Health inspection·August 3, 2023

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Change end caps (valve microclave) weekly and as needed every day shift, every Wednesday for PICC Line care. R14's July 2023 TAR showed his PICC line dressing was changed on 7/12/23 and was due to be changed on 7/19/23 but was not signed out as being completed. The next dressing change due was 7/26/23 and a 9 was documented: a 9 meant other/see nurses notes. R14's July 2023 TAR showed his PICC line end cap was changed on 7/12/23 and was due to be changed on 7/19/23 but was not signed out as being completed. The next end cap change due was 7/26/23 and a 9 was documented: a 9 meant other/see nurses notes. The EMAR (Electronic Medication Administration Record) Medication Administration Note dated 7/26/23 for R14 showed, Note Text: Change PICC line dressing weekly and PRN every day shift every Wednesday for PICC line care. Endorse to night shift. Report to oncoming nurse. The EMAR (Electronic Medication Administration Record) Medication Administration Note dated 7/26/23 for R14 showed, Note Text: PICC Line Care: Change end caps (Valve microclave) weekly and prn every day shift every Wednesday for PICC line care. Endorse to night shift. Report to oncoming nurse. The Care Plan dated 7/10/23 for R14 showed, potential for infiltration and site infection related PICC line. Change IV (intravenous) cap per facility protocol or as needed. The plan did not show the frequency of when the PICC line dressing was to be changed. The facility's Central Venous Catheter Dressing Changes policy (4/7/23) showed, the purpose of this procedure is to prevent catheter-related infections that are associated with contaminated, soiled, or wet dressings. Dressings must stay clean, dry, and intact. Change transparent semi-permeable membrane (TSM) dressing at least every 5-7 days and PRN (when wet, soiled, or not intact. 6. R132's admission Record sheet shows he was admitted on [DATE]. The same document shows his diagnoses includes type 2 diabetes, depression, anxiety, recent right knee replacement, alcoholic cirrhosis of the liver, hypertension, and repeated falls. R132's POS (Physician Order Sheet) shows daily weights for CHF (Congestive Heart Failure) was ordered on 7/30/23. The initial visit from V10 NP/APN (Nurse practitioner/Advanced Practice Nurse) dated 8/2/23 shows R132 had +3 pitting edema on the right knee and lower leg and +1 edema on the left lower extremity. On 8/2/23 at 2:30 PM, R132 said, they do not weigh him every day. The Facility's Weights and Vitals Summary shows one weight for R132 on 7/29/23. R132's Care Plan does not list daily weights or CHF as a concern. On 8/03/23 at 11:02 AM, V12 CNA (Certified Nursing Assistant) said, she knows who to weigh because it will be on her CNA daily task sheet. V12 said, if the resident refuses, she'll try again later and if they still refuses, she'll get the nurse to talk with the resident. V12 said, she will put all weight on sheet and give to nurse. On 8/03/23 at 11:31 AM, V11 RN (Registered Nurse) said, she expects daily weights to be done as ordered by the Physician. V11 said, once the CNA gets the weights, she (V11) will put them into the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146069 If continuation sheet Page 2 of 17 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 146069 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE East Bank Center, LLC 6131 Park Ridge Road Loves Park, IL 61111 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some computer and look to see if the resident had a weight gain. For residents with CHF a significant weight gain could mean an exacerbation (worsening) of CHF, with SOB (shortness of breath). V11 said, if there is a significant weight gain the Nurse should call Physician or NP who may want to order a diuretic or a chest x-ray. On 8/03/23 10:12 AM, V10 said, weights should be done as ordered, especially for CHF. V10 said, resident who have CHF with a significant weight gain could put a strain on their heart and could experience breathing difficulties. V10 said, nurses should contact her with any concerns if residents have significant weight gain. The Weight Assessment and Intervention Policy and Procedure (revised 9/2008) shows, it is the facility's policy to strive to .monitor . weight. 7. R137's admission Record sheet shows he was admitted on [DATE]. The same document shows his diagnoses includes drug induced retention of urine, chronic systolic congestive heart failure, hypertension, and a urinary tract infection. R137's POS (Physician Order Sheet) shows daily weights for CHF (Congestive Heart Failure) was ordered on 7/22/23. R137's Care Plan shows he may experience chest pain related to CHF, and the intervention is to do his vital signs as ordered. The Facility's Weights and Vitals Summary shows R137 was weighed on 7/24/23, and the next weight was on 7/29/23, skipping 4 days. No weights were documented for August 2023. On 8/1/23 at 2:45 PM, R137 refused to interview with this surveyor. 2. R24's admission Record, printed by the facility on 8/3/23, showed he had diagnoses including diabetes mellitus due to underlying condition with diabetic autonomic polyneuropathy (damage to the nerves that control automatic body functions. It can affect blood pressure, temperature control, digestion, bladder function and sexual function) and diabetic amyotrophy (a rare condition in which patients develop severe aching or burning pain in hips and thighs), and chronic kidney disease stage 3. R24's care plan dated 6/24//23 showed R24 has a self-care deficit/impaired physical mobility/activities of daily living deficit related to weakness. R24's Order Summary Report, printed by the facility on 8/3/23, showed, check blood glucose before meals and at bedtime. The order was started on 6/23/23. The Order Summary Report also showed an order for Insulin Lispro inject 6 units with meals in addition to insulin Lispro per sliding scale (additional insulin given based on the resident's blood glucose level obtained before each meal and at bedtime). R24's facility assessment dated [DATE] showed he was cognitively intact. On 8/01/23 at 12:22 PM, V7 (Registered Nurse-RN) and V3 (LPN/Infection Control Preventionist) were standing by the medication cart, by the nurse's desk. V7 told V3 that she still needed to get R24's blood sugar level. V3 said, We should do that before he starts eating. V7 said R24 had already started eating. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146069 If continuation sheet Page 3 of 17 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 146069 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE East Bank Center, LLC 6131 Park Ridge Road Loves Park, IL 61111 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 8/01/23 at 12:22 PM, R24 was in his room eating the lunch meal. V3 put the test strip in the glucometer (device for checking blood sugar levels) and seemed unfamiliar with the lancet used to obtain a blood sample, asking this surveyor if the diagram on the lancet made sense, and asking where the needle was. V3 said, Well, we will try it. At 12:23 PM, V3 poked R24's third digit on his left hand and got a drop of blood on his finger. V3 went to pull the test strip out of the glucometer and reinsert it so the device did not register an error, due to too much time elapsing. V3 dropped the test strip on the floor and went out of R24's room, down the hall to get another test strip from V7's medication cart. At 12:25 PM, V3 came back into R24's room. V3 used the blood that was already on R24's finger before she exited his room for another test strip. 3. R17's admission Record, printed by the facility on 8/2/23, showed he had diagnoses including type II diabetes mellitus, hypertension, and chronic diastolic (congestive) heart failure. R17's Order Summary Report, printed by the facility on 8/2/23, showed the following order: Check blood glucose before meals and at bedtime. R17's care plan initiated on 7/27/23 showed R17 had the potential for an alteration in his blood sugar levels. On 8/01/23 at 12:28 PM, V3 went into R17's room and informed him that she needed to check his blood sugar level. R17 was already eating his lunch meal. V3 placed the glucometer, alcohol wipes, and test strip on R17's bedside table. There was a white substance, which appeared to be salt or sugar on the bedside table. The test strip was sitting directly in the white substance. V3 used the test strip to check R17's blood sugar level. At 12:31 PM, V3 said she should not have set the test strip on the bedside table because there was a white substance on the table where she put the test strip. On 8/3/23 at 10:08 AM, V10 (Advanced Nurse Practitioner-ANP) said the residents' blood sugar levels should be checked before the residents eat their meals. V10 said, You would get an inaccurate reading. V10 said it is not the best practice to use a test strip that was placed in a white substance on the resident's bedside table. It could be contaminated. On 8/3/23 at 11:13 AM, V11 (Registered Nurse-RN) said the resident's blood sugar levels should be checked before the resident starts eating; that is the best way to control a resident's insulin level. V11 said she would have wiped the blood that was on the resident's finger off and used fresh blood to check the resident's glucose level. V11 said, You should not use a test strip that was sitting in a white substance on the resident's bedside table because it is contaminated and could affect the result. R17's Order Summary Report, printed by the facility on 8/2/23, also had an order for daily weights, every day shift for CHF (congested heart failure). The order was received on 7/26/23. R17's Weights and Vitals Summary, printed by the facility on 8/2/23, showed no weights were obtained on 7/30/23 and 7/31/23. R17's July 2023 Treatment Administration Record showed no weight on 7/31/23. 4. R4's admission Record, printed by the facility on 8/2/23, showed she had diagnoses including cerebral infarction (stroke), chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia (low levels of oxygen in the body tissues) and hypercapnia (elevated carbon dioxide levels). R4's Progress Note dated 8/3/23 from V17 (Nurse Practitioner-NP) showed R4 also had a diagnoses of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146069 If continuation sheet Page 4 of 17 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 146069 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE East Bank Center, LLC 6131 Park Ridge Road Loves Park, IL 61111 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 0684 heart failure. Level of Harm - Minimal harm or potential for actual harm R4's care plan initiated on 7/22/23, showed she has a potential risk for chest pain related to insufficient coronary blood flow, congested heart failure, coronary artery disease. The care plan did not address the need for daily weights as ordered. The care plan showed take vital signs as ordered and as needed. Residents Affected - Some R4's Order Summary Report, printed by the facility on 8/2/23, showed an order received on 7/21/23 for daily weights every day shift for CHF. R4's Weights and Vitals Summary, printed by the facility on 8/2/23, showed no weights for the following days: 7/23/23; 7/25/23; 7/26/23; 7/28/23; 7/30/23 and 7/31/23. R4's July 2023 Treatment Administration Record showed no weights for 7/25/23; 7/26/23; and 7/28/23-7/31/23. 5. R1's admission Record, printed by the facility on 8/2/23, showed she had diagnoses including atherosclerotic heart disease and chronic atrial fibrillation. R1's Order Summary Report, printed by the facility on 8/2/23, showed an order dated 7/9/23 for daily weights. The Order Summary Report showed the order was active and did not show an end date. R1's July 2023 Treatment Administration Record (TAR) showed no weights were obtained on 7/10/23; 7/15/23; 7/16/23; 7/20/23; 7/21/23; 7/22/23; 7/28/23; 7/28/23; 7/29/23 and 7/31/23. R1's Weights and Vitals Summary, printed by the facility on 8/2/23, showed no weights for the following days: 7/16/23; 7/20/23; 7/22/23; 7/26/23; 7/28/23 and 7/31/23. R1's progress note dated 8/2/23 from V17 (NP) showed R1 had 1+ pedal edema. R1's care plan initiated 7/9/23 showed she has a potential risk for chest pain related to insufficient coronary blood flow, atrial fibrillation, congested heart failure and coronary artery disease. The care plan showed take vital signs as needed. The care plan did not address the order for daily weights. On 8/3/23 at 11:39 AM, V6 (Medical Records/CNA) said when the CNAs get the residents' weights, they document it on the sheet that is on the back of the computer screen at the nurse's desk. The nurse for that resident will document the weight in PCC (electronic medical record system) under the vitals tab. V6 said after the weight is entered into PCC, the sheet is put under the Director of Nursing's door. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146069 If continuation sheet Page 5 of 17 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 146069 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE East Bank Center, LLC 6131 Park Ridge Road Loves Park, IL 61111 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. Based on observation, interview, and record review the facility failed to ensure a residents safety when the brakes on her wheelchair did not engage completely putting her at risk for falling for 1 of 2 residents (R87) reviewed for safety and supervision in the sample of 17. The findings include: On 8/1/23 at 9:33 AM, V6 CNA (Certified Nursing Assistant) went into R87's room to assist her to the bathroom. V6 asked if R87 wanted to use her walker or wheelchair. R87 stated the brakes on her wheelchair were not working right and don't keep the wheels on the chair locked. V6 went over to R87's brake on her wheelchair and engaged the brakes. R87's wheelchair continued to move. V6 stated the brakes were loose. R87 stated she told someone about the brakes on her wheelchair, the person wrote the information down, but nothing has been done about it. On 8/1/23 at 9:36 AM, the surveyor checked the brakes on R87's wheelchair and the left brake did not stop the left wheel from moving when the brake was engaged. On 8/1/23 at 9:46 AM, V6 CNA (Certified Nursing Assistant) stated R87's chair was not safe because she could fall and/or the wheelchair could slide out from under her. On 8/1/23 at 9:48 AM, R87 stated she gets up to her wheelchair but the wheelchair slides because the brakes don't work and she is afraid of falling. R87 stated she noticed it 3 days ago. R87 stated the ladies in therapy knew about it because they were putting 5-pound weights behind the wheels to keep the chair from moving. On 8/3/23 at 10:50 AM, V8 PTA (Physical Therapy Assistant) stated she didn't have R87 assigned to her for therapy. V8 stated V9 was a prn (as needed) PTA that was working with R87. V8 stated they check resident's equipment such as wheelchairs and walkers. On the wheelchairs we check the brakes and for loose parts. We check anything on equipment that the resident reports. If the brake isn't working properly the wheelchair could move when they try to stand and it's not safe. If it's a simple problem on a wheelchair we try to fix it and if we can't there is a form we can fill out and give to maintenance. The Face Sheet dated 8/2/23 for R87 showed medical diagnoses including unspecified fracture of right pubis, multiple fractures of ribs, atrial fibrillation, hypertension, chronic obstructive pulmonary disease, and hyperlipidemia. The Occupational Therapy Treatment Encounter Note dated 8/2/23 for R87 showed partial/moderate assistance for bed mobility, sit to stand transfers, toilet transfers, and bathing. The Physiatry History and Physical Consult Evaluation dated 7/19/23 for R87 showed she was admitted to the facility for skilled nursing and rehabilitation secondary to deficits in mobility and ADLs. R87 tripped over a table in the dark at home. R87 sustained rib and pelvic fractures. The Care Plan dated 7/17/23 for R87 showed, R87 is at risk for falls related to impaired physical mobility due to weakness. R87's Care Plan showed she has a self-care deficit - impaired physical mobility/ADL (activities of daily living) deficit related to weakness. Maintain safety at all times. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146069 If continuation sheet Page 6 of 17 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 146069 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE East Bank Center, LLC 6131 Park Ridge Road Loves Park, IL 61111 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 Report any complications related to resident's physical mobility. Level of Harm - Minimal harm or potential for actual harm The admission Note dated 7/17/23 for R87 showed she was alert and oriented to person, time, place and situation. Residents Affected - Few The facility's Safety and Supervision policy (7/2017) showed, Safety risks and environment hazards are identified on an ongoing basis through the combination of employee training, employee monitoring, and reporting processes Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The facility's Falls Prevention and Management policy (no date) showed, The interdisciplinary team plays a significant role in falls prevention and management, promotes open communication and monitors the outcome of the program. Director of Nursing - Ensures fall and fall related injury prevention is the standard of care. Coordinates with maintenance to ensure equipment in facility is working properly. Therapy Assesses and recommends assistive equipment such as wheelchair, walkers, canes, and lifts. Environmental considerations: Ensure all assistive device such as canes, crutches, and walkers are working properly by inspecting them on a regular basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146069 If continuation sheet Page 7 of 17 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 146069 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE East Bank Center, LLC 6131 Park Ridge Road Loves Park, IL 61111 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 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview and record review, the facility failed to provide catheter care in a manner to prevent infection for 1 of 2 residents (R182) reviewed for catheters in the sample of 17. Residents Affected - Few The findings include: R182's admission Record, printed by the facility on 8/3/23, showed he had diagnoses including retention of urine, profound intellectual disabilities, and benign prostatic hyperplasia (an enlarged prostate that can cause symptoms such as blocking the flow of urine out of the bladder). R182's Order Summary Report, printed by the facility on 8/3/23, showed an order for a Foley catheter size 16 fr (French)/10 ml (milliliter) balloon. R182's Order Summary Report (current) also showed orders to provide catheter care every shift and as needed. R182's care plan initiated on 7/26/23 showed he has a self-care deficit/impaired physical mobility/activities of daily living deficit related to weakness. R182's care plan initiated on 7/26/23 shows R182 is at risk for infection related to an indwelling catheter. One of the interventions listed on the care plan was Wash hands thoroughly before and after peri-care. On 8/03/23 at 8:48 AM, R182 was sitting on the side of his bed. V16 (Certified Nursing Assistant-CNA) went into R182's room to provide catheter care for R182. R182's wheelchair was next to his bed. There was a brown substance on the seat of the wheelchair. V16 said it was stool. The seat of R182's pants was also covered in stool. V16 removed R182's soiled clothes and cleaned the stool from R182's buttocks. V16 removed gloves and applied a new pair of gloves. V16 did not wash her hands. V16 started cleaning the tubing to R182's catheter. V16 used moist wipes to wipe along the catheter tubing, starting about four inches out in a continuous motion towards where the catheter tubing entered R182's penis. V16 then wiped the tip of R182's penis with the same section of wipe used to wipe the catheter tubing. At 8:58 AM, V16 emptied 900 cc (cubic centimeters) of tea-colored urine into the container. V16 reattached the spout to the catheter bag. V16 emptied the container and then drained the rest of the urine that was in the catheter bag into the container. V16 attached the drainage spout back to the connection on the side of the catheter bag. V16 did not use alcohol to wipe the spout either time before reconnecting it to the catheter bag. V16 transferred R182 from his bed to a wheelchair. While transferring R182, his catheter bag was dragging on the floor, with the spout/tubing side touching the floor. On 8/03/23 at 9:11 AM, V16 said she should have removed her gloves and washed her hands before performing catheter care to prevent introducing bacteria into R182's body. V16 said she should have wiped away from the opening of the penis to prevent introducing bacteria into the body; for infection control. On 8/3/23 at 11:13 AM, V11 (Registered Nurse-RN) said the CNAs should wipe away from the opening of the body when they are providing catheter care so they do not introduce bacteria into the body. V11 said staff should remove their gloves after cleaning stool, wash their hands and put clean gloves on before providing catheter care. V11 said when going to a different area of the body and you do not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146069 If continuation sheet Page 8 of 17 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 146069 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE East Bank Center, LLC 6131 Park Ridge Road Loves Park, IL 61111 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 want to cross-contaminate and cause an infection. V11 said the catheter bag should not be allowed to drag on the floor and staff should alcohol the end of the catheter tubing after emptying the bag, before reconnecting the spout to the bag. V11 said this should be done to prevent introducing bacteria and causing an infection. The facility's 2001 policy and procedure titled Emptying a Urinary Drainage Bag, with a review date of 3/1/23, showed, Steps in the Procedure .2. Wash and dry your hands thoroughly. 3. Put on disposable gloves .6. Open the drainage bag and let the urine flow into the measuring container. 7. After the drainage bag has emptied, close the drain. 8. Wipe the drain with an alcohol sponge or swab. Discard the sponge or swab into the designated container. 9. Replace the drain tube back into its holder . The facility's policy and procedure titled Catheter Care, with a revision date of 5/1/2023, showed Procedure: 1. Wash your hands thoroughly before beginning the procedure .12. Cleanse area of catheter insertion well, using soap and water and being careful not to pull on catheter or advance further into urethra. Rinse well. 13. Wash catheter itself by holding on to catheter at insertion side, wash with one stroke downward from meatus, and rinse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146069 If continuation sheet Page 9 of 17 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 146069 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE East Bank Center, LLC 6131 Park Ridge Road Loves Park, IL 61111 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm **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 pain level was controlled. This resulted in the resident experiencing severe pain. This applies to 1 of 2 residents (R138) reviewed for pain in the sample of 17. Residents Affected - Few The findings include: R138's admission Record sheet shows he was admitted on [DATE]. The same document shows his diagnoses includes right knee joint replacement surgery, depression, and anxiety. On 8/01/23 at 2:34 PM, R138 was in his room with the ice water pump attached to his right knee. R138 had periods of facial grimacing when he moved his leg. On 8/01/23 at 2:34 PM, R138 said, he just had a right knee replacement and he is in severe pain. R138 said, the only thing the nursing staff will give him is Acetaminophen. R138 rated his pain at an 8 during our interview. R138 said, he tells everyone he can, both the nurses and CNA's (Certified Nursing Assistants) that he is in pain. R138 said, he told the nursing staff he needed something stronger. On 8/02/23 at 8:30 AM, V13 Agency LPN (Licensed Practical Nurse) asked R138 about his pain level and he said, it was at an 8 out of 10. R138 told V13 didn't want to take the Acetaminophen because R138 said they didn't work, however V13 encouraged him to take them anyway. R138 took the Acetaminophen. V13 did not discuss other options with R138 about pain relief. Tramadol and oxycodone were available. On 8/2/23 at 1:30 PM, V13 was not in the facility for an interview. On 8/02/23 at 10:00 AM, R138 said, V13 never came back to him to ask if the Acetaminophen was effective. R138 said it was not effective. R138 said, none of the nursing staff ask me if pain medication is effective, and they use letters like PRN and never explained what it means. R138 said he would ask the nursing staff if he could have a stronger pain pill and they all gave him different answers. R138 said staff didn't communicate very well. On 8/02/23 at 1:37 PM, V14 RN said, the nurse should assess the resident for pain and ask their pain level, then medicate the resident with ordered pain meds and then re-assess to see if pain level is improved. V14 said if the pain has not improved, the nurse can see if the resident has any other options, or the nurse can call the Physician to see if they want to order something stronger. On 8/03/23 10:12 AM, V10 NP said, it's her expectation that the nurse will assess the resident for pain, and medicate the resident with whatever is ordered on the MAR. V10 said the nurse should re-assess the resident to see if the medication decreased their pain. V10 said if the resident remains in pain after all the medication options the Physician or NP (Nurse Practitioner) should be contacted. A failure to properly assess pain could cause the resident to experience severe pain. The initial visit from V10 NP/APN (Nurse practitioner/Advanced Practice Nurse) dated 8/3/23 shows R138 had is a total right knee replacement on 7/25/23. The same document shows a nurse contacted her on 8/2/23 in the evening about the residents pain. V10 documented that R138 feels he is confused as to what and when he can get pain medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146069 If continuation sheet Page 10 of 17 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 146069 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE East Bank Center, LLC 6131 Park Ridge Road Loves Park, IL 61111 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 0697 R138's Nursing Progress Notes shows he was admitted on [DATE], with a pain rating at 9 out of 10. Level of Harm - Actual harm R138's 7/31/23 (3:33 PM) Comprehensive Pain Assessment shows he is in constant, throbbing pain, rated at a 10 out of 10. R138 verbalized his pain as severe and makes it hard for him to sleep. Residents Affected - Few R138's 8/1/23 Care Plan shows R138 is at risk for pain and discomfort due to being a post-operative patient. Interventions includes to administer medications and monitor for its effectiveness, and notify the Physician if pain is not resolved. R138's MAR (Medication Administration Record) his pain was never less than a 8 out of 10. The Pain Management Policy and Procedure (revised 3/1/23) shows the Facility's policy is to provide effective pain management for residents experiencing acute or chronic pain. Basic Concepts of Pain Management #4 shows, the resident has the right to expect a rapid and effective response to a complaint of pain. Treat the pain, re-assess and continue to treat the pain until the resident is comfortable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146069 If continuation sheet Page 11 of 17 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 146069 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE East Bank Center, LLC 6131 Park Ridge Road Loves Park, IL 61111 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on observation, interview and record review, the facility failed to ensure an Licensed Practical Nurse did not provide IV (intravenous) care for residents, unless they were IV certified. This applies to 1 of 1 resident (R137) reviewed for competent nurse staffing in the sample of 17. The findings include: On 8/02/23 at 8:26 AM, V13 (Licensed Practical Nurse-LPN) was in R137's room. V13 informed R137 that she needed to flush his IV line. V13 was observed flushing the PICC line (a long catheter that is inserted into a vein in the arm, leg or neck. The tip of the catheter is positioned in a large vein that carries blood into the heart) in R137's left arm. At 8:48 AM, V13 went back into R137's room because one of the Certified Nursing Assistants informed her that R137's IV machine was beeping. Upon entering the room, R137's IV machine was not beeping. An antibiotic (Vancomycin) was infusing into R137's left arm through the PICC line. On 8/2/23 at 4:10 PM, V1 (Administrator) said an LPN must be IV certified from the facility pharmacy or another reputable pharmacy in order to do IVs. On 8/3/23 before 8:45 AM, V1 was asked if V13 was IV certified and to provide any documentation the facility had to show proof of V13's IV certification. On 8/03/23 at 1:41 PM, V1 said V13 should not be providing IV care if she is not IV certified. V1 said HR (Human Resources) for the facility was trying to find out if V13 was certified to do IVs or not. When asked if the facility would ask for proof of IV certification before assigning an LPN to a resident with an IV. V1 said if there is an RN (Registered Nurse) working, the RN could tend to the IV for the LPN. This surveyor informed V1 that V13 was seen flushing the IV PICC line for R137. No documentation or verification of V13's IV certification was provided prior to exiting the facility on 8/3/23 at 3:50 PM. R137's Order Summary Report, printed by the facility on 8/2/23, showed an order for Vancomycin HCL (hydrochloride) Intravenous Solution 1500 mg (milligrams)/300 ml (milliliters). Use 1.25 grams intravenously in the morning for sepsis. Run at 250 ml an hour. R137's Medication Administration Record (MAR), printed by the facility on 8/2/23, showed V13 as having administered the Vancomycin to R137 on 8/2/23. The MAR also showed V13 flushed R137's IV with 10 ml sodium chloride before and after administering the Vancomycin to R137 on 8/2/23. The facility's policy and procedure titled Administering Medications, with a review date of 4/7/23, showed 22. As required or indicated for a medication, the individual administering the medication records in the resident's electronic medical record: a. The date and time the medication was administered . The facility's policy and procedure titled Administration of IV Medications by LPNs in Illinois, with a review date of 4/30/23, showed 3. The scope of the LPNs practice is often dictated based upon the LPNs education, training and experience. 4. However, this scope is not to be read as allowing all types of procedures or practices. 5. Applying these above referenced principles, to the LPN who (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146069 If continuation sheet Page 12 of 17 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 146069 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE East Bank Center, LLC 6131 Park Ridge Road Loves Park, IL 61111 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 0726 Level of Harm - Minimal harm or potential for actual harm possess the proper education, training and experience may in fact administer medications through peripheral IV lines (PIV/MID) via IV piggyback for continuous infusion of fluids, with or without medications. 6. Antibiotics may also be administered through peripheral access for intermittent infusions. The medication should be pre-measured and pre-packed. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146069 If continuation sheet Page 13 of 17 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 146069 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE East Bank Center, LLC 6131 Park Ridge Road Loves Park, IL 61111 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure medications were not left at the resident's bedside for 3 of 3 residents (R12, R81, & R137) reviewed for medications in the sample of 17. The findings include: 1. On 8/1/23 at 9:50 AM, R12 was sitting up on the side of his bed with his tray table in front of him. R12 had a cup of medication on his tray table next to his untouched breakfast. V7 RN (Registered Nurse) was out in the hall and stated they are not supposed to leave medications at the bedside. V7 stated she left R12's door open to make sure R12 took his pills. V7 stated if she waited for R12 to take his medications she wouldn't get her medications passed. V7 then dispensed medications into a cup and went into another resident's room and shut the door. The Face Sheet dated 8/2/23 for R12 showed medical diagnoses including dysphagia, pneumonia, acute respiratory failure with hypoxia, sepsis, vomiting, unspecified intestinal obstruction, opioid dependence, hypothyroidism, neuromuscular dysfunction of the bladder, hyperlipidemia, gastro-esophageal reflux disease, chronic pain, muscle spasms of the back, dorsalgia, muscle weakness, benign prostatic hyperplasia, and need for assistance with personal care. The August 2023 MAR (Medication Administration Record) for R12 showed he received the following morning medications on 8/1/23: acidophilus 1 capsule, aspirin 81 mg, clopidogrel bisulfate 75 mg, coenzyme Q10 - 10 mg, Fibercon 625 mg, fish oil 1000 mg, furosemide 20 mg, magnesium oxide 400 mg, oxybutynin chloride 5 mg, zinc sulfate 220 mg, ascorbic acid 500 mg, amoxicillin-pot clavulanate 875-125 mg, Colace 100 mg, Entresto 24-26 mg, multiple vitamin -1 tablet, morphine sulfate ER 15 mg, and sucralfate 1 gm. The Orders Note dated 7/27/23 for R12 showed, Patient observed with difficulty swallowing medication at med pass. ST (speech therapy) to evaluate and treat as necessary. The Care Plan dated 7/24/23 for R12 showed R12 has a self-care deficit/impaired physical mobility/ activities of daily living deficit related to weakness. Always maintain safety. R12's care plan did not show a plan in place for the self-administration of medications. The MDS (Minimum Data Set) assessment dated [DATE] for R12 showed limited assistance needed with bed mobility, transfer, dressing, and toilet use; extensive assistance needed for personal hygiene. 2. On 8/1/23 at 10:20 AM, R81 was sitting in bed and there was a large white pill sitting on the over the bed tray table next to him. R81 stated it was his potassium pill. R81 stated, I don't know why I am on it or if I should even take it now. The Face Sheet dated 8/2/23 for R81 showed medical diagnoses including displaced bimalleolar (ankle) fracture of right leg, cellulitis, iron deficiency anemia, adjustment disorder with mixed anxiety and depressed mood, atherosclerotic heart disease, paroxysmal atrial fibrillation, gastro-esophageal reflux disease, and chest pain. The August MAR for R81 showed on 8/1/23 it was signed out that he had taken a potassium chloride ER (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146069 If continuation sheet Page 14 of 17 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 146069 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE East Bank Center, LLC 6131 Park Ridge Road Loves Park, IL 61111 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 0755 20 meq tablet at 7:00 AM for a diagnosis of atherosclerotic heart disease. Level of Harm - Minimal harm or potential for actual harm R81's Care Plan dated 7/26/23 did not show a plan in place for the self-administration of medications. Residents Affected - Few On 8/2/23 at 1:15 PM, V2 DON (Director of Nurses) stated, the facility does allow residents to self-medicate if it is physician approved. They would then get an order stating the resident could self-administer the eye drop or nebulizer treatment. The resident would be care planned for the self-administration of medications. V2 stated the resident must be alert, oriented and observed to see if they could do it. V2 stated there isn't an assessment form but the resident would have a progress note. The nurse would document about the observation. V2 stated they very rarely have residents self-administer medications other than nebulizer treatments. Nurses are not to leave medication at bedside and that is for safety. Another resident may go into the room that is confused and take the medication. V2 stated they don't leave medications at bedside and the nurse needs to watch the resident take the medication. On 8/2/23 at 1:20 PM, V1 (Administrator) stated, the nurses are not to walk away from medication. The nurse needs to be able to verify that the resident has taken the medication. They can't leave their side until the resident has taken the medication. The nurse must be able to see them. It is the only way to make sure they take the medication. The facility's Administering Medications policy (4/7/23) showed, Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medications are administered within 1 hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). The individual administering medications verifies the resident's identity before giving the resident his/her medications. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Residents may only self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined they have the decision-making capacity to do so safely. 3. R137's admission Record, printed by the facility on 8/2/23, showed he had diagnoses including UTI (urinary tract infection), MRSA (methicillin resistant staphylococcus aureus infection), and bacteremia (bacteria in the blood), and sepsis. On 8/02/23 at 8:26 AM, V13 (Licensed Practical Nurse-LPN) was in R137's room. V13 exited R137's room, leaving a medication cup containing pills in it, on R137's bedside table. V13 closed the door to R137's room, walked to the medication cart, then walked down the hall and around the corner, towards another hall. V13 walked back to the medication cart, prepared medications for another resident in a different room, then went in to administer the medications to the other resident. At 8:48 AM, V13 went back into R137's room because one of the CNAs (Certified Nursing Assistants) informed her that R137's IV machine was beeping. The medication cup on R137's bedside table had 9 pills in the cup. When this surveyor asked R137 about the medications in the cup, V13 asked R137 if she could take the pills in the cup. R137 said no, he will take them later. At 8:56 AM, V13 said medications should not be left at the resident's bedside. On 8/3/23 at 11:13 AM, V11 (Registered Nurse-RN) said medications should not be left at a resident's bedside. The nurse should watch the resident take the medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146069 If continuation sheet Page 15 of 17 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 146069 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE East Bank Center, LLC 6131 Park Ridge Road Loves Park, IL 61111 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 observation, interview and record review the facility failed to ensure droplet precautions were maintained for residents positive with covid-19 by not keeping doors shut on rooms that were safe to have them shut and ensuring staff wore eye protection when entering a covid-19 positive residents' room. This has the potential to affect all the residents in the facility. Residents Affected - Many The findings include: The facility's CMS (Centers for Medicare & Medicaid Services) form 672 Resident Census and Condition of Residents dated August 2, 2023, showed 29 residents reside in the facility. 1. On 8/1/23 at 9:50 AM, R12 was sitting up on the side of his bed with his tray table in front of him. R12 had a cup of medication on his tray table next to his untouched breakfast. V7 RN (Registered Nurse) was out in the hall and stated the door shouldn't be left open because he is on isolation for covid. V7 stated she left R12's door open to make sure R12 took his pills. V7 stated if she waited for R12 to take his medications she wouldn't get her medications passed. V7 then dispensed medications into a cup and went into another resident's room. R12's door remained open. On 8/1/23 at 10:00 AM, V3 (Infection Control Preventionist) walked down the hall and was outside of R12's room. V3 stated R12's door should not be left open; it should be shut. The Face Sheet dated 8/2/23 for R12 showed medical diagnoses including dysphagia, pneumonia, acute respiratory failure with hypoxia, sepsis, vomiting, unspecified intestinal obstruction, opioid dependence, hypothyroidism, neuromuscular dysfunction of the bladder, hyperlipidemia, gastro-esophageal reflux disease, chronic pain, muscle spasms of the back, dorsalgia, muscle weakness, benign prostatic hyperplasia, and need for assistance with personal care. The Nurse's Note dated 7/31/23 for R12 showed, Informed patient he is covid positive and will be in isolation x 10 days. 2. On 8/1/23 at 10:29 AM, there was a red sign outside resident room that stated, Stop please see nurse before entering. Under the red sign was a blue sign that stated, Covid-19 quarantine room and had the following personal protective equipment listed that needed to be worn in the room: N95 mask, eye protection, gloves, proper hand hygiene, and gown. The door to room was open and R84 was sitting in his wheelchair in the room. R84 stated the therapist had been in to do exercises with him and left the door open. R84 stated the door was supposed to be shut because he tested positive for Covid-19 on 7/31/23 and has a runny nose. 8/2/23 at 1:15 PM, V2 DON (Director of Nursing), V3 (Infection Control Preventionist), and V1 (Administrator) were present for an infection control interview. They stated during a covid-19 outbreak they institute the highest level of droplet precautions. V1 stated the doors to residents rooms that are covid-19 positive are to remain closed unless it wasn't safe to do so. V1 stated basically the doors should be closed unless the resident has dementia. V1 stated the reason the doors should be closed is to prevent the covid-19 virus from sprroomeading. The Face Sheet dated 8/1/23 for R84 showed medical diagnoses including Parkinson's disease, congestive heart failure, Covid-19, insomnia, left femur fracture, depression, hypertension, lumbar disc degeneration, left bundle branch block, hyperlipidemia, and benign prostatic hyperplasia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146069 If continuation sheet Page 16 of 17 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 146069 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE East Bank Center, LLC 6131 Park Ridge Road Loves Park, IL 61111 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 The Nurse's Note dated 7/31/23 for R84 showed, Informed patient he is covid positive and will be in isolation for 10 days. The Physician Orders for R84 showed an order dated 7/31/23 for droplet isolation precautions for positive covid. Residents Affected - Many R84's Care Plan was updated on 7/31/23 by V2 DON (Director of Nursing) and showed, isolation precaution needed due to infectious organism covid. Practice good infection control and universal precautions at all times during patient care. 3. On 8/2/23 at 12:08 PM, V4 (Dietary Aide) went into room wearing a gown, gloves and N95 mask. She did not have any eye protection on. V4 went into the room to give residents (R82 & R83) drinks from her cart. There was a red sign under the room number that stated to, Stop please see nurse before entering. Under the red sign was a blue sign that showed, Covid 19 quarantine room. The PPE required for going into the room was listed and was as follows: N95 mask, eye protection, gloves, proper hand hygiene, and gown. V5 (Dietary Manager) was standing at the end of the hall observing V4. On 8/2/23 at 12:11 PM, V5 (Dietary Manager) stated, V4 was supposed to have eye protection on when she went into the room and didn't. I noticed that. That room is a covid isolation room. 8/2/23 at 1:15 PM, V2 DON (Director of Nursing), V3 (Infection Control Preventionist), and V1 (Administrator) were present for an infection control interview. They stated during a covid-19 outbreak they institute the highest level of droplet precautions. Staff are to wear N95 masks. When going into a covid positive room staff wear N95 masks, eye protection, gowns, and gloves. R82 and R83 were the residents that resided in room on 8/2/23. The Physician Orders for R82 and R83 dated 7/31/23 showed isolation precautions - droplet for covid-19. The facility's Covid Response policy (5/15/23) showed, Residents who (1) have been screened and their test is POSITIVE (RED) for COVID-19 OR (2) have signs/symptoms of respiratory viral infection (Orange) will have: Maintain Standard, Contact and Droplet Precautions (including eye protection). Residents with confirmed COVID 19 (RED) or displaying respiratory symptoms should receive all services in their room with the door closed if safe to do so. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146069 If continuation sheet Page 17 of 17