3/5/24 at 11:35 AM, observed R1 in the Dining Room awaiting lunch. R1 stated, what she liked to do the most was to smoke. Then R1 pulled out one lighter and 14 cigarettes from her shirt pocket. R1 stated she usually kept the smoking materials with her. R1's face-sheet showed she is admitted to the facility on [DATE] with diagnoses to include schizoaffective disorder and lumbar disc degeneration. R1's Minimum Data Set (MDS) dated [DATE] showed moderate cognitive impairment. R1's Care Plan dated 5/19/23, reviewed 1/4/24, had a goal, R1 will understand and accept facility policy on smoking. On 10/17/22 R1 signed facility policy on 'Smoking', stating ' . I will immediately turn over all smoking materials (i.e. cigarettes, ., lighters, matches to a staff person) if so requested. Also 'I understand I must follow each and every rule governing smoking '. 2) On 3/5/24 at 10:20 AM, V12 (RN-Registered Nurse) administered R26's medications in the hallway. R26 turned his wheelchair to move on and asked why his wheelchair was not moving. V12 stated, R26 had dropped his lighter and one cigarette. V12 picked up the lighter and returned it to him. R26 took the lighter and put it in his shirt pocket. The cigerette was crushed under the wheel of the wheelchair. Then V12 (RN) propelled R26 back to his room, returned and continued with her medication administration. R26's face-sheet showed he is admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease and left hemiplegia. R26's Minimum Data Set (MDS) dated [DATE] showed moderate cognitive impairment. R26's Care Plan dated 6/5/23, reviewed 2/19/24, had a goal, R26 will be compliant with facility's smoking rules and policies. On 10/17/22 R26 signed facility policy on 'Smoking', stating ' . I will immediately turn over all smoking materials (i.e. cigarettes, ., lighters, matches to a staff person) if so requested. Also 'I understand I must follow each and every rule governing smoking '. On 3/7/24 at 10:57 AM, V11 (Receptionist) stated, At set smoking hours, residents come and ask for their cigarette and lighter. Each resident had their own lighter and it is labelled. Each resident get one cigarette for each smoking hour/time. After smoking, they are expected to return their lighter back to the receptionist. The next time they come to get their cigarette, if the receptionist does not have their lighter, they do not get their cigarette and their lighter is taken from them. The following smoking time, they get their one cigarette and their lighter as long as they bring their lighter back to the receptionist. Residents are not allowed to keep their lighter with themselves at any time for risk of fire hazard. On 3/7/24 at 11:20 AM, V4 (Social Worker) stated, residents are expected to return the smoking (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146065 If continuation sheet Page 9 of 19 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 03/08/2024 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 0689 materials to the receptionist when they are done with smoking for that particular 'smoking time'. Level of Harm - Minimal harm or potential for actual harm On 3/7/24 at 11:15 AM, V2 (DON-Director of Nursing), residents holding onto their lighters is a fire hazard risk and hence staff should ensure they return their smoking materials to the receptionist as per policy. Residents Affected - Few On 3/7/24 at 8:30 AM, V1 (Administrator) stated, residents are not allowed to keep the smoking materials with themselves at any time due to fire hazard. Residents are educated by the Social Worker and they sign a 'Smoking Behavior Contract'. V1 (Administrator) stated, the staff must ensure that the residents practice the policy. Facility policy on Smoking Times, undated, showed, 'See receptionist . You must return your lighter to the receptionist'. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146065 If continuation sheet Page 10 of 19 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 03/08/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident's urinary catheter drainage bag was kept off the floor. This applies to 1 of 4 residents (R49) reviewed for catheter care and services. The findings include: On 03/05/24 at 10:15 AM, R49 was observed in her bed and her catheter bag was on the floor. On 03/05/24 at 12:51 PM, R49 was observed in her bed and her catheter bag was hanging from her bed and the bag was touching the floor. On 03/05/24 at 01:49 PM R49 was in bed and her catheter bag was hanging from her bed and the bag was touching the floor. R49 is a [AGE] year old female with diagnoses including urinary retention with indwelling catheter and history of urinary tract infections. On 03/07/24 at 12:13 PM V1 (Administrator) said that catheter bags and tubing should not be on the floor for infection control reasons. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146065 If continuation sheet Page 11 of 19 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 03/08/2024 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to administer medications as ordered. There were 32 opportunities with 3 errors, resulting in a 9.38% error rate. Residents Affected - Few This applies to 2 (R26 and R41) out of 6 residents observed for medication pass. Findings include: 1. On 3/5/24 at 10:20 AM, V12 (RN-Registered Nurse) checked the blood pressure for R26 and it was 131/60 mmHg. V12 (RN) stated, the BP (blood pressure) was out of the parameters set by the ordering physician and she did not administer metoprolol to R26. The order stated, 'Metoprolol tartrate tablet; 25 mg; amt: 1/2 tablet; oral, Twice A Day; 09:00 AM, 05:00 PM'. Special Instructions: hold if SBP (Systolic Blood Pressure-top number) is < 110/70. 2. On 3/5/24 at 10:20 AM, V12 (RN-Registered Nurse) checked the blood pressure for R26 and it was 131/60 mmHg. V12 (RN) stated, the BP was was out of the parameters set by the ordering physician and she did not administer Lisinopril to R26. The order stated, 'Lisinopril tablet; 20 mg; amt: 1 Tablet; oral Once A Day; 09:00 AM. Special Instructions: Hold if SBP <110/70. On 3/7/24 at 11:38 AM, V12 (RN) stated, she did not administer the metoprolol and the lisinopril on 3/5/24 because the diastolic pressure was less than the stipulated 70 mmHg. Facility 'Medication Pass protocol', revised 7/2022, showed, ' .11. Follow medication instructions specifically .'.3. R41's Physician Order Report dated 2/07/2024 showed an order for cyanocobalamin (vitamin B-12) tablet; 1000 mcg; amt: 2 tablet; oral Once A Day; 09:00 AM. On 3/06/2024 at 8:52 AM, V5 (Registered Nurse/RN) was preparing R41's scheduled 9 AM medications. V5 omitted R41's scheduled cyanocobalamin (vitamin B-12) 1000 mcg (microgram) 2 tablets to be taken orally at 9 AM. At 9:34 AM, V5 said R41 missed his morning scheduled dose of cyanocobalamin because he did not administer it as ordered. The facility's policy titled Medication Administration Record with a revised date of 7/2022 said Procedure: .7. It will be the responsibility of the licensed nurse to assure all meds are given . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146065 If continuation sheet Page 12 of 19 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 03/08/2024 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm . Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure residents are free from repeated significant medication errors with blood pressure medications. This applies to 1 (R26) out of 6 residents observed for medication administration in a sample of 24. Findings include: 1) On 3/5/24 at 10:20 AM, V12 (RN-Registered Nurse) checked the blood pressure for R26 and it was 131/60 mmHg. V12 (RN) stated, the BP (blood pressure) was out of the parameters set by the ordering physician and did not administer metoprolol to R26. The order stated, 'Metoprolol tartrate tablet; 25 mg; amt: 1/2 tablet; oral, Twice A Day; 09:00 AM, 05:00 PM'. Special Instructions: hold if SBP (Systolic Blood Pressure- top number) is &lt; 110/70. V12 also stated she did not administer Lisinopril to R26 because it was outside the blood pressure parameters as well. The order stated, 'Lisinopril tablet; 20 mg; amt: 1 Tablet; oral Once A Day; 09:00 AM. Special Instructions: Hold if SBP &lt;110/70. 2) On 3/7/24 at 11:30 AM, R26's MAR (Medication Administration Record) showed, V12 (RN) did not administer the metoprolol due at 9:00 AM on 3/4/24 as R26's BP was 120/62 mmHg, and did not administer the Lisinopril due at 9:00 AM. On 3/7/24 at 11:38 AM, V12 stated, she did not administer the metoprolol and the lisinopril on 3/4/24 and 3/5/24 because the diastolic pressure (bottom number) was less than the stipulated 70 mmHg. On 3/7/24 at 11:38 AM, V2 (DON) stated, V12 should have administered the metoprolol and the lisinopril on 3/4/24 and 3/5/24, when R26's SBP was &gt; 110/70 mmHg. Facility 'Medication Pass protocol', revised 7/2022, showed, ' .11. Follow medication instructions specifically .'. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146065 If continuation sheet Page 13 of 19 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 03/08/2024 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to monitor the refrigerator temperatures for 4 residents' refrigerators (R49, R18, R5, & R19) in a sample of 24. Residents Affected - Some Findings include: 1. On 3/5/34 at 10:45 AM, R5's personal refrigerator was observed with a package in the refrigerator and a dried brown substance on the floor of the refrigerator. The February/March 2024 Refrigerator Temperature Log taped outside of the refrigerator showed one entry for February 4th and the documented temperature was 40&deg;. On 3/06/24 at 12:39 PM, V14 (Nurse) went into R5's room and observed R5's temperature log with only one entry dated for February 4th and said that staff should be checking the refrigerators daily. 2. On 03/05/24 at 10:45 AM, R18's personal refrigerator in his room was observed with salad dressing, cream, and butter in it and no temperature log on the refrigerator. On 3/6/24 at 12:39pm v14 (Nurse) went into R18's room and observed that R18 did not have a temperature log on his refrigerator and said that R18 should have a temperature log posted on his refrigerator. 3. On 03/05/24 at 11:25 AM R19's personal refrigerator in his room was observed with food in it. The food included: 2 sandwiches in bags with no dates on them,1 open package of salami with no date on it, several cans of pop, 1 sealed container of orange juice with the sealed lid bulging, 2 packages of cheese with no dates on them, and 1 cup of liquid with no date on it. The February/March 2024 temperature log on the refrigerator hand only one entry on it and it was for February 4th and the documented temperature was 50&deg;. On 03/06/24 at 12:44 PM V14 observed and removed R19's temperature log. The log only had one entry on it, and it was for February 4th. 4. On 03/05/24 at 10:15 AM R49's personal refrigerator in her room was observed with food inside of the refrigerator. The food included: a bagged plate of food with no date on it, pop and milk. The February/March 2024 temperature log taped to the outside of the refrigerator only had one entry and that was for February 4th documenting a temperature of 50&deg;. On 03/06/24 at 12:12 PM R49's personal refrigerator was observed with the February/March 2024 Temperature log taped to it showing only one entry, and that was for February 4th 2024. On 03/07/24 at 12:10 PM, V1 (Administrator) said that the residents' personal refrigerators should have temperature logs on them, and staff should be checking the refrigerators daily for food, cleanliness, and logging the temperatures. V1 said that the CNAs (Certified Nurse's Assistants) are the staff who are responsible for checking the food and logging the temperatures daily. The housekeeping staff are responsible for wiping down the refrigerators weekly. The facility's Refrigerator (Resident) policy (no date) showed to ensure that all residents refrigerators are in proper working order and are kept clean. The staff are responsible to ensure residents' refrigerators are in proper working order and clean. The CNA responsible for overseen care for a resident with a refrigerator will check all contents for proper date of food items and check for cleanliness of the refrigerator on a daily basis. If CNA finds the refrigerator has outdated food, the CNA will dispose of all outdated food and notify the resident. If the CNA finds that the refrigerator is not clean, he/she will notify the maintenance/housekeeping staff to clean the refrigerator. The maintenance/housekeeping staff will clean resident refrigerator on a weekly basis and as needed. Maintenance/housekeeping supervisor will ensure all residents refrigerators are in working order and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146065 If continuation sheet Page 14 of 19 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 03/08/2024 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 0813 kept clean. A thermometer will be kept in a residence refrigerator and the temperature will be taken and recorded daily. 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: 146065 If continuation sheet Page 15 of 19 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 03/08/2024 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 Based on observations, interviews, and record reviews, the facility failed to perform handwashing and glove changes when moving from soiled to clean areas. Residents Affected - Few This applies to 2 of 24 residents (R5, R56) reviewed for infection control practices in the sample of 24. Findings include: 1. On 03/06/24 at 10:56 AM V3 (Nurse) was providing wound care for R5's wound to his right calf. With gloved hands, V3 removed R5's soiled dressing, cleaned R5's wound, and then applied a new dressing to R5's wound. V3 did not remove her soiled gloves, clean her hands, and put on clean gloves after she cleaned the wound. On 03/06/24 01:42 PM V3 said that she should have removed her gloves, cleaned her hands and put on new gloves after cleaning the wound for infection control. On 03/07/24 at 12:16 PM V1 (Administrator) said that when staff are providing wound care, staff are to clean their hands before putting on new gloves when going from dirty to clean. V1 said they are to do this for infection control, so they don't spread bacteria. The facility's Dressing Change Procedure (7/2022) showed, the single most important technique in preventing spread of disease is good hand washing. The procedure showed that after assessing a resident's pain the nurses to wash her hands, remove soiled dressing, wash hands, put on clean gloves, clean wound according to physicians' orders, remove gloves and wash hands, put on clean gloves, perform wound dressing according to physicians' orders, remove gloves, and wash hands. 2. On 03/07/24 10:31 AM V8 Certified Nurse's Assistant (CNA) provided incontinence care for R156. V8 with gloved hands, cleaned R156's perineal area, removed the soiled brief, applied a new brief, and adjusted R156's bed linen. V8 did not remove his gloves or perform hand hygiene after cleaning R156's perineal area and removing the soiled brief. 3. On 03/07/24 at 10:41 AM, V8 (CNA) provided incontinence care for R5. V8 put on gloves before beginning, cleaned R5's perineal area, removed R5's soiled brief, applied a new brief, adjusted R5 in the bed, adjusted R5's linen, and adjusted the bed using the bed control. V8 did not remove his soiled gloves or perform hand hygiene when going from a dirty area and before going to a clean area. On 03/07/24 at 10:52 AM V8 said he did not realize he had not removed his soiled gloves and perform hand hygiene before he moved to a clean area, but he should have. On 3/7/24 at 11:48 AM, V1 (Administrator) said that when staff are providing incontinence care, staff are to remove their gloves and clean their hands before putting on new gloves when going from a dirty area to a clean area to prevent cross contamination. The facility's Hand Hygiene Policy Procedure (no date) showed all members of the healthcare team will comply with current Centers for Disease control and prevention hand hygiene guidelines. A. Indications for hand washing- when hands are visibly dirty or contaminated with proteinaceous materials or visibly soiled with blood or other bodily fluids, wash hands with either a non-antimicrobial soap and water or with an antimicrobial soap and water. Hand washing may also be used for routine decontamination of hands for the following clinical situations: before and after having direct contact with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146065 If continuation sheet Page 16 of 19 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 03/08/2024 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 patients and during ADL care, after contact with the residence intact skin, after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings, even if hands are not visibly soiled, when moving from a contaminated body site to a clean body site during patient care, and after removing gloves. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146065 If continuation sheet Page 17 of 19 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 03/08/2024 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the toaster in the kitchen was functional. Residents Affected - Many This applies to all residents that receive a regular diet from the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 3/5/24 documents that the total census was 58 residents. On 3/7/24 at 11:35 AM, V15 (Dietary Manager) said mechanical soft diets do not get toast, they are given soft bread because the toast would be too crunchy for them to eat. The diet list provided by V15 (Dietary Manager) on 3/7/24 shows that 46 of the 58 residents receive a regular diet, for a total of 79% of the residents. On 3/5/24 at 11:18 AM, R26 said the facility doesn't have a toaster. R26 said the facility used to have a toaster, but it broke and they have been saying they will get a new toaster for over a year. On 3/6/24 at 3:37 PM, R51 said he is not the only one who is upset that the toaster is broke. R51 said everybody is upset that we don't have a toaster and he would prefer his bread was toasted for breakfast like the menu says. The Fall/Winter 23/24 Menu Daily Spreadsheet shows toast on the menu for 10 days out of the 28 day cycle. Most recently according to the Week at a Glance Menu, the residents on a regular diet should have received toast on Tuesday March 5th and Thursday March 7th. On 3/6/24 at 11:44 AM, V15 (Dietary Manager) said the facility toaster broke around November 2023. V15 said V10 (Maintenance Director) removed the toaster from the kitchen when it broke and ordered the parts to fix it. V15 said until the toaster is fixed, the cook has been toasting the bread in the oven. On 3/6/24 at 12:20 PM, V16 (Cook) said the toaster has been broken for a long time; it broke around September 2023. V16 said she prepares breakfast for the residents and she does not toast the bread in the oven because when she tried to, the bread became too hard and the residents couldn't chew it. V16 said she just gives a regular, untoasted slice of bread to the residents on a regular diet. On 3/6/24 at 2:49 PM, V10 (Maintenance Director) said the toaster motor broke and he ordered a new motor around 12/25/23. V10 said he got notice that the toaster was backordered in January 2024 so he canceled the order and reordered the motor from another company in the middle of February 2024. On 3/6/24 at 3:15 PM, V10 provided invoices that showed the original replacement motor was ordered on 10/25/23. E-mail confirmation shows V10 received notification on 12/20/23 that the motor was backordered and was not estimated to ship until 2/16/24. The second invoice for the most recent replacement motor was placed on 2/23/24. On 3/7/24 at 11:37 AM, V1 (Administrator) said she was aware that the toaster was broken but she could not remember when it broke. V1 said she thought the [NAME] was toasting the bread in the oven. V1 said the facility does have petty cash available that could have been used to buy a toaster until the original toaster could be fixed. The facility's policy titled, Menu Production last revised April 2016 states, Procedure: .2. Accurately follow menu prepared and approved by Registered Dietician . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146065 If continuation sheet Page 18 of 19 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 03/08/2024 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 residents' rooms were located at or above ground level. Residents Affected - Some This applies 11 residents (R3, R7, R13, R16, R20, R26, R34, R37, R45, R51, and R52) reviewed for facility environment. The findings include: On 3/05/2024 at 9:52 AM during the initial tour of the facility, 11 residents (R3, R7, R13, R16, R20, R26, R34, R37, R45, R51, and R52) were observed residing on the first floor in rooms located below ground level. The facility's Resident Roster report dated 3/05/2024 showed R3, R7, R13, R16, R20, R26, R34, R37, R45, R51, and R52 were all residing in rooms on the first floor below ground level. On 3/06/2024 at 4:16 PM, V1 (Administrator) said she was aware of the facility's noncompliance with having residents residing in rooms below grade level on the first floor. V1 said the facility had not received a building waiver for the rooms located below ground level (101, 102, 103, 104, 105, 106, and 107). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146065 If continuation sheet Page 19 of 19