Inspection·January 25, 2024

F 0607 2. R133's face sheet showed a [AGE] year-old male admitted to the facility on [DATE]. Level of Harm - Minimal harm or potential for actual harm R113's 1/25/24 criminal history check showed a hit. This record showed a 2004 sentence of 60 days in jail and 2 years special conditional discharge for criminal trespass to residence and knowingly damaging property and a 2006 sentence to jail for domestic battery. Residents Affected - Few R133's record had no assessment of his risk level as an offender housed in a long-term care facility. R133's care plan had no care plan to address his offender status. R133's record showed required department of corrections, state and national sex offender registry searches were not completed until 1/25/24. There was no evidence the Identified Offender Program was notified of R133's facility admission. 3. R2's face sheet showed a [AGE] year-old female admitted to the facility on [DATE]. R2's record showed required department of corrections, state and national sex offender registry searches were not completed until 1/25/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146133 If continuation sheet Page 2 of 21 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 146133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandwich Living & Rehab Center 902 East Arnold Street Sandwich, IL 60548 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 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R17's face sheet printed on 1/25/24 showed diagnoses including but not limited to diabetes mellitus, right below the knee amputation, left great toe amputation, and cognitive communication deficit. R17's facility assessment dated [DATE] showed moderate cognitive impairment. The same assessment showed substantial to total staff dependence required for toileting, showering, dressing, and personal hygiene. Residents Affected - Few R17's January physician orders showed an order start dated 12/22/23 to monitor left lower extremity for any changes every shift. On 1/24/24 at 10:20 AM, R17 was seated in the group lounge area wearing red shorts and a plaid short sleeved shirt. R17 had multiple scabs in various stages on his forearms and left leg. A white dressing was observed on the left knee. R17 had long, dirty fingernails that extended past the fingertips. R17 was confused and unable to explain the cause of the scabs or reason for the knee dressing. On 1/25/24 at 8:26 AM, R17 was seated in the dining room wearing a short sleeved top and his fingernails were still long and dirty. At 8:32 AM, V4 (Licensed Practical Nurse) said R17 was not supposed to have a dressing on his knee and there was no order for it. V4 said, Somebody put that on, so I took it off now. He (R17) is a picker and scratches at his arms and legs constantly. It is a behavior thing. We use education and pants to stop him from picking at his skin. His legs were being wrapped in the past, but he has low cognition and does not understand the need. He was removing them himself. V4 said the aides should be checking his nails daily and trim them as needed. Diabetic residents need the nurse to trim fingernails and he is a diabetic. V4 removed the cover from R17's left knee. A quarter size open, oozing wound was observed. V4 was questioned about the multiple scratches and scabs on the forearms and leg. V4 verified they were all caused by R17 scratching and picking at his skin. V4 checked R17's fingernails and said the nails were unacceptable. They should have been trimmed long ago. It is needed to help reduce the risk of him scratching himself. V4 said the physician needs to be notified today of the open area on the knee. On 1/25/24 at 9:05 AM, V9, V10 and V11 (Certified Nurse Aides) transferred R17 from the wheelchair to the bed and began incontinence care. V10 stated R17 has cognitive decline and can't make decisions by himself. He does not understand his needs or reminders. R17 picks and scratches, especially when he is in shorts. He needs long sleeves and pants to cover his skin. Aides should report to the nurse when a diabetic resident needs their nails cut. The CNAs stated R17's nails should have been cut long ago. At 9:29 AM, V7 (LPN) stated she had never seen R17 in pants and did not believe he even owned any. V7 said pants would help remind him not to pick at his skin. It needs to be covered. R17's care plan was reviewed. There were no focus areas or interventions in place to reduce his risk of picking and creating open wounds to his skin. R17's skin evaluation dated 1/25/24 (after observations with surveyor) showed an open area to the left knee measuring 0.5 x 0.7 x 0.1 centimeters. The evaluation showed a second open area to the right forearm measuring 0.4 x 0.3 x 0.1 centimeters. The report stated dressing applied to left knee per MD order. Skin assessment performed. Resident educated on picking of skin and scabs however due to resident's cognition, resident unable to repeat back education. Tubi grip in place to right arm to protect healing open area and deter resident from picking. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146133 If continuation sheet Page 3 of 21 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 146133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandwich Living & Rehab Center 902 East Arnold Street Sandwich, IL 60548 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 - Few The facility's Preventative Skin Care policy review dated 3/16/23 states: 15. Keep the resident's fingernails and toenails short and smooth to prevent them from accidentally scratching themselves. Based on observation, interview and record review the facility failed to ensure initial and weekly wound assessments were completed and failed to put interventions in place to address a resident's refusal of care and a resident's scratching behavior for 2 of 3 residents (R18, R17) reviewed for skin condition in the sample of 17. The findings include: 1. R18's face sheet showed a [AGE] year-old male with diagnosis of anemia, difficulty walking, and chronic venous hypertension with ulcer of unspecified lower extremity. On 01/24/24 at 10:17 AM, R18 was in his bed. R18 sat upright. There was a gauze dressing to the right leg saturated with yellow drainage. The left lower leg had an ace wrap covering. R18 said there was a dressing to the left lower leg under the ace wrap. R18 said he does his dressing changes himself. R18 removed the gauze from his right leg with his bare hands, removed a large ABD pad which was saturated in yellow and red tinged drainage, and pulled back a yellow petroleum dressing partially to reveal a large beefy red wound at least 8 centimeters wide. No odor was noted, and the irregular shape silhouette could be seen through the petroleum dressing and comprised much of the right lower leg in length. R18 then replaced all the saturated dressings with the same bare hands. R18 said he doesn't do his dressing changes until dinner time. R18 said he saw his wound doctor yesterday and sees an Infectious Disease (ID) doctor. R18 said he was on an antibiotic due to an infection and pointed to his legs. On 01/25/24 at 9:40 AM, V5 Registered Nurse (RN) said R18 doesn't like anyone touching him. He does his own dressing changes 75-80% of the time. He gets spicy and yells if a nurse tries to change the dressings. We don't have a wound nurse and he usually keeps his dressing supplies in his room. V5 said V4 Licensed Practical Nurse (LPN) does rounds with the wound doctor but is not sure who does rounds for residents that don't see the facility wound doctor such as R18. At 10:58 AM, V7 Assistant Director of Nursing (ADON) said R18 allows staff to change his dressings 0% of the time. He requests supplies and does his own dressing changes. He has put urine on his wounds to heal them. He recently had a skin graft that he picked right off. V7 said wounds should be assessed on admission by the nurse on duty. A wound assessment would include measurements, appearance, drainage, and color. Weekly wound assessments are important to have a baseline to gauge healing or declining wound conditions. V7 said R18 was admitted with the venous wounds to both legs and V4 was supposed to do wound assessments. On 01/25/24 at 11:11 AM, V22 Advanced Practice Nurse (wounds) said she was very familiar with R18 and had been treating him for years. V22 said R18 was found homeless on the streets and extensive workup and testing had been done for his bilateral leg wounds. R18 was seen in her office every 3-4 weeks, and he also sees an ID physician who confirmed a chronic Methicillin Resistant Staphylococcus Aureus (MRSA) infection to R18's leg wounds. V22 said R18 was on antibiotics for the infection, was non-compliant with care at the facility, kicked out of another facility in town and a difficult case. V22 said R18 had skin graft surgery to his leg wounds (December) and 6 days later he removed the skin grafts and left only some staples which she removed in the office. They had a bloody mess. V22 said R18 was always cooperative with her but she believes he is self-sabotaging the wounds. Ideally, they (staff) should be changing and looking at the wounds daily. V22 said she was not aware R18 had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146133 If continuation sheet Page 4 of 21 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 146133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandwich Living & Rehab Center 902 East Arnold Street Sandwich, IL 60548 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 put urine on his wounds. Level of Harm - Minimal harm or potential for actual harm R18's initial and weekly wound assessments were requested three times, and none were received. Residents Affected - Few The facility's 1/2018 Skin Condition Monitoring Policy showed it is the policy of the facility to provide proper monitoring, treatment, and documentation of any resident with skin abnormalities. Documentation of the skin abnormality must occur upon identification and at least weekly thereafter until the area is healed. Documentation of the area must include the following: Characteristic-size, shape, depth, odor, color and presence of granulation tissue or necrotic tissue; Treatment and response to treatment. Prevention techniques that are in use for the resident. R18's 8/2/23 quality review note showed R18 was provided his own linen to wash his legs with soap and water, apply calcium alginate with silver to legs. This note showed he was on an antibiotic for infection. The right leg vascular wound measured 11.6 centimeters (cm) X 14.2 cm X 0.3 cm, the left lower leg vascular wound measured 5.2 cm X 6.7 cm X 0.3 cm and there was moderate drainage noted. (This note is the only measurement found in R18's records). R18's 1/17/24 facility assessment showed he was cognitively intact. R18's wound care plan showed to see the weekly measurements for status update and size/depth. The goal showed the wounds wound decrease in size and depth. There were no care plans identifying his wound care treatment non-compliance, the fact that he was performing his own wound care treatments or interventions/education to aid in obtaining compliance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146133 If continuation sheet Page 5 of 21 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 146133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandwich Living & Rehab Center 902 East Arnold Street Sandwich, IL 60548 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a physician ordered dressing was in place for 1 of 4 residents (R133) reviewed for pressure ulcers in the sample of 17. Residents Affected - Few The findings include: R133's face sheet printed on 1/25/24 showed diagnoses including but not limited to multiple sclerosis, neuromuscular bladder, and pressure ulcer of the buttocks. R133's facility assessment dated [DATE] showed moderate cognitive impairment. The same assessment showed total staff assistance required for transfers, bed mobility, dressing and hygiene. The assessment showed R133 uses an indwelling catheter for urine and is always incontinent of bowel. R133's January 2024 physician order summary report showed a treatment order for the left ischium (lower and back side of the hip bone) to cleanse with normal saline, pat dry, skin prep peri-wound. Pack with Dakins gauze and cover with dry dressing every 12 hours and prn (as needed). R133's skin evaluation dated 1/23/24 showed the ischium wound measuring 6.2 x 5.8 x 0.7 centimeters. The evaluation showed R133 was readmitted a week ago with the wound following a hospital stay greater than two weeks. On 1/25/24 at 10:27 AM, V9 and V23 (Certified Nurse Aides) rolled R133 to his side and removed the incontinence brief. R133 had a pen length, open wound to his lower buttock area and red, watery drainage was observed on the inside of the brief. The wound was uncovered and located near the center of the left buttock. V9 stated there should be a dressing on the pressure sore. He is incontinent of bowel and it helps keep bacteria out. It should have been reported missing as soon as the night shift saw that it was gone or soiled. V23 exited the room and alerted V4 (Licensed Practical Nurse) of the situation. On 1/25/24 at 10:47 AM, V4 (LPN) performed wound treatment and placed a dressing to R133's uncovered wound. V4 said there is a high risk of infection if the area is left uncovered. V4 said aides should be reporting any missing, soiled, wet, or loose dressings right away. Wounds can get worse or take longer to heal if they are not treated as ordered. On 1/25/24 at 12:01 PM, V3 (Director of Nurses) stated wound dressings are needed to keep germs out and help cushion the wound against pressure. It is a form of infection control. Missing or soiled dressings should be reported right away so the treatment can be put back in place. R133's care plan showed a focus area related to a wound on the left ischium. Major contributing factors included multiple sclerosis. Interventions showed to administer treatments as ordered. The facility's Decubitus Care/Pressure Areas policy revision dated 1/18 states: It is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146133 If continuation sheet Page 6 of 21 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 146133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandwich Living & Rehab Center 902 East Arnold Street Sandwich, IL 60548 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 an indwelling catheter was changed as ordered and failed to keep it off the floor for 1 of 2 residents (R133) reviewed for catheters in the sample of 17. The findings include: R133's face sheet printed on 1/25/24 showed diagnoses including but not limited to multiple sclerosis, neuromuscular bladder, and pressure ulcer of the buttocks. R133's facility assessment dated [DATE] showed moderate cognitive impairment. The same assessment showed total staff assistance required for transfers, bed mobility, dressing and hygiene. The assessment showed R133 uses an indwelling catheter for urine and is always incontinent of bowel. R133's January 2024 physician order summary report showed an order for urinary catheter care to be done every shift and to change the drainage bag monthly. R133's care plan showed a focus area related to catheter care and to change as needed. On 1/25/24 at 8:12 AM, R133 was lying in bed and his indwelling catheter drainage bag was directly on the floor next to the bed. The urine in the bag was a dark, tea color and sediment was visible along the tubing. At 9:44 AM, the bag was still lying on the floor. On 1/25/24 at 10:27 AM, V9 and V23 (Certified Nurse Aides) assisted R133 to his side and began incontinence care. V23 picked the drainage bag up off of the floor and V9 stated it should not be there. It is an infection control issue and can spread germs. Catheter bags need to be kept clean to prevent germs from entering the urinary tract. At 10:47 AM, V4 (LPN) said catheter bags and tubing are to be changed as needed. Contaminated bags and high sediment in the urine are both an indication that the items need to be changed. V4 viewed R133's catheter bag and tubing. V4 stated yes, that is very high sediment and should have been changed before now. On 1/25/24 at 12:05 PM, V3 (Director of Nurses) stated there is the potential for bags to open if left lying on the floor. Infection and germs could enter urinary tract. Catheter bags and the tubing need to be changed monthly and prn. Sediment, bad drainage, or discolored urine are reasons to change them. Pain, infection, and illness can result if they are not addressed. The facility's Catheter Care policy revision dated 2/2018 states: Catheter care is provided daily and as needed to all residents who have an indwelling catheter to reduce the incidence of infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146133 If continuation sheet Page 7 of 21 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 146133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandwich Living & Rehab Center 902 East Arnold Street Sandwich, IL 60548 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 0692 Provide enough food/fluids to maintain a resident's health. 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 implement interventions for a resident experiencing significant weight loss for 1 of 4 residents (R8) reviewed for weight loss in the sample of 17. This failure resulted in R8 experiencing a 19.47% weight loss from 11/23/23 to 1/24/24 (2 months and 1day.) Residents Affected - Few The findings include: R8's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include abnormal posture, cerebral infarction, dysphagia, Gastro-Esophageal Reflux Disease, major depressive disorder, Type 2 Diabetes, and weakness. R8's facility assessment dated [DATE] showed she has no cognitive impairment and requires substantial to maximum assistance with eating. R8's weight was recorded in her medical record as follows: 11/23/23 she weighed 113 lbs, on 12/4/23 she weighed 89 lbs, and as of 1/24/24 she weighs 91 lbs (19.47% weight loss over 2 months). R8's January 2024 Physician Order sheet showed nutritional supplements including 2.0 Calorie Supplement, Magic Cup, and Mighty Shake all starting 1/13/24 (over 1 month after the significant weight loss was identified). R8's care plan initiated 7/20/23 showed, Potential risk for altered nutritional status and/or weight loss. Related Diagnosis: dysphagia, Additional Risk Factors: noncompliance . Resident will gain 1# (pound) per month for next 90 days. Assist/feed mealtimes as needed to complete meal. Educate family, visitors and staff not to provide food from outside the facility without checking with charge nurse before giving to resident. Encourage self-feeding. Feed resident to complete as much of meal as possible . R8's care plan initiated 1/5/24 showed, The resident has unplanned/unexpected weight loss related to poor intake . The resident will consume 75-100% two of three meals/day . Alert dietitian if consumption is poor for more than 48 hours . Give the resident supplements as ordered. Alert nurse/dietitian if not consuming on a routine basis. If weight decline persists, contact physician and dietitian as soon as practical . Monitor and evaluate any weight loss. Determine percentage lost and follow facility protocol for weight loss. Monitor and record food intake at each meal. Offer substitutes as requested or indicated. The residents prefers: ___________ (no preferences mentioned) . On 1/24/24 at 12:20 PM, R8 was sitting in the dining room in her wheelchair at the table. A tray of pureed meatloaf was given to R8 and placed out of reach. At 12:25 PM, there was a CNA sitting across the round table from R8 and she was assisting two other residents with their lunch. At 12:38 PM (18 minutes after R8's lunch was placed on the table), V11 CNA (Certified Nursing Assistant) sat down next to R8. V11 placed R8's spoon into the meatloaf and moved it in front of R8. R8 did not attempt to eat the meatloaf. V11 then put the spoon into R8's dessert and moved that in front of R8. R8 did not eat the dessert. At 12:50 PM, R8 left the dining room without eating any of her lunch. Staff did not offer assistance at any time during the meal. There was no Magic Cup or ice cream provided. On 1/24/24 at 2:20 PM, R8 said, They give me pureed food and it is gross. My feeding tube came out (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146133 If continuation sheet Page 8 of 21 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 146133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandwich Living & Rehab Center 902 East Arnold Street Sandwich, IL 60548 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 0692 Level of Harm - Actual harm before and I don't know how it happened, but I had an infection . Most of my weight loss happened before the feeding tube came out. I do sometimes eat the pureed food, but I hate their meatloaf and I don't like chili. I can't ask for anything else, they won't get it for me. I've asked before. I like Spaghetti-O's and ice cream, but they don't give me that very often. Residents Affected - Few On 1/25/24 at 11:04 AM, V10 CNA (Certified Nursing Assistant) said, [R8's] appetite is not good, and she refuses a lot of her meals. We try to encourage her, but she tends to refuse a lot. She just says she isn't hungry, or she doesn't like the meal. If she does not like the main meal or the substitute, we can offer her a peanut butter and jelly or a deli sandwich. We also have snack bins that have chips, pudding, jello, and crackers. I would say it is very rare that she does request a sandwich. I know she likes pop, chips, mac and cheese, canned ravioli, and spaghetti. She really likes those. I haven't seen her get any supplements. I haven't seen a magic cup or anything. I don't recall ever seeing ice cream on her tray either. On 1/24/24 at 12:45 PM, V14 (Dietary Manager) said R8 always refuses the pureed diet. V14 said family bring in canned Spaghetti-Os and raviolis and she will eat that, applesauce or pudding. She will not eat pureed food, always refuses it. On 1/25/24 at 1:25 PM, V14 (Dietary Manager) said the Registered Dietitian (RD) comes in once a month to review residents. V14 said, The RD comes into the kitchen and looks at everybody. She talks about the menu to see if there is any problems. I am learning how to monitor weight loss, but it's been a little hard because I started in November, and we were down a couple people in the kitchen. Dietary assessments should be done by me but I'm still learning so the floor nurse is doing the assessments while I am being trained. I am trying to talk to the residents about their preferences but haven't had much of a chance to do that due to staffing shortage. I am starting to do one on one interviews with the residents and ask how things are going, allergies, likes and dislikes. If a resident does not like something we are serving, we also have a substitute. If they don't like the substitute, they can get a deli sandwich or a peanut butter and jelly sandwich. We have a weight meeting once a week that I sit in on and they talk about gains and losses, and we work out a game plan. I have a notebook that I have written down some things in from the weight meeting, but I don't have anything that I put in their chart. For R8, I know we are giving her ice cream at every meal if she takes it. We are doing chocolate pudding; she likes tomato soup, so we try and give her tomato soup. Anything she wants we are giving her just because we are trying to get her to gain weight. We have not given her any ravioli or Spaghetti-O's because her husband brings some of that in, but it is in my notes to see if that is something they want to start doing. On 1/25/24 at 2:12 PM, V2 (Regional Clinical Director) said, the nurses are doing the dietary assessments right now until the Dietary Manager is trained. They are assessing weight, diet, their diagnoses, hydration needs, chewing ability, swallowing, any issues like that. R8 can have whatever she wants, and I know one of the nurse's has brought a can of ravioli in at times because she does eat that. If they told her she can't have a substitute, I know who that would have been in the kitchen. The facility's policy and procedure revised 9/2008 showed, Resident Weight Monitoring . If there is an actual significant weight change, the resident, family/guardian, physician and dietitian are notified. The date of notification for the physician and family/guardian is documented on the Report of Monthly Weight form . The food service manager and/or dietitian reviews the resident's nutritional status and makes recommendation for interventions in the nutrition progress note. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146133 If continuation sheet Page 9 of 21 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 146133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandwich Living & Rehab Center 902 East Arnold Street Sandwich, IL 60548 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure oxygen was being administered as ordered for 1 of 1 resident (R6) reviewed for oxygen services in the sample of 17. Residents Affected - Few The findings include: R6's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include dementia without behavioral disturbance, hypertension, cerebral infarction, anxiety disorder, and hyperlipidemia. R6's January 2024 Physician Order Sheet showed an order started on 1/18/24 showed Oxygen at 2L via nasal cannula every shift. Another order dated 1/18/24 showed, Oxygen- tubing and humidifier, Change every night shift every Sunday . On 1/24/24 at 11:14 AM, R6 was lying in her bed with her oxygen on. R6's oxygen concentrator was set at 4.5 L/min and the humidifier canister was dated 12/18/23 (approximately 6 weeks ago) and had no water in it. On 1/25/24 at 9:42 AM, R6 said she uses her oxygen all the time while she is in bed and thinks she uses 2-3 liters of oxygen. R6 said her oxygen dries her nose out but there is a container of water on it that the nurses fill every so often. On 1/25/24 at 1:30 PM, V4 LPN (Licensed Practical Nurse) went into R6's room with surveyor and verified R6's oxygen was set at 4.5 L per minute and the humidifier bottle was empty and dated 12/18/23. V4 checked R6's order and stated she should be on 2L per minute per her current orders. On 1/25/24 at 2:12 PM, V2 (Regional Director of Clinical Operations) said oxygen should be administered as ordered and she expects the nurses to be monitoring and ensuring the oxygen concentrator is set on the correct amount. V2 said it is important to ensure the oxygen concentrator is set at the correct amount because depending on the resident's diagnoses, administering oxygen at too high of a level could cause C02 (carbon dioxide) retention. The facility's policy revised 8/03 showed, Oxygen Therapy, Policy: Oxygen is administered to promote adequate oxygenation and provide relief of symptoms of respiratory distress. Responsibility: Licensed nursing personnel . Oxygen therapy may be used provided there is a written order by the physician. The order must state liter flow per minute, mask or cannula, time frame . Procedure: 1. Verify physician's order . 8. Adjust delivery rate per the physician's order . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146133 If continuation sheet Page 10 of 21 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 146133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandwich Living & Rehab Center 902 East Arnold Street Sandwich, IL 60548 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 0725 Level of Harm - Minimal harm or potential for actual harm Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on interview and record review, the facility failed to have licensed nursing coverage 24 hours a day. This failure has the potential to affect all 27 residents in the facility. Residents Affected - Many The findings include: The CMS (Centers for Medicare and Medicaid Services) 671 form titled Long-Term Care Facility Application For Medicare and Medicaid, dated 1/24/24, showed 27 residents resided in the facility. The PBJ (Payroll Based Journal-Staffing Data Report) dated 12/1/23, showed the facility triggered for not having 24- hour Licensed Nursing coverage on 4/16/23, 6/12/23, 6/13/23, 6/14/23, and 6/17/23. On 1/25/24 the facility was asked to provide timecard documentation showing that a licensed nurse was working on 4/16/23, 6/12/23, 6/13/23, 6/14/23, and 6/17/23. The facility was only able to provide documentation of timecard data showing 24-hour licensed nursing coverage for 4/16/23. On 1/25/24 at 10:53 AM, V1 (Administrator) said V18 (Registered Nurse-RN/ MDS/Care Plan Nurse) worked from 12:13 PM - 7:00 PM on 6/12/23. V1 said the rest of the nursing coverage for 6/12/23 was agency staff, so the facility does not have that information available in their time sheet system. V1 said V2 (Regional Director of Clinical Operations) is working on getting the information from the agency. V1 said on 6/13/23, V19 (RN) worked from 7:30 PM to 7:02 AM the next morning (leaving at 7:02 AM on 6/14/23), No other information was provided for 6/13/23. V1 said on 6/14/23, V19 (RN) was the nurse until 7:02 AM, V18 (RN/MDS Nurse) was the nurse on duty from 11:37 AM to 11:14 PM, and V20 (RN) was the nurse from 9:40 PM to 10:49 AM the next morning. The facility did not provide proof that a licensed nurse was working from the time V19 left at 7:02 AM until 11:37 AM when V18 took over. V1 said on 6/17/23, V7 (Licensed Practical Nurse-LPN/Resident Care Coordinator and Scheduler) worked from 6:00 PM to 7:30 AM. On 1/25/24 at 10:57 AM, V7 came into V1's office and said V21 (RN) and another nurse also worked on 6/17/23. V7 said she would have to get the information as to the exact hours they worked. No further information was provided prior to exiting the facility. On 1/25/24 at 11:30 AM, (LPN/Scheduler) said she has been doing the schedules since 11/11/23. V7 said V2 (Regional Director of Clinical Operations) helps do the schedules. V7 said she is told how many staff are needed by V2. On 1/25/24, the facility provided the payroll/timecard document for V18 for 6/12/23. The document showed V18 worked on 6/12/23 from 12:13 PM to 6:57 PM. On 1/25/24, the facility provided the payroll/timecard document for V19 for 6/13/23. The document (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146133 If continuation sheet Page 11 of 21 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 146133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandwich Living & Rehab Center 902 East Arnold Street Sandwich, IL 60548 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 0725 showed V19 worked from 7:32 PM on 6/13/23 to 7:00 AM on 6/14/23. Level of Harm - Minimal harm or potential for actual harm On 1/25/24, the facility provided the payroll/timecard document for V20 for 6/14/23. The document showed V20 worked on 6/14/23 from 9:40 PM to 10:49 AM on 6/15/23. Residents Affected - Many On 1/25/24 at 3:34 PM, V2 (Director of Nursing) said she did not have any more information or documentation to provide regarding staffing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146133 If continuation sheet Page 12 of 21 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 146133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandwich Living & Rehab Center 902 East Arnold Street Sandwich, IL 60548 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) worked at least 8 hours a day. This has the potential to affect all 27 residents in the facility. Residents Affected - Many The findings include: The CMS (Centers for Medicare and Medicaid Services) 671 form titled Long-Term Care Facility Application For Medicare and Medicaid, dated 1/24/24, showed 27 residents resided in the facility. On 1/25/24, a review of the facility's January 2024 schedule showed no RN working on Saturday, 1/6/24 and on Sunday 1/14/24. On 1/25/24 at 11:18 AM, V2 (Regional Director of Clinical Operations) said she was in the building on 1/6/24 from 7:00 -5:00 PM. V2 said she did not enter any information into the system regarding her being in the building on 1/6/24. V2 said she will have to see if V6 (RN) worked on 1/14/24. No further documentation was provided prior to exiting the facility. On 1/25/24 at 3:34 PM, V2 said she did not have any further information or documentation to provide regarding staffing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146133 If continuation sheet Page 13 of 21 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 146133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandwich Living & Rehab Center 902 East Arnold Street Sandwich, IL 60548 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 a resident's medication was not left at the bedside for 1 of 1 resident (R18) reviewed for medications in the sample of 17. The findings include: R18's face sheet showed a [AGE] year-old male with diagnosis of anemia and chronic venous insufficiency with ulcer of unspecified lower extremity. On 01/24/24 at 10:17 AM, R18 was in bed. There was a clear plastic medication cup on the bedside table. Inside the medication cup were a blue capsule and a white capsule. R18 said, They're for my infection and pointed to his legs. R18 was able to communicate clearly in English. On 01/24/24 at 2:40 PM, V6 Registered Nurse (RN) said she left R18's medications on his bedside table this morning. V6 said he was asleep and said just to leave them there. V6 identified the two medications as antibiotic and a probiotic. At 01/24/24 at 2:43 PM, V3 Director of Nursing (DON) said It is not acceptable to leave a resident's medications at the bedside. It's unsafe to leave them there. The nurse won't know who took it or if it was taken. R18's Medication Administration Record (MAR) showed V6 administered the 8:00 AM dose of antibiotic and probiotic on 1/24/24 at 8:00 AM. R18's Physician Order Sheet (POS) did not have a current order to leave his medications at the bedside. R18's facility assessment showed he was cognitively intact. The facility's 11/18/17 Medication Administration Policy showed medications must be administered within one hour of the designated time or as ordered. Observe the resident consume the medication to insure resident swallows medication. Never leave prepared medications unattended. No medication should be left at bedside unless specifically ordered by the physician . Destroy medications prepared for a resident if not used immediately. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146133 If continuation sheet Page 14 of 21 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 146133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandwich Living & Rehab Center 902 East Arnold Street Sandwich, IL 60548 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure the bucket used for wiping down the dining room tables had the correct amount of chemical level to achieve sanitation; the facility failed to ensure food temperatures remained at 135 degrees Fahrenheit or above, prior to serving; the facility failed to prevent cross-contamination during the lunch meal service; and the facility failed to ensure temperature and sanitation logs were completed. This has the potential to affect all 27 residents in the facility. The findings include: The CMS (Centers for Medicare and Medicaid Services) 671 form titled Long-Term Care Facility Application For Medicare and Medicaid, dated 1/24/24, showed 27 residents resided in the facility. The Diet Type Report, provided by the facility on 1/25/24, showed all 27 residents take food by mouth. 1. On 1/24/24 at 9:16 AM, V16 (Housekeeping) was washing off the tables in the dining room after the breakfast meal. V16 was asked to check the sanitation bucket to ensure the proper chemical level. V16 asked V17 (Dietary Aide) for the test strips. V16 performed the test for the sanitation bucket she was using to clean the tables. The test strip results were a light yellowish color. V16 was asked what color the strip should turn. V16 said she thought it should be green. At 9:19 AM, V17 (Dietary Aide) tested a different bucket and showed this surveyor the results. The strip had turned green from the chemicals. The test strips used were hydrion QT-40 test strip. V17 verified that the strip should be green. V17 said the results should show about 400 ppm (parts per million). On 1/24/24 at 9:23 AM, V14 (Dietary Manager) said they did not get enough sanitizer in the bucket. V14 pointed to the gallon jug containing the chemical used for the sanitation buckets and said it is low; We need to change the jug. At 9:24 AM, V17 said the bucket V16 was using was an old bucket, adding that they have to change the contents of the bucket every 2 hours. V17 said V16 grabbed the bucket before she changed the water in it. On 1/25/24 at 9:52 AM, V14 said it is important to make sure the chemicals in the sanitation buckets have the right amount of chemicals in them to disinfect and sanitize. The facility's January 2024 Sanitizing Solution Log showed 4 days where there was no information entered. The Log showed the sanitizing solution for the Quat chemical used in the sanitizing buckets should be 200 ppm (parts per million). This would show up as green on the test strip. 2. On 1/24/24 at 11:48 AM, V15 (Dietary Cook) obtained the temperatures of the food items in the steam table prior to serving the lunch meal. The temperatures were as follows: Meatloaf 118 degrees Fahrenheit Baked potato, 1 large 140 degrees Fahrenheit (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146133 If continuation sheet Page 15 of 21 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 146133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandwich Living & Rehab Center 902 East Arnold Street Sandwich, IL 60548 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Vegetable medley 120 degrees Fahrenheit Level of Harm - Minimal harm or potential for actual harm Pureed meatloaf 85 degrees Fahrenheit Pureed creamed spinach 85 degrees Fahrenheit Residents Affected - Many Chili 120 degrees Fahrenheit V15 verified each food temperature with this surveyor as she was obtaining them. On 1/24/24 at 12:05 PM, V15 washed her hands, put gloves on and started plating food for the residents' lunch meals. On 1/24/24 at 12:34 PM, V14 said the pureed foods should be brought back up to 165 degrees Fahrenheit prior to serving. usually, we put the pureed foods in the microwave and bring it to 165 degrees Fahrenheit prior to serving. V14 said the foods on the steam table should be at least 140 degrees Fahrenheit prior to serving. To prevent food borne illness. On 1/25/24 at 9:52 AM, V14 clarified that the logs that were provided titled food temperature chart, is where the cooks list the temperatures of foods on the steam table prior to serving. V14 verified that some of the days did not have entries in them. V14 said there should be entries at every meal. V14 said it is important to make sure the food is at the proper temperature to prevent food-borne illness. V14 said it is important to fill out the logs to make sure staff are following the procedures and that the equipment is working correctly. The Food Temperature Charts provided by the facility showing weeks 1-3 for January 2024, showed 6 meals where all of the food temperatures were not recorded. The facility's policy and procedure titled Food Temperatures, with a revision date of 4/2017, showed It is the policy of (the facility) to ensure that food is served at a temperature that is proper to prevent the growth of harmful bacteria and other foodborne illnesses .1. The cook is responsible for taking and recording the temperatures for all hot and cold food at each meal .4. Food temps should be taken prior to the meal service and recorded on the Food Temperature Chart. 5. Hot foods must read a minimum of 135 degrees Fahrenheit before residents can be served. The facility's 4/2017 Food Safety document, as well as the recipes provided by V14 (DM) on 1/24/24, for the meatloaf, potatoes, and Normandy Grande Classic vegetables showed the temperatures should be held at 135 degrees Fahrenheit or higher. 3. On 1/24/24 at 12:05 PM, V15 washed her hands, put gloves on and started plating food for the residents' lunch meals. V15 picked up the pieces of meatloaf with both of her gloved hands and placed the meatloaf on a plate. V15 grabbed a potato and removed the foil, then placed it on a plate. V15 used a ladle to place the vegetable medley onto the plate, grabbed a lid to cover the plate, then removed the meal card from the holder to see the next resident's meal card. At 12:06 PM, V15 walked over to the cooler, opened the door and came out with a plate of burgers. V15 grabbed one of the burgers off the plate using her gloved hand, placed the burger on a plate, opened the microwave door, put the plate in, closed the door and touched the control panel on the microwave to enter the time and start the microwave. V15 opened the microwave door when it stopped and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146133 If continuation sheet Page 16 of 21 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 146133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandwich Living & Rehab Center 902 East Arnold Street Sandwich, IL 60548 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many grabbed a potato. V15 removed the foil and placed the potato on the plate. V15 picked up the pieces of meatloaf every time using both of her gloved hands, instead of a utensil. V15 touched all of the potatoes after removing the foil and would peel the potato (with her gloved hands) if the plate she was making was for a resident receiving a mechanical soft diet. During the lunch meal service, V15 opened the cooler door 3 additional times using the same gloves that she was picking up the meatloaf and potatoes with. After finishing each plate, V15 would remove that meal card from the holder to view the next meal card. V15 did not change gloves or wash her hands other than the initial handwashing prior to service. On 1/24/24 at 12:27 PM, V14 (Dietary Manager-DM) said she has told staff to change gloves with every task. V14 said it is not acceptable to wear the same gloves throughout the meal, touching the meat and potatoes with the same gloves used to open the cooler door and the microwave. V14 said it is important to change gloves to prevent cross contamination and food-borne illness. On 1/25/24 at 9:52 AM, V14 said V15 should not pick up the meatloaf with gloved hands, touch the door handles to the cooler and the microwave and then pick up meatloaf because there could be germs on the door handles and contaminate the food. The facility's 10/2017 policy and procedure titled Glove Usage showed 3. Disposable gloves should be changed between tasks and no worn continuously .5. Gloves should be changed if ripped or soiled .8. Gloves, tongs, deli paper, spatulas or other serving utensils should be used when handling any foods, ready to eat or otherwise .9. Food contact gloves should not be used for nonfood tasks . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146133 If continuation sheet Page 17 of 21 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 146133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandwich Living & Rehab Center 902 East Arnold Street Sandwich, IL 60548 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 interview and record review, the facility failed to continue testing residents and staff for Covid-19 until there was no positive cases for 14 consecutive days, and failed to notify the local health department of a Covid-19 breakout. Residents Affected - Many This has the potential to affect all of the 27 residents in the facility. The findings include: On 1/25/24 at 1:07 PM, V2 (Regional Director of Clinical Operations) said V7 (Licensed Practical Nurse/Resident Care Coordinator) was in charge of testing and making sure that all staff and residents were tested. On 1/25/24, a review of the facility's testing documents showed the last positive case of Covid-19 was on 1/2/24. The documents showed the last testing was done on 1/12/24. On 1/25/24 at 2:36 PM, V7 said she was not aware that testing had to continue for 14 days. V7 verified that the last positive resident case was on 1/2/24 and the last day of testing was on 1/12/24. V7 said she was not provided any policies and procedures showing what was expected, adding I was pretty much just thrown into the job. On 1/25/24 at 2:40 PM, V2 (Regional Director of Clinical Operations) said testing should have continued until there were 14 days with no new positive cases. V2 said testing should have been done on 1/16/24. On 1/25/24 at 2:44 PM this surveyor spoke with the V25 (Infection Control Coordinator at the local health department). V25 identified V24 (Registered Nurse-RN) as the person that handles calls from the nursing homes in the county. V25 said V24 was not in the office, but she would ask her to return this surveyor's call on 1/26/24. On 1/26/24 at 9:04 AM, V24 (RN/Public Health Nurse for the local Health Department) said she was not notified by the facility of a Covid-19 outbreak in the facility in December 2023 or January 2024. V24 said the last outbreak the facility reported to the local Health Department was in March of 2023. V24 said the facility is supposed to notify her if there is an outbreak, and put the positive cases into a small report for the local Health Department. V24 said this was not done. V24 said the facility is supposed to continue testing the residents and staff until there are no positive cases for 14 days. The facility's policy and procedure titled Monitoring and Surveillance-HCP (Health Care Personnel), with a revision date of 5/19/23, showed Testing of HCP and Residents in Response to Outbreak. 1. Upon notification of a single new case of facility associated Covid-19 infection in any staff member or resident, all staff and residents should have a series of three viral tests. The first test should be completed, not earlier than 24 hours from time of exposure, if negative, repeat testing 48 hours after initial test and if negative after the second test, repeat testing in another 48 hours. (This will usually be days 1, 3, and 5, with the date of exposure being day ).). If no further cases of Covid-19 are identified, then no further testing is required. 2. If additional HCP and/or residents test positive during the initial outbreak testing, then residents and staff should be retested every 3-7 days until testing identifies no new cases of Covid-19 involving HCP or residents for a period (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146133 If continuation sheet Page 18 of 21 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 146133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandwich Living & Rehab Center 902 East Arnold Street Sandwich, IL 60548 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 of 14 days since the most recent positive result. The policy also showed Notifications and Reporting .2. Written notification will be provided immediately to LHD (local Health Department) upon the confirmation of Covid-19 infection of a resident or staff member. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146133 If continuation sheet Page 19 of 21 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 146133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandwich Living & Rehab Center 902 East Arnold Street Sandwich, IL 60548 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure information regarding immunization status was in the residents electronic or paper charting for 2 of 5 residents (R17, R23) reviewed for immunizations in the sample of 17. Residents Affected - Few The findings include: On 1/25/24 no information was found by this surveyor in R17's and R23's electronic medical record or paper charting regarding their immunization status. On 1/25/24 at 1:31 PM, V2 (Regional Director of Clinical Operations) said she could not find any records of R17's vaccination status in his paper medical records, or his electronic medical record. V2 said V7 (Resident Care Coordinator) told her that R17 had the influenza vaccine on 9/5/23. V2 said V7 told her that is all she could find. She is still looking. V2 said she did not find any information regarding R23's immunization status in his electronic or paper medical records. This surveyor asked V2 to provide all of the information they had regarding consents obtained and vaccination status for the 5 residents reviewed for immunizations. This surveyor informed V2 that she could send them to her via her government email. At 3:35 PM, V2 said she sent all of the information they found to this surveyor's email. The information sent did not show documentation of R17 having an influenza vaccine, or any other vaccines (e.g. pneumonia vaccines or Covid-19 vaccines). The only information provided regarding R17 was a consent form for the influenza vaccine dated 9/5/23. The consent form was not filled out or signed. No information was provided for R23 regarding his vaccine status. The facility's Influenza Control Measures policy, with a revision date of 11/4/2021, showed Influenza Vaccine: 1. Encourage residents and staff to receive the influenza vaccine annually. 2. Standing orders should be in effect for all residents, unless contraindicated. The facility's Survey Binder had a document titled Pneumococcal Vaccine Timing for Adults. The document showed The vaccine is recommended for adults [AGE] years of age and older, and for Adults 19-[AGE] years of age with certain underlying medical conditions or other risk factors. R17's Transfer/Discharge Report, and R23's admission Record showed both of them are over the age of 65. The facility's Resident Influenza Vaccine Consent form, with a revision date of 3/17/22, showed As a resident of this facility, you are afforded the opportunity to receive an influenza vaccine every year. The facility's Resident Pneumonia Vaccine Consent form, with a revision date of 3/22/22, showed As a resident of this facility, you are afforded the opportunity to receive an influenza vaccine every year and the pneumonia vaccine as recommended. The facility's policy titled immunizations of Residents, with a revision date of 4/21/22, showed (the facility) will offer immunizations and vaccinations that aid in the prevention of infectious diseases unless medically contraindicated or otherwise ordered by the resident's attending physician or the facility's Medial Director. The policy showed it should be explained to the resident, resident's guardian or the resident's Durable Power of Attorney for Health Care at the time of admission, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146133 If continuation sheet Page 20 of 21 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 146133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandwich Living & Rehab Center 902 East Arnold Street Sandwich, IL 60548 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 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete importance of vaccination. 2. Obtain a written order for the vaccination, unless otherwise ordered by the resident's attending physician, or the resident or authorized representative refuses. 3. Obtain consent to administer the ordered vaccine, unless contraindicated. 4. Verify the date of the last vaccination. Obtain proof of previous Pneumococcal and Influenza vaccination for residents when able. Assess all newly admitted resident's pneumococcal and influenza vaccination status upon admission and record last known immunization on the resident's Immunization Record. Event ID: Facility ID: 146133 If continuation sheet Page 21 of 21