Inspection·August 31, 2023

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview the facility failed to provide privacy during a blood draw. This applies to 1 of 1 resident (R248) observed for blood draws in the sample of 13. Residents Affected - Few Findings include: On August 28, 2023 at 11:23 AM V20 (Phlebotomist) was drawing R248's blood from his right arm while R248 was sitting at a table in the common area dining room on the second floor. R29 was also sitting in the same dining room at the same time. V20 finished drawing R248's blood and placed the vials of blood on the dining room table on top of a magazine in front of R248. The vials of blood rolled off the magazine and onto the table. V20 stated she was told by the company she works for that she could draw blood in the dining room if no one else was around. V6 (Registered Nurse) stated V20 should not be drawing blood in the dining room and then went over to tell V20 about it. V30 (Assistant Director of Nursing, ADON) then came over and introduced herself as the ADON to V20 (Phlebotomist). V30 told V20 that blood draws should not be done in the dining room and should be done in resident's room. On August 30, 2023 at 10:00 AM, V28 (V20's Manager) stated that it was not their policy to have their phlebotomist draw blood in the dining room. V28 stated that V20 (Phlebotomist) knows better and has had eight hours training, and 6 weeks of on the job training. On August 30, 2023 at 2:49 PM, V2 (Director of Nursing) stated the facility does not allow blood draws to be done in the dining room because it is an infection control, dignity, and privacy issue. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146178 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 146178 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victorian Village Hlth & Well 12525 W Renaissance Circle Homer Glen, IL 60491 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 0688 Level of Harm - Minimal harm or potential for actual harm Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, interview and record review the facility failed to assess and provide adaptive device/equipment to a resident, to prevent further reduction in mobility and ROM (range of motion). Residents Affected - Few This applies to 1 of 1 resident (R12) reviewed for mobility and range of motion in the sample of 13. The findings include: R12 had multiple diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, fracture of unspecified part of the left clavicle and wedge compression fracture of unspecified thoracic vertebra, based on the face sheet. R12's admission MDS (minimum data set) dated August 14, 2023 showed that the resident was cognitively intact and required extensive assistance with her ADLs (activities of daily living). The same MDS showed that R12 had functional limitation in range of motion on one side of her lower extremity. On August 28, 2023 at 10:46 AM, R12 was in bed, alert, oriented and verbally responsive. R12 had weakness on her left arm and hand. R12 was not able to move her left hand without the help of her right hand and R12 was not able to open her left third, fourth and fifth fingers without the help of her right hand. R12 did not have any adaptive device/equipment on her left hand. V10 and V21 (CNAs/Certified Nursing Assistants) were both present during the observation. On August 28, 2023 at 1:12 PM, R12 was sitting in her wheelchair inside the unit dining room. R12 had weakness on her left arm and hand and was slightly leaning to her left side. R12 was not able to move her left hand without the help of her right hand and R12 was not able to open her left third, fourth and fifth fingers without the help of her right hand. R12 did not have any adaptive device/equipment on her left arm or hand and no device to prevent her from leaning on to her left side. On August 29, 2023 at 11:15 AM with V2 (Director of Nursing), R12 was sitting in her wheelchair inside her room. R12 had weakness on her left arm and hand. R12 was not able to move her left hand without the help of her right hand and R12 was not able to open her left third, fourth and fifth fingers without the help of her right hand. V2 was asked what adaptive device/equipment R12 uses for her left sided weakness? V2 responded, I will ask therapy to evaluate her. During the same conversation, R12 stated that she wanted some type of a device, like a sling for her left arm or hand to prevent her from leaning to her left side. On August 29, 2023 at 2:37 PM, V22 (Certified occupational therapy assistant) stated that she screened R12 at around 12:00 noon that same day per request of V2. V22 stated that based on the screening, R12 had tone issues on the left upper extremities, which meant that the resident had limited ROM (range of motion) on her left hand, left wrist, left elbow and left shoulder. According to V22, R12 was able to partially extent her left first and second fingers without assist, but R12 was not able to extend her left third, fourth and fifth fingers without the help of the right hand. V22 stated that based on the records, R12 had history of CVA (cerebrovascular accident) about a year ago, affecting her left side. According to V22, based on the screening she was recommending for R12 to use a cone protective pads for the left palm to prevent contracture. V22 stated that the cone protective pads (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146178 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 146178 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victorian Village Hlth & Well 12525 W Renaissance Circle Homer Glen, IL 60491 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few should be applied to R12's left hand throughout the day intermittently when not performing ADL self-care and at bed time. According to V22 she was also recommending for R12 to use a left arm trough with elevated wedge cushion for normalization of tone and for awareness of the left side due to some level of possible left side neglect, which meant that for resident's with history of CVA, there is a tendency to ignore the side that was affected and in the case of R12 was her left side. During the same interview, V22 stated that R12 was receiving occupational therapy, however it was possible that the tone issues on the left upper extremities did not present at the time of the prior assessment, which was why no recommendations were made to address the issues. R12's occupational daily treatment notes dated August 29, 2023 created by V22 showed in-part, [Patient] participated in functional movements of the [left upper extremities], reassesses possible positioning adaptations for prevention of contractures and improve normalization of positing for improved function with self-care. The same occupational daily treatment notes showed in-part, [patient] will benefit from hand palm grip band-wash cloth roll fabricated with [patient] instructed to use for night or at rest throughout the day to encourage extension not to be squeezed which [patient] verbalized understanding. Recommend also trial use of arm trough with elevated wedge cushion for improved positioning, normalization of tone impacting movements, comfort and functional use for transfers and self-care. On August 30, 2023 at 1:27 PM, V2 (Director of Nursing) stated that as part of the nursing service, the nursing staff should monitor any changes in a resident's range of motion, including any need for adaptive device/equipment to maintain the resident's range of motion and positioning, and to refer to the therapy department for screening, to receive any services or for any recommendation for adaptive devices/equipment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146178 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 146178 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victorian Village Hlth & Well 12525 W Renaissance Circle Homer Glen, IL 60491 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. Based on observation, interview and record review the facility failed to ensure that a resident's urinary catheter tubing was kept off the floor to prevent potential urinary tract infection and trauma to the urinary tract. This applies to 1 of 2 residents (R5) reviewed for indwelling urinary catheter in the sample of 13. The findings include: R5 had multiple diagnoses which included UTI (urinary tract infection), retention of urine and stage 3 chronic kidney disease, based on the face sheet. R5's admission MDS (minimum data set) dated August 1, 2023 showed that the resident was moderately impaired with cognition and required extensive assistance from the staff with most of her ADLs (activities of daily living) including toilet use. The same MDS showed that R5 had an indwelling urinary catheter in place. On August 28, 2023 at 11:38 AM, R5 was sitting in her wheelchair inside her room, watching television. R5 was alert and verbally responsive. R5's urinary catheter tubing was resting directly on the floor. According to R5 she had history of UTI. On August 28, 2023 at 9:30 AM, R5 was inside the therapy room. R5 was participating in therapy. While R5 was ambulating during therapy with V13 (PTA/Physical Therapy Assistant) and V14 (OTA/Occupational Therapy Assistant), the resident's urinary catheter tubing was dragging on the floor and when the therapist asked R5 to sit in her wheelchair and wheeled the resident's chair, R5's urinary catheter tubing was again dragging on the floor. V13 and V14 were prompted to place R5's urinary catheter tubing off the floor. R5's active order summary report showed an order dated August 7, 2023 to reinsert the resident's indwelling urinary catheter. R5's active indwelling urinary catheter care plan initiated on July 27, 2023 showed that the resident uses the urinary catheter due to urinary retention. The facility's policy and procedure regarding catheter care last reviewed by the facility on August 12, 2023 showed, [Indwelling urinary catheter] care is provided to prevent infection and reduce irritation. The facility's policy and procedure regarding urinary catheter insertion, removal and changing, last reviewed by the facility on October 11, 2022 showed that the urinary catheters are utilized and maintained according to best practice. The same policy under procedure showed that the facility should follow infection control procedures. Under procedure it showed in-part, 14. Secure urinary drainage bag below the level of the bladder and keep off the floor at all times. Coil extra tubing and secure. On August 30, 2023 at 1:25 PM, V2 (Director of Nursing) stated that the resident's urinary catheter tubing should be off the floor at all times to prevent accident, potential urinary tract infection (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146178 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 146178 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victorian Village Hlth & Well 12525 W Renaissance Circle Homer Glen, IL 60491 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 trauma to the urinary tract. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146178 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 146178 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victorian Village Hlth & Well 12525 W Renaissance Circle Homer Glen, IL 60491 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** 2. R11 had multiple diagnoses which included wedge compression fracture of the fist lumbar vertebrae, interstitial pulmonary disease and dependence on supplemental oxygen, based on the face sheet. Residents Affected - Few R11's admission MDS (minimum data set) dated July 5, 2023 showed that the resident was severely impaired with cognition and required limited to extensive assistance from the staff with her ADLs (activities of daily living). On August 28, 2023 at 11:18 AM, R11 was in bed alert and verbally responsive. R11 was receiving continuous oxygen via nasal cannula using the oxygen concentrator. R11 was receiving more than 5 liters of oxygen as shown in the oxygen concentrator gauge set above the 5 liters per minute line/indicator. On August 28, 2023 at 12:42 PM, R11 was sitting in her wheelchair inside the unit dining room. R11's oxygen nasal cannula was in place, however the portable oxygen was not running because the portable oxygen gauge was set at 0 (zero). R11 stated, I do not feel any air coming out of this referring to her oxygen cannula. V10 (CNA/Certified Nursing Assistant) stated that she brought R11 to the unit dining room at 12:10 PM for lunch. Prior to wheeling R11 to the unit dining room, V10 stated that she removed the oxygen nasal cannula attached to the oxygen concentrator (from inside the room) from R11 and placed the oxygen nasal cannula attached to the portable oxygen (located on the back of the wheelchair) on the resident. V10 stated that she did not start the portable oxygen because she wanted the nurse to turn it on. However, V10 stated that she did not tell the nurse about starting the oxygen. At 12:47 PM, V11 (Registered Nurse) who was on her lunch break was asked to check the resident's oxygen and V11 stated that the portable oxygen was set at 0 which meant that the oxygen was not running and R11 was not receiving the oxygen as ordered. According to V11, R11 should be on 2 liters/min of continuous oxygen. On August 29, 2023 at 11:21 AM, R11 was in bed, alert and verbally responsive. R11 was receiving continuous oxygen via nasal cannula using the oxygen concentrator. R11 was receiving more than 5 liters of oxygen as shown in the oxygen concentrator gauge set above the 5 liters per minute line/indicator. At 11:22 AM, V12 (Registered Nurse) was asked to check R11's continuous oxygen. While V12 was checking R11's continuous oxygen, V12 stated that the resident was receiving very high amount of oxygen because the concentrator gauge was set higher than 5 liters per minute. V12 adjusted the oxygen concentrator gauge to 2 liters/minute after prompting. R11's order summary report dated August 17, 2023 showed an order for, oxygen per nasal cannula at 2 liters per minute every shift for oxygenation. R11's oxygen therapy care plan initiated on June 29, 2023 showed an added intervention on July 25, 2023 to check the resident frequently to make sure that the oxygen was applied. The facility's policy and procedure regarding oxygen administration last reviewed by the facility on June 15, 2023 showed that the oxygen administration is the responsibility of the licensed staff. The policy showed under the purpose, Oxygen is administered to the client when necessary for adequate tissue oxygenation. The same policy showed in-part, 1. A practitioner's order is necessary for oxygen therapy. Check practitioner's order for liter flow and method of administration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146178 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 146178 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victorian Village Hlth & Well 12525 W Renaissance Circle Homer Glen, IL 60491 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On August 30, 2023 at 1:30 PM, V2 (Director of Nursing) stated that only the nurses can remove, regulate and restart a resident's oxygen. V2 further stated that oxygen therapy are like medications, therefore the oxygen order should be followed. Based on observation, interview and record review the facility failed to provide oxygen therapy as ordered by the Physician. This applies to 2 of 2 residents (R10, R11) reviewed for oxygen in the sample of 13. The findings include: 1. R10's diagnoses on face sheet included diagnoses of chronic obstructive pulmonary disease, acute on chronic diastolic (congestive) heart failure, unspecified, encounter for palliative care, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, obstructive sleep apnea (adult) (pediatric), history of falling. R30's significant change MDS dated [DATE] showed that R10 was moderately impaired in cognition and required extensive assistance from the staff with ADL (activities of daily living) care except for eating. R10's POS (Physician Order Sheet) included Oxygen at 2L (liters) per nasal cannula continuously (order date June 15, 2023). On August 28, 2023 at 10:56 AM, R10 was seated in activities with portable cylinder which was set at 2L. R10 remarked I get 2 liters. On August 29, 2023 at 9:47 AM, R10 was seated at dining room with portable oxygen setting showing 3L. R10 remarked that it should be at 2L. R10 stated that an aide helped to get him up and attached the oxygen. R10 could not recall which staff member it was that helped him. On August 29, 2023 at 9:49 AM, V2 (Director of Nursing) who was in the area, verified the dial setting of the oxygen was at 3L and stated that he will check the POS to determine the orders for the same. V2 returned and stated that the POS showed 2L. V2 added that Physician orders should be followed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146178 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 146178 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victorian Village Hlth & Well 12525 W Renaissance Circle Homer Glen, IL 60491 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 Residents Affected - Some 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. 5. R11 had multiple diagnoses which included dysphagia, oropharyngeal phase, based on the face sheet. R11's admission MDS (minimum data set) dated July 5, 2023 showed that the resident was severely impaired with cognition and required limited assistance from the staff during eating. On August 28, 2023 at 1:05 PM, R11 was served her lunch meal in three separate bowls consisting of pureed rice, pureed fish and pureed vegetables. R11 was eating independently with V18 (SLP/Speech Language Pathologist) present. On August 29, 2023 at 12:54 PM, R11 was served her lunch meal in five separate bowls consisting of pureed turkey, pureed noodles, pureed green beans with mushrooms, pureed bread roll and pureed cake. R11 was eating independently with occasional encouragement from the staff. R11's active order summary report showed an order dated August 17, 2023 for full liquid diet, full liquid texture, nectar thick liquid consistency. R11's active care plan initiated on June 29, 2023 addresses the resident's poor nutritional intake. The same care plan showed an added intervention dated August 17, 2023 to provide full liquid diet, nectar thick consistency. On August 30, 2023 at 12:36 PM, V18 (SLP) stated that on August 28, 2023 during lunch meal, R11 was received pureed diet because she was doing the trial feeding. V18 stated that on August 29, 2023 during the lunch meal, R11 should have received the ordered diet of nectar thick full liquid because she (V18) had not made the recommendation to upgrade the diet to pureed and there was no physician order to change the diet to pureed. According to V18, the facility should follow the physician's order to give the nectar thick full liquid diet to R11 and not the pureed diet, until the diet is changed and/or upgraded. V18 stated that R11 had a video swallow at the hospital prior to admission to the facility, and the video swallow showed that the resident had pharyngeal esophageal weakness which was unclear, because pharyngeal esophageal weakness could mean possible esophageal stricture, possible difficulty with food transport from the esophagus to the stomach or possible esophageal weakness which could cause regurgitation or vomiting. V18 stated that during the trial on August 28, 2023 with the pureed diet, R11 tolerated the food, but she does not want to recommend the diet consistency upgrade until the diagnostic imaging (video swallow) confirms that the resident could safely swallow. On August 30, 2023 at 1:33 PM, V2 (Director of Nursing) stated that the diet orders of the residents should be followed at all times for safety, especially for those resident's with swallowing problems. Based on observation, interview and record review, the facility failed to provide diet as ordered by the Physician. This applies to 5 of 5 residents (R1, R2, R11, R27, R30) reviewed for diet orders in the sample of 13. The findings include: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146178 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 146178 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victorian Village Hlth & Well 12525 W Renaissance Circle Homer Glen, IL 60491 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 Residents Affected - Some 1. On August 28, 2023 at 12:49 PM, during lunch meal service in the dining room, R30 received small portions (per request) of meat loaf, mashed potatoes and vegetables. Facility diet order listing showed magic cup (fortified ice cream) twice a day and R30 did not receive the same. On August 29, 2023 at 12:28 PM, during the lunch meal service, R30 received small portion of braised turkey, green beans and noodles. R30 did not again receive magic cup. R30 stated that she receives ice cream only when she asks for it and that she likes the same. R30 added that nursing gives her nutritional supplement (Ensure) routinely but she doesn't care for it. On August 29, 2023 at 12:36 PM, V16 (CNA/Certified Nursing Assistant) stated that the meal service is completed. V16 added They got everything they should get. V16 added that there is no magic cup available in the unit refrigerator and that the nurses also give supplements at medication pass. R30's diet order on POS (Physician Order Sheet) included magic cup two times a day related to nutritional deficiency (start date September 6, 2022). R30's care plan intervention updated on August 25, 2023 showed to provide and serve (General) diet as ordered, supplements & magic cups as ordered. 2. On August 29, 2023 at 12:20 PM, during the lunch meal, R1 received braised turkey cut up into large pieces (about 1-2 inches/piece) along with a side of vegetables and noodles served by V16. R1 had earlier stated that she has her upper teeth missing. When V16 was asked how she knows what diet to serve, V16 stated that she reviews the diet order listing that was on the service counter. When this diet order listing was reviewed, it showed Mechanical Soft diet for R1. V16 was notified of the same and V16 stated that she made a mistake and that R1 should have received ground turkey. R1's diet order on POS showed General diet, Mechanical Soft texture, Thin Liquids consistency (start date on March 8, 2023). 3. On August 29, 2023 at 02:31 PM, R2 received his lunch meal with a glass of regular consistency milk in the dining room. There was also a can of ginger ale soda pop close to his plate. This was verified with V17 (CNA). Facility diet order listing showed nectar thick liquids. V17 stated that she was only aware that R2 was on regular consistency liquids and added that R2 usually receives milk and ginger ale as he likes the same. R2's diet order on POS showed NAS (No Added Salt) diet, Regular texture, Nectar Thick Liquids consistency (start date April 28, 2023). R2's care plan interventions updated on April 28, 2023, included to serve NAS diet with Nectar Thick Liquids). 4. On August 29, 2023 at 12:45 PM, R27 received a pureed meal and 8 fluid ounces of Ensure Plus high protein (nutrition supplement) in the dining room. Facility diet order listing included magic cup and R27 did not receive the same. V17 (CNA) was not aware of magic cup listed on diet order listing. R27's diet order on POS included magic cup two times a day related to Nutritional Deficiency (start date October 19, 2023). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146178 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 146178 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victorian Village Hlth & Well 12525 W Renaissance Circle Homer Glen, IL 60491 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 Residents Affected - Some On August 30, 2023 at 11:47 AM, V15 (Director of Dining Services) stated that the Dietary Department does not distribute magic cups and that the nutritional supplements are managed by the nursing department. On August 30, 2023 at 11:57 AM, V26 (Dietitian) stated that R1 should get diet of mechanical soft consistency as ordered by the Physician. V26 stated that magic cup is given by nursing. V26 stated that she was told that R2's family had earlier signed a waiver for nectar thick liquids. V26 was not able to verify this information. On August 30, 2023 at 01:05 PM, V7 (Registered Nurse) who had worked as the floor nurse on August 28, 2023 and August 29, 2023, stated that he did not give magic cup to R30 and R27. V7 stated that either the dietary or nursing gives the magic cup to the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146178 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 146178 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victorian Village Hlth & Well 12525 W Renaissance Circle Homer Glen, IL 60491 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 store pots and pans in a sanitary manner and failed to discard dented cans. Residents Affected - Many This applies to all 49 residents that reside in the facility. The findings include: Facility Resident Census and Conditions of Residents form (CMS Form 672) dated August 28, 2023, showed that the facility census was 49. Facility gave verbal confirmation that 48 residents received oral diets and one resident was on dual (oral and tube) feedings. On August 28,2023 at 9:41 AM, during the initial tour of kitchen, the dish room had multiple cleaned pots and pans inverted on trays that were placed on a free-standing rack. These trays were noted to have marked miscellaneous debris, dust and unknown dried stains or spills. This was brought to the attention of V15 (Director of Dining Services) who acknowledged the findings and stated that she will ensure that the holding trays be cleaned and the pots and pans rewashed. In the dry storage cabinet, there were two cans of Country Style Sausage Gravy (6 lbs/pounds and 8 oz/ounce each can) and one can of Peach Pie Filling (7 lb) which had the top edges of cans dented in several areas. V15 remarked They should be checking it immediately on delivery and it should not go in. I will do an in-service. On 08/30/23 at 11:57 AM, V26 (Dietitian) stated that cans that have their rims and (side) seals dented in, should be discarded. Facility provided delivery dates for above dented cans as August 1, 2023, and August 8, 2023. Facility Policy titled Storage of Pots/Pans/Dishes and Utensils (reviewed August 29, 2023) included: All cooking equipment should be stored in a manner that maximizes safety of foods served. Facility Policy titled Receiving (last revised and reviewed September 11, 2022) included: Policy: All food should be checked for proper condition as it is received in the facility. Procedure: Receiving Dry Goods 1) Inspect cans for leaks, incomplete labels, dents, bulges, and other visible signs of damage. Reject flawed cans and put in a designated area for credit. 3) Notify the unit supervisor or designee to call the vendor when damaged items are found so the product can be picked up and returned and a credit issued. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146178 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 146178 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victorian Village Hlth & Well 12525 W Renaissance Circle Homer Glen, IL 60491 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow their infection control policy and don personal protective equipment (PPE) required for transmission based precautions, and also failed to perform hand hygiene upon entering and exiting a room requiring transmission based precautions. Residents Affected - Few This applies to 3 of 3 residents (R19, R249, R250) reviewed for infection control in the sample of 13. Findings include: R249's face sheet documents R249 was admitted to the facility on [DATE] with diagnoses including a right knee wound infection and Methicillin Resistant Staphylococcus Aureus (MRSA) infection. On August 28, 2023 at 10:53 AM V4 (Maintenance) was going from room to room checking to see if call lights are working. V4 started in R19's room turned on the call light in R19's room, came out to the entry to see if the call light was illuminated, and then went back in to turn the call light off. V4 then went into R249's contact isolation room without donning any PPE and did not sanitize his hands before entering the room. V4 turned on the call light in R249's room, came out to the entry to see if the call light was illuminated, and then went back in to turn the call light off. V4 left R249's room and did not sanitize his hands. V4 then entered R250's room and did not sanitize his hands before entering R250's room. V4 went in to turn on R250's light came back to the entry to check to see if light was illuminated. V4 did not sanitize his hands when he exited R250's room. V4 then went in to R247's room and did not sanitize his hands before entering the room. V4 turned on R247's call light, came back to the entry to check to see if the call light illuminated, and then went back into R247's room and turned the call light off. V4 stated that he had infection control training, and he did not see the contact isolation sign on R249's door. R249's door had a contact isolation sign on the door, a PPE bin was outside of the door, and gloves were on the rack on the outside of the door. On August 28, 2023 at 1:24 PM, V5 (CNA) wearing only gloves walked from the dining area to R249's room with a food tray and took the tray into R249's room. V5 did not don a gown before entering the contact isolation room. When V5 came out of the room she was wearing the same gloves. V5 did not remove the gloves and sanitize her hands before exiting the room. The hand sanitizer was located inside the room on the wall of the exit door. V5 stated she should have put on a gown and sanitize her hands before entering the room but just wanted to go in quickly. On August 29, 2023 at 11:30 AM, V4 stated yesterday he was going from room to room checking to see if the call lights were working. V4 stated he went into each room, hit the call light, came out to see if the call light illuminated, then went back in and turned call lights off. V4 stated that he should have performed hand hygiene after hitting the call light in R249's isolation room and after testing the call lights in the other rooms. V4 stated he should have donned PPE before entering R249's room. On August 29 at 4:02 PM, V2 (DON) stated R249 has MRSA in the wound and is on contact isolation. V2 stated that the staff should definitely put on gown and gloves when entering a contact isolation room. V2 stated that staff should remove gloves and sanitize their hands every time they leave the isolation room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146178 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 146178 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victorian Village Hlth & Well 12525 W Renaissance Circle Homer Glen, IL 60491 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 The facility's Infection Prevention and Control Program Policy Dated 2/2020 documents the following: Level of Harm - Minimal harm or potential for actual harm Isolation: 1) Standard precautions are used for all clients at all times. This includes appropriate hand hygiene and use of gloves. Residents Affected - Few 2) Contact Precautions are necessary when an illness is transmitted by direct contact. Requirements include gloves, gown, private room or cohort. The sign that was on R249's door had 2 Stop signs, and stated contact precautions everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146178 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 146178 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victorian Village Hlth & Well 12525 W Renaissance Circle Homer Glen, IL 60491 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview; the facility failed to maintain an effective pest control program. Residents Affected - Some This applies to 5 of 5 (R9, R14, R15, R20, R31) residents reviewed for environment in a sample of 13. The findings include: 1. R14's admission record, showed R14 was admitted to the facility on [DATE]. R14 had multiple diagnoses including disorder of the muscle, malignant neoplasm of the prostrate, malignant melanoma of the skin, chronic pulmonary embolism, history of falling, and major depressive disorder. R14's MDS (Minimum Data Set) dated July 26, 2023, showed R14 was cognitively intact, and required limited assistance from staff with ADLs (Activities of Daily Living), including bed mobility, transfer, toilet use and personal hygiene. On August 28, 2023, at 11:20 AM, R14 stated he had too many flies in his room, while he spoke there were three flies observed on his pillow next to his head and two observed on his bedside table. On August 29, 2023, at 10:12 AM, R14 stated he still had flies in his room he said he swatted at three flies earlier in the morning. On August 30, 2023, at 10:20 AM, R14 stated he saw three flies in his room earlier, but he can't find his fly swatter. V3 (Assistant Administrator) was in the hall outside of R14's room and made aware of R14's concern. 2. R9's admission record showed R9 was admitted to the facility on [DATE]. R9's multiple diagnoses included cardiac arrhythmia, unspecified, idiopathic peripheral autonomic neuropathy, benign prostatic hyperplasia with lower urinary tract symptoms requiring the use of indwelling urinary catheter, pressure ulcers of both left and right buttocks and essential hypertension. R9's MDS showed R9 is cognitively intact, and required extensive assistance from staff with ADLs, including bed mobility, transfer, toileting, and personal hygiene. On August 28, 29, and 30, 2023, during multiple observations, R9's room door had a sign on pink paper that read, keep door closed at all times due to flies. On August 29, 2023, at 4:57 PM, R9 was observed in the room swatting at a fly away from his face while sitting in his room. V29 (LPN) was present and stated we have had a fly problem here for a while. 3. R31's admission record showed R31 was admitted to the facility on [DATE], with multiple diagnoses including disorder of the muscle, hemiplegia, dementia, urinary tract infection, and osteoarthritis of the left shoulder. R31's MDS dated [DATE], showed R31 was cognitively intact and requires extensive assistance from staff with ADLs including bed mobility, transfer, toileting, dressing and personal hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146178 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 146178 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victorian Village Hlth & Well 12525 W Renaissance Circle Homer Glen, IL 60491 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 0925 On August 28, 2023, at 11:31 AM, R31 stated the flies around here are terrible, I wish I had a fly swatter. Level of Harm - Minimal harm or potential for actual harm On August 29, 2023, at 10:20 AM, R31 stated she still had a bothersome fly in her room earlier that morning. Residents Affected - Some 4. R15's admission record showed R15 was admitted to the facility on [DATE], with multiple diagnoses including orthopedic care after surgical amputation, chronic obstructive pulmonary disease, chronic diastolic congestive heart failure, chronic peripheral venous insufficiency, and age-related osteoporosis. R15's MDS dated [DATE], showed R15 was cognitively intact and required extensive assistance from staff with ADL's including bed mobility, transfer, toileting, dressing, and personal hygiene. On August 28, 2023, at 1:28 PM, R15 was seated at the dining table in the main dining room, eating lunch and asked this surveyor, Is there anything you can do about the flies around here? There were two flies observed in the dining area, flying around the table, at the time. 5. R20's admission record showed R20 was admitted to the facility on [DATE]. R20 had multiple diagnoses including Heart failure, diabetes, atrial fibrillation, generalized osteoarthritis, lymphedema, and pressure ulcer. R20's MDS, dated [DATE], showed R20 was cognitively intact, and required extensive assistance from staff for bed mobility, dressing, toileting, and personal hygiene and was dependent on staff for transfer. On August 28, 2023, at 11:39 AM R20 stated she had a concern because there are flies in her room, including tiny baby flies and the flies are also seen in the dining room. On August 28, 2023, at 1:15 PM, V7 (RN) stated the flies have been a problem for about a week now, there's nothing we can do about them they are coming through the entrance doors. On August 29, 2023, at 10:05 AM, V19 (CNA) stated the flies started in a garbage can in the soiled utility room and the garbage was left for a long-time flies had babies and the fly population grew. The flies were so bad on Sunday (August 27, 2023) that the nurse took the garbage can outside. On August 29, 2023, at 10:30 AM, during the soiled utility room observation with V17 (CNA) there was no regular garbage can in the soiled utility room only red bag waste container and soiled clothing bin. On August 29, 2023, at 11:21 AM, V8 (Maintenance Director) stated he became aware of the fly situation in the small house during the morning meeting on August 28, 2023. V8 also stated normally the staff tell the receptionist so a work order can be put in or tell V8 directly. The facility policy titled Pest Control dated October 12, 2022, showed staff is to Dispose of garbage quickly and correctly. Keep garbage containers clean, in good condition, and tightly covered in all areas (indoor and outdoor), Clean up spills around garbage containers immediately. Wash, rinse and sanitize containers regularly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146178 If continuation sheet Page 16 of 16