Inspection·October 21, 2022

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The facility presented a call light policy revised 7/15/22 document: The facility must be adequately equipped to allow residents to call for staff assistance through a communication system that relays the call directly to a staff member. 4. On 10/18/2022, approximately at 11:17 AM entered R147's room and heard R1 softly calling out to get someone to help her. R147 said, I am sitting on my bowel movement and waiting for a long time for someone to clean me R147's call light was hanging on the bedside drawer away from her, and R147 said, I can't reach the call light, and I am too weak to shout for help R147 verbally confirmed knowing the function of the call light and having the ability to use it appropriately. V8(Certified Nursing Assistant), propelling a wheelchair for another resident in the hallway, notified that R147 required assistance. V7 entered the room, secured R147's call light within reach of R147, and provided incontinent care. V8 said the call light should be within reach of the residents. R147 is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including urinary incontinence, heart failure, anxiety, and depression. Review of R147's BIMS (Brief Interview of Mental Status) summary score of the quarterly MDS (Minimum Data Set) dated 10/13/2022 showed R147 is cognitively moderately intact and requires one-two staff assistance for activities of daily living. The current care plan showed the call light to be within reach of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146197 If continuation sheet Page 2 of 7 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 146197 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jennings Terrace 275 South Lasalle Aurora, IL 60505 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received nutritional supplements or an alternative supplement as ordered by the Physician and recommended by the facility's registered dietitian to prevent weight loss. Residents Affected - Some This applies to 4 of 12 residents (R21, R33, R34, R149) reviewed for nutrition with the nutritional supplements in a sample of 19. The Findings include: 1. R21 was admitted to the facility on [DATE] with diagnoses including diabetes, dysphagia, gastroesophageal reflux disease, and dementia. R21's Quarterly Minimum Data Set (MDS) dated [DATE] showed that R21 is severely cognitively impaired and requires extensive assistance with eating. R21's admission weight on 04/08/2022 is noted to be 151 pounds and 153 pounds on 08/01/2022. R21's last weight was noted to be 143 pounds on 09/03/2022. On 10/18/2022 at 1:17PM, R21 was sitting in the dining room, and V 9(R21'S POA-Power of Attorney) was assisting R21 in eating lunch. R21 appeared thin/emaciated, with protruding collarbones and a gaunt appearance on his face, with protruding cheekbones. V 9 (R2's family member) said his supplement is back ordered, and she is bringing it from home and giving it to R21 whenever she feeds him. On 10/19/2022 at 10:10 AM, V 6(Registered Nurse) said his supplement was back ordered, and he offered R21 an alternative supplement for breakfast, and R21 refused. Physician order upon admission documents for R21 to get 120cc Med Pass Supplement three times daily. V7's (Registered Dietician) progress notes dated 09/12/2022 showed R21 had 5.9 percent weight loss in a month. V7 documented that R21 is on 120 ml Med Pass 2.0 three times a day. R21's care plan dated 04/18/2022 showed R21 had significant weight loss per family, and intervention included providing and serving supplements as ordered. On 10/20/2022, approximately at 12:50 PM, V7(Registered Dietician) said she was unaware of the back order and assumed residents were receiving nutritional supplements. On 10/20/2022, at approximately 02:50 PM, V 1(Administrator) and V 2(Director of Nursing) said Med Pass was back ordered since they both started at the beginning-mid of this year, and they were not aware that V7 was not aware. 2. R33 was admitted to the facility on [DATE] with diagnoses including degenerative disease, major depression, and dementia. R33's Quarterly Minimum Data Set (MDS) dated [DATE] showed R33 was cognitively severely impaired and required assistance with eating. R33's weight record documented 148 pounds on 07/25/2022 and 130 pounds on 10/18/2022. admission order initiated 90 Med Pass Supplement daily. V7's (Registered Dietitian) progress notes dated 10//12/2022 showed R33 had 9.9 percent of weight loss in one month. V7 recommended 120 ml Med Pass supplement daily once. R33's care plan dated 07/26/2022 showed R33 was at nutritional risk, and intervention included providing nutritional supplements per Physician/Dietitian orders to promote wound healing and maintain weight. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146197 If continuation sheet Page 3 of 7 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 146197 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jennings Terrace 275 South Lasalle Aurora, IL 60505 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3) R34 was admitted to the facility on [DATE] with diagnoses including dementia, hypokalemia, and osteoporosis. R34's Quarterly Minimum Data Set (MDS) dated [DATE] showed that R34 was cognitively moderately impaired and required assistance with the meal tray set. R34's weight record documented weight of 131.2 pounds on 07/21/2022 and 125 pounds on 10/07/2022. The Physician ordered 90 Med Pass supplements daily on 10/17/2022 for weight loss. V7's (Registered Dietician) progress notes document that R34's BMI (Body Mass Index) at 21.0 which is low and indicating impaired nutritional status and V7 recommended increasing Med Pass 2.0 to 120 ml two times a day. R34's care plan dated 07/26/2022 showed R34 was at nutritional risk, and intervention included providing nutritional supplements as ordered. R34 was not provided the Med Pass supplement. 4) R149 was admitted to the facility on [DATE] with diagnoses including esophagitis, neoplasm of the breast, and osteoarthritis. R149 also had a facility-acquired pressure ulcer in Coccyx. R149's Quarterly Minimum Data Set (MDS) dated [DATE] showed that R149 is severely cognitively impaired and required extensive assistance with eating. R149's weight record documented a weight 105 pounds on 10/10/2022. The physician order dated 07/28/2022 documents an order for Med Pass Supplement 120ml every evening for weight loss. V7 (Registered Dietician) progress notes dated 09/12/2022 showed a 4.1 weight loss in one month, and Med passes 120 ml every evening. V7's progress notes dated 10/12/2022 showed 120 ml Med Pass 2.0 every evening and increased nutrient needs related to the wound. R147's care plan dated 04/08/2022 documents that R147 is at nutritional risk, and intervention included providing nutritional supplements to aid wound healing and promote optimal weight per physician/dietician orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146197 If continuation sheet Page 4 of 7 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 146197 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jennings Terrace 275 South Lasalle Aurora, IL 60505 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, failed to properly secure resident medications and failed to remove over the counter medications from resident's rooms. This applies to 4 of 4 residents (R22, R23, R25 and R195) reviewed for medications in a sample of 19. Findings include: 1. On 10/18/22 at 10:32 AM during the initial tour, there bottle of Afrin nasal spray and Robitussin nighttime maximum strength cough syrup on R195's bedside table. R195 said she brought both medications from home, and she uses the nasal spray for sinus congestion. R195's current electronic POS (Physician Order Sheet) was reviewed; there was no order for both medications, and R195 did not have an order for any medications to be at the bedside. 2. On 10/18/22 at 11:03 AM, there was tube of Bengay ultra strength topical analgesic cream on R22's bed. At 11:12 AM, R22 said he uses the Bengay for his knee pain but has not used it in a while. On 10/20/22 at 9:33 AM, V2 DON (Director of Nursing) said R22's daughter brought in the Bengay and R22 does not have an order for it to be at the bedside. R22's current electronic POS was reviewed, there was no order for this medication; R22 had the following order, Resident may self-medicate his medications. 3. On 10/18/22 at 11:06 AM, R25 was observed in bed resting. On R25's bedside table there was 1 unlabeled white medication in the medication cup. R25 said the nurse gave her the medication in the morning; R25 said she did not know what the medication was and was going to take the medication when she wakes up. On 10/18/22 at 11:20 AM, V5 (Agency LPN/Licensed Practical Nurse) said she gave R25 all her medications this morning and R25 took the medications. V5 said she does not know where R25 got the unlabeled medication, maybe it dropped. V5 said she will check the medication and will document the incident. V5 asked R25 where she got the medication, R25 said she does not know where she got the medication from. R25's current electronic POS was reviewed, there was no order for any medications to be left at the bedside. 4. On 10/19/22 at 9:19 AM during medication administration with V6 RN (Registered Nurse) there was a bottle of Systane complete optimal dry eye relief eye drops and a small tube of Oragel medicated toothache and gum instant relief oral antiseptic pain reliver astringent found on R23 bedside table. R23 said they were both his, and he has not used them in a while. On 10/19/22 at 9:21 AM, V6 RN said R23 does not have orders for the medications or for the medications to be at the bedside. R23's current electronic POS was reviewed, there were no orders for both medications and there was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146197 If continuation sheet Page 5 of 7 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 146197 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jennings Terrace 275 South Lasalle Aurora, IL 60505 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 no order for medications to be at the bedside. Level of Harm - Minimal harm or potential for actual harm On 10/20/22 at 10/18/22 at 9:33 AM, V2 DON said R22, R23 and R195 do not have orders to have the medication at their bedside and the nurse should ensure that the residents take all medications during administration. Residents Affected - Some The facility's policy titled Storage of Medications (Revised April 2007) states, 7. Compartments (including but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use . The facility's policy titled Self-Administration of Medications (December 2016) states, 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. 8. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication cart or in the medication room. 9. Staff shall identify and give to the charge nurse any medications found at the bedside that are not authorized for self-administration, for return to the family or responsible party. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146197 If continuation sheet Page 6 of 7 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 146197 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jennings Terrace 275 South Lasalle Aurora, IL 60505 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. On 9/28/22 at 10:30 AM, during the resident groups, the group members (R9, R12, R13, R22, R35, R40, R43, and R44) unanimously stated, We are not getting any bedtime snack. They are not offering any bedtime snack. Sometimes we are hungry at 3:00 AM, so we should get some snack at bedtime. On 10/20/22 10:00 AM V4 (Dietary Director) stated, Our old menu includes pre-made snacks. For some reason, the vendor was running out of those pre-made snacks for bed time. So we were planning inhouse bedtime snack. But, we have an issue with staff not preparing bedtime snack. We rolled out new menu yesterday to include bedtime snack including PBJ, cookies, juice, fruit, apple sauce and graham crackers. Based on interview and record review, the facility failed to provide bedtime snack to residents. This applies to 9/9 residents (R9, R12, R13, R22, R30, R35, R40, R43, and R44) reviewed for meal frequency and bedtime snacks in a sample of 19. Findings include: On 10/18/2022 at 11:03 AM R30 stated she has not been offered bedtime snack in two months. R30 stated she gets hungry around 2 AM. R30 stated that she did not know she can ask for snacks after dinner. On 10/20/2022 at 11:41 AM, V4 (Dietary Manager) provided untitled policy and procedure stating HS (7 PM) snacks must be put at each nurse's station (North and South) in Nursing Center by the 10 AM aide before the PM [NAME] leaves at night. On 10/20/22 at 12:07 PM, interview with DON stated that all residents are offered bedtime snacks every night. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146197 If continuation sheet Page 7 of 7