Health inspection·January 10, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm On 1/8/25 at 10:48 AM, R43 stated she wanted the bathroom repainted. On 1/8/25 at 11:40 AM, R50 stated, All the bathrooms are like that. They are all peeling. I would love for them to repaint it. It would look much better. R43's MDS dated [DATE] shows a BIMS score of 13, which means she is cognitively intact. Residents Affected - Some R50's MDS dated [DATE] shows a BIMS score of which 12, which means she is moderately impaired in cognition. On 1/18/25 at 10:14 AM, V10 (Maintenance Director) stated, This is a big issue, an ongoing issue with paint peeling, wallpaper peeling, holes in wall, and missing base boards. We are planning on remodeling our building. So, I'm hesitant to do all this work now. I'm not sure when or if we will remodel. We are waiting for an answer from corporate. I can't find a policy on this. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146159 If continuation sheet Page 2 of 16 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 146159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terrace 1615 Sunset Avenue Waukegan, IL 60087 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assist residents needing assistance with eating, oral care, and grooming. Residents Affected - Few This applies to 4 out of 4 residents (R57, R1, R28, and R26) reviewed for activities of daily living in a sample of 19. Findings include: 1. R57's EMR (Electronic Medical Record) showed she had multiple diagnoses including Alzheimer's disease, left-hand contracture, dysphagia, cognitive communication deficit, stage 4 pressure injury to the sacrum, seizures, and anemia. R57's MDS (Minimum Data Set) dated 12/04/2024 said she required substantial to maximal assistance with eating and was dependent on staff for her personal and oral hygiene needs. On 1/07/2025 at 11:30 AM, R57 was sitting in her reclining wheelchair in the dining room. R57 was confused and non-interviewable. R57 had overgrown facial hair on her upper lip and chin areas. R57's teeth were unkept they had food residue and had a foul mouth odor. At 12:30 PM R57 was trying to feed herself a folded slice of bread with a slice of a barbeque pork tenderloin, unsupervised. R57 was unable to feed herself because she had a surgical mask covering her mouth which was soiled with sauce. Then V8 (Certified Nurse Assistant/CNA) went to R57 to pull her surgical mask down to her chin and handed her the folded slice of bread with the pork tenderloin again. R57 was still having difficulty feeding herself and then V8 guided her with her hand to put the food in her mouth. At 12:45 PM V8 returned to R57 and started to feed her but then stopped and left her unsupervised again. On 1/08/2025 at 12:12 PM, R57 was again in the dining room for lunch. R57 continued to have overgrown facial hair. V9 (CNA) served R57 her lunch meal and did not feed her. R57 was trying to feed herself but was having difficulty. Then at 12:30 PM V6 (Restorative Aide) sat next to her and started to feed her. V6 said R57 was unable to feed herself and had to be fed by the staff. R57's Restorative Observation and Planning form dated 12/04/2024, said R57 was unable to state needs to have needs met .Resident is dependent of staff with all ADL's requires a feeder for meals. 2. R1's EMR showed she had multiple diagnoses including Alzheimer's disease, bilateral hand contractures and pain, weakness, dysphagia, cognitive communication deficit, and generalized osteoarthritis. R1's MDS dated [DATE] said she required supervision to touching assistance with eating and was dependent on staff for her personal and oral hygiene needs. On 1/07/2025 at 10:55 AM, R1 was sitting in her wheelchair in the dining room. R1 was wearing bilateral hand splints. R1 had two cups of thickened water and cranberry juice untouched in front of her. At 12:35 PM V7 (CNA) served R1 her lunch meal and removed the previously served cups of liquids which remained untouched. V7 said R1 was sometimes able to feed herself and did not assist her. R1 started to try to feed herself but her surgical mask was covering her mouth. R1's surgical mask was soiled with pureed food. V7 returned to remove R1's surgical mask and then left her unsupervised again. On 1/08/2025 at 12:25 PM, R1 was trying to feed herself lunch. R1 was having difficulty at times and spilled food on the side of her partially removed surgical mask and clothing protector. R1 had two (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146159 If continuation sheet Page 3 of 16 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 146159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terrace 1615 Sunset Avenue Waukegan, IL 60087 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm cups of thickened water and milk untouched. Then at 12:58 PM, V6 (Restorative Aide) came to assist R1 with her drinks. V6 said R1 was able to feed herself food most of the time but required supervision and assistance with her drinks. V6 said R1 was unable to grip drinking cups with her hands because of her contractions and splints. V6 fed R1 her milk which she drank the entire serving and then proceeded with her water. Residents Affected - Few R1's Restorative Observation and Planning form dated 1/02/2025 said R1 had contractions to her hands and cannot state needs to have needs met .Resident is dependent of care on all ADL's, including feeding. 3. R28's EMR showed he had multiple diagnoses including hemiplegia and hemiparesis following an intracranial hemorrhage affecting his right dominant side, dysphagia, right hand and elbow contractions, and other musculoskeletal system symptoms. R28's MDS dated [DATE] said he was dependent on staff for his oral hygiene care. On 1/07/2024 at 11:07 AM, R28 was in bed. R28's teeth were unkept and they had a thick build up of food residue. On 1/08/2024 at 12:20 PM, R28 again had a thick build-up of white residue substance on his teeth. V9 (CNA) was asked to inspect R28's mouth and said his teeth were dirty. V9 said CNAs brush residents' teeth at least daily. V9 said sometimes R28 would not allow for daily oral care but was seen by the dentist. R28's Restorative Observation and Planning form dated 11/12/2024, said R28 had weakness to his right side and requires one assist for ADLs. R28's Dentist consultation report dated 11/11/2024 said Extremely heavy, generalized plaque and heavy calculus present on pt's teeth. Assistance with daily OH (oral hygiene) recommended. 4. R26's EMR showed he had multiple diagnoses including hemiplegia and hemiparesis following an intracranial hemorrhage affecting his right dominant side, malignant neoplasm of the brain, cognitive impairment, seizures, and adult failure to thrive. R26's MDS dated [DATE] said he was dependent on staff for his oral hygiene care. On 1/07/2025 at 10:55 AM, R26 was sitting in his reclining wheelchair in his room. R26's teeth were unkept, had food residue, and were stained with an orange substance. On 1/08/2024 at 12:15 PM, R26 again had a thick white food substance on his front lower teeth. V5 (Registered Nurse/RN) was asked to assess R26's mouth and with her gloved finger, she removed a thick white chunk of white substance from his left gum area. V5 said it appeared to be food residue. V5 said CNAs provide daily oral care to the residents. On 1/09/2025 at 9:50 AM, V2 (Director of Nursing/DON) said she expects staff to assist residents with their ADLs (Activities of Daily Living) including feeding, oral hygiene, and grooming care. V2 said residents who are unable to feed themselves should be assisted if not they can be at risk for improper nutrition, weight loss, choking, or aspiration pneumonia. V2 said residents should be assessed and assisted daily with their grooming needs, including shaving. V2 said it was appropriate to assume that female residents would expect to be assisted with the removal of unwanted facial hair. V2 also said oral care should be provided to residents in the AM, PM, and any time in between if needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146159 If continuation sheet Page 4 of 16 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 146159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terrace 1615 Sunset Avenue Waukegan, IL 60087 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete V2 said for residents who may be resistant to oral care staff should at a minimum attempt to swab their teeth and mouth to assist them in promoting healthy oral hygiene. The facility's policy titled Maintaining ADL's dated 3/2021, said Guideline: The facility provides the necessary care and services to attain or maintain the highest practical physical, mental, and psychological wellbeing for the resident in accordance to the comprehensive assessment and plan of care. Event ID: Facility ID: 146159 If continuation sheet Page 5 of 16 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 146159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terrace 1615 Sunset Avenue Waukegan, IL 60087 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** 2) On 1/7/25 at 2:20 PM, observed R67 on her chair with the urinary bag on the floor. R67 was alert, oriented x 3 and stated that she is ready to go & take her shower. Meanwhile, V21 (CNA-Certified Nursing Assistant) picked up the urinary bag and placed it under the blanket near the feet of R67. R67's record review showed R67 was admitted to the facility on [DATE] with diagnoses to include spinal stenosis (C1-C4), quadriplegia and chronic obstructive pyelonephritis. R67's care-plan dated 12/3/24 showed, 'Clean catheter bag with vinegar and water solution, hang to dry. Attach clean catheter bag to resident'. On 1/7/25 at 2:25 PM, observed a urinary bag with no cap on the spout, hanging on the handle bar in the bathroom, in R67's room. On 1/7/25 at 2:28 PM, V21 (CNA) stated, everyday morning, she disconnects R67's urinary bag from the catheter, rinses it with vinegar & water solution & hangs it to dry in the bathroom. V21 (CNA) stated, the one that is already washed & hung in the bathroom by the previous shift CNA, she would fix that onto R67's catheter. On 1/7/25 at 2:35 PM, V20 (LPN-Licensed Practical Nurse) stated, Urinary catheter is changed once a month and as needed, per orders. The urinary bag with tubing is cleaned everyday and a new bag is applied every two weeks and as needed. V20 (LPN) stated, twice a day (morning and night), the bag is disconnected from the urinary catheter, rinsed with water and vinegar solution, and is hung in the bathroom to dry. The one that the previous shift cleaned is applied to the pt. Thus the two bags are switched for a couple weeks. On 1/8/25 at 3:00 PM, V3 (IP-Infection Preventionist) stated, morning and evening shift staff clean the urinary bag. They remove the existing bag, clean it with vinegar solution (4 capful of vinegar in 3 cups of water). After rinsing it with this solution, it is hung in the resident's bathroom and covered in a plastic bag to dry. Meanwhile, the bag that was cleaned by the previous shift would be connected to the pt. V3 (IP) stated, this is the practice of the facility for all pts with urinary catheter. On 1/8/25 at 3:00 PM,V3 (IP) stated, the urinary catheter system must be kept closed, as much as possible, to prevent infection. Leaving the bag open to air and reconnecting to the urinary catheter of the resident is a source of infection for the pt. V3 (IP) stated, it is ideal to use a new bag every time the system is disconnected. V3 (IP) stated, disconnecting, cleaning & re-using the bag is a source of infection for the pt. On 1/9/24 at 9:50 AM, V2 (DON-Director of Nursing) stated, the urinary bag is disconnected and cleaned twice a day to keep the system clean. V2 (DON) stated, they are trying to keep the system as clean as possible. V2 (DON) stated, she in-serviced the CNAs on this practice. V2 (DON) stated, they have not received approval from the facility MD (Medical Director) or Urologist for this practice nor is there a physician's order for it. Facility policy 'Foley Catheter- Use and Management' dated 05/2024 showed, ' 10. Cleaning of Leg bags: Night shift will be responsible for cleaning the leg bags. a. The night shift will be responsible for preparing the following vinegar solution. The vinegar (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146159 If continuation sheet Page 6 of 16 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 146159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terrace 1615 Sunset Avenue Waukegan, IL 60087 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 and water solution ratio are 2 cups vinegar to 3 cups water Level of Harm - Minimal harm or potential for actual harm b. Pour one cup of the above vinegar solution into the leg bag. Swish the solution in the bag around. Leave this solution in the bag for 20 minutes. Make sure all ports are closed. DO NOT BRING INTO RESIDENT'S ROOM. Leave in utility room. Residents Affected - Few c. When completed, empty the vinegar solution, and close all ports. Store in a clean plastic bag labeled with the resident name until ready to use. d. Cleaning of the leg bag should be done every 24 hours. Based on observation, interview, and record review, the facility failed to properly provide urinary catheter care for 2 of 2 residents (R44, R67) reviewed for urinary catheter care in a sample of 19. The findings include: 1. On January 8, 2025 at 10:14 AM, V18 (CNA/Certified Nurse Assistant) said he changed R44's catheter bag from the hanging bag to the leg bag. V18 said he washed the catheter bag by taking two capfuls of vinegar and water and pouring it into a piston with a syringe in it. V18 said he then pushed the vinegar and water mix into the tubing and the catheter bag and swished it around in the bag and then emptied it into the toilet. V18 said he then does this process again before following it up with water. V18 said he then puts the catheter bag into a plastic bag to dry. V18 said he would put the leg bag on during the day and the hanging catheter bag at bedtime. V18 showed the surveyor the catheter bag, which said the catheter bag was sterile and said not to re-sterilize. On January 9, 2025 at 9:54 AM, V18 said V3 (IP/Infection Preventionist) told them to wash the catheter bags during an in-service. On January 8, 2025 at 10:10 AM, V5 (RN/Registered Nurse) said R44 has a suprapubic catheter, and the CNAs change the bag twice a day. V5 said they wash the bag with vinegar and hang it in the bathroom to dry. V5 said the leg bag is used for the day and the regular hanging bag is used during the night. On January 8, 2025 at 12:21 PM, V17 (Nephrology Nurse Practitioner) said it was recommended to replace the whole catheter set at least once every 30 days. V17 said it was not recommended to disconnect the catheter system because it increases the risk of infection as it would break the sterility and increase the risk of infection. R44's face sheet shows diagnoses including Parkinson's disease, Alzheimer's disease, gastro-esophageal reflux disease, urinary tract infection, neuromuscular dysfunction of bladder, chronic kidney disease, and benign prostatic hyperplasia without lower urinary tract symptoms. R44's POS (Physician Order Sheet) showed to Change catheter bag and tubing every 4 weeks on Tuesdays one time a day every 4 weeks on [Tuesday] for UTI (Urinary Tract Infection) precaution starting tomorrow. Give Bactrim DS prior to and after [catheter] change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146159 If continuation sheet Page 7 of 16 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 146159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terrace 1615 Sunset Avenue Waukegan, IL 60087 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 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to dispose of controlled medication and verify the accuracy of controlled medication logs for residents with controlled medications. Residents Affected - Some This applies to 4 out of 4 (R57, R5, R26, and R44) residents reviewed for controlled medications in a sample of 19. Findings include: 1. On 1/08/2025 at 9:30 AM, V4 (Licensed Practical Nurse/LPN) was asked to verify the controlled medications located in the 2-East medication cart. V4 said nurses confirmed they completed the end-of-shift handoff count of controlled medications by signing the accountability record log. V4 reviewed the log and confirmed the log for the AM shift on 1/08/2025 was not signed by the incoming morning nurse. V4 said R26 had an open medication bottle of Clonazepam 0.5 mg (milligrams) with 42 tablets. V4 then said R26 did not have an Individual Controlled Drug Administration Record log to verify the medication's quantity. V4 said that nurses should ensure that all controlled medications have Individualized Controlled Drug Administration Record logs to verify the proper count of each medication. R26 had another bottle of Clonazepam 0.5 mg with 9 tablets. V4 reviewed and confirmed that the medication's Individual Controlled Substance Record log said the last removed tablet was on 1/07/2025 and there should be a total of 10 tablets available. V4 said nurses needed to log every removed controlled medication in their Individual Controlled Substance Record logs when removed to ensure accuracy and prevent discrepancies. The document titled Shift Change Accountability Record for Controlled Substances for January 2025 showed multiple omitted nurses' signatures including for the 1/08/2025 AM shift. R26's Individual Controlled Substance Record log for Clonazepam 0.5 mg tablets dated 12/24/2024, showed the last logged removed tablet was on 1/07/2025 at 6 PM and there should be an amount remaining of 10 tablets. The log also had missing signatures for tablets removed on 1/03/2025 at 9 AM and 12:00 PM. R26's MAR (Medication Administration Record) for January 2025 said R26 last received Clonazepam 0.5 mg by mouth at 9 AM. R26's Order Summary Report dated 1/08/2025 showed an active order for clonazepam Oral Tablet 0.5 MG (Clonazepam) Give 1 tablet by mouth three times a day for anticonvulsant. 2. V4 continued to remain present during the following observations: R5's Hydrocodone-APAP 5-325 mg medication punch card was observed with the #7 pill slot punched open with a pill inside, the slot was covered with a piece of cloth tape. R5's Order Summary Report dated 1/08/2025 showed R5 did not have an active order for Hydrocodone. R5's Controlled Drug Administration Record Tablet log for Hydrocodone showed the medication was dispensed on 8/21/2024 and R5's last removed tablet was on 8/23/2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146159 If continuation sheet Page 8 of 16 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 146159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terrace 1615 Sunset Avenue Waukegan, IL 60087 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 - Some 3. R57's Lorazepam 0.5 mg medication punch card was observed with the #5 through #8 pill slots punched open with pills inside, the slots were covered with a plastic band-aid and clear pieces of tape. R57's Order Summary Report dated 1/08/2025 showed R57 did not have an active order for Lorazepam. R57's Controlled Drug Administration Record Tablet log for Lorazepam showed the medication was dispensed on 10/04/2023 and R57's last removed tablet was on 2/6 (year unknown). The log showed the following instructions TAKE 1 TABLET BY MOUTH EVERY 8 HOURS AS NEEDED FOR ANXIETY FOR 14 DAYS. 4. On 1/08/2025 at 9:50 AM, V4 (LPN) was asked to verify the controlled medications located in the 1-East medication cart. The cart's accountability record log for controlled medications was not completed. The document titled Shift Change Accountability Record for Controlled Substances for January 2025 showed multiple omitted nurses' signatures including for the 1/08/2025 AM shift. R44's Tramadol 50 mg medication punch card was observed with the #17 and #26 pill slots punched open with pills inside, the slots were covered with tape. R44's Order Summary Report dated 1/08/2025 showed R44 did not have an active order for Tramadol. R44's Controlled Drug Administration Record Tablet log for Tramadol showed the medication was dispensed on 4/02/2024 and R44's last removed tablet was on 6/04/2024. On 1/09/2025 at 9:40 AM, V2 (Director of Nursing/DON) said all controlled medications need to be accounted for to ensure medication safety and prevent variances. V2 said nurses were expected to count controlled medications with the oncoming shift nurse and sign the accountability record log. V2 said that when a medication is removed from the controlled box it needs to be logged immediately in the resident's individual medication log. V2 continued to say controlled medications need to be disposed of appropriately when discontinued or not used. V2 said removed medications should not be placed back into the punch card slots and taped. The facility's policy titled Medications-Controlled dated 3/2021, said Controlled substances are signed out upon dispensing of the medication. A count of controlled drugs is maintained by nurses of the off-going and oncoming shifts. Any irregularities are reported to the director of nursing .Controlled medication documentation: a. A separate controlled substance administration control record is kept on all scheduled II or higher drugs. It contains the amount verifiable inventory .Disposition of unused portion or prescriptions is documented .a. Do not place in container b. Record refusal as per policy c. Destroy drug in accordance with policies of facility for destruction of refused controlled medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146159 If continuation sheet Page 9 of 16 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 146159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terrace 1615 Sunset Avenue Waukegan, IL 60087 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to label and store medications for residents receiving insulins and eye drops. This applies to 5 out of 5 (R61, R23, R44, R71, and R42) residents reviewed for medication storage in a sample of 19. Findings include: 1. On 1/08/2025 at 9:30 AM, the medication storage task was done with V4 (Licensed Practical Nurse/LPN) on the 2-East and 1-East medication carts. V4 remained present during the following observations: R44's Levemir insulin vial was opened and undated. R44's Levemir medication package bag said it was dispensed on 12/22/2024 and was also undated. R44's Order Summary Report dated 1/08/2025 showed an active order for Levemir Solution 100 UNIT/ML (Insulin Detemir) Inject 26 units subcutaneously in the morning for DM (Diabetes Mellitus). 2. R42's Humulin R insulin vial was open and dated with an open date of 11/11/2024. R42's Humulin R medication package had instructions to MUST DISCARD W/ IN 31 DAYS after opening. R42's Order Summary Report dated 1/08/2025 showed an active order for HumuLIN R Solution 100 UNIT/ML (Insulin Regular Human) .subcutaneously two times a day for Diabetes. 3. R61's Fiasp insulin vial was unopened at room temperature. R61's Fiasp medication package bag said it was dispensed on 1/03/2025 and had instructions of HIGH ALERT, REFRIGERATE UNTIL OPEN. R61's Order Summary Report dated 1/08/2025 showed an active order for Fiasp 100 UNIT/ML Solution Inject as per sliding scale .subcutaneously before meals and at bedtime for Diabetes. 4. R23's two Glargine insulin pens were opened, unbagged and undated. R23's Lantus and Lispro insulin vials were also opened and unbagged. R23's insulins were stored in an open multi-resident use container with other residents' opened insulins. R23's Order Summary Report dated 1/08/2025 showed active orders for Insulin Glargine Subcutaneous Solution Pen-Injector 100 UNIT/ML (Insulin Glargine) Inject 17 units subcutaneously one time a day for DM and Insulin Lispro Solution 100 UNIT/ML Inject as per sliding scale .subcutaneously before meals for Diabetes. 5. R71's Latanoprost eye drop container was open and undated. R71's Latanoprost medication package bag said it was dispensed on 9/24/2024 and had instructions to DISCARD AFTER 6 WKS after opening. R71's Order Summary Report dated 1/08/2025 did not show an active order for Latanoprost eye drops. On 1/09/2025 at 9:40 AM, V2 (Director of Nursing/DON) said insulin and eye drop medications should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146159 If continuation sheet Page 10 of 16 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 146159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terrace 1615 Sunset Avenue Waukegan, IL 60087 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete be stored inside their packages and package instructions for storing should be followed for safety storage. V2 continued to say multi-dose medications should be labeled when opened and discarded as indicated to ensure medication safety administration. The facility's policy titled Medication Storage dated 3/2021, said The facility maintains proper store of a variety of medications in accordance to the pharmacy recommendations and regulatory guidelines. Event ID: Facility ID: 146159 If continuation sheet Page 11 of 16 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 146159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terrace 1615 Sunset Avenue Waukegan, IL 60087 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 0808 Level of Harm - Minimal harm or potential for actual harm Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on observation, interview, and record review, the facility failed to provide thickened liquids for a resident (R60) with an order for nectar-thickened liquids. Residents Affected - Few This applies to 1 of 4 residents (R60) reviewed for diets in a sample of 19. Findings include: R60's EMR (Electronic Medical Record) showed he had multiple diagnoses including dementia, muscle weakness, and respiratory infection. R60's MDS (Minimum Data Set) dated 10/29/2024 said he required setup assistance for his meals and had an altered diet requiring thickened liquids. On 1/07/2025 at 12:25 PM, V9 (Certified Nurse Assistant/CNA) served R60 lunch in the dining room. R60's meal tray had multiple drinks including a cup of coffee and a carton of milk, both were thin liquid consistency. R60's meal ticket said he required nectar thickened liquids. V8 (CNA) was asked to assess R60's served drinks and said he was served the incorrect type of liquids. V8 removed the drinks and proceeded to thicken R60's coffee and milk. V8 said the dietary staff prepares the residents' meal trays in the kitchen, including their drinks. V8 continued to say that residents who require thickened liquids, usually receive pre-thickened beverages ready to serve and was unsure why R60's drinks did not come thickened. V9 said he should have checked R60's meal ticket prior to serving him to ensure he received the correct consistency of liquids. On 1/09/2025 at 9:40 AM, V2 (Director of Nursing/DON) said the dietary staff prepares the residents' meal trays based on their prescribed diets including drinks. V2 said CNAs are expected to do a final check prior to serving the residents. V2 said dietary cards and meal trays need to be checked to ensure they are correct. V2 said residents' prescribed diets need to be followed to ensure resident meal safety and prevent potential complications such as choking and aspiration pneumonia. R60's Order Summary Report dated 1/09/2025 showed R60 had an active diet of NAS (No Added Salt) diet Regular texture, Nectar consistency. The facility's policy titled Meal Service dated 3/2021, said Purpose: To provide a diet identification system as well as to ensure accuracy of the prescribed diet given to each resident. Guideline: Each resident diet shall be identified using the medical record. Procedure .2. The diet will specify: Diet type, diet texture, and fluid consistency and additional instructions can be entered under special instructions. 3. Dietary aides will check resident name and picture prior to offering appropriate food choices per diet order as well as any special instructions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146159 If continuation sheet Page 12 of 16 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 146159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terrace 1615 Sunset Avenue Waukegan, IL 60087 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 store, prepare, and distribute food in a manner that would prevent foodborne illnesses. This applies to 71 residents who ate food from the kitchen. The findings include: On January 10, 2025 at 2:35 PM, V2 (DON/Director of Nursing) said two residents were NPO (Nothing By Mouth) and did not receive trays from the kitchen. On January 7, 2025 at 10:28 AM, during the initial tour of the kitchen, the dry food storage area was observed to have the following: -5 cartons of [Brand] tomato Juice from concentrate with a best if used by date of September 11, 2024. -16 packets of [Brand] creamy classic mashed potatoes with no 'received on' dates or expiration dates. -5 packets of tortillas with no 'received on' dates. -An opened 25-lb box of instant food thickener, left open to air, with no 'opened on' date. -An opened box of long grain rice with a bag within it, open to air, with no 'opened on' date. On January 7, 2025 at 10:50 AM, the milk refrigerator was checked, and did not contain a thermometer within the refrigerator. There were 32 cartons of 2% milk which were undated. On January 7, 2025 at 10:50 AM, V11 (Cook) said he would not serve the undated milk because there were no dates on them. On January 7, 2025 at 12:20 PM, several residents in the first-floor dining room were served the undated milk. On January 8, 2025 at 3:07 PM, the milk refrigerator still did not have a thermometer inside of it. On January 9, 2025 at 9:46 AM, the milk refrigerator did not have a thermometer inside of it. On January 7, 2025 at 11 AM, the kitchen cooler was checked. The cooler had a disposable, plastic cup with coffee and a straw within it, and a plastic bag with water bottles and a canned beverage, which belonged to staff. The cooler also had the following: -12 cups of juice in the cooler without a plastic cover over it. At 11 AM, V11 said the cups should be covered in plastic and dated. -Opened cheese, wrapped, but not dated. -Opened bologna, wrapped, but not dated. -Cut beets and cauliflower in stainless steel steam table pans, without plastic covers or dates on them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146159 If continuation sheet Page 13 of 16 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 146159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terrace 1615 Sunset Avenue Waukegan, IL 60087 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 On January 7, 2025 at 11:12 AM, the kitchen freezer had the following: Level of Harm - Minimal harm or potential for actual harm -Raw, frozen pork chops on the top shelf -Tray of tator tots placed on the shelf below the pork chops, not completely covered in plastic and undated. Residents Affected - Many -Frozen sausages in an undated Ziploc bag. -Cooked sausage crumbles in packaging that was open and exposed to air, and no date on the packaging. -Undated Ziploc of beef hotdogs. -Undated frozen pancakes wrapped in plastic wrap. -Undated raw, frozen chicken in plastic wrap. On January 7, 2025 at 11:25 AM, the second kitchen freezer had the following: -A tray of cooked enchiladas, not properly covered and undated. V11 said the enchiladas had been here a minute. -An opened and undated bag of corn. -An undated tub of vanilla ice cream with a broken lid, exposed to air. On January 8, 2025 at 12:27 PM, the food carts were delivered uncovered to the first and second floor dining halls. The carts contained trays with open cups. On January 9, 2025 at 12:15 PM, V13 said the food on the carts should not be exposed to air and should be covered when delivered to the units. The facility's Food Receiving and Storage dated May 2020 showed Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). Such foods will be rotated using a first in-first out system. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Wrappers of frozen foods must stay intact until thawing. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the food and nutrition services manager or designee and documented. Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetables, and other ready-to-eat foods. Refrigerators must have working thermometers and be monitored for temperature according to state-specific guidelines. Open containers of food and liquid must be dated and resealed/covered. The facility's undated Storage of Food and Supplies policy showed Prepared foods stored in the refrigerator until service will be covered, labeled, and dated with an expiration date. TCS (Time/Temperature Control for Safety) foods prepared on site must be labeled with the name of the food, the date it should be sold, consumed or discarded. All foods will be covered, labeled, and dated. Items should be stored in original packaging. If removed from its original packaging, wrap in clean (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146159 If continuation sheet Page 14 of 16 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 146159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terrace 1615 Sunset Avenue Waukegan, IL 60087 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 moisture-proof material, or place it in a clean sanitized container with a tight fitting lid. All packaging and contaienrs should be labeled with the name of the food and expiration date. Refrigerators and freezers will be equipped with an internal thermometer and monitored. Temperatures will be documented. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146159 If continuation sheet Page 15 of 16 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 146159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terrace 1615 Sunset Avenue Waukegan, IL 60087 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 wear PPE (Personal Protective Equipment) for residents who were on EBP (Enhanced Barrier Precautions). Residents Affected - Few This applies to 2 of 2 residents (R64, R44) reviewed for infection control in a sample of 19. The findings include: 1. On January 8, 2025 at 12:03 PM, V14 (Restorative Aide/CNA-Certified Nurse Assistant) was in R64's room and was not wearing a gown. R64's doorway showed he was on EBP, with gowns and gloves in an isolation cart outside the room. V14 provided incontinence care, assisted in changing his clothes, and assisted in transferring the resident from the bed to the wheelchair. On January 9, 2025 at 10:10 AM, V14 said if a resident was on EBP, the staff should wear gloves and a gown. On January 9, 2025 at 10 AM, V16 (RN/Registered Nurse) said the staff should wear a gown and gloves when giving direct patient care for residents on EBP. V16 said residents with catheter bags and G-Tubes (Gastrostomy) would require gowns and gloves. V16 also said transferring and incontinence care would be considered direct patient care. R64's face sheet showed he was admitted with diagnoses including hemiplegia and hemiparesis, contractures, anemia, seizures, dysphagia, and dementia. R64's POS (Physician Order Sheet) showed an order for Enhanced Barrier Precautions, gown and gloves, ordered on December 30, 2024. 2. On January 8, 2025 at 10:14 AM, V18 (CNA) was in R44's room without wearing a gown. V18 transferred R44 from the bed to the wheelchair to take him to the shower room. V18 said he had just changed R44's catheter bag. On January 9, 2025 at 9:54 AM, V18 said he needed to wear a gown and gloves to take care of R44 for care such as changing his catheter, changing his incontinence brief, dressing, bathing, showering, transferring, assisting with toileting, and device care. V18 said because R44 has a catheter, the PPE is worn to protect him since there was an opening. On January 9, 2025 at 12:46 PM, V2 (DON/Director of Nursing) said the staff should wear a gown and gloves for residents on EBP for care such as incontinence care and transferring. R44's face sheet shows diagnoses including Parkinson's disease, Alzheimer's disease, gastro-esophageal reflux disease, urinary tract infection, neuromuscular dysfunction of bladder, chronic kidney disease, and benign prostatic hyperplasia without lower urinary tract symptoms. R44's POS showed an order for Enhanced Barrier Precautions, ordered on April 18, 2024. The facility's Enhanced Barrier Precautions dated December 2019 showed Gloves and gowns should be used when providing the following high-contact activities: a. Dressing, b. Bathing/showering, c. Transferring, d. Providing hygiene, e. Changing linens, f. Changing briefs or assisting with toileting, g. Device care or use of a device: central line, catheter, feeding tube or tracheostomy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146159 If continuation sheet Page 16 of 16