Inspection·March 31, 2025

F 0600 services due to his diagnosis of low back pain. Level of Harm - Immediate jeopardy to resident health or safety R1's current care plan showed R1 was cognitively intact, ambulatory, and needed no staff assistance to complete his activities of daily living. The plan showed R1 had a history of verbally aggressive behaviors towards others. The plan showed R1 was an identified offender due to his criminal history of attempted armed violence. Residents Affected - Few R1's progress and nursing notes dated November 2024-March 2025 were reviewed. These notes showed multiple documented episodes of R1 having alcohol, drugs, and drug paraphernalia in the facility. The notes showed incidents of R1 being verbally aggressive and threatening towards residents and staff. The notes showed incidents of R1 repeatedly disobeying facility rules and leaving the facility despite his community pass privileges being revoked due to his behaviors. They showed multiple incidents of the local police being called to the facility due to R1's behaviors. A note dated 2/6/25 showed the facility served R1 a 30-day discharge notice due to his behaviors and R1 no longer needing skilled nursing services. R1 appealed his discharge. A note dated 3/3/25 showed a coat, belonging to R1, was found in the facility containing 9 bags of marijuana, a scale and a pipe. A note dated 3/11/25 showed R1 was sent to a local behavioral health hospital due to R1 threatening to shoot V1 Administrator and V2 Assistant Administrator. R1 was allowed to return to the facility on 3/19/25 pending the appeal related to his discharge. Upon return from the hospital, R1's notes dated 3/20/25-3/31/25 showed R1's behaviors continued. On 3/21/25, R1 walked out of the facility and did not return until noon on 3/22/25. On 3/23/25, R1 was verbally aggressive with staff. On 3/23/25, it was reported to facility staff that R1 had been smoking crack with another resident. On 3/25/25, R1 was found in another resident's room. R1 took food from the resident's room, and left. On 3/27/25 at 8:45 AM, R1 was in his room, lying in bed. R1 denied selling drugs to any residents in the facility. When this surveyor asked R1 about his interactions with R2 and if he had ever threatened R2, R1 began to get upset and his voice became louder. He immediately stood up from his bed, took a step towards this surveyor and stated, I have already told this story before. I already talked to the police. R1's voice continued to raise his voice as he spoke. R1 began walking towards the door of his room. R1 very loudly asked this surveyor to leave his room. This surveyor exited R1's room. 1. R2's admission Record dated 12/5/24 showed R2 was admitted to the facility with diagnoses of autism, developmental delays and a heart transplant. R2's admission nurse practitioner note dated 12/30/24 showed R2 was cognitively intact. On 3/27/25 at 8:30 AM, R2 was in his room, lying in bed, with the lights off. R2 stated R1 threatened to kill R2 sometime in late February if I snitched and told anyone where I got my pot (marijuana) from. R2 stated he had bought marijuana from R1 in February. R1 stated, After I bought pot from him, there were a couple of times when (R1) would just come into my room (unannounced). I was definitely scared of him then. He never asked to come in my room . after that, I finally told on him because I was angry from what he said to me and I was also a little scared of him . Now that (R1) is back from the hospital, I just stay away from him. I stay in my room to avoid him. I know he has other people (residents) watching me so he knows who I talk to. I am still a little scared of him . On 3/27/25, V5 Social Services stated R2 had reported to V5 in the past that R2 did not feel safe around R1 because R1 had threatened to choke him (R2) out if R2 told anyone he bought marijuana from R1. V5 stated when R1 returned from the hospital, R2 reported feeling afraid because of (R1). (R2) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145308 If continuation sheet Page 2 of 9 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 145308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River View Rehab Center 50 North Jane Elgin, IL 60123 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few has been spending more time in his room to avoid conflicts . V5 stated, (R1) is very intimidating. He becomes verbally aggressive. Staff are afraid he will hit them if they try to enforce the rules. I worry that (R1) will attack me or other staff . I don't feel comfortable with (R1) and he intimidates me. The dilemma is that we don't know what to do with him when he acts out other than call the police . A social service noted for R2, dated 3/25/25, showed R2 reported to social services that a co-resident came into his room when he wasn't present and the he doesn't want this co-resident to come into his room anymore . On 3/27/25 at 12:27 PM, V4 Social Services was asked about the resident referenced in R2's social service note dated 3/25/25. V4 stated, The resident in (R2's) room was (R1). (R2) came to me and told me that the day before (3/24/25), (R2) walked into his room and found (R1) standing in his room, talking to (R2's) roommate. (R2) reported to me that he immediately felt uncomfortable and walked back out of his room. I think he was a little fearful when he saw (R1) in his room. Since his return from the hospital, we try to monitor where (R1) is at when he is in the building but he goes where he wants. We have tried to revoke (R1's) community pass privileges due to his behaviors but he doesn't care. He feels like he's above the rules and leaves anyway. On 3/27/25 at 9:13 AM, V1 Administrator stated on 3/17/25, R2 reported to V1 that R1 had threatened to kill R2 if he told anyone R1 had sold him marijuana. V1 stated all staff and many residents are afraid of R1 due to his behaviors. V1 stated, We were finally able to send (R1) out to the hospital after he threatened to kill me, (V2 Assistant Administrator), and our families but he was allowed to return. When he came back, we tried to put him (R1) in a private room, but he refused. We tried to move him to a room on the first floor, but he refused. We revoked his community pass privileges but he doesn't care, he still leaves the facility. We try to monitor where he is every hour that he is in the facility . V1 stated facility staff are afraid to enforce the facility's rules with R1 because they are afraid he will try to hurt and physically assault them. 2. On 3/27/25 at 10:45 AM, R6 was asked about his interactions with R1. R6 was initially hesitant to speak with this surveyor, stating, I don't want to get involved. If I say something, there is nothing you can do. I already made my statement (during the abuse investigation) . R6 continued to talk and then stated he had been threatened by R1 in the past. R6 stated, One night, when he (R1) wasn't sober, he came into my room and threatened to break my neck and throw me out a window. He said he could break my neck and tell staff it was a seizure since there is no cameras in my room. I started yelling and a CNA (certified nursing assistant) came and got him out of my room . Many residents are afraid of him. He has power and no one can stop him. He is big and intimidates people . It would be better if he left and never came back. The police just bring him back and he does whatever he wants . (R1) has said before he can leave people crippled in a wheelchair or a vegetable, what are they waiting for? Someone to die or get hurt? On 3/27/25 at 9:13 AM, V1 Administrator stated on 3/18/25, R6 reported to V1 that he was scared of R1 because R1 had threatened to break R6's neck. 3. On 3/27/25 at 11:10 AM, R3 refused to speak to this surveyor about R1. On 3/27/25 at 11:10 AM, R4 stated R3 won't come down and talk to you guys because he's fearful of his safety. (R1) is big and has threatened (R3) before. I have seen (R1) drinking (alcohol) in (R3's) room before. (R3) is timid and shy .He doesn't want to get beat up by (R1) . R4 stated she was the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145308 If continuation sheet Page 3 of 9 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 145308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River View Rehab Center 50 North Jane Elgin, IL 60123 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few resident that reported R1 had threatened to kill V1 Administrator and V2 Assistant Administrator. R4 stated, (R1) was pissed off because he thought (V2) was trying to get him kicked out of the facility. He told me that he could be sitting in a bar and have someone shoot (V1) and (V2) and their families so I reported that to (V2). R4 stated she has seen R1 smoke weed and drink alcohol in the facility. A social service note dated 3/19/25 for R3 showed, Resident is upset and scared that a co-resident (R1) got admitted back to the facility . On 3/31/25 at 10:24 AM, V7 Social Services was asked about the note she documented on 3/19/25 for R3. V7 stated R3 said he was scared because R1 had been readmitted to the facility. On 3/27/25 at 9:13 AM, V1 Administrator stated on 3/18/25, (R3) told me he felt terrible. He said he was afraid of (R1). He said (R1) was very threatening. He said (R1) hides alcohol and drugs in (R3's) room. (R3) can't tell on him because (R3) is scared of him. On 3/27/25 at 10:20 AM, V2 Assistant Administrator stated, I spoke with (R3). He told me he is afraid of (R1). (R3) said his room is where (R1) hides his drugs and alcohol. (R3) is afraid that if he snitches and tells on (R1), (R1) will have people come and get (R3) and kill him .(R4) came to me and told me (R1) threatened to kill me and my family . Since then, I don't stay home alone . V2 became tearful during the interview. V2 stated, We are all afraid that (R1) is back. We are sitting ducks right now . On 3/27/25 at 1:00 PM, V6 Psychiatric Nurse Practitioner stated he has been treating R1 for a mood disorder but recently also for substance abuse and his threatening behaviors. V6 stated, (R1) doesn't follow the rules. When staff try to enforce the rules, he gets upset and starts threatening staff and residents. It's a big deal. That is why we sent him to the hospital and then he was allowed to come back. He's threatened to hurt staff and residents. I am very concerned about his behaviors. His behaviors are worsening. I am not sure if that's related to his substance abuse or there is something else going on. Staff and residents are fearful of him. He is a risk. His homicidal threats are a big deal. The facility's Abuse Prevention-Program Policy revised 2/26/25 showed, Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment . Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is also the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident . Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation . Mental abuse is also the use of verbal or nonverbal contact which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation . The facility presented an abatement plan to remove the immediacy on 3/31/25. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a second revised abatement plan on 3/31/25. The abatement plan was returned to the facility for revisions. The facility presented a third revised abatement plan on 3/31/25 and the survey team accepted the abatement plan on 3/31/25. The Immediate Jeopardy that began on 3/17/25 was removed on 3/31/25 when the facility took the following actions to remove the immediacy: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145308 If continuation sheet Page 4 of 9 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 145308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River View Rehab Center 50 North Jane Elgin, IL 60123 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 0600 1. On 3/31/25, R1 was placed on 1:1 monitoring. Level of Harm - Immediate jeopardy to resident health or safety 2. On 3/31/25, the police will be called for assistance every time R1 violates community restriction. R1 will be discharged in 10 days per court order. 3. On 3/31/25, an order of protection will be filed on R1, by R2, R3, and R6 pending their consent. Residents Affected - Few 4. On 3/31/25, recent abuse in-services/education will be continued on all newly hired employees and agency nurses. 5. On 3/31/25, the resident admission process was reviewed with the Admissions Director and Social Services and will be implemented per facility guideline. It will ensure that resident background checks are being completed on time. The background checks will also be reviewed to ensure that appropriate interventions are put into place for the safety of all residents. 6. On 3/31/25, it was decided that should a resident become noncompliant with facility protocols and guidelines, the resident will be counseled by staff. If the resident continues to be noncompliant, he/she will be sent out for psychiatric evaluation and will be served a 30-day discharge notice as deemed appropriate. Should he/she become harmful to other residents, he/she will be placed on 1:1 monitoring. V1 Administrator will be responsible for overall compliance to the plan of correction in conjunction with the Social Services Director by making sure that the above plan is being implemented. A QA (quality assurance) will be used to monitor for compliance by checking if the monitoring sheet is followed. The Quality Assurance/Quality Improvement (QAQI) Team meets monthly. The event will also be brought to the next monthly QAQI meeting for discussion and re-evaluation of interventions. If further interventions are needed at that time, they will be implemented accordingly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145308 If continuation sheet Page 5 of 9 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 145308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River View Rehab Center 50 North Jane Elgin, IL 60123 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow their abuse policy by not completing pre-admission screening of residents to ensure resident safety for 6 of 6 residents (R4, R10, R11, R12, R13, R1) reviewed in the sample of 14. Residents Affected - Some The failure has the potential to affect all 179 residents in the facility. The findings include: The Facility Data Sheet form dated 3/27/25 showed a resident census of 179. 1. R4's admission Record showed R4 was admitted to the facility on [DATE]. R4's electronic medical records dated 2/19/25-3/31/25 showed no IDOC (Illinois Department of Corrections), Illinois Sex Offender Registry, or National Sex Offender Registry website checks had been completed on R4. 2. R10's admission Record showed R10 was admitted to the facility on [DATE]. R10's National Sex Offender Registry check was not completed until 3/31/25. 3. R11's admission Record showed R11 was admitted to the facility on [DATE]. R11's electronic medical records dated 3/17/25-3/31/25 showed no IDOC, Illinois Sex Offender Registry, or National Sex Offender Registry website checks had been completed on R11. 4. R12's admission Record showed R12 was admitted to the facility on [DATE]. R12's electronic medical records dated 1/27/25-3/31/25 showed no IDOC, Illinois Sex Offender Registry, or National Sex Offender Registry website checks had been completed on R12. R12's Criminal History Information Response Process (CHIRP) report dated 1/27/25 showed R12 was an identified offender due to his convictions of aggravated battery resulting in great bodily harm, theft, possession of drug paraphernalia, criminal damage to state property, and resisting a peace officer. R12's fingerprint-based criminal history background check was not completed until 2/4/25. 5. R13's admission Record showed R13 was admitted to the facility on [DATE]. R13's National Sex Offender Registry check was not completed until 3/31/25. R13's CHIRP dated 1/8/25 showed R13 was an identified offender due to his convictions of obstructing justice, theft, deceptive practice, resisting a peace officer, and endangering life/health of a child. R13's fingerprint-based criminal history background check was not completed until 2/4/25. On 3/31/25 at 11:00 AM, V1 Administrator stated, A CHIRP should be run on a resident within 24 hours of their admission. If the CHIRP shows the resident is an identified offender, fingerprints should be ordered and done on that resident immediately. V1 Administrator stated all criminal history background checks, for newly admitted residents, are to be completed within 24 hours of a resident's admission. On 3/31/25 at 11:05 AM, V7 Social Services stated the ISP, IDOC, and National Sex Offender Registry website checks had never been completed on R4, R11, or R12. V7 she had just completed the National Sex Offender Registry website checks on R10 and R13 today (3/31/25). 6. R1's admission Record showed R1 was admitted to the facility on [DATE]. R1's, name based, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145308 If continuation sheet Page 6 of 9 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 145308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River View Rehab Center 50 North Jane Elgin, IL 60123 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Criminal History Information Response Process report (CHIRP) dated 9/19/24 showed R1 was an identified offender due to his conviction of attempted armed violence. R1's fingerprint-based criminal history background check was completed on 9/26/24. An email dated 11/18/24 from the State Identified Offenders program showed the program had received all of the required information on R1 to process his criminal analysis security report. The email stated if the facility did not receive R1's security report within 45 days of the email, the facility was to contact the State police. On 3/31/25 at 8:04 AM, V1 Administrator stated the facility had never received the results of R1's criminal analysis security report from November 2024. V1 stated, We don't know if (R1) is a low, medium, or high risk identified offender. I don't think we ever followed up on this. V1 stated it was important for the facility to know the risk level, for any identified offender resident in the facility, so they can initiate an appropriate care plan for the offender and safety interventions for residents as needed. The facility's Resident Background Checks policy dated October 2024 showed, When a resident is admitted to the facility, an electronic name-based background check must be ordered within 24 hours . If the background check response contains convictions that match the Identified Offender offenses, the resident is an identified offender . Once the facility determines the resident is an Identified Offender, the facility must arrange for the resident to undergo a live scan State and FBI (national) fingerprint-based Fee Applicant criminal history check within 72 hours . The facility's Abuse Prevention Program-Policy revised 2/26/25 showed, The residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment . The purpose of this policy and the Abuse Prevention Program is to describe the process for identification, assessment, and protection of residents from abuse, neglect, misappropriation of property, and exploitation. This will be accomplished by: conducting pre-employment screening of employees and pre-admission screening of residents . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145308 If continuation sheet Page 7 of 9 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 145308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River View Rehab Center 50 North Jane Elgin, IL 60123 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 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to initiate discharge planning for 1 of 3 residents (R1) reviewed for discharge planning in the sample of 14. Residents Affected - Few The findings include: R1's admission Record showed R1 was admitted to the facility on [DATE] for rehabilitation therapy services due to his diagnosis of low back pain. R1's current care plan showed R1 was cognitively intact, ambulatory, and needed no staff assistance to complete his activities of daily living. R1's progress and nursing notes dated November 2024-March 2025 were reviewed. These notes showed multiple documented episodes of R1 having alcohol, drugs, and drug paraphernalia in the facility. The notes showed incidents of R1 being verbally aggressive and threatening towards residents and staff. The notes showed incidents of R1 repeatedly disobeying facility rules and leaving the facility despite his community pass privileges being revoked due to his behaviors. They showed multiple incidents of the local police being called to the facility due to R1's behaviors. A note dated 2/6/25 showed the facility served R1 a 30-day discharge notice due to his behaviors and R1 no longer needing skilled nursing cares. R1 appealed his discharge. R1's physician progress note dated 2/26/25 showed, The resident has demonstrated sufficient stability and independence in their current condition, with no ongoing medical needs requiring skilled nursing services. (R1) is now safe and capable of transitioning to the PAD program (program for homeless persons)/shelter. The resident no longer requires the specialized care provided by a skilled nursing facility and is suitable for the next level of care. R1's social service notes dated 2/6/25-3/31/25 were reviewed. These notes showed no documentation of any discharging planning for R1, including no referrals for R1's placement after his discharge or documentation of R1's discharge needs or goals. On 3/27/25 at 8:45 AM, this surveyor attempted to interview R1 in his room. R1 became verbally aggressive towards this surveyor. R1 asked this surveyor to leave his room and surveyor exited R1's room. This surveyor was unable to interview R1 on his discharge plans or goals. On 3/31/25 at 12:03 PM, V4 Social Services stated he was R1's case worker in the facility. V4 stated he had not initiated any discharge planning for R1. V4 stated he had not made any referrals for R1's placement after being discharged from the facility. V4 stated he had not done any discharge planning for R1 because R1 had not expressed any desire to leave. On 3/31/25 at 11:55 AM, V5 Social Services stated had not initiated any discharge planning for R1. V5 stated social services is responsible for discharge planning, however, social services does not begin discharge planning for a resident until we know a discharge plan is in place. On 3/31/25 at 10:24 AM, V7 Social Services stated she had not initiated any discharge planning for R1 because he doesn't want to leave. V7 stated if a resident is issued a 30-day discharge notice, we (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145308 If continuation sheet Page 8 of 9 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 145308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River View Rehab Center 50 North Jane Elgin, IL 60123 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 0660 should help that resident find placement for when he is discharged . Level of Harm - Minimal harm or potential for actual harm The facility's Discharge/Transfer of Resident policy dated November 2018 showed, Purpose: To provide safe departure from the facility. To provide continuity of care and treatment . Procedure: Explain discharge procedure to resident and family . Inform all departments of anticipated and actual discharge . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145308 If continuation sheet Page 9 of 9