Inspection·February 15, 2024

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 2/15/24 11:51 AM, V2 stated R2's bordered dressing, which was removed by V17 on 2/14/24, was not the correct dressing. V2 said the dressing should have been a gauze wrap due to the irritation the bordered dressing was causing R35's skin. 2. R31's Face Sheet showed a current admission date of 6/26/23 with diagnoses to include diabetes and cognitive communication deficit. R31's Physician Order Report showed an order for sliding scale rapid acting insulin (Dosage of insulin is dependent upon blood sugar readings.) to be given three times a day before meals. The order showed, in addition to the sliding scale insulin, Special Instructions: Blood sugar greater than 400 give 12 units and call doctor. The order was started on 11/8/23 and was active as of 2/15/24. R31's Blood Sugar showed on 2/6/24 at 9:43 PM a value of 516. R31's Blood Sugar showed on 2/3/24 at 8:41 AM a value of 403. R31's Blood Sugar showed on 2/1/24 at 8:27 PM a value of 426. R31's Blood Sugar showed on 12/5/23 at 11:50 AM a value of 489. On 2/15/24 at 10:04 AM, V2 Director of Nursing stated the order to notify a physician for blood sugars greater than 400 is a typical order for sliding scale insulin. V2 said the reason to notify the physician is a reading over 400 is a high value and the provider may want to order additional insulin. V2 said the blood sugar values at night should have also been called to the physician. V2 said if the nurse contacted the physician there should either be a progress note or an electronic record of the physician notification. (Documentation of physician notification for the out-of-range blood sugars was requested.) On 2/15/24 at 11:40 AM, V2 stated, she was not able to find any documentation the physician was notified of R31's blood sugars greater than 400 for the dates requested. The facility's Change in Resident's Condition policy (revised 12/2002) showed, The nurse will notify the resident's attending physician when .there is a need to alter the resident's treatment significantly . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146193 If continuation sheet Page 2 of 11 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 146193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Rochelle 2203 Flagg Road Rochelle, IL 61068 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R42's face sheet printed on 2/14/24 showed diagnoses including but not limited to acute embolism and thrombosis of deep veins of lower extremity, cellulitis of lower limb, and pressure induced deep tissue damage of right heel. R42's facility assessment dated [DATE] showed no cognitive impairment and a stage 4 pressure ulcer. Residents Affected - Few R42's February 2024 physician order report showed an order start dated 11/11/23 for boots to be worn at all times to float heels. R42's wound evaluation dated 2/9/24 showed a right heel, stage four pressure ulcer measuring 0.6 x 0.6 x 0.3 centimeters. The report showed a treatment plan to off-load the wound. The treatment plan for the wound was for a collagen sheet with gauze island dressing three times per week. R42's February 2024 physician order report showed the treatment to be done daily, not three times per week as order by the wound physician. R42's treatment administration report for February documented the treatments had been on a daily basis. On 2/13/24 at 9:43 AM, R42 was seated in a wheelchair in her room. A pair of purple heel protectors were lying on the bed. R42 wore socks on both feet and her heels were directly on the floor. R42 was trying to hold her right foot up off the ground. R42 said she has a sore on that heel, and it hurts to leave it on the cold floor. At 10:30 AM, R42 was in a group activity with V5 (Activity Aide). R42 was not wearing any heel protectors and was holding her right foot up, off the floor. At 11:45 AM, R42 was self-propelling her wheelchair out of her room. She was not wearing any socks and was using her bare feet to push the wheelchair across the hall. On 2/14/24 at 12:29 PM, R42 was seated at the group dining table and her feet were resting directly on the floor. There were no heel protectors on her feet. On 2/14/24 at 12:16 PM, V4 (Licensed Practical Nurse) stated R42 has a pressure ulcer on her right heel. She is seen weekly by the wound doctor and the wound nurse follows him. R42 gets daily dressing changes to the heel and wears heel protectors. R42 can push herself in the wheelchair and the boots reduce pressure to the area. V4 said the dressing gets changed daily and was done for the day. V4 said it would be changed again tomorrow. On 2/14/24 at 2:37 PM, V2 (Director of Nurses) said R42 needs heel protectors on all day. She likes to sit in her chair most of the day and the boots help prevent pressure to her heels. She has a wound on the right heel and there is the potential for it to get worse if they are not on. V2 said physician orders are an intervention and should be followed to ensure proper wound healing. On 2/15/24 at 12:43 PM, V2 stated R42 was incorrectly getting the heel wound dressings changed on a daily basis. The order was just corrected today and will be done three times per week as ordered. R42's care plan showed a focus area related to pressure ulcers and was start dated 7/6/21. Interventions included treatment/dressings as ordered by MD. The facility's Pressure Injury Prevention and Treatment Protocol policy revision dated 10/24/22 states: An individualized plan of care will be developed for the resident following the guidelines of the assessment. Special devices will be used to relieve pressure. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146193 If continuation sheet Page 3 of 11 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 146193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Rochelle 2203 Flagg Road Rochelle, IL 61068 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to implement Physician ordered interventions. This applies to two of four residents (R11 and R42) reviewed for pressure injuries in the sample of 19. The findings include: Residents Affected - Few 1. The facility face sheet for R11 shows a diagnosis of pressure ulcer of the sacral region. The facility assessment dated [DATE] shows R11 to be cognitively intact and requires moderate assistance with activities of daily living. The care plan dated 7/17/22, shows R11 was admitted to the facility with a stage 4 pressure ulcer to her sacrum. The interventions show a low air mattress on her bed and to change her wound dressing as ordered by Physician or wound nurse. The Physician orders dated February 2024 shows R11 is to have an air loss mattress to her bed and her sacral dressing wound care is to be completed daily. The wound Physician notes dated 2/9/24 shows the dressing is to be changed three times a week by the staff nurses, and a low air loss mattress is to be on R11's bed. On 2/14/24 at 9:57 AM, no low air mattress was observed on R11's bed. On 2/14/24 at 10:30 AM, V10 Memory Care Director when asked if R11 had an air mattress, said Is she supposed to? On 2/15/24 at 10:30 AM, V9 LPN (Licensed Practical Nurse) said R11 gets the dressing to her sacrum changed every day. V9 said the wound Physician sees her every Friday to apply the inner dressing and the staff nurses change the secondary dressing every day. On 2/15/24 at 11:12 AM, V2 Director of Nursing said she has an air mattress added to R11's bed on 2/14/24 after she was told R11 did not have one. V2 said she was not aware that R11 was supposed to have her dressing changed three times a week to her sacrum. V2 said the nurses are to follow the Physician orders. The treatment administration record for February 2024 shows the treatment was completed by the staff daily. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146193 If continuation sheet Page 4 of 11 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 146193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Rochelle 2203 Flagg Road Rochelle, IL 61068 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure fall interventions were in place (R48) and failed to provide a safe transfer (R49) for 2 of 2 residents reviewed for safety in the sample of 19. The findings include: 1. R48's face sheet printed on 2/15/24 showed diagnoses including but not limited to early onset Alzheimer's disease, dementia with agitation, osteoarthritis of the knee, amnesia, anxiety, and repeated falls. R48's facility assessment dated [DATE] showed moderate cognitive impairment. The same assessment showed partial/moderate staff assistance required for bed mobility, sit to stand positioning, and transfers. The last six months of the facility's fall log showed R48 had five falls. The falls occurred in R48's room when he was attempting to self-transfer or rolling himself out of bed. R48's care plan showed a focus area related to risk for falls start dated 4/5/23. Interventions included: Place mats on floor next to bed and keep bed in low position and Dysem (anti-slip pad) placed on top of cushion in wheelchair. On 2/13/24 at 9:07 AM, R48 was sitting in his room alone and in a wheelchair next to the bed. The room door was closed and there was no staff present. R48 was confused and answered questions with nonsense words. On 2/15/24 at 9:12 AM, R48's room door was closed and R48 was sleeping in bed. The bed was in the high position, two fall mats were laying up against the wall, and there was no anti-slip pad in the wheelchair. At 9:35 AM, V4 (Licensed Practical Nurse) and this surveyor entered R48's room. V4 stated R48 has had several falls in the past. He has poor safety awareness and self-transfers a lot. V4 said, He tries to get out of the bed or the wheelchair by himself. The bed should not be up this high and the mats should be on the floor. He should have an anti-slip pad in the wheelchair to prevent him from sliding out. (R48's) door should be open unless care is being provided. He is a high fall risk and doesn't understand the directions to wait for help from staff. On 2/15/24 at 10:28 AM, V2 (Director of Nurses, Fall Coordinator) stated resident falls are reviewed and interventions are put into place to reduce the potential for more falls. V2 said R48 is very impulsive and does not use the call light. R48 likes to self-transfer and has rolled out of bed in the past. R48 has dementia and the room door needs to remain open as needed. There is the chance of R48 falling again and being injured when fall interventions are not in place. The facility was unable to provide any policies related to fall prevention. 2. R49's face sheet printed on 2/14/24 showed diagnoses including but not limited to dementia, anxiety, heart disease, and prostate cancer. R49's facility assessment dated [DATE] showed moderate cognitive impairment and partial/moderate staff assistance required for transfers. On 2/13/24 at 9:25 AM, V6 (Resident Assistant) and V7 (Certified Nurse Aide) transferred R49 from his wheelchair to the bed using a mechanical lift. V7 operated the lift while V6 stood next to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146193 If continuation sheet Page 5 of 11 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 146193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Rochelle 2203 Flagg Road Rochelle, IL 61068 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 lift during the transfer. R49 was laid on the bed and V7 provided incontinence care. Level of Harm - Minimal harm or potential for actual harm On 2/13/24 at 11:36 AM, V7 and V8 (Certified Nurse Aide) stated resident assistants can only pass water, make beds, or stock linens. They cannot provide any hands-on care to the residents. They are not allowed to feed or transfer residents. A certified nurse aide is required for that. Residents Affected - Few On 2/14/24 at 2:30 PM, V2 (Director of Nurses) stated resident assistants cannot provide direct care. V2 said all mechanical lift transfers require two certified nurse aides. It is needed for safety and to ensure a resident does not fall. CNAs are trained on how to do the transfers properly. Resident assistants do sit through the training just so they understand how the lifts work but are not able to do the actual transfers. V2 said R49 is a mechanical lift transfer, and two CNAs are needed for all transfers. The facility's Safe Resident Handling policy revision dated 11/12 states under the procedure section: 5. When using Full Mechanical Lift or Sit to Stand Mechanical Lift, two members are used with additional help as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146193 If continuation sheet Page 6 of 11 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 146193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Rochelle 2203 Flagg Road Rochelle, IL 61068 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to implement physician ordered weight loss interventions for a resident with weight loss. This applies to 1 of 4 residents (R35) reviewed for weight loss in the sample of 19. Residents Affected - Few The findings include: R35's Face Sheet showed a current admission date of 5/11/21 with diagnoses to include abnormal weight loss, dementia, depression, and nausea. R35's 12/29/23 dietitian note showed, she weighed 108 pounds. The note showed, .considered underweight for age per BMI (body mass index) of 20. Wt. (weight) loss of 6 percent in 1 month and 14 percent in 6 months noted . The note showed she was on a liquid nutritional supplement drink twice a day. The note showed a recommendation to increase the supplement to three times a day. R35's 1/16/24 dietitian note showed R35 weighed 107 pounds, .weight loss of 10% in 6 months . The note showed R35 was still ordered the nutritional supplement drink twice daily. The note showed, [R35] continues to lose wt. Recommend review for increasing [nutritional drink] to TID (three times daily) . R35's Request for Dietary Change PCP (primary care provider) FAX Report from 1/16/24 showed the provider agreed with increasing the nutritional drink to three times a day. The fax was signed by the provider on 1/17/24. (On 2/15/24, the facility was unable to produce a fax for the dietitian's recommendation from 12/29/23.) R35's Physician Order showed from 11/2/23 through 2/15/24, R35 was ordered to receive the nutritional supplement only twice daily. The order was changed to three times daily on 2/15/24. On 2/15/24 at 10:17 AM, V2 said, R35's order for her nutritional supplement had not been changed to three times daily. V2 stated R35 has had weight loss due to decreased intake because of her progressing dementia. V2 said increasing the nutritional supplement to three times a day was an intervention to combat her weight loss. V2 said she does not know why the order was not carried out in December 2023 or January 2024. R35's Vitals Report showed her weight has remained stable at approximately 108 pounds from 11/1/23 through 2/1/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146193 If continuation sheet Page 7 of 11 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 146193 B. Wing (X3) DATE SURVEY COMPLETED A. Building 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Rochelle 2203 Flagg Road Rochelle, IL 61068 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure food temperatures on steam tables were 135 degrees Fahrenheit or above prior to serving, failed to ensure the dish machine temperature for the wash cycle reached the appropriate temperature, failed to ensure staff documented the dish machine temperatures on the daily logs, and failed to ensure dietary staff were knowledgeable regarding how to properly test the dish machine to ensure the proper temperatures were obtained for sanitation. This has the potential to affect all the residents in the facility. The findings include: The CMS 671 form dated 2/13/24 showed 68 residents resided in the facility. The facility's Order Report by Category documents, printed by the facility on 2/14/24, showed all the residents in the facility take food by mouth. On 2/13/24 at 12:03 PM, V16 (Dietary Aide) took the temperatures of the food on the steam table on the 200-unit, prior to serving. The temperature of the meatloaf was taken five times prior to serving. The meatloaf temperatures were as follows: 119.1 degrees Fahrenheit, 131.6 degrees Fahrenheit, 115.3 degrees Fahrenheit, 119.3 degrees Fahrenheit, and 127.4 degrees Fahrenheit. V16 took the temperature of the pureed meatloaf. The pureed meatloaf was 128.9 degrees Fahrenheit. After obtaining the temperatures for all the food that would be served and documenting in the temperature log binder, V16 started serving the food to the residents on the 200-unit. After serving the residents on the 200 unit, the pans of food were loaded back into the heated cart and taken to the 100-unit (this surveyor did not observe the pans being loaded and taken to the 100 unit). On 2/13/24 at 12:36 PM, V16 took the temperatures of the food on the steam table on the 100-unit. V16 verified that this was the same food that was brought from the 200 unit. The temperatures were taken from the two front pieces of meatloaf by V16. The first two pieces were 140.6 degrees Fahrenheit and 153.6 degrees Fahrenheit. This surveyor asked V16 to check the temperatures of a couple more pieces (due to this surveyor not observing the food being placed in the heated cart and taken to the 100-unit). The next two temperatures for the meatloaf were 94.6 degrees Fahrenheit, and 114.6 degrees Fahrenheit. The facility's 200-unit Food Temperature Log showed on 2/13/24 V16 documented a temperature of 120.4 degrees Fahrenheit for the meatloaf on the 200 unit and 127.4 degrees Fahrenheit for the pureed meatloaf on the 200 unit. These temperatures do not match the temperatures observed. The facility's 100-unit Food Temperature Log showed on 2/13/24 V16 documented a temperature of 180 degrees Fahrenheit for the meatloaf on the 100 unit. This temperature does not match the temperatures observed. On 2/14/24 at 9:20 AM, V15 (Food Services Supervisor-FSS) said the food temperatures should be at least 135 degrees Fahrenheit on the steam tables to prevent the food from going into the danger zone where bacteria can grow; to prevent food-borne illness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146193 If continuation sheet Page 8 of 11 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 146193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Rochelle 2203 Flagg Road Rochelle, IL 61068 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 The facility's February 2024 High Temperature Dish Machine Temperature Log showed no temperatures were recorded into the log for the dish machine for any of the meals on 2/8/24; 2/9/24; 2/10/24; and 2/11/24. The facility's 08/2019 Proper Food Preparation/Holding Temperature document, provided by the facility on 2/14/24, showed food held in a warming cabinet or on a steam table should be kept at 135 degrees Fahrenheit. The facility's 08/2019 Food Temperatures-Measuring Procedure showed hot foods should be held at 135 degrees Fahrenheit, at least, or higher. On 2/13/24 at 9:28 AM, V14 (Diet aide/dishwasher) said she thinks the facility's dishwashing machine is a high temperature dishwasher and not a chemical dishwashing machine. V14 had been running trays of dirty dishes through the dish machine. The gauges on the first cycle this surveyor observed showed the wash cycle temperature was 144 degrees Fahrenheit. V14 said she was not sure how to test the temperature to ensure the gauges were correct. V14 grabbed a couple of bottles from the shelf adjacent to the dish machine and said she thinks those bottles are used to test the dish machine. V14 said whenever she works, she just records the temperature that is on the gauges that are on the outside of the machine. The temperature gauges on the second set of dishes ran through the dishwashing machine were 147 degrees Fahrenheit for the wash cycle. At 9:38 AM, V15 (FSS) came in and said the temperatures are checked by placing a strip that is in the temperature logbook onto a dish and running it through the machine. V15 said the strip should turn orange if the correct temperature is obtained. On 2/14/24 at 9:17 AM, V14 (Dietary Aide/Dishwasher) handed the temperature logbook to the surveyor and said some of the dietary staff are not filling out the temperature log for the dishwasher. V14 said she has been filling out the temperature log for the dish machine on the days that she works. V14 said she just writes down the temperature that shows on the gauges on the outside of the machine. V14 said she does not run a test strip through the machine like V15 did the previous day. At 9:20 AM, V15 (FSS) was asked about the missing information on the Dish Machine Temperature logs. V15 said it has been an ongoing thing. The staff are new, and they write the temperatures in the wrong columns, or do not fill out the temperature logs. At 9:23 AM, V15 said it is important to test the dish machine to ensure it is working properly, to ensure the temperatures are high enough to sanitize the dishes. V15 said this is important to prevent food-borne illness, because the dishwasher is not a chemical dishwasher, so it is important to make sure the water is hot enough to sanitize. The facility's 08/2019 Dish Machine High Temperature Recording Procedure showed Hot water is used for sanitizing in high temperature dish machines, not a chemical sanitizer. Therefore, it is important to record wash temperatures and final rinse temperatures three times a day. After all three meals, before you wash meal dishes, check and record dish machine wash and final rinse temperatures .The policy showed goal temperatures were located on the metal plate located on the front of the dish machine. Appropriate temperatures are as follows; Wash Temperature 150-160 degrees Fahrenheit .Staff will test the dish machine periodically with 180 degree Fahrenheit test strips for accuracy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146193 If continuation sheet Page 9 of 11 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 146193 B. Wing (X3) DATE SURVEY COMPLETED A. Building 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Rochelle 2203 Flagg Road Rochelle, IL 61068 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 perform testing on day 5 of an outbreak of Covid-19 in the facility and failed to report a covid-19 positive case to the local health department. Residents Affected - Many This has the potential to affect all the residents in the facility. The findings include: The CMS form 671 dated 2/13/24 showed 68 residents resided in the facility. On 2/13/24 at 8:30 AM, a sign on the front entrance indicated that the facility had a positive covid case in the building. On 2/14/24 at 1:54 PM, V2 (Director of Nursing-DON) and V11 (the facility's Infection Preventionist) said they are both doing Infection Preventionist duties, until V11 gets fully trained in the position, as V11 has only been in the facility for a couple of weeks. V2 said V12 (Certified Nursing Assistant-CNA) tested positive for Covid-19 on 2/6/24. V2 said V12 had tons of symptoms. V2 said she thinks all the residents and staff on the unit the CNA worked on (the memory lane unit) were tested on [DATE]. V2 said they (the staff and residents on the memory care unit) were tested on e more time after that on day 3. V11 (The facility's Infection Preventionist-IP nurse) said V13 (the previous IP nurse) reported the positive case to NHSN (National Healthcare Safety Network). V11 said she was not sure if it was reported to the local health department. V2 (DON) said she was not aware if the local health department was notified either. V2 said she did not report it to the local health department herself. V2 said one positive case of Covid-19 signifies an outbreak. Both V2 and V11 said when a resident or staff member tests positive, testing should be done on days 1, 3 and 5, with the day the first positive test result was obtained being day zero. V2 and V11 said if no new positive cases, the facility stops testing, but continues to monitor for symptoms for 14 days. V2 and V11 were asked to provide the testing logs and proof that NHSN and the local Health Department were notified of the positive Covid-19 case in the facility. The facility's schedule showed on 2/4/24, V12 worked a double shift on the memory lane unit (second shift and the overnight shift). On 2/15/24 at 8:50 AM, V2 and V11 were interviewed again. V2 said V18 (RN working the memory care unit) tested all the residents and staff on the memory lane unit on 2/7/24. V2 said the facility did not report the positive case to the local Health Department. V11 said V13 (the facility's previous IP nurse) reported the positive case to the NHSN site on 2/8/24. V11 provided a document showing the case was reported on 2/8/24. V2 said the facility should have tested the residents and staff on the memory unit on day 5 which would have been 2/12/24, according to V2. On 2/15/24 at 9:07 AM, V2 said according to our policy, the local health department should have been notified. V2 said it is important to make sure the local Health Department is aware of the positive Covid-19 case and get instructions on what we may need to do differently. V2 said the residents on memory lane do come out of the memory lane unit to go to the beauty shop, restorative-exercise group, and some other activities. V2 said it is important to test to make sure no other residents or staff are positive, so that it does not spread. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146193 If continuation sheet Page 10 of 11 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 146193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Rochelle 2203 Flagg Road Rochelle, IL 61068 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete The facility's testing documents showed residents on the memory lane unit and staff were tested on [DATE] and 2/10/24. (that was day 1 and day 4). No further testing was performed. The facility's Covid-19 policy and procedure, with a revision date of 08/28/23, showed Return to Work Criteria Following Exposure: After Exposure: 1. Have a series of three viral tests for SARS-CoV-2 infection. a. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test, and if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5 .Notifications: 1. Local health department and other government agencies as required will be notified if Covid-19 is diagnosed in either residents or staff. Event ID: Facility ID: 146193 If continuation sheet Page 11 of 11