Health inspection·March 6, 2024

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review, the facility failed to ensure a resident's urinary indwelling catheter bag was not touching the floor to prevent contamination for 1 of 4 residents (R86) reviewed for catheters in the sample of 21. The findings include: On 3/3/24 at 9:44 AM, R86 was sitting in her wheelchair in her room. R86's catheter bag was hanging from the underside of her wheelchair. R86's catheter bag was touching the floor. On 3/3/24 at 10:52 AM, R86 was propelling herself down the hallway. R86's catheter bag was dragging on the floor as she propelled herself down the hallway. R86 did not have a privacy bag on the catheter bag. On 3/4/24 at 2:31 PM, V2 (Director of Nursing) said urinary catheter bags should be kept off of the floor for infection control reasons. R86's Urinary Catheter Care Plan shows, Do not allow tubing or any part of the drainage system to touch the floor. The facility's Caring for Residents with Foley Catheter Drainage Setups Policy, revised 1/2024, shows, The catheter bag container is attached to the side of the bed frame. Do not allow the bag to touch floor. When resident is up in the w/c (wheelchair), place foley drainage bag in drainage pouch under w/c seat. Tubing should be threaded under seat, above cross bars. Be sure pouch is attached securely under w/c seat and is high enough off floor to not sag onto floor with weight of urine FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145547 If continuation sheet Page 2 of 8 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 145547 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dekalb County Rehab & Nursing 2600 North Annie Glidden Road Dekalb, IL 60115 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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide behavioral interventions for a resident with a diagnosis of dementia that was displaying behaviors for one of 15 residents (R62) reviewed for dementia care in the sample of 21. Residents Affected - Few The findings include: R62's admission Record, dated 3/4/24, shows R62 was admitted tot he facility on 2/26/19, with diagnoses including dementia, Alzheimer's, restlessness and agitation, generalized anxiety disorder, major depressive disorder, anxiety disorder, over active bladder, and need for assistance with personal care. R62's Care Plan, initiated 3/1/24, shows, I have a history of often ambulating up and down the halls and will become momentarily tearful, whimper, and cry out before continuing to ambulate against/down the hall. Care Plan initiated 11/16/23, shows, Walk with me to/from resident dining room for all meals or as often as I will tolerate. Encourage me to walk as much as I will tolerate and praise my efforts. On 3/3/24 at 9:30 AM, R62 was sitting in her wheelchair in the large dining room. V11, Activity Aide, was sitting in a chair next to R62. R62 made numerous attempts to stand up; V11 guided R62 to sit back down. At 9:47 AM, V10, CNA (Certified Nursing Assistant), said she is going to take R62 to the bathroom to see if that is why she keeps trying to stand up. V10 took R62 to the bathroom. R62 was placed back at the table with V11 after using the bathroom. At 10:10 AM, R62 was attempting to stand up and was trying to walk. V11 again guided R62 to sit down. R62 was crying out loud. R62's wheelchair was locked and in front of a table. R62 made numerous attempts to stand up until 11:08 AM. At 11:08 AM, V11 placed R62 in the small dining room in front of a table and locked her wheelchair. At 11:42 AM, V9, RN (Registered Nurse), was shaking a maraca in front of R62. Each time R62 attempted to stand up and move, R62 was guided to sit back down in her wheelchair. R62 attempted to stand up and move at 11:41 AM. V9 was holding onto R62's left arm and R62 yelled, Let me go! I want to move! V9 again guided R62 to sit down. V10, CNA, came over to R62 and switched spots with V9. V10 continued to shake the maraca in front of R62. R62 continued to make multiple attempts to stand up and move until lunch came at 12:00 PM. There were no attempts made by staff to ambulate R62 during the entire observation. On 3/4/24 at 11:41 AM, V8, RN, said R62 is able to walk with a gait belt and a walker with a wheelchair following her, depending on the day. V8 said when R62 is showing behaviors of restlessness or anxiety, then ambulation and toileting are the staffs' first go to. V8 also said snacks and drinks are also offered. V8 said R62 also likes to color. V8 said sometimes walking works and sometimes it does not, but walking is an intervention that staff use to help with restlessness. On 3/5/24 at 11:14 AM, V6, CNA, said R62 constantly tries to stand up. V6 said R62 screams and tries to walk unsafely. V6 said R62 can get frustrated at times when staff try to help her. V6 said if R62 is restless, then staff offer her snacks, take her to the bathroom, and offer her root beer because R62 really likes root beer. V6 said sometimes R62 can walk safely and sometimes she can't. V6 said walking R62 can be used to manage R62's behaviors. On 3/5/24 at 1:51 PM, V15 (R62's Daughter) said R62 was a pacer. V15 said when R62 lived at home, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145547 If continuation sheet Page 3 of 8 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 145547 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dekalb County Rehab & Nursing 2600 North Annie Glidden Road Dekalb, IL 60115 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 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete R62 would pace back and forth. V15 said R62 roamed the facility on her own, until it was not safe to do it on her own. The facility's Activity Schedule policy, undated, shows, Dementia residents are often unable to cope with set agendas due to their cognitive impairment. The purpose is to ensure we are providing an environment conducive to our residents needs. To maintain a resident at the highest functional level possible. Event ID: Facility ID: 145547 If continuation sheet Page 4 of 8 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 145547 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dekalb County Rehab & Nursing 2600 North Annie Glidden Road Dekalb, IL 60115 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to provide residents eating from the Oak and Birch dining rooms with the correct serving sizes for the parmesan herb potatoes, regular carrots, mechanical soft ham, pureed ham, au gratin potatoes, and mashed potatoes. This applies to 4 of 21 residents (R9, R32, R50, R75) reviewed for diets in the sample of 21. The findings include: Facility provided list of residents served from the Oak dining room kitchenette for lunch on 3/3/24 shows R32 was served. Facility provided list of residents served from the Birch dining room kitchenette for lunch on 3/3/24 shows R9, R75, and R50 were served. Facility Diet Spreadsheet, dated 10/17/23, shows the lunch meal for 3/3/24 consisted of baked glazed ham, parmesan herb potatoes, carrots, apple pie, and a dinner roll. On 3/3/24 at 11:40 AM, V12 (Food Service Director) and V13 (Assistant Dietary Manager) began to place serving utensils in the appropriate foods for the lunch service in the Oak dining room kitchenette. The parmesan herb potatoes had a #10 scoop, which provides 3 ounces (oz) of volume. The carrots had a 3 oz spoodle. The mechanical soft ham had a #20 scoop, which provides 1.625 oz of volume. The pureed ham had a #12 scoop, which provides 2.66 oz of volume. The au gratin potatoes had a #10 scoop, which provides 3 oz of volume. The mashed potatoes had a #12 scoop, which provides 2.66 oz of volume. On 3/3/24 from 11:55 AM until 12:15 PM, V14 (Cook) served each plate out of the Oak dining room with a single scoop of all foods. V14 then packed up the foods and transported them with the serving utensils to the Birch dining room kitchenette. On 3/3/24 from 12:35 PM until 1:15 PM, V14 served each plate out of the Birch dining room kitchenette with a single scoop of all foods. The parmesan herb potatoes had a #10 scoop, which provides 3 oz of volume. The carrots had a 3 oz spoodle. The mechanical soft ham had a #20 scoop, which provides 1.625 ounces of volume. The puree ham had a #12 scoop, which provides 2.66 oz of volume. The au gratin potatoes had a #10 scoop, which provides 3 oz of volume. The mashed potatoes had a #12 scoop, which provides 2.66 oz of volume. Facility Diet Spreadsheet, dated 10/17/23, shows the parmesan herb potatoes was supposed to be served using a 4 oz spoodle. The #10 scoop used provides 1 ounce less than the 4 oz spoodle. Facility Diet Spreadsheet, dated 10/17/23, shows the carrots were supposed to be served using a 4 oz spoodle. The 3 oz spoodle used provides 1 ounce less than the 4 oz spoodle. Facility Diet Spreadsheet, dated 10/17/23, shows the mechanical soft ham was supposed to be served using a #8 scoop, which provides 4 oz of volume. The #20 scoop used provides 2.375 ounces less than the #8 scoop. Facility Diet Spreadsheet, dated 10/17/23, shows the pureed ham was supposed to be served using a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145547 If continuation sheet Page 5 of 8 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 145547 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dekalb County Rehab & Nursing 2600 North Annie Glidden Road Dekalb, IL 60115 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some #10 scoop, which provides 3 oz of volume. The #12 scoop used provides 0.33 ounces less than the #10 scoop. Facility provided au gratin recipe, dated 3/22/23, shows the au gratin potatoes were supposed to be served using a #8 scoop, which provides 4 oz of volume. The #10 scoop used provides 1 ounce less than the #8 scoop. Facility provided mashed potato recipe, dated 3/22/23, shows the mashed potatoes were supposed to be served using a #8 scoop, which provides 4 oz of volume. The #12 scoop used provides 1.33 ounces less than the #8 scoop. On 3/3/24 at 12:37 PM, V14 said the carrots were supposed to be served using a 4 oz spoodle, but believes they are low on them, which is why a 3 oz spoodle was used instead. On 3/4/24 at 10:37 AM, V12 said, If cooks don't use the correct scoop sizes, residents are at risk of getting the incorrect amount of calories, protein, and total nutrients. This can lead to weight loss. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145547 If continuation sheet Page 6 of 8 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 145547 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dekalb County Rehab & Nursing 2600 North Annie Glidden Road Dekalb, IL 60115 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, and record review, the facility failed to provide two residents with a smooth consistency pureed pork chop that was free of chunks. This applies to 2 of 2 residents (R13, R55) reviewed for pureed diets in the sample of 21. The findings include: On 3/3/24 at 1:24 PM, the facility provided a test tray of pureed ham, pureed pork chop, and pureed carrots. The pureed pork chop was not smooth and contained chunks of pork chop that required chewing. On 3/3/24 at 1:34 PM, V12 (Food Service Director) said the pureed pork chop texture was not good because it had chunks. The ideal texture should be smooth, free of chunks, and similar to baby pudding or applesauce. R13's lunch meal ticket, dated 3/3/24, shows R13 received the pureed pork chop. R55's lunch meal ticket, dated 3/3/24, shows R55 received the pureed pork chop. Facility Puree Food Texture log, dated February 2024, states, . Food must be smooth, with no beads of meat or other food present. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145547 If continuation sheet Page 7 of 8 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 145547 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dekalb County Rehab & Nursing 2600 North Annie Glidden Road Dekalb, IL 60115 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to handle and store three bulk bin scoops in a sanitary manner. This has the potential to effect all residents in the facility. Residents Affected - Many The findings include: The CMS 671, dated 3/3/24, shows there are 105 residents residing in the facility. On 3/3/24 at 09:13 AM, the bulk bin of white rice in the dry storage room had a scoop inside the bin, lying on top of the white rice. On 3/3/24 at 11:21 AM, a bulk container of brown sugar outside of the Oak dining room kitchenette had a purple handle ice cream scoop inside the container, lying on top of the brown sugar. On 3/4/24 at 10:17 AM, the bulk bin of flour underneath the food prep counter had a scoop in the bin, resting on top of the flour. On 3/4/24 at 10:30 AM, V12 (Food Service Director) said, They (the kitchen staff) know scoops should not be on top of food ingredients. This can increase the risk of cross contamination and bacterial growth. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145547 If continuation sheet Page 8 of 8