Inspection·May 17, 2024

F 0558 left footrest attached. Level of Harm - Minimal harm or potential for actual harm On 05/16/2024 at 8:30 AM, V6 (Physical Therapy Director) said wheelchairs are provided to the residents based on their height and weight, to ensure the wheelchairs are not too narrow, too low, or too wide. V6 said he was familiar with R49. V6 continued to say R49 was tall and would benefit from a high back tilt wheelchair for proper positioning, and a toilet riser to assist him during toileting transfers based on his height. V6 said he was also familiar with R41, and based on her small body frame size she would benefit from a [NAME] tilt-back wheelchair for positioning and comfort. V6 continued to say footrest should be provided to maintain proper positioning, and also cushions and pillows can be provided for comfort when sitting up in a wheelchair. Residents Affected - Few The facility's document titled Wheelchair Measurement dated 02/2009 showed Following are some guidelines on measuring the parameters when prescribing a wheelchair. Seat Width .measurement should be as narrow as possible to ensure optimal access .Back Height .back height for an individual will vary according to their physical attributes .Consider: Client skills eg balance, Client posture .Seat To Footplate Distance .Consider: Adequate thigh support to ensure optimal seating pressure distribution. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145447 If continuation sheet Page 2 of 14 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 05/17/2024 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 assist residents needing assistance with eating during meal service. This applies to 2 of 5 residents (R40 and R44) reviewed for activities of daily living when eating in a sample of 21. Residents Affected - Few The findings include: 1. According to the Electronic Health Record (EHR) R44 has diagnoses including hypertensive heart disease, dementia, Alzheimer's Disease, gastro-esophageal reflux disease, and diabetes. The Minimum Data Set (MDS) dated [DATE] showed R44's cognition was severely impaired and was dependent on staff for eating, which means helper does ALL of the effort. A Care Plan dated 04/30/2024 shows staff provides R44 with extensive assistance with eating. The care plan was updated on 05/14/2024, after observations of resident eating with fingers, to include Resident has been observed to be eating with her hands despite staff's encouragement and health teachings to use the utensils. On 05/14/24 at 12:26 PM, R44 was sitting in the dining room during lunch and was eating pork tips in gravy, egg noodles, steamed vegetables. with the fingers of their right hand. Eating utensils were sitting on the table off to R44's right side. R44 was not wearing a clothing protector. V19 (Certified Nursing Assistant/CNA) was seated at the table across from R44 feeding a resident another resident. Nobody offered assistance or reminders to R44 to use utensils. As R44 was eating, R44 would wipe R44's hands on the front of the shirt, at the shirt hemline, and on the pants. R44 had food particles on front of shirt and at hemline in front of shirt. On 05/14/24 at 1:16 PM, V19 (CNA) said R44 can eat by herself with utensils, but sometimes will get confused and not use them. On 05/15/24 at 12:09 PM, R44 was eating lunch independently using utensils but was also using their left fingers to scoop mashed potatoes off plate. V15 (CNA) was sitting at the same table feeding another resident but did not offer prompts or reminders to use utensils. On 05/15/24 at 12:35 PM, V20 (Activity Aide) said R44 can eat independently but will give R44 directions because R44 can be forgetful. 2. R40 was admitted to facility on 9/8/2020. Diagnoses includes sequelae of cerebral infarction, dysphagia, right hemiplegia and hemiparesis, aphasia, and vascular dementia. R40's MDS (Minimum Data Set) assessment dated [DATE] documents that R40's cognitive function is severely impaired. R40 needs supervision or touching assistance during meals. It is also documented in the MDS that R40 does not exhibit rejection of care. R40's ADL (Activity of Daily Living) care plan dated 3/1/2024 showed interventions of assist with all my ADLs and provide me supervision while I am eating. R40's Progress Notes reviewed from January 2024 to present, no documentation of R40 refusing care during meals noted. On 5/14/2024 at 12:05 PM, R40 was in the dining room for lunch. She had a right-hand splint, and her right hand and arm was resting on an arm trough. R40 was observed eating with left hand, she was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145447 If continuation sheet Page 3 of 14 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 05/17/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few having a hard time and was spilling food on herself. R40 was observed eating pasta with her left hand and using her tongue to scoop the fruit out from a bowl. Food particles was noted on her clothing protector. No staff supervision or assistance was observed during meal. On 5/15/2024 at 8:04 AM, R40 was eating breakfast. R40 was observed scooping oatmeal from the bowl with her tongue. Her silverware was still wrapped around the napkin on the left side of her plate. A whole egg was noted on her clothing protector. No staff assistance or supervision noted during meal. On 5/16/2024 at 8:17 AM, R40 was observed licking the bowl to get the oatmeal out. Her silverware was still wrapped around the napkin on the left side of her plate. Food particles observed all over her clothes. No staff observed assisting or supervising her. On 05/16/24 at 09:54 AM, V8 (Rehab Aide) said R40 only needs set-up help with eating, she said she can eat with one hand. She has a splint on her right hand and eats with her left hand. She said if resident spills her food, they make sure they clean her up after meals and help her when she is dropping food or not eating. On 05/16/24 at 10:06 AM, V9 (LPN-Licensed Practical Nurse) said R40 needs supervision with eating. She said occasionally, R40 needed assistance with eating. On 05/16/24 at 10:37 AM V5 (Restorative Nurse) said R40 feeds self. She said R40 needs set-up and supervision during meals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145447 If continuation sheet Page 4 of 14 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 05/17/2024 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The Electronic Health Record (EHR) shows R35 has diagnoses including hypertensive heart and chronic kidney disease, acute on chronic combined systolic and diastolic congestive heart failure, atrial fibrillation, hypothyroidism, diabetes, morbid obesity, cardiomyopathy, atherosclerosis of coronary artery bypass graft, non-ST elevation myocardial infarction, and presence of cardiac pacemaker. Residents Affected - Few The admission Minimum Data Set (MDS) dated [DATE] showed R35's cognition was moderately impaired and was dependent on staff for rolling in bed, moving from lying to sitting and sitting to stand, and dependent on staff for movement in the wheelchair. The MDS also showed R35 had a cardiac pacemaker and automatic implantable cardiac defibrillator. A Care Plan shows R35 had a cardiac pacemaker with a transmitter at the bedside which reads information from the implanted pacemaker and sends it to a server where the cardiology clinic will call this facility on what to do based on the information transmitted. Interventions include all staff are aware of the transmitter at the bedside. An Electrophysiology Progress Note dated 02/16/2024, written by V21 (Medical Doctor/MD Electrophysiologist) showed R35 was post biventricular ICD (Implantable Cardioverter Defibrillator) implantation and has had episodes of non-sustained atrial as well as ventricular tachycardia. The note showed R35 has had episodes of splenic rupture as well as gastrointestinal bleed making him a candidate for a [NAME] implantation to be scheduled in March. On 05/14/2024 at 4:09 PM, R35 said his cardiac output monitor-transmitter was not working. R35 said the pacemaker should have a full interrogation every three months to check for issues. R35 said he can't call the cardiology clinic because he didn't have a working phone currently. On 05/15/2024 at 2:27 PM, V14 (Certified Nursing Assistant/CNA) said R35 had a pacemaker but did not know what or if she should do anything and would talk to the nurse (V10). On 05/15/2024 at 2:31 PM, V10 (Licensed Practical Nurse/LPN) said the only person with a pacemaker on the unit is R225. V10 said this resident had a transmitter on the bedside table and thought the machine would light up if there was a problem, then V10 would call the phone number listed on the machine. V10 said I am not aware of R35 having a pacemaker. V10 said (V17) MDS coordinator would probably know about R35's pacemaker. On 05/15/2024 at 2:43 PM, V17 (Registered Nurse/RN MDS Coordinator) said R35 had a pacemaker and has a transmitter at the bedside. V17 said R35's transmitter does continuous monitoring to the cardiology office and the cardiology office will call the facility if there was a problem and tell us what to do. V17 with this writer present, looked in R35's room, closet, drawers and could not find transmitter. Later V17 and V4 (RN) said they found R35's transmitter and plugged it in. On 05/15/2024 at 3:57 PM, V18 (Device Tech -Pacemaker Clinic) explained the whole monitor was a transmitting station. If there was an alert of a adverse cardiac event based on the parameters entered, an alert will be triggered to the website. V18 said as long as the transmitter is plugged in, it is paired to the implanted pacemaker and will send a transmittal every 24 hours ONLY if there was an alert. V18 said the transmitter device was set to download a full interrogation every 91 days as long as the machine does not get unplugged. The transmitter device will pair to the pacemaker by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145447 If continuation sheet Page 5 of 14 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 05/17/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few plugging in and pressing the start button to pair. V18 said if the machine is unplugged for longer than 30 days, they will receive a notification the transmitter had lost contact with the pacemaker device. V18 said the transmitter must have been unplugged since 02/28/2024 because a notification was received on 03/29/2024 the transmitter has lost contact with the device. When this happens, the clinic would have tried to make contact with R35 to find out if there were issues. R35's transmitter had not paired with the pacemaker device until a short time ago today. Potential problems to not having the transmitter plugged in and paired would be the clinic would not be notified of a cardiac event in real time. Some possible symptoms would depend on what type of event R35 had but could include shortness of breath, lightheadedness, and passing out. V18 said if the clinic had received an event notification, they would call R35 directly to ask questions about what R35 was doing and how he was feeling. If the clinic could not reach R35 for any reason, including if R35's phone was not working or lost, the clinic would call the facility as long as the clinic knew what facility R35 was at. V18 said the last known contact address for R35 was that of the former nursing facility. V18 said when R35 was last in the clinic he did not have a permanent address to update and had also said there was not always have a place to keep the transmitter plugged in. V18 said it would be important to have this information, especially now because this pacemaker clinic offices will be closing 07/31/2024 and the patients will need to find a news electrophysiologist office by 06/15/2024. V18 said V21 (MD/Electrophysiologist) manages the pacemaker clinic. On 05/16/2024 at 8:36 AM, V2 (Director of Nursing/DON) presented a copy of R35's pacemaker care plan showing R35 had a pacemaker transmitter at the bedside which sends the information to the cardiology clinic. V2 said she had called corporate about a facility policy regarding pacemaker care but has not received one. V2 said R35 has a scheduled appointment with cardiology on 07/14/2024. No orders were seen in the Physician Orders provided by V2 regarding R35's cardiology appointment. A Progress Note dated 05/16/2024 at 8:58 AM, written by V4 (RN) showed she spoke to the facility today and noted the next scheduled appointment of 07/11/2024. This note was written after an interview with V2 (DON) at 8:36 AM. On 05/16/2024 at 11:54 AM, V21 (CNA) said he has worked in the facility for 15 years. V21 said he does care for R35 and had just found out yesterday R35 had a pacemaker. V21 said he did not know of anything he would need to do differently when caring for R35. 2. R5's facesheet showed she was admitted to the facility on [DATE] and R5's MDS Assessment of May 1, 2024 documents that R5 has moderate cognitive impairment and needs minimum assistance with all ADLs (activities of daily living). R5's MDS (Minimum Data Set) dated 5/1/24 showed, she had moderate cognitive impairment and needed minimum assistance for ADLs. R5 was observed on May 14, 2024 at 11:30AM with maroon-red papules on the dorsum of the right foot and the right calf area. R5 stated she has been getting these papules for the past few weeks. R5 added that she notified the nursing staff but could not recall the specific person. On 5/15/24 at 10:00 AM, Observed maroon-red papules on the dorsum of the right foot and on the right calf area. V13 (CNA-Certified Nursing Assistant) witnessed the observation and stated that she did not know anything about it till now. V13 stated she had provided care to R5 on 5/12/24, 5/13/24 and 5/15/24 during the 7AM to 3PM shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145447 If continuation sheet Page 6 of 14 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 05/17/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm On 5/15/24 at 10:15 AM, V16 (LPN-Licensed Practical Nurse) stated, she did not know about R5 having any rash. On 5/15/24 at 10:20 AM, V23 (WCN-Wound Care Nurse) stated she did not know anything about R5 having any rash. Residents Affected - Few The Progress Notes for R5 did not show any nursing assessment or documentation of the papules. R5's Care-Plan dated 5/1/24 did not address the papules on the right foot and calf area. R5's POS (Physician Order Sheet) for May 2024 did not include any treatment orders for the papules on the right foot and calf area. Policy on 'pressure injury and skin condition assessment' revised on 1/17/2018 showed, 2. Residents will have weekly skin assessment by a licensed nurse. 4. Each resident will be observed for skin breakdown daily and on the assigned bath day by the CNA. Based on observation, interview, and record review, the facility failed to evaluate and treat residents with skin conditions. The facility also failed to ensure a resident with an implanted pacemaker had the pacemaker transmitter functioning at the bedside and failed to ensure all staff were aware of the residents who had a pacemaker. This applies to 3 of 3 residents (R44, R5, R35) reviewed for quality of care in a sample of 21. The findings include: 1. R44's face sheet showed R44 was admitted to the facility on [DATE] with diagnoses including hypertensive heart disease, type 2 diabetes mellitus, congestive heart failure, dementia, gastro-esophageal reflux disease, anemia, osteoarthritis, and Alzheimer's disease. R44's MDS (Minimum Data Set) Assessment showed R44 had severe cognitive impairment. R44's POS (Physician Order Sheet) showed an order on May 15, 2024 (during the survey) for Triamcinolone 0.1% ointment apply to bilateral arms and back twice daily for 10 days. The POS also showed an order for skin check every shift high risk for skin breakdown document weekly and as needed every shift. R44's care plan revised on April 30, 2024 showed Recurrent rash to arms and back will be resolved in 2 weeks. Staff check skin [Every] shift high risk for skin breakdown [Document] weekly and [As Needed]. On May 15, 2024 at 12:21 PM, R44 was observed to have scattered red marks on both of her arms. R44 was itching both her arms and there were reddened areas, pink areas, open areas, and scabbed areas visible on bilateral arms. At 12:28 PM, R44 was still itching her arms. On May 15, 2024 at 02:03 PM, R44 was itching her arms while lying in bed. R44 said she was itching her arms and it was awful. R44 said it hurt her when she scratched her arms, and it was bad. On May 15, 2024 at 02:12 PM, V10 (CNA/Certified Nurse Assistant) and V31 (CNA) provided incontinence care to R44. When R44's posterior skin was observed during incontinence care, R44 had redness and scratch marks behind her left knee. When V10 was asked what happened to R44's knee, V10 said it was a rash and the staff were putting ointment on the back of her knee. V10 said she had seen the rash before, and it was the same rash she had on her arms. On May 16, 2024 at 10:49 AM, R44's skin was observed with V19 (CNA). R44 had redness, open, and scabbed areas over the arms, upper back, right lower leg, left knee, as well as scattered rashes across the chest and stomach. V19, V8 (Restorative Aide), and V24 (Restorative Aide) said they had not seen those rashes and if they had, they would have notified the nurse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145447 If continuation sheet Page 7 of 14 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 05/17/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On May 15, 2024 at 02:56 PM, V9 (LPN/Licensed Practical Nurse) said R44 had a rash on her bilateral arms and a portion of her upper back. V9 said the CNAs should be doing skin checks every shift. On May 16, 2024 at 11:07 AM, V9 said she had only checked R44's arms. On May 16, 2024 at 11:18 AM, V25 (RN/Registered Nurse) said she assessed R44 and saw the redness on her arms and upper back. V25 said she did not see any other areas of redness. V25 said she did the treatment only on R44's upper back and arms. V25 said the CNAs should do skin checks during incontinence care, every shift, and during showers, and they needed to chart any abnormalities in the EMR (Electronic Medical Record). V25 said she did not notice any skin abnormalities behind R44's knee and it was only on the arms. On May 16, 2024 at 11:34 AM, V2 (DON/Director of Nursing) said the CNAs should be checking the resident's entire body and notifying the nurse of any abnormalities. V2 said the staff's charting should match what the staff are seeing. The progress note dated May 15, 2024 at 01:14 PM showed the following, Observed with some rash on bilateral arms and upper back. [Medical Doctor] informed with new order for Triamcinolone 0.1% ointment apply to both arms and back [Twice Daily] for 10 days. The Weekly Skin Observations dated May 15, 2024 at 07:18 PM, the document showed the section skin problems checked off showing the skin was intact and comments showing Noted recurrent rash to arms and back. The EMR (Electronic Medical Record) showed the Documentation Survey Report for May 2024 showed no skin abnormalities documented for the month of May 2024. The facility's Pressure Injury and Skin Condition Assessment revised on January 17, 2018 showed Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA. Changes shall be promptly reported to the charge nurse who will perform the detailed assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145447 If continuation sheet Page 8 of 14 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 05/17/2024 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 Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess a dependent resident's transferring status, failed to safely use a transfer device, and safely assist residents with positioning when in wheelchairs. This applies to 4 of 4 (R41, R49, R57, and R275) residents reviewed for accidents and hazards in sample of 21. Findings include: 1. The EMR (Electronic Medical Record) showed R41 had multiple diagnoses including hemiplegia affecting the right side following a cerebral infarction, osteoporosis, seizures, and generalized osteoarthritis. R41's MDS (Minimum Data Set) dated 05/01/2024 showed she was severely cognitively impaired and was dependent on staff for transfers and bed mobility. On 05/14/2024 at 9:40 AM, R41 was in the unit's common area sitting in her high-back wheelchair which only had the left footrest attached. R41 was leaning on the right side of the wheelchair resting her head on the right side handrest and R41's feet were resting on the left footrest. R41 appeared fatigued and uncomfortable in her sitting position, R41 requested to go to bed. V11 (Certified Nurse Assistant/CNA) and V12 (CNA) used the mechanical sit-to-stand lift to transfer R41 to the bed. R41 said she could not use the machine because her right hand was not working. They proceeded to assist R41 by placing and securing the machine's belt around her waist area and attaching it to the machine's hooks, then placing her feet on the machine's foot plate, and placing her left hand on the machine's left handle. When the machine started to lift R41 in a standing position R41 said she was hurting. Then when R41 was placed in a sitting position on the edge of the bed, V11 had to assist her by placing her hands over R41's back area to provide physical trunk support. On 05/15/2024 at 11:45 PM, R41 was in the dining room. R41 was again observed in her wheelchair resting her head on and off the handrails and only the left side footrest attached. On 5/15/2024 at 3:53 PM, V5 (Restorative Nurse) said she assessed residents for transfers. V5 said residents who are not able to hold on to the mechanical sit-to-stand lift's handles should not use the machine. V5 said she uses the facility's Transfer Assessment Tool when determining the use of the mechanical sit-to-stand lift. R41's care plan reviewed on 05/17/2024 showed R41 was at risk for injuries related to decreased safety awareness, history of an injury to the head due to poor trunk positioning on 11/11/2023, impaired cognitive skills, poor steadiness, and needed assistance with activities of daily living. The care plan had multiple interventions including Assess me for any environmental safety, fall risk, and review interventions. R41's Restorative Observations-SSL assessment dated [DATE] showed R41 was alert and responsive with confusion had limited mobility on her right upper extremity and requires two staff total assistance with the use of a mechanical sit-to-stand lift for transfers. The facility's document titled Transfer Assessment Tool with a revised date of 02/07/2003 showed Does the resident have independent sitting balance while sitting at the edge of the bed? No The resident can be designated as a full size mechanical or Hoyer lift transfer .Special Considerations: .If (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145447 If continuation sheet Page 9 of 14 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 05/17/2024 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 Residents Affected - Some the resident cannot follow commands and needs greater than 25 lbs. assistance from the caregiver for transfers, the resident may be more appropriate for a full size total lift transfer as deemed by the transfer status designator. 2. The EMR showed R49 had multiple diagnoses including weakness, difficulty in walking, unsteadiness on feet, generalized osteoarthritis, history of falls, and vascular dementia. R49's MDS 05/06/2024 showed he was severely cognitively impaired and required substantial to maximal assistance from staff for transfers. On 05/14/2024 at 10:03 AM, R49 was in his room sitting in his wheelchair. R49 appeared uncomfortable he was sitting on his wheelchair cushion which was not positioned properly over the seat of his wheelchair, it was positioned halfway off the seat. R49's legs were also awkwardly positioned; his knees were raised not at level with his hips. R49 was attempting to place his feet on the wheelchair's footrest and maintain his knees in a flexed sitting position but was unable, R49's legs started to extend forward causing his feet to fall off the footrests. R49 started to fidget in his wheelchair and requested to go to the bathroom. V10 (CNA) and V13 (CNA) used the mechanical sit-to-stand lift to transfer R49 onto the toilet seat. They placed and secured the machine's belt around his waist area and attached it to the machine's hooks, then placed his feet on the machine's foot plate not using the shin support strap, and assisted him by placing his hands on the machine's handles. When R49 was lowered into a sitting position on the toilet seat he appeared uncomfortable because the toilet seat was too low. R49 became frustrated and said he was hurting, and then V10 and V13 attempted to assist R49 off the toilet seat with the mechanical sit-to-stand lift. When they started to raise R49 with the lift his feet were not fully placed on top of the foot support plate and the shin support strap was not applied. R49 said it was too hard for him and became upset, R49 started to bend his knees positioning himself in a squatting position. On 05/15/2024 at 11:54 AM, R49 was in the unit's common area sitting in his wheelchair. R49 was in a slouched position sliding off the wheelchair's seat. V14 (CNA) and V16 (Licensed Practical Nurse/PN) each pulled underneath R49's armpit area to position him but R49 continued to slide down. Then V11 (CNA) came to assist them, V14 and V11 again each pulled underneath R49's armpit area and gripped and pulled on his pants while V16 held his legs. On 5/15/2024 at 2:56 PM, V7 (Restorative Aide) said when the mechanical sit-to-stand lift is being used the staff need to ensure the resident's feet are fully placed on the footplate and use the shin strap to keep the legs positioned inside and prevent an accident from occurring. On 5/15/2024 at 3:53 PM, V5 (Restorative Nurse) said staff should not use the residents' pants or pull underneath their arms when positioning, it is uncomfortable and may cause an injury to the resident. The facility provided the Lift & Stand Operator's Manual not dated which showed Instruction Lifting patients can be challenging and delicate work. It demands your utmost attention, skill, and care. This manual will show you how to use the Lift and Stand to make lifting easier and safer. It is important that you use the proper lifting and transfer procedures. Learning the proper technique for smooth, efficient lifts and transfers will help maximize the safety and comfort of staff and residents . Stand Lift .Because the Stand was designed as an assistive device, it requires more advanced motor skills than a traditional lift such as our mechanical Lift. It is important to first determine the appropriateness of this piece of equipment for any patient. The Stand lift is intended for resident's who are semi weight-bearing and require some lifting to perform the activities of daily living (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145447 If continuation sheet Page 10 of 14 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 05/17/2024 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 Residents Affected - Some .Stand Operations Positioning Stand 1 .have the resident place their feet on the foot support plate, (assist the resident if necessary) with their shins against the shin support. The facility's policy titled Sit to Stand Procedure not dated showed Positioning the Stand .4. Have the resident place his/her feet on the foot support plate (assist the resident if necessary) with their shins against the shin support. The heels of the resident's feet should be at the front edge of the foot support plate. The facility's policy titled Transfers-Manual Gait Belt and Mechanical Lifts with a revision date of 01/19/2018 showed Purpose: In order to protect the safety and well-being of the Staff and Residents, and to promote quality care, this facility will use Mechanical lifting devices for the lifting and movement of Residents .Guidelines: .5. The transferring needs of residents will be assessed on an ongoing basis .6. Resident transferring and lifting needs shall be documented in care plans and reviewed via care plan time frame and as needed. 7. Assessment of the resident's transferring needs shall include: a. Mobility status b. Weight bearing ability c. Cognitive status. 3. The EMR showed R275 had multiple diagnoses including seizures, generalized osteoarthritis, and dementia. R275's MDS dated [DATE] showed she was severely cognitively impaired and dependent on staff with mobility and activities of daily living. On 05/14/2024 at 11:28 AM, R275 was sitting in her high-back wheelchair and was being transported to the dining room. R275 was observed slouching down and leaning on her right side not positioned appropriately in a sitting position. R275's care plan was reviewed on 05/17/2024 and showed R275 was at risk for falls and injuries. The care plan had multiple interventions including assess me for any environmental safety, fall risk and review interventions and staff will assist me with all my ADLs. 4. The EMR showed R57 had multiple diagnoses including weakness, seizures, arthropathy, generalized osteoarthritis, and malignant neoplasm of the cerebellum. R57's MDS dated [DATE] showed she was severely cognitively impaired and required substantial to maximal staff assistance with mobility and activities of daily living. On 5/14/2024 at 11:19 AM, R57 was in the common unit area sitting in her wheelchair. R57 was observed slouched down not positioned appropriately in a sitting position. V10 (CNA) told R47 it was time for lunch and proceeded to reposition her. V10 stood behind R57 to position her, and V10 gripped and pulled onto R57's pants. On 5/16/2024 at 8:30 AM V6 (Physical Therapy Director) said residents should be seated fully back when in their wheelchairs and should have both footrests in place for proper positioning. V6 said staff can consider using a non-skid pad between the wheelchair's seat and the cushion to prevent sliding. V6 said residents who scoot down in their chairs should be cued to assist with repositioning or staff can use a pad or cushion to assist with repositioning. V6 said staff should never pull underneath the resident's arms for position because there is a risk for injury. V6 continued to say some residents with deficits can use the mechanical sit-to-stand lift for transfers but if they are unable to grip on the handles they should not. V6 said residents' feet should be fully placed on the machine's platform and the shin strap should be used as an extra precaution for residents that are weaker or fatigued to ensure safety during transfers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145447 If continuation sheet Page 11 of 14 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 05/17/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm . Residents Affected - Few Based on Observation, Interview and Record Review the facility failed to ensure the resident received respiratory care and services that is in accordance with professional standards of practice for 2 of 2 residents (R7 and R16) reviewed for oxygen therapy in the sample of 21. Findings include: 1. On 5/14/24 at 9:30 AM, observed R7 sitting in the activity room, using oxygen via nasal cannula at 2 lpm (liters per minute) from an oxygen cylinder. Observed oxygen cylinder was empty. On 5/14/24 at 10:45 AM, V12 (CNA- Certified Nursing Assistant) took R7 to the toilet along with the same empty oxygen cylinder. V12 stated, oxygen cylinder was empty. 2. On 5/14/24 at 10:15 AM, observed R16's CPAP (Continuous Positive Airway Pressure) mask is not in use and is lying on his bed next to his pillow and is not contained in a bag. R16 is using oxygen via nasal cannula. On 5/15/24 at 10:10 AM, the CPAP mask is on the bed next to his right hand and is not contained in a bag. R16 is using oxygen via nasal cannula. On 5/15/24 at 11:00 AM, the CPAP mask is on the floor and is not contained in a bag. R16 is using oxygen via nasal cannula. On 5/15/24 at 2:30 PM, the CPAP mask is on the bedside table, not contained in a bag. R16 is using oxygen via nasal cannula. On 5/16/24 at 11:10 AM, the CPAP mask is on the floor. V4 (IP-Infection Preventionist) witnessed the mask on the floor. She said that the CPAP mask must be contained in a bag when not in use to prevent dust collection and potential problem of respiratory infection. On 5/16/24 at 2:00 PM, facility could not provide a policy for oxygen use. R16's POS (Physician's Order Sheet) for May 2024 showed, R16 may use oxygen at 2 lpm continuously. The POS also showed, May use CPAP by mask - on at HS (bedtime) and off in the morning. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145447 If continuation sheet Page 12 of 14 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 05/17/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review the facility failed to properly label, date, seal, and store food items in the kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Longterm-Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 5/14/24 documents that the total census was 73 residents. On 5/16/24 at 12:14 AM, V2 (DON-Director of Nursing) stated, there are zero NPO (Nothing by Mouth) residents that do not eat from the facility kitchen. On 5/14/24 starting at 8:35 AM, the facility kitchen was toured in the presence of V26 (Dietary Manager) and the following was found: In the walk-in freezer: 2 boxes of beef liver 10 pounds each with a receiving date of 2/28/2020 and no expiration date. V26 (Dietary Manager) & V29 (Cook) stated, those beef [NAME] are expired. In the 'Dry Storage Room': 1. A 32 ounce can of Pumpkin pulp dated as 'best by [DATE]'. 2. One bag of 32 ounce of slivered almonds with a received date of 12/28/22 and an expiry date 9/6/23. In the kitchen cooler: 1. Opened bag of 'Shredded Mozarella Cheese', with date of opening as 4/11/24. V28 (Cook) stated, once opened, cheese can be used for 5 days. V28 (Cook) and V26 (Dietary Manager) stated, that bag of cheese was expired. 2. Opened Bag of shredded cheddar cheese with date of opening as 5/7/24. V28 (Cook) and V26 (Dietary Manager) stated, that bag of cheese was expired on 5/12/24. 3. A slab of leftover meat - Buffet Ham - with date of 5/10/24. V28 (Cook) stated, leftover meat is good for 3 days and that it is expired as of today. On 5/14/24 at 10:00 AM, V26 (Dietary Manager) said all expired items should be discarded, so they are not accidentally given to the residents with the potential to make the residents sick. On 5/16/24 at 12:10 PM, V27 (Dietician) stated, If expired food is served to residents, they could get sick or get food poisoning (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145447 If continuation sheet Page 13 of 14 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 05/17/2024 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 0812 The facility's policy titled, Food Storage (Dry, Refrigerated and Frozen) last revised in 2020 showed, Procedure: c. Discard food that has passed the expiration date . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145447 If continuation sheet Page 14 of 14