Inspection·May 9, 2025

F 0627 R1's progress notes showed the following: Level of Harm - Minimal harm or potential for actual harm On April 16, 2025 11:26 PM, V2 wrote, Called [Name] (POA/Power of Attorney) when Assigned RN (Registered Nurse) informed writer. Addressed her concern that Assigned RN did not have to call 911 to send resident to ED (Emergency Department) since she only lives 2-3 minutes away. She also addressed that her family was at the facility during dinner time and resident was alright. POA also addressed her concern that a facility was waiting for resident to be admitted and just waiting for that referral to be approved. POA also informed writer multiple times regarding the hospital bills that they have to address to. Residents Affected - Some On April 16, 2025 at 11:38 PM, Resident up around 8:30 PM started walking in the hallway and cross the room into the other female resident's room, urinated on floor in the resident's room, assisted resident with 2 assist to come out of female resident's room, resident agitated and started walking through the end of hallway trying to push the door. Entered to another resident's room took banana and trying to sleep in other resident's room bought out with difficulty with 2 assist during the time resident hit the CNA (Certified Nurse Assistant) as was agitated and was combative to come out of the room. Resident bought to room with 2 assist and assisted nursing station, resident wouldn't sit at one place then assisted back to bed trying to hit another CNA, so called 911 as per MD (Medical Doctor) order to send ER (Emergency Room) for further eval for combative behavior. DON (Director of Nursing) notified, daughter notified was not happy and started screaming at the writer and said you couldn't wait until morning to send him out. DON made aware. The facility was unable to provide written documentation provided to R1 or R1's representative. 2. R2's face sheet showed she was admitted to the facility on [DATE] with diagnoses including venous insufficiency, vascular dementia, obsessive-compulsive disorder, anxiety, gastro-esophageal reflux disease, osteoporosis, depression, hypertension, weakness, and dysphagia. R2 was transferred to the hospital on May 8, 2025. R2's EMR showed a progress note on May 8, 2025 at 8:33 AM, which documented the following Around 8:30 am noted resident lethargic, increased perspiration. Resident confused, verbally responsive .Resident POA (Power of Attorney) Daughter [Name] was informed and she agreed to send resident to ER. Resident was transfer to [Name] Hospital ER around 9 am at stable condition by [Company Name] ambulance. Report was given. DON informed. On May 8, 2025 at 1:08 PM, V6 (LPN/Licensed Practical Nurse) said she had transferred R2 to the hospital. V6 said she had given the paramedics copies of the face sheet and the medication list. V6 said she did not give R2 or her representative the written notice of bed hold as it was not her job title and she had never done it. V6 said possibly V2 (DON) would give the resident the document. On May 8, 2025, the facility was unable to provide a copy of the written notice of bed hold given to the resident or representative. 3. R3's face sheet showed he was admitted to the facility on [DATE] with diagnoses including non-pressure chronic ulcer, anemia, hyperlipidemia, peptic ulcer, low back pain, chronic kidney disease, history of falling, and spinal stenosis. R3's EMR showed a progress note on March 27, 2025 at 4:26 PM, which documented the following, Upon further discussion with [Name] NP (Nurse Practitioner) and Administrator, it was best for resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145111 If continuation sheet Page 2 of 3 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 145111 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elmhurst Extended Care Center 200 East Lake Street Elmhurst, IL 60126 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 0627 Level of Harm - Minimal harm or potential for actual harm to be transferred to acute care hospital for further care of his wounds. Assigned RN was informed and was able to transfer patient. On May 8, 2025 at 1:08 PM, V6 said she transferred R3 to the hospital and did not give R3 or his representative the written notice of bed hold. Residents Affected - Some On May 8, 2025, the facility was unable to provide a copy of the written notice of bed hold given to the resident or representative. 4. R4's face sheet showed she was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, hypothyroidism, depression, adult failure to thrive, dysphagia, type 2 diabetes mellitus, bipolar disorder, and anorexia nervosa. R4's EMR showed a progress note on at 5:15 PM, the progress note showed, . Resident has midline on LUE (Left Upper Extremity) patent, left hand noted swollen elevated on pillows, cholecystostomy tube with 10 ML (Milliliters) output with resistance noted during flushing MD (Name) and 911 called @ 9.17 PM with ETA (Estimated Time of Arrival) of 5 to 7 minutes. POA notified @ 5.18 PM approximately. paramedics staff arrived @ 5.17 PM, all required documents required for transfer along with report provided to paramedics. paramedics left facility @ 5.26 PM. DON notified. On May 8, 2025 at 1 PM, V5 (RN/Registered Nurse) said when she sends the residents to the hospital, she gives the paramedics two face sheets, the advanced directive, and the medication list. V5 said she calls the POA and notifies them of the transfer. V5 said residents are allowed to return to the facility but if their care cannot be managed at the facility, they could not accept the resident. V5 said for example, if the resident required a psych unit, the facility does not accept them back. V5 said the admission coordinator and the social services team gets the doctors from the hospital. V5 said the bed hold notice should be given to the resident by the social worker since nursing does not deal with the bed hold policy. On May 8, 2025, the facility was unable to provide a copy of the written notice of bed hold given to the resident or representative. The facility's Bed Hold policy dated January 4, 2024 showed Medicaid residents properly admitted , have a right to return to the facility to the first available bed after a hospital transfer .If there is not a return, written notification will be provided with the reason for non-admittance and appeal rights and contract determination. The facility's Discharge Policy dated January 4, 2023 showed The resident, physician, representative will be notified of discharge. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145111 If continuation sheet Page 3 of 3