Health inspection·July 31, 2024

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 medications with the date when opened and failed to remove discontinued eye medication from the medication cart. This applies to 4 of 4 residents (R5, R10, R21, R63) reviewed for medication storage in the sample of 18. The findings include: On July 29, 2024, between 2:32 PM to 4:30 PM, the medication cart inspections were conducted with V3 (Registered Nurse/RN) and V4 (License Practical Nurse/LPN). The following was observed: 1. R63's Insulin Lispro Kwik Pen was opened and not dated. The Pharmacy's undated Insulin Storage Recommendation Beyond Use Date procedure showed to discard the insulin pen 28 days after opened. 2. R10's Humulin Lantus Solostar Injectable 100 ml (milliliters). was opened and not dated. The Pharmacy's undated Insulin Storage Recommendation Beyond Use Date procedure, showed to discard the insulin pen 28 days after opened. 3. R5's Netarsudil and Latanoprost 0.2%/0.005% eye drops were opened and not dated, with instructions to keep refrigerated. The Pharmacy's undated Recommendation for Eye Drop Storage procedure, showed that the eye drops can be stored up to 6 weeks after opened. 4. R21 Moxifloxacin 0.5% eye drops were opened and not dated. R21's Medication Administration Record (MAR) showed that this medication had been discontinued on July 9, 2024. On July 30, 2024 at 1:14 PM, V2 (Director of Nursing/DON) stated that staff must date the insulin, and the eye drops, when opened, to identify the expiration date of the medications. The facility's undated Medication Labeling and Storage Policy and Procedure showed Medication Storage: 3. If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146173 If continuation sheet Page 2 of 5 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 146173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs at Monarch Landing, The 2308 North Route 59 Naperville, IL 60563 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to sanitize pots and pans per facility policy. Residents Affected - Many This applies to all 81 residents receiving oral diets in the facility. The findings include: Long term Care Facility Application for Medicare and Medicaid, dated July 28, 2024, shows the facility census was 82. Diet Type Report dated July 28,2024, shows one resident did not receive an oral diet at the facility. On July 28, 2024, at 10:18 AM with V6 (Food Service Manager), the dish machine sanitizer temperature was measured using a 180 degree F (Fahrenheit) test strip. The test strip instructions showed the black indicator line on the test strip was to turn completely orange when 180 degrees F was reached during the sanitizing cycle of the dish machine. After running through a full cycle of the dish machine, the test strip indicator line remained gray. During the sanitizing cycle, the dish machine water temperature (as indicated by the dish machine thermometer) did not elevate above 174 degrees F. Instructions posted on the dish machine showed the minimum water temperature for the final rinse sanitizing water was 180 degrees F. V6 stated the local health department recommended the 180 degree F strips were utilized to check the sanitizing temperature of the dish machine. July Dish Washer Temperature Log, dated July 2024, shows none of the Dishwasher Temperature strips turned completely orange to indicate the dish machine reached the desired temperature of 180 degrees F. On July 29, 2024, at 11:15 AM, the facility's July dish machine sanitizing water temperature test strip results showed none of the test strips turned completely orange indicating the sanitizing water temperature reached 180 degrees F. V6 stated on July 28, 2024, facility maintenance identified that the switch on the booster heater was turned off. V6 stated the booster heater switch was turned on which provided sanitizing water at 180 degrees F to the final rinse of the dish machine. Facility Dishwashing Machine Use Policy/Procedure, reviewed July 30, 2024, shows, 2. Dishwashing machines may use hot water to sanitize must maintain the following: .b. 180 degrees F for a final rinse cycle (160 degrees F at the rack level/dish level surface reflects a 180 degree F temperature at the manifold, which is the area just before the final rinse nozzle where the temperature of the dish machine is measured 4. A supervisor or designee will check the machine for proper temperature and report inadequate temperatures for immediate correction. a. A secondary thermometer or temperature gauge will be run through machine to compare temperature to gauge on machine daily. b. If hot water temperatures do not meet requirements, cease use of dishwashing machine immediately until temperatures are adjusted. Dish machine test strips instructions showed, 1. Attach the test strip to a utensil or rack by wrapping around and slipping the color bar through the slit . Wash the item. 2. If the color bar has turned bright orange, the dishwasher is maintaining the proper temperature. 3. When finished with the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146173 If continuation sheet Page 3 of 5 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 146173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs at Monarch Landing, The 2308 North Route 59 Naperville, IL 60563 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 test, sign, date and place the strip in dishwasher temperature log. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146173 If continuation sheet Page 4 of 5 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 146173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs at Monarch Landing, The 2308 North Route 59 Naperville, IL 60563 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 follow standard infection control practices with regards to hand hygiene and gloving during provisions of care. Residents Affected - Few This applies to 1 of 4 residents (R28) reviewed for infection control in the sample of 18. Findings include: 1. On July 29, 2024, at 4:55 PM, V5 (Certified Nursing Assistant/CNA) provided incontinence care to R28, who was wet with urine. V5 wiped/cleaned R28's perineum from front to back, placed a new incontinence brief, pulled his pants back in place, repositioned R28, placed the motorized wheelchair at bedside and assisted R28 to transfer from bed to wheelchair, while wearing the same soiled gloves all throughout the different tasks. On July 30, 2024, at 1:26 PM, V2 (Director of Director/DON) stated during provisions of incontinence care, staff must perform hand hygiene and change gloves before and after, and in between tasks to prevent cross contamination and spread of infection. The facility's undated Handwashing/Hand Hygiene policy and Procedure, showed: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: 6. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: f. Before moving from a contaminated body site to a clean body site during resident care. g. After contact with a resident's intact skin. h. After contact with blood and body fluids. 1. After handling used dressings, contaminated equipment, etc. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146173 If continuation sheet Page 5 of 5