Inspection·April 20, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 04/18/23 at 10:46 AM, V9 stated she assessed R53 as not being able to physically leave the facility on the Exit Seeking/Wandering Screeners because he does not attempt to exit seek or leave the facility. V9 stated she did not read question #1 as asking if he was only physically able to leave the facility but asking if R53 was seeking exits. V9 stated R53 was not at risk for elopement because he did not exit seek. V9 stated if the residents were assessed on the Exit Seeking/Wandering Screeners as being at risk for elopement, the residents would have their pictures placed in a binder at the front door and other elopement-preventative interventions would be implemented. On 04/19/23 at 10:56 AM, V9 stated she spoke with her consultant who clarified any residents able to physically walk should be assessed as yes on the Exit Seeking/Wandering Screeners. V9 stated she re-assessed all ambulatory residents and identified R53 as well as R6, R30, R57 and R58 as being able to physical leave the facility. V9 stated although the residents were marked yes on two or more of the Screener questions, she did not assess those residents as at risk for elopement or place the residents' information/pictures in the front desk elopement book because the residents had not sought exits and had not yet attempted to elope. Review of R53, R6, R30, R57 and R58's Exit Seeking/Wandering Screeners, all dated 4/19/23, all show the residents were identified as having scored 2 or more on the assessment and therefore were assessed as being at risk for exit seeking. The Screeners show, A score of 2 or greater indicates increased risk for Exit Seeking. On 04/19/23 at 1:16 PM, V2 (Director of Nursing) reviewed the Exit Seeking/Wandering Screeners of R53, R6, R30, R57 and R58 and stated all of the residents were identified by the Screeners as being at risk for Exit Seeking. However, V2 stated the residents were not at risk for elopement because they were not exit seeking and had not already attempted to elope. V2 stated there were no residents identified at elopement risk at the time and no resident's information was located in the elopement risk binders at the facility. After review of the facility policy, V2 stated the five residents should have interventions implemented to prevent elopement from the facility. On 4/19/23 at 1:23 PM V2 stated the five residents re-assessed as being at risk for elopement by the 4/19/23 Exit Seeking/Wandering Screeners (R53, R6, R30, R57 and R58) were all being fitted for wander guards and their information was being placed in the elopement risk book at the front desk and nursing stations per facility policy. Facility policy Wandering Resident / Elopement, revised 10/2011, shows, The facility will properly assess residents and plan their care to prevent accidents related to wandering behavior or elopement Each resident's level of supervision required will be assessed based on observed wandering behaviors. This information will be documented in the resident's medical record and used in the care planning process If a resident is identified at risk for elopement, the following steps will be taken: a. An alarm bracelet may be placed on the resident to audibly alert staff of attempts by the resident to exit, in facilities with this capability c. An ID bracelet containing the facility address and phone number may be placed on the resident for ease of identification should elopement occur. D. A current picture of the resident will be maintained in the facility 2. On 4/19/22 at 3:13 PM, R58 was standing close the front door exit watching two facility employees working. Face sheet, dated 4/19/23, shows R58's diagnoses included Alzheimer's disease, dementia, and a history of falling. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145447 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 145447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Fox River 355 Raymond Street Elgin, IL 60120 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 MDS, dated [DATE] and 2/24/23, shows R58's cognition was severely compromised and R58 had not exhibited any wandering behavior. Exit Seeking/Wandering Screener, dated 2/22/23, shows R58 was assessed as not being physically able to leave the building on her own and therefore was not at risk for Exit Seeking. Residents Affected - Some Nursing note, dated 4/5/23, shows R58 required constant redirection and reorientation but to no avail. R58 was very argumentative with staff and other residents, was going in other residents' rooms and rummaging in their belongings, and was upset when redirected. Nursing note, dated 3/21/23, shows V9 spoke with R58's family to discuss placement of R58 on the secure special care wing due to her behaviors. Exit Seeking/Wandering Screener, dated 4/19/23, shows R58 was physically able to leave the building on her own, had impaired decision making, had a history of wandering, and was experiencing wandering behaviors at the time of the assessment. Care plan, updated 4/19/23, shows I am ambulatory but I do not actively seek the exit and I am not an elopement risk. Intervention, dated 2/24/23, shows, Redirect me when wandering in other residents rooms . If unable to redirect me, refer me to social services. 3. Face sheet, dated 4/19/23, shows R57's diagnoses included Alzheimer's disease and dementia. Exit Seeking / Wandering Screener, dated 11/18/22 and 2/21/23, both show R57 was assessed as not physically able to leave the building on her own and therefore not at increased risk for exit seeking. Care plan, initiated 2/23/23, shows R57 was observed wandering in other residents rooms but did not seek out the exit and did not intend on leaving the facility. The care plan shows R57 was placed on the secure special care wing of the facility. Social Services notes, dated 11/22/22 and 2/21/23, shows R57's cognition was severely impaired and R57 was ambulatory with no assistive device. Exit Seeking / Wandering Screener, dated 4/19/23, shows R57 was reassessed and identified as able to physically leave the building on her own, having impaired decision making, having a history of wandering, and having a current behavior of wandering. The Screener shows R57 was at increased risk for exit seeking. 4. Face sheet, dated 4/19/23, shows R30's diagnoses included dementia. MDS assessments, dated 11/17/22, 12/20/22, and 3/22/23, all show R30's cognition was severely impaired and R30 was not assessed as having wandering behaviors. Care plan, initiated 3/22/23, shows R30 was observed to be wandering in other residents' rooms but did not seek the exit door and was not intending to leave the facility. Social Service Notes, dated 12/19/22 and 3/21/23, show R30 was observed to continuously wander in and out of resident rooms but was easily redirected. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145447 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 145447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Fox River 355 Raymond Street Elgin, IL 60120 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 Exit Seeking/ Wandering Screeners dated 12/19/22 and 3/21/23, both show R30 was assessed as being unable to physically leave the building on her own and therefore was not at risk for Exit Seeking. Exit Seeking/Wandering Screener, dated 4/19/23, shows R30 was assessed as being able to physically leave the building on her own and was at risk for Exit Seeking. Residents Affected - Some 5. Face sheet, dated 43/19/23, shows R6's diagnoses included dementia. MDS assessments, dated 9/9/22, 12/6/22 and 3/10/23, all show R6's cognition was severely impaired and R6 was not assessed as having wandering behaviors. Care plan, initiated 3/10/23, shows R6 was observed wandering in and out of resident rooms but did not seek the exit door and had no intention of leaving the facility. Social Services note, dated 3/9/23, shows R6 was frequently observed wandering in other resident's rooms but was easily redirected. Exit Seeking / Wandering Screeners, dated 12/5/22 and 3/9/23, show R6 was assessed as not being physically able to leave the building on her own and therefore was not at risk for Exit Seeking. Exit Seeking / Wandering Screener, dated 4/19/23, shows R6 was able to physically leave the building on her own and was at risk for Exit Seeking. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145447 If continuation sheet Page 4 of 4