Inspection·March 13, 2025

F 0692 Provide enough food/fluids to maintain a resident's health. 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 identify and provide interventions for tube feeding intolerance and fluid needs, that meet the nutritional needs of a resident dependent on enteral feeding in accordance with the facility policy. Residents Affected - Few This applies to 1 of 3 residents (R28) reviewed for nutrition in the sample of 18. The findings include: R28's EMR (Electronic Medical Record) showed R28 was admitted to the facility on [DATE], with multiple diagnoses including Wernicke's encephalopathy, attention to gastrostomy, dementia unspecified, gastro-esophageal reflux disease without esophagitis, thiamine deficiency, pressure ulcer of the sacrum and right buttocks and multiple contractures of the upper and lower extremities. R28 physician orders showed R28 was NPO (nothing by mouth). Tube feeding orders initiated on January 1, 2025, showed Jevity 1.2, 500 ml (milliliter) bolus every shift, scheduled for administration at 12 midnight, 08:00 AM and 4:00 PM. V10 (Dietitian) initial assessment dated [DATE], showed R28 was recommended to receive 180cc water flush at and past each feeding with total flush of 1080 ml per day, and Jevity 1.2 ,500 ml per shift for a total 1500 ml per day. R28's progress note dated February 21, 2025, 04:37 showed R28's tube feeding was on hold due to bloating. R28's progress note dated February 21, 2025, 3:25 PM Jevity feeding was restarted at 250 ml with 100 cc water flush each feeding and documented as well tolerated. R28's progress note dated February 22, 2025, 12:46 showed enteral feeding of 500 ml Jevity bolus and 100 ml of water flush was well tolerated, was to be given twice a day. R28's progress note dated February 22, 2025, 20:26 showed enteral feeding Jevity 250 ml bolus with 100 ml water flush given was given and was well tolerated. R28's physician order initiated on February 23, 2025, showed Jevity 1.2 ml 500 ml every 12 hours with 100 ml water flush with each feeding. R28's progress note dated March 7, 2025, at 7:03 AM showed R28 had feeding residual at 200 ml, physician was notified and order to decrease the tube feeding. R28's physician order initiated on March 7, 2025, showed Jevity 1.2 ml 250 ml bolus with 100 cc water flush twice a day and was scheduled for 6:00 AM and 6:00 PM. V10's nutrition note dated March 8, 2025, 2:39 PM showed Tube feeding below resident estimated needs. Receiving 1000 calories daily, 90 grams protein daily and 603.5 cc daily with free water and flush. Resident on hospice care. TF for comfort only and will not maintain nutritional status. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145447 If continuation sheet Page 2 of 5 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 03/13/2025 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R28's intake and output record for the week of March 5, through March 12, 2025, showed R28's intake was 700 cc per 24 hours from March 7 through March 11, 2025. On March 12, 2025, at 2:40 PM, V12 (Physician) stated in response to 700 cc fluid intake per day was not adequate. V12 stated he was told R28's belly was distended as the reason for need to decrease the feeding. V12 stated he will consult with the nursing staff and explore other avenues such as slower rate at continuous feeding as possibility tomorrow. On March 12, 2025, at 1:15 PM, V11 (RN- Restered Nurse) provided the intake and output record for R28 and reviewed the total intake per day as 700 cc and stated for me as an RN, that is not enough fluid for someone. V11 proceeded to empty R28's urinary catheter and noted the color to be dark amber. V11 stated the color indicates someone that needs more fluids. V11 stated since R28's admission no other alternative has been tried, including continuous feeding or lower rate over longer time period to address R28's tube feeding intolerance. V11 stated she was unsure why only that R28 was admitted on bolus feedings and on hospice. On March 12, 2025, at 1:45 PM, V10 (Dietitian) stated the water flush amount was ordered by the physician and was not based on her recommendation. V10 stated a protein supplement was added to address R28's need for wound healing, however the total calorie amount of the current order was not meeting R28's calorie needs. V10 stated R28's fluid intake of 700 cc over 6 days could cause dehydration, drier skin, and decreased urine output. V10 stated for someone with tube feeding intolerance the feeding could be given at a decreased rate over a longer period of time. V10 stated when R28 experienced bloating or high residual feeding she did not ask nursing staff regarding the potential for constipation. V10 stated continuous feeding method was not considered because R28 was on hospice. V10 stated she did not consult with R28's hospice nurse regarding R28's tube feeding. The facility's policy titled Enteral Nutrition (EN)-Tube Feeding dated 2020, showed Procedure: 1. Selection of Enteral Feeding .a. The choice of the EN depends on the medical and nutritional needs of the individual as assessed by the Registered Dietician and Physician .b. when selecting a formula consider an individual's tolerance to fiber, carbohydrate level, and lactose as well as the fat source and protein content. There are a number of formulas specifically designed for digestive and absorptive disorders, stress, trauma, renal, and hepatic disease, diabetes, pulmonary disease, etc .7. Calculating Adequate Fluid for EN: a. To ensure adequate fluids are given, the total volume (ml) of daily fluids required is calculated .Water flushes should be divided and spread out during the day .8. Close monitoring of tube feeding tolerance, intake and output records, nursing notations on physical assessment for characteristics such as skin turgor, available labs, etc. are essential to ensure adequate fluids are being provided .12. Complications: .abdominal distension .cause .lactose intolerance, volume intolerance, possible intolerance to the fiber in the formula .prevention intervention .assess possibility of a lactose or other nutrient intolerance in the content of the enteral product being administered; consider changing to a more concentrated enteral product to reduce the total volume needed Nausea/Vomiting .high residual: .Hold tube feeding .stop feeding if gastric residual volume is greater than 500 cc .evaluate the delivery rate to be sure it is appropriate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145447 If continuation sheet Page 3 of 5 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 03/13/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) R179 has a physician order dated January 21, 2025 for Enhanced Barrier Precautions (EBP) due to tracheostomy and Jejunostomy feeding tube (J-tube). Residents Affected - Many On March 11, 2025 at 9:11 AM, during observation of medication administration, R179 room door has an EBP sign posted on it that showed the following: Stop. Enhanced Barrier Precautions, Everyone must: Clean their hand, including before entering and when leaving the room. Providers and staff must also wear gloves and a gown for the following High-Contact Resident Care Activities: Device care or use: central line, urinary catheter, feeding tube, and Tracheostomy. There were no personal protective equipment (PPE) on the outside of R179's room or outside any of the rooms that were on EBP. V3 (Registered Nurse/RN) removed 3 medications from her medication cart for R179 then crushed and prepared the medications. V3 grabbed those cups of medication and entered R179's room without performing hand hygiene and without donning a gown. V3 then donned new gloves without performing hand hygiene. V3 listened for placement of R179's Jejunostomy feeding tube then went out of the room with the same gloves on and grabbed a spoon to stir the medication that was in the cups. V3 entered the room with the same gloves on her hands and did not perform hand hygiene, or don a gown. V3 then flushed R179 tubing and administered the medications. 3) On March 12, 2025 at 11:21 AM, during observation of medication administration, V3 prepared and administered oral medication to R180 in the dining room. On the way out of the dining room, V3 pushed the lid to the garbage can to deposit some things into the garbage. However, the medication cup she tried to throw away fell to the floor. V3 picked up the medication cup and pushed the lid again with her hand to place the medication cup into the garbage can. V3 then went to her medication cart in the hallway outside of the dining room and prepared one medication for R40 along with water and applesauce. V3 did not perform hand hygiene after administering medications to R180, touching the garbage can and the medication cart and before preparing and administering medication to R40. On March 12, 2025 at 2:55 PM, V2 (Director of Nursing) stated that Enhanced Barrier Precautions (EBP) is used to prevent residents from contracting infections. V2 stated EBP requires the staff to wear gloves, gown, and mask if necessary when performing direct care, which includes administering medication through a feeding tube. V2 stated the staff should also perform hand hygiene before entering a room where residents are on EBP. V2 stated when leaving the room of someone on EB precautions the staff should take off all personal protective equipment and perform hand hygiene. V2 stated after touching the environment, staff should perform hand hygiene and don new gloves before performing direct care. V2 stated that staff should perform hand hygiene after touching a garbage can and the environment and also before preparing medications for a resident. The facility's Hand Hygiene/Handwashing policy revised July 30, 2024 showed the following: examples of when to perform hand hygiene: at room entry, before exiting room, after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient, after glove removal . The facility's Enhanced Barrier Precautions Policy revised May 7, 2024 showed the following: Purpose: to reduce risk of transmitting multidrug-resistant organisms (MDRO) and targeted MDRO when contact precautions do not apply for residents identified as higher risk. Guidelines: EBP are used in conjunction with standard precautions and expand to use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following; indwelling medical device examples include: Feeding tubes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145447 If continuation sheet Page 4 of 5 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 03/13/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to develop control measures for identified internal factors that increase the risk of Legionella growth and failed to have ways to intervene when control measures were not met. The facility also failed to follow their policy for Enhanced Barrier Precautions and hand hygiene. Residents Affected - Many This applies to all 81 residents residing in the facility. The findings include: 1. The facility's Long-Term Facility Application for Medicare and Medicaid dated March 10, 2025, showed the facility census was 81. On March 12, 2025, at 8:32 AM, V6 (Maintenance Director) said for the facility's water management plan for Legionella, V6 performs weekly faucet flushes, periodic eye wash station flushes, daily hot water tank temperature checks, and they clean the ice machine every two weeks. V6 said he does not test for chlorine levels in the water. On March 12, 2025, at 9:11 AM, V1 (Administrator) said the facility's policy titled Water Management Program for Prevention of Legionella Growth is the facility's water management plan for Legionella. V1 said the facility does not regularly test for Legionella. V1 continued to say the facility will test for Legionella if there is a suspected case and corporate says the facility can test. V1 said the facility does not test for chlorine levels in the water. V1 said the facility uses the city's water report to know chlorine levels in the city water coming to the facility. V1 said the most recent water report from the city is from 2023. On March 12, 2025, at 1:36 PM, V8 (Vice President of Operations) said the facility does not test the facility water for chlorine levels. V8 continued to say the facility does not have control measures in place to monitor the disinfectant levels of the water in the facility. The facility's policy titled Water Management Program for Prevention of Legionella Growth dated May 17, 2024, showed Purpose: To identify and reduce the risk of Legionella growth and spread. Guidelines: Definition: Legionella is found naturally in [NAME] environments, like lakes and streams, but generally the low amounts in [NAME] do no lead to disease. Legionella can become a health problem in building water systems. To pose a health risk, Legionella first has to grow (increase in numbers). Then it has to be aerosolized so people can breathe in small, contaminated water droplets . Internal factors that may increase the risk of Legionella growth: Even if the water entering your building is of high quality, it may contain Legionella. In some buildings, processes such as heating, storing, and filtering can degrade the quality, it may contain Legionella. These processes use up the disinfectant the water entered with, allowing the few Legionella that entered to grow into a large number if not controlled . Inadequate disinfectant: Does not kill or inactivate Legionella . The facility's water management plan does not show control measures to monitor disinfectant levels, acceptable ranges of disinfectant levels, or established ways to intervene when control limits are not met. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145447 If continuation sheet Page 5 of 5