Inspection·September 23, 2025

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few including obtaining his vital signs. V5 said R1 was having behaviors and was difficult to manage. V5 said V3 told V5 R1 was not a good fit for the facility so the admission process stopped for R1. V5 said another nurse had already assisted V5 with entering R1's admission orders. On September 22, 2025, at 3:03 PM, V7 (PRSD/Psychiatric Rehabilitation Services Director) said she assisted with monitoring R1 when he returned from the local hospital on the evening of September 8, 2025. V7 said R1 was in the facility for a few hours because V7 stayed after her shift for about two hours to monitor R1 while they waited for an ambulance to take R1 back to the hospital. V7 said when R1 returned to the facility a week later on September 16, 2025, V7 also monitored R1 while they waited for an ambulance to transport R1 back to the original hospital. On September 22, 2025, at 4:13 PM, V6 (RN) said she was R1's nurse when he returned from the local hospital in the evening of September 8, 2025. V6 said R1 came back to the facility but V6 was told they were not readmitting R1 and he was to be sent back to the original hospital. V6 said R1 was still having behaviors and V6 obtained the order from the psychiatrist to have R1 sent back to the hospital. V6 said the ambulance was supposed to take R1 back to the original hospital but the ambulance crew said R1 was too aggressive so they had to take R1 to the local hospital. A progress note dated September 8, 2025, at 12:38 PM, by V5 (RN) showed Resident arrived to the facility from [original hospital] with two EMTs (Emergency Medical Technicians) via stretcher. Resident is alert but disoriented at times to place and time. He uses a wheelchair for mobility due to poor gait and is able to use walker in the room. Resident has a diagnosis of schizophrenia and mild intellectual disability. He was observed talking to himself out loud at time of admission. Upon admission assessment towards resident, resident made a sexual inappropriate comment towards writer. The writer immediately informed the Assistant Administrator. The resident was also observed spitting on the window. Vitals taken 98.2 temperature, 148/87 blood pressure, 99% (percent) pulse oximetry room air, 99 heart rate. Psychiatric nurse practitioner, [Physician] and Nurse Practitioner were informed of new admit. A progress note dated September 8, 2025, at 4:45 PM, by V6 showed Resident arrived back from [local hospital] Emergency Room, via [ambulance company] stretcher. Ordered to be transferred to [original hospital] emergency room for psychiatric per nurse practitioner. Resident refused all assessments stated 'Get out [expletive],' when attempting to ask questions. Arrived from hospital without belongings or clothing on. In room on one to one until transferring back out. Calm and cooperative at this time. A progress note dated September 8, 2025, at 6:50 PM, by V6 showed Resident aggressive towards co residents and staff, yelling, threatening and swinging fists. Told writer 'I will [expletive] you when I get back baby and I'm coming back for you sent [local hospital] emergency room via [ambulance company] on stretcher. [Ambulance company] was unable to take the resident to [original hospital] due to needing to restrain the resident because of aggressive behavior swinging and spitting at ambulance drivers. No signs/symptoms of pain or distress upon leaving, no belongings to send, bed hold not in place, refused vitals and skin assessment. A progress note dated September 8, 2025, at 7:02 PM, by V11 (Restorative Nurse) showed Resident was admitted into facility for a short-period of time. Functional ability assessments was conducted with information gathered from therapist, floor nurse, and CNAs (Certified Nursing Assistants). Upon admission, resident demonstrated significant aggressive behaviors that were challenging to manage. Following a comprehensive evaluation, it was determined that resident required a higher level of care than the facility could provide. Resident was promptly transferred back to the hospital for further assessment and treatment. On September 22, 2025, at 3:56 PM, V1 (Administrator) said the facility should have followed the facility's policy and completed the proper paperwork and documentation for R1's involuntary discharge. The facility does not have documentation to show R1 or R1's representative was issued a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145308 If continuation sheet Page 2 of 4 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 09/23/2025 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 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few notice in writing regarding R1 not being allowed to return to the facility. R1's medical record does not show a physician documented the reason for R1's discharge was due to the safety of others was endangered. The facility's undated policy titled Involuntary Discharge or Transfer showed A. The facility will provide proper procedure and notification of an involuntary transfer or discharge pursuant to the regulations of the Health Care Financing Administration for States and long term care facilities, 42 CFR 483.12 (federal regulations); and State rules and regulations. B. Procedure: Reason For Transfer or discharge: 1. A resident can be transferred or discharged from the facility based on one of the following reasons: a. The resident's welfare cannot be met at the facility. b. The resident's health has improved sufficiently and the resident no longer needs the services provided by the facility. c. The health and/or safety of individuals in the facility are endangered. This would include residents, facility staff, or facility visitors. d. The resident has failed after reasonable and appropriate notice, to pay for a stay at the facility. Notification and Documentation: 2. Residents, family members, surrogate, and representative must be notified of the transfer and the reasons for the transfer. This notice must be provided in writing thirty days prior to transfer or as soon as practicable in a language and manner understood. As soon as practicable would depend on the reason for the transfer which would include the endangerment; urgent medical needs; or the resident has resided in the facility for less than thirty days. The transfer or discharge shall be discussed with the resident, resident's representative, and person or agency responsible for the resident's placement in the facility. The following forms and documentation will be completed: a. The resident's record must include the (1) reason for the transfer/discharge, (2) needs that cannot be met by the facility, steps taken to meet those needs, and needs that can be met by new facility as documented by resident's physician. Documentation in the notice must (1) demonstrate the condition which warrants the transfer, (2) effective discharged /transferred (4) name, mailing address and phone number of the person responsible for supervising the transfer, (5) name, mailing address, email address and phone number of the Office of the State Long Term Care facility Ombudsman and (6) is the person has intellectual/developmental disabilities or serious mental illness, the name, mailing address, email address and phone number of Equip for Equality. b. The resident's physician must document in the record the reason for discharge is either the resident's welfare cannot be met or the resident's health has improved sufficiently; or any physician can document in the resident's record when the safety of other individuals are endangered. c. The explanation and discussion of the transfer or discharge with the resident and his representative shall be summarized in the resident record. d. the Illinois Department of Public Health (IDPH) prescribed form entitled 'Notice of Involuntary Transfer or Discharge and Opportunity for a Hearing' must be completed and given to the resident with a copy placed in the resident record. Additional copies must be sent by registered or certified mail to the Illinois Department of Public Health, the resident's representative, the Illinois Department of Public aid if applicable, State Long Term Care Ombudsman or Equip for Equality. This information must be documented in the record with corresponding notation of the information having been provided to the resident and appropriate individuals/agencies listed above. The notice to IDPH should be addressed to the Regional Health Officer in the region where the facility is located. Reminders: 5. a. All forms/notices must be accurate and complete. b. Copies of all forms/notices must be placed in the resident record and sent to the appropriate agencies c. The resident's record must include descriptive ongoing documentation to demonstrate the need for transfer/discharge. d. The resident record should include descriptive documentation of all actions taken with dates and times. The record should include all attempts to assist the resident in the transfer/discharge. e. The resident's record should include all attempts (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145308 If continuation sheet Page 3 of 4 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 09/23/2025 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 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete made through care planning or other means to assess the resident's needs prior to issuing a thirty day notice. f. The IDPH prescribed form titled 'Notice of Involuntary Transfer or Discharge and Opportunity for a Hearing' includes the required information identifying the Long Term Care Ombudsman and agency responsible for the protection and advocacy of the developmentally disabled or mentally ill. This information needs to be explained at the time of issuing the thirty day notice with corresponding documentation in the resident's record. g. The resident should be offered counseling services with the corresponding documentation placed in the record. f. The facility shall assist the resident in the arranging alternative living arrangements. All assistance will be documented in the resident record. Event ID: Facility ID: 145308 If continuation sheet Page 4 of 4