Health inspection·February 26, 2024

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 12/11/2023 with V22 (LPN). I was only CNA on the unit that night. I was monitoring residents assigned to me, but I was also asked by a supervisor, to help monitor V22's (LPN) residents as well. R2 was among residents assigned to V22 (LPN). When I checked on R2, upon the beginning on my shift (11:00 PM), she was sleeping. Later that night (between 00:30 AM and 3:00 AM), V22 (LPN) asked me to bring him an extra sheet. Then V22 (LPN) placed the sheet across R2's legs and tucked it underneath the mattress. V22 (LPN) then said, I hope she's going to stay in bed now. I didn't check on R2 after that. V1 (Administrator) called me and talked to me about the incident the following day, and then I was suspended for about a week and a half. Per record review, V22 (Licensed Practical Nurse) interview (no date and time included) reads in part, At 12:30 AM, Tucked (it) pretty tight. Why tucked it tight? Didn't want (R2) to get up and fall. At 1:30 AM, Sheets still secured. At 5:00 AM (R2) was still tucked in as left it. At 7:00 AM, The sheets were still tucked in as left. Facility Abuse Prevention Program policy dated 7/28/2022 reads in part, The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145994 If continuation sheet Page 2 of 25 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 145994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement their fall prevention care plans and have an effective process in place to ensure direct care staff are aware of and educated about care plan interventions for 4 (R1, R3, R4, R6) of 5 residents reviewed for care plans in the sample. Findings include: Facility policy dated [DATE] titled Fall Prevention Program reads in part, Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. A care plan for fall prevention will be implemented and maintained to assure the safety of residents who are at risk. The IDT will meet to review all resident falls that have occurred. Fall incident reports will be studied to determine any significant factors that may have caused the fall and to identify additional fall prevention strategies. The DON and nurse mangers and/or designee will be responsible for implementing and communicating resident-specific recommendations from the IDT to the nursing staff assigned to the resident. The nursing staff will be responsible for assuring the recommendations are followed through. Fall prevention strategies will be utilized for all residents at risk for falls including individualized interventions in accordance with the assessed needs of each resident. 1. R1 is a [AGE] year-old with diagnoses of respiratory failure with hypoxia, type 2 diabetes, congestive heart failure, gait abnormality, and cardiomyopathy. Care plan dated [DATE] reads in part, R1 is at risk for falls. The resident has balance or walking impairments. The resident experiences weakness. The resident takes medications that may cause dizziness, loss of balance, or impair judgement. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Interventions: Fall risk evaluation; Refer to therapy for screen/evaluation and treatment as indicated. Assist and encourage the resident in wearing non-skid footwear when out of bed. Keep bed in lowest position acceptable by the resident when the resident is in bed. Remind to request assistance when getting up if need. Remind resident to sit away from edge of mattress when sitting on the bed. Remind resident to request staff assistance with transfers out of bed. On [DATE] at 02:41 AM, V27 (Agency nurse) wrote in part, [DATE] at 02:41 AM Event Note: Resident was observed on the floor in left side lying position & rubbing her right hip/leg area. Resident stated she fell & when writer asked how it happened, she said she can't remember. Also asked if she hit her head, she did, pointing on her forehead. Resident unable to move her right leg, also said she has pain on the right hip/leg 10/10. Noted a bump with mild bruising to her forehead. Notified doctor and called 911. Applied ice pack to bump on forehead & stayed with resident till paramedics came. On [DATE] at 07:55 AM, V31 (LPN Nurse Manager) wrote in part, Health Status Note: Nurse spoke with hospital nurse. Resident is being transferred to alternate hospital for orthopedic surgery. Resident has a pelvic fracture. On [DATE] at 12:09 PM, V26 (agency RN) stated, Yes I remember R1. She was alert but forgetful and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145994 If continuation sheet Page 3 of 25 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 145994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some ambulates with some assistance and she spoke a little English. I would say her gait was very unsteady and she was tall skinny and weak and was supposed to use a cane. I think she was a fall risk, but I don't remember anyone telling me this. I'm agency here if you didn't know that so I have to figure things out on our own here. Surveyors asked if she received any training or orientation from the facility about fall risk interventions in the care plan or if the facility identified any residents who were at risk for falls before the start of her shifts. V6 stated, No. I've never received any training like that. On [DATE] at 11:15 AM, V30 (family member) stated, I was called that my mom was found on the floor, and they sent her to the hospital because she was in a lot of pain and the hospital told me she had a hip fracture. Surveyor asked if this was the first time her mother fell. V30 stated, No, she had just fallen several days prior to this one and no one told me until she fell the second time when she was sent to the hospital. If they were doing what they said they were going to do for my mom, this would not have happened. Hospital records dated [DATE] at 10:02 AM written by V29 (emergency room Doctor) reads in part, Patient arrived via emergency medical services from facility following being found on floor. Unwitnessed fall. Does not recall how got to floor. Positive for hematoma to mid forehead. Positive for pain and deformity to right hip with decreased range of motion. reports increased pain. Problem list: Atrial fibrillation, Blunt head injury, right Hip fracture. 2. R3 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including but not limited to Type 2 Diabetes Mellitus; Chronic Diastolic Heart Failure; Chronic Kidney Disease; Hyperlipidemia; Spinal Stenosis; Essential Hypertension; Cognitive Communication Deficit; and Dizziness and Giddiness. R3's Fall care plan dated [DATE] reads in part, Anticipate and meet (R3's); Be sure (R3's) call light is within reach and encourage (R3). No intervention pertaining to monitoring noticed. On [DATE] at 11:31 AM Surveyor observed R3 sitting up in the bed. Surveyor noticed bilateral bruising around R3's eyes, R3 stated, I got up to the bathroom, tripped and fell down. I think it was last week. I went to the hospital, and they said I broke my hip. When I came back to the facility, they told me I can walk, but only with assistance, and put 20% of weight on my left leg. Surveyor noticed R3's demeanor to be quiet and sad, surveyor clarified how is R3 feeling. R3 stated, I'm depressed and looked away. Surveyor observed bed in the lowest position; no fall mats; reaching device laying on recliner, out of R3's reach; call light in the nightstand's drawer, out of R3's reach; room cluttered and dark. On [DATE] at 3:53 PM Surveyor observed R3 in his room, sitting in the wheelchair, in the bathroom. R3 said, I think I need to go to the bathroom; I'm going to sh*t myself. Surveyor observed call light in R3's nightstand ' s drawer. Call light not initiated upon surveyor entrance to R3's room. On 02/22 2024 between 9:00 AM and 4:00 PM, in 3 separate attempts, surveyor called V28 (Licensed Practical Nurse/LPN); however, V28 did not answer, voicemail was left. On [DATE] at 12:21 PM V2 (Director of Nursing/Fall coordinator) who related the following in summary: R3 is pretty impulsive, likes to get up on his own and do things for himself. R3 usually transfers with 1 person assistance. R3 is able to use a call light. At the time of the incident (on [DATE]), R3 got dizzy, lost his balance, and fell. R3 was transferred out to the hospital due to head and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145994 If continuation sheet Page 4 of 25 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 145994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some left side pain. Hospital records showed left femur fracture. Prior to the fall on [DATE], R3 was not a fall risk resident. Surveyor clarified if R3 has history of falls that would place him at risk for falls, V2 (DON/Falls coordinator) responded, R3 had another fall on [DATE] and on [DATE]. That would put him at a risk for falls. I think R3 ' s care plan interventions are appropriate to prevent him from falling. According to record review, progress note written by V28 (Licensed Practical Nurse) dated [DATE] at 00:51 AM reads in part, During shift report, heard loud noise from R3's room and R3 screamed for help. Immediately, writer (V28 LPN) and certified nursing assistant in the room. R3 lying on the floor on his left side. R3 with raised area to left side of forehead. Left knee abrasion and right-hand abrasion in between fingers. R3 stated, I started walking toward bathroom to take a dump, I felt dizzy and fell down. Upon full body assessment ROM (range of motion) WNL (within normal limits), R3 assisted back to level of comfort. First aid to areas of injury given. Ice pack placed on forehead r/t (related to) raised area. Left knee cleansed with NSS (normal saline solution) and (antibiotic ointment) applied. Right hand cleansed with NSS, (antibiotic ointment) applied. Neurological checks initiated. Peri care and toileting provided. 911 called, R3 taken to (local) hospital for further f/u (follow up). Final Facility Reported Incident report dated [DATE] at 12:33 PM reads in part, Investigation/Conclusion: R3 experienced change in condition which resulted in sudden change in plane. R3 was admitted to the (local) hospital. Hospital record dated [DATE] authored by V32 (ER doctor) reads in part, (R3) was apparently trying to transfer from chair to the toilet and did not have any help. He felt dizzy and hit forehead on the ground; also, c/o (complaining of) right knee pain with a bruise to the right knee; some left knee abrasion; soreness to the left shoulder. He had severe pain in the left hip after the fall. X-ray Pelvis 1 or 2 views: Left femoral greater trochanter avulsion fracture. 3. R4 is a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Unspecified Dementia; Essential Hypertension; Hyperlipidemia; Muscle Weakness; Cardiomegaly; Alzheimer's Disease; and Personal History of Transient Ischemic Attack. R4's Fall care plan dated [DATE] reads in part, Be sure (R4's) call light is within reach and encourage (R4) to use it for assistance as needed. Place floor mats on the floor beside the bed. R4's Fall risk assessment dated [DATE] reads in part, (R4) is at high risk for falls. On [DATE] at 11:20 AM R4 not in the room at this time. Fall mats and wheelchair stored in R4's bathroom. On [DATE] at 3:52 PM R4 was in bed asleep at this time. Bed in the lowest position, but no fall mats were on the floor and fall mats remained stored in the bathroom. Call light was placed on the nightstand, out of R4's reach. 4. R6 is an [AGE] year-old with diagnosis of Parkinson's disease, dementia, delusional disorder, and anxiety disorder. A facility reported fall incident on [DATE] by V2 (DON) reads in part, Upon making rounds when arrived at 11:00 PM, CNA informed that resident (R6) had blood on the floor of the room and was scooting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145994 If continuation sheet Page 5 of 25 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 145994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some around on the floor. I went to assess the resident's condition and noticed some specks of dried blood on the floor. Noticed dried blood on the back right side of resident's head. Resident was alert and oriented times 1. Resident is very confused and very fidgety. Resident mumbling incoherent words and moved all extremities without any signs of pain. Once stabilized, left the room and proceeded to call 911. V2's root cause analysis reads, (R6) has tendencies to attempt self-transfers and will at times attempt to transfer herself out of bed or from her wheelchair. Staff will place the resident in areas of high staff visibility for closer supervision when awake. Fall care plan dated [DATE] reads in part, (R6) is at risk for falls. The resident has Impaired cognition and impaired safety awareness due to dementia and Parkinson's. The resident has balance impairments. The resident has a history of falls. The resident experiences weakness. The resident takes medications that may cause dizziness, loss of balance, or impair judgement (psychotropic). The resident has vision impairments. She can be impulsive and does things on her own. Has tendency to reach for things on the floor, at nurses' station, or at the table in the dining room. With periods of restlessness due to Parkinson's and dementia. Goal: Prevent a serious fall related injury. Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Fall risk evaluation. Assist the resident in wearing non-skid footwear when out of bed. Keep bed in lowest position when the resident is in bed. Place floor mattress on the floor beside the bed while resident is in bed. Ensure proper positioning when seated in wheelchair and remind resident not to lean forward when in wheelchair. Keep resident in areas of high staff visibility for closer supervision when awake. High back wheelchair for positioning. Offer group activities for resident to attend as she allows. On [DATE] at 10:15 AM, R6 was in her room with the door fully closed. R6 was observed lying in bed awake and flailing her arms and appeared agitated. The room was dark with no lights on and with drapes that were closed. A heater was blowing air directly toward the resident who was immediately adjacent to the heater. Per care plan, R6 should have been placed in a high visibility area when the resident was awake. V10 (agency nurse) was at the other wing of the unit and was asked about R6. V10 stated, This is only my second day here. I have 2 CNAs today, I think. I don't know who they are. Surveyor asked if the residents she took care of today were considered at risk for falls. V10 stated, I don't know which residents are fall risk, sorry. Surveyor asked if she was told by anyone from the facility before she started her shift anything about her residents. V10 stated, No I wasn't told anything special, why? Surveyor asked if she received any in-service training before taking on a shift at the facility. V10 stated, No, I didn't get any in-services, it's only my second day here. On [DATE] at 10:30 AM the doors to R6 were once again closed and resident was observed awake in a bed. V10 was again observed on the same wing and asked if she obtained any endorsement from the outgoing nurse, V10 stated, No the nurse didn't tell me anything this morning because she was gone when I got here. On [DATE] at. 11:18 am: V2 (DON) said I am in charge of falls. When we have a fall I determine the root cause, update the plan of care with appropriate interventions. I type up the summary of any fall and meet with my IDT (interdisciplinary team) which consist of all the dept heads, but clinical team are my ADON (Assistant Director of Nurses) and nurse managers. They know who fell and generally speaking, they know what the interventions are. Surveyor asked if she maintained a list of residents at risk for falls. V2 stated, I maintain list of residents who fell, but I don't have a list of residents at risk for falls that I provide to staff. Surveyor asked how agency nursing staff are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145994 If continuation sheet Page 6 of 25 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 145994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some provided the information necessary for them to identify residents at risk for falls. V2 stated, When agency nurses start here, we have a packet that they are supposed review and usually they sign off when they receive the packet that they've read the packet. Surveyor asked about agency CNA staff. V2 stated, CNAs are also given in a binder to review and it is in the employee lounge. Surveyor asked if the orientation packets provided to agency staff are reviewed by her or any of her nurse managers prior to agency staff coming on board. V2 stated, They are just given a packet, but no one goes through it with them. We just trust they did it. Surveyor asked how she ensured agency nursing staff knew how to care for the residents in the facility they are unfamiliar with. V2 stated, I can't ensure that, they should know this. On [DATE] at 10:30 AM, V9 (ADON) was observed walking the units and was asked about falls. V9 stated, I don't know which residents are fall risk residents. I'd have to check their (electronic note card). Surveyor asked if she had to look up every resident's record every time a nurse cares for a resident to determine if they were at risk for falls. V9 stated, Yes. Surveyor asked how that would be considered preventative fall interventions if her nurses cannot identify which residents were at risk or high risk for falls. V9 stated, Well, all our residents our fall risk residents. Every one of us is considered a fall risk including you (referring to the surveyor). Surveyor clarified her rationale to determine everyone including surveyors were at risk for falls. V9 stated, Yes, you (referring to the surveyor) can fall at any time, just like I can fall. Surveyor reminded V9 that the surveyor was not a resident in the facility. V9 stated, Yes but we are all still at risk to fall. Surveyor asked if this rationale was in their fall risk policy, V9 stated, No it is not. [DATE] 12:50 PM, follow up interview with V9 (ADON) stated, I was the fall nurse but (V2 DON) has kind of taken over so we are all involved in fall program. In our morning meeting we discuss our falls and discuss how the resident fell, how fall happened, and what can we do to prevent from happening again. Surveyor asked how this information gets conveyed to staff. V9 stated, It is conveyed to front line staff by a shift report. We transfer the fall intervention to the (electronic note card). Surveyor asked how this information is given to agency staff. V9 stated, Every time we have agency, they go through an orientation pack. It talks about the (electronic note card) and we talk about falls, change of condition and this packet is given to agency staff. Surveyor asked V9 to go through the orientation packet provided to agency staff to show where this information is. V9 stated, It says Falls identification but no it doesn't have preventative fall measures, it just directs agency staff to go to the (electronic note card). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145994 If continuation sheet Page 7 of 25 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 145994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 provide care in accordance with professional standards of quality by 1. Failing to provide adequate supervision and monitoring of residents at risk for falls and with a history of falls; 2. Failed to implement and follow the plan of care to prevent falls and future falls; 3. Failed to train all staff, including agency staff on fall prevention; 4. Failed to provide staff with necessary information and immediate access for this information of all residents at risk for falls in order to keep residents safe from harm. This failure affects for 4 (R1, R3, R4, R6) of 5 residents reviewed for accident hazards in the sample and has the potential to affect all 117 residents residing in the facility. Residents Affected - Few Findings include: On [DATE] at 10:00 AM, V1 (administrator) presented the survey team with the facility census number showing 117 residents. On 2//20/24 at 10:30 AM, V2 (director of nursing) presented survey team with their fall incidents log in the past 60 days which showed 56 unwitnessed falls and 3 witnessed falls (averaging nearly 1 fall per day). V2 informed the survey team that she was in charge of managing falls in the facility along with her IDT (interdisciplinary team) which consisted of her assistant director of nursing and nurse managers. 1. R1 is a [AGE] year old with diagnoses of respiratory failure with hypoxia, type 2 diabetes, congestive heart failure, gait abnormality, and cardiomyopathy. Care plan dated [DATE] reads in part, R1 is at risk for falls. The resident has balance or walking impairments. The resident experiences weakness. The resident takes medications that may cause dizziness, loss of balance, or impair judgement. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Interventions: Fall risk evaluation; Refer to therapy for screen/evaluation and treatment as indicated; Assist and encourage the resident in wearing non-skid footwear when out of bed; Keep bed in lowest position acceptable by the resident when the resident is in bed; Remind to request assistance when getting up if need; Remind resident to sit away from edge of mattress when sitting on the bed. Remind resident to request staff assistance with transfers out of bed. Facility records showed: On [DATE] at 03:06 AM V26 (agency RN) wrote in part, Health Status Note: called by the CNA to the room saying the patient is on the floor. Nurse immediately responded, found the patient sitting on the floor, close to the bed, back supporting the bed, with leg extended. patient is alert and oriented stated that she did not hit her head. Patient was assessed before moving, level of consciousness at baseline, no change, range of motion within normal limits. Vital signs stable, no new pain, no injury/ redness noted at this time, Neurological check initiated, Primary physician is notified. Will endorse to morning nurse to notify social service. On [DATE] at 02:41 AM, V27 (Agency nurse) wrote in part, [DATE] at 02:41 AM Event Note: Resident was observed on the floor in left side lying position & rubbing her right hip/leg area. Resident stated she fell & when writer asked how it happened, she said she can't remember. Also asked if she hit (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145994 If continuation sheet Page 8 of 25 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 145994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few her head, she did pointing on her forehead. Resident unable to move her right leg, also said she has pain on the right hip/leg 10/10. Noted a bump with mild bruising to her forehead. Notified doctor and called 911. Applied ice pack to bump on forehead & stayed with resident till paramedics came. On [DATE] at 07:55 AM, V31 (LPN Nurse Manager) wrote in part, Health Status Note: Nurse spoke with hospital nurse. Resident is being transferred to alternate hospital for orthopedic surgery. Resident has a pelvic fracture. On [DATE] at 12:09 PM,V26 (agency RN) stated, Yes I remember R1, she was alert but forgetful and ambulates with some assistance and she spoke a little English. I would say her gait was very unsteady and she was tall skinny and weak and was supposed to use a cane. I think she was a fall risk but I don't remember anyone telling me this. I'm agency here if you didn't know that so I have to figure things out on our own here. Surveyors asked if she received any training or orientation from the facility about fall risk interventions or if the facility identified any residents who were at risk for falls before the start of her shifts, V6 stated, No. I've never received any training like that. I remember they just gave me this thick stack of papers (V6 describing the thickness with her hand) when I first started and I was supposed to read through it all and sign when I was done. Surveyor asked if she knew what she was signing, V6 stated, It was pretty much some directions on how to get in to PCC (electronic medical records) and where everything was. Surveyors asked if there were any topics related to the care of the residents, V6 stated, Not that I can remember. Surveyors asked if the facility conducted any regular inservice training during her time working at the facility, V6 stated, The only time was the inserviced today by and it was conducted by he wound nurse which was general inservice. Surveyor's asked what she meant by general inservice, V6 stated, It was the wound nurse so she mentions stuff about turning and repositioning I remember, but she just passed around a signature sheet and we all signed it. Surveyor asked if there was any inservice training specific to fall prevention, V6 stated, Not that I recall. Hospital records dated [DATE] at 10:02 AM written by V29 (emergency room Doctor) reads in part, Patient arrived via emergency medical services from facility following being found on floor. Unwitnessed fall. Does not recall how got to floor. Positive for hematoma to mid forehead. Positive for pain and deformity to right hip with decreased range of motion. reports increased pain. Problem list: Atrial fibrillation, Blunt head injury, right Hip fracture. 2. R3 is a [AGE] year old male admitted to the facility on [DATE] with diagnosis including but not limited to Type 2 Diabetes Mellitus; Chronic Diastolic Heart Failure; Chronic Kidney Disease; Hyperlipidemia; Spinal Stenosis; Essential Hypertension; Cognitive Communication Deficit; and Dizziness and Giddiness. Fall care plan dated [DATE] reads in part, Anticipate and meet (R3's); Be sure (R3's) call light is within reach and encourage (R3). No intervention pertaining to monitoring of the resident was absent from the care plan. On [DATE] at 11:31 AM Surveyor observed R3 sitting up in the bed. Surveyor noticed bilateral bruising around R3's eyes, R3 stated, I got up to the bathroom, tripped and fell down. I think it was last week. I went to the hospital, and they said I broke my hip. When I came back to the facility, they told me I can walk, but only with assistance, and put 20% of weight on my left leg. Surveyor noticed R3's demeanor to be quiet and sad, surveyor clarified how is R3 feeling, R3 stated, I'm depressed and looked away. Surveyor observed bed in the lowest position; no fall mats; reaching device laying on recliner, out of R3's reach; call light in the nightstand ' s drawer, out of R3's reach; room (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145994 If continuation sheet Page 9 of 25 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 145994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067 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 0658 cluttered and dark. Level of Harm - Minimal harm or potential for actual harm On [DATE] at 3:53 PM Surveyor observed R3 in his room, sitting in the wheelchair, in the bathroom. R3 said, I think I need to go to the bathroom; I'm going to poop myself. Surveyor observed call light in R3's nightstand ' s drawer. Call light not initiated upon surveyor entrance to R3's room. Residents Affected - Few On 02/22 2024 between 9:00 AM and 4:00 PM, in 3 separate attempts, surveyor called V28 (Licensed Practical Nurse); however, V28 (LPN) did not answer, voicemail was left. On [DATE] at 12:21 PM Surveyor interviewed V2 (Director of Nursing/Fall coordinator) who related the following in summary: R3 is pretty impulsive, likes to get up on his own and do things for himself. R3 usually transfers with 1 person assistance. R3 is able to use a call light. At the time of the incident (on [DATE]), R3 got dizzy, lost his balance, and fell. R3 was transferred out to the hospital due to head and left side pain. Hospital records showed left femur fracture. Prior to the fall on [DATE], R3 was not a fall risk resident. Surveyor clarified if R3 has history of falls that would place him at risk for falls, V2 (DON/Falls coordinator) responded, R3 had another fall on [DATE] and on [DATE]. That would put him at a risk for falls. I think R3 ' s care plan interventions are appropriate to prevent him from falling. Progress note written by V28 (Licensed Practical Nurse) dated [DATE] at 00:51 AM reads in part, During shift report, heard loud noise from R3 ' s room and R3 screamed for help. Immediately, writer (V28 LPN) and certified nursing assistant in the room. R3 lying on the floor on his left side. R3 with raised area to left side of forehead. Left knee abrasion and right hand abrasion in between fingers. R3 stated, I started walking toward bathroom to take a dump, I felt dizzy and fell down. Upon full body assessment ROM (range of motion) WNL (within normal limits), R3 assisted back to level of comfort. First aid to areas of injury given. Ice pack placed on forehead r/t (related to) raised area. Left knee cleansed with NSS (normal saline solution) and (antibiotic ointment) applied. Right hand cleansed with NSS, (antibiotic ointment) applied. Neurological checks initiated. Peri care and toileting provided. 911 called, R3 taken to (local) hospital for further f/u (follow up). Final Facility Reported Incident report dated [DATE] at 12:33 PM reads in part, Investigation/Conclusion: R3 ' s experienced change in condition which resulted in sudden change in plane. R3 was admitted to the (local) hospital. Hospital record dated [DATE] authored by V32 (ER doctor) reads in part, (R3) was apparently trying to transfer from chair to the toilet and did not have any help. He felt dizzy and hit forehead on the ground; also, c/o (complaining of) right knee pain with a bruise to the right knee; some left knee abrasion; soreness to the left shoulder. He had severe pain in the left hip after the fall. X-ray Pelvis 1 or 2 views: Left femoral greater trochanter avulsion fracture. A general tour of the facility along with observations and staff interviews beginning on [DATE] at AM showed: 3. R4 is a [AGE] year old female admitted to the facility on [DATE] with diagnosis including but not limited to Unspecified Dementia; Essential Hypertension; Hyperlipidemia; Muscle Weakness; Cardiomegaly; Alzheimer's Disease; and Personal History of Transient Ischemic Attack. R4's Fall care plan dated [DATE] reads in part, Be sure (R4's) call light is within reach and encourage (R4) to use it for assistance as needed. Place floor mats on the floor beside the bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145994 If continuation sheet Page 10 of 25 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 145994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067 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 0658 R4's Fall risk assessment dated [DATE] reads in part, (R4) is at high risk for falls. Level of Harm - Minimal harm or potential for actual harm On [DATE] at 11:20 AM R4 was not in the room at this time. Fall mats and wheelchair were stored in R4's bathroom. Residents Affected - Few On [DATE] at 3:52 PM R4 was asleep in bed at this time. Bed was in the low position, but no fall mats were on the floor and fall mats remained stored in the bathroom. Call light was placed on the nightstand, out of R4's reach. 4. R6 is a [AGE] year old with diagnosis of Parkinson's disease, dementia, delusional disorder, and anxiety disorder. A facility reported fall incident on [DATE] by V2 (DON) reads in part, Upon making rounds when arrived at 11:00 PM, CNA informed that resident (R6) had blood on the floor of the room and was scooting around on the floor. I went to assess the resident's condition and noticed some specks of dried blood on the floor. Noticed dried blood on the back right side of resident's head. Resident was alert and oriented times 1. Resident is very confused and very fidgety. Resident mumbling incoherent words and moved all extremities without any signs of pain. Once stabilized, left the room and proceeded to call 911. V2's root cause analysis reads, (R6) has tendencies to attempt self-transfers and will at times attempt to transfer herself out of bed or from her wheelchair. Staff will place the resident in areas of high staff visibility for closer supervision when awake. Fall care plan dated [DATE] reads in part, (R6) is at risk for falls. The resident has Impaired cognition and impaired safety awareness due to dementia and Parkinson's. The resident has balance impairments. The resident has a history of falls. The resident experiences weakness. The resident takes medications that may cause dizziness, loss of balance, or impair judgement (psychotropic). The resident has vision impairments. She can be impulsive and does things on her own. Has tendency to reach for things on the floor, at nurses station, or at the table in the dining room. With periods of restlessness due to Parkinson's and dementia. Goal: Prevent a serious fall related injury. Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Fall risk evaluation. Assist the resident in wearing non-skid footwear when out of bed. Keep bed in lowest position when the resident is in bed; Place floor mattress on the floor beside the bed while resident is in bed; Ensure proper positioning when seated in wheelchair, and remind resident not to lean forward when in wheelchair. Keep resident in areas of high staff visibility for closer supervision when awake; High back wheel chair for positioning. Offer group activities for resident to attend as she allows. On [DATE] at 10:15 AM, R6 was in her room with the door fully closed. R6 was observed laying in bed awake and flailing her arms and appeared agitated. The room was dark with no lights on and with drapes that were closed. A heater was blowing air directly toward the resident who was immediately adjacent to the heater. Per care plan, R6 should have been placed in a high visibility area when the resident was awake. V10 (agency nurse) was at the other wing of the unit and was asked about R6, V10 stated, This is only my second day here. I have 2 CNA's today I think. I don't know who they are. Surveyor asked if the residents she took care of today were considered at risk for falls, V10 stated, I don't know which residents are fall risk, sorry. Surveyor asked if she was told by anyone from the facility before she started her shift anything about her residents, V10 stated, No I wasn't told anything special, why? Surveyor asked if she received any inservice training before taking on a shift at the facility, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145994 If continuation sheet Page 11 of 25 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 145994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few V10 stated,No, I didn't get any inservices, it's only my second day here. Surveyor asked if she recalled anything in orientation or if she received orientation, V10 stated,We don't get orientation, I'm agency. I pick up a shift, the facility accepts and I work the floor. Surveyor asked how she would know anything about each resident V10 stated, I try to write it down on a sheet. Surveyor asked if would receive any endorsement from the outgoing nurse, V10 stated,No, I came late today so I didn't see the nurse before me. Surveyor asked specifically about R6, V10 looks at her resident roster and stated, Yes she's mine but I can't tell you much about her. I just know which room she's in and she's mine today. On [DATE] at 10:30 AM the doors to R6 were once again closed and resident was observed awake in a bed. V10 was again observed on the same wing and asked if she obtained any endorsement from the outgoing nurse, V10 stated, No the nurse didn't tell me anything this morning because she was gone when I got here. On [DATE] at. 11:18 am: V2 (DON) I am in charge of falls. when we have a fall I determine the root cause, update the plan of care with appropriate interventions. I type up the summary of any fall and meet with my IDT (interdisciplinary team) which consist of all the dept heads. Surveyor asked if there are any inservice training's conducted related to fall prevention, V2 stated, Yes we inservice on falls and the last time was right around first week of December and it was on a variety of topics. Surveyor asked what the specifics were regarding this fall inservice training, V2 stated, It points out where to locate fall intervention which located on the [NAME] (electronic medical note cards). It shows to our agency nurses know how to access the [NAME]. Surveyor asked if there are actual fall interventions provided to staff including agency nurses, V2 stated, No, it just directs them to the specific resident's [NAME] with that information. Surveyor asked if she maintained a list of residents at risk for falls, V2 stated, I maintain list of residents who fell, but I don't have a list of resident's at risk for falls that I provide staff to. Surveyor asked how agency nursing staff are provided the information necessary for them to identify residents at risk for falls, V2 stated, When agency nurses start here, we have a packet that they are supposed review and usually they sign off when they receive the packet that they've read the packet. Surveyor asked about agency CNA staff, V2 stated, CNA's are also given in a binder to review and it is in the employee lounge. Surveyor asked if the orientation packets provided to agency staff are reviewed by her or any of her nurse managers prior to agency staff coming on board, V2 stated, They are just given a packet but no one goes through it with them. We just trust they did it. Surveyor asked how she ensured agency nursing staff knew how to care for the residents in the facility they are unfamiliar with, V2 stated, I can't ensure that, they should know this. Surveyor asked if agency nurses are provided any information about the resident's fall risk status during shift to shift endorsements, V2 stated, We don't put this down on the 24 hour report because we got rid of it because its not reliable but only except if its a new admission. Surveyor clarified if the shift to shift reports were written anywhere or if it was a verbal endorsement, V2 stated, No the nurses do write down the endorsements from shift to shift, but these 24 hour reports don't get maintained and are shredded at the end of the day so I can't show you any past ones. On [DATE] at 10:30 AM, V9 (ADON) was observed walking the units and was asked about falls, V9 stated, I don't know which residents are fall risk residents, I'd have to check their [NAME] (electronic note card). Surveyor asked if she had to look up every resident's record every time a nurse cares for a resident to determine if they were at risk for falls, V3 stated, Yes. Surveyor asked how that would be considered preventative fall interventions if her nurses cannot identify which residents were at risk or high risk for falls, V3 stated, Well, all our residents our fall risk residents. Everyone of us is considered a fall risk including you (referring to the surveyor). Surveyor clarified her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145994 If continuation sheet Page 12 of 25 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 145994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few rationale to determine everyone including surveyors were at risk for falls, V3 stated, Yes, you (referring to the surveyor) can fall at any time, just like I can fall. Surveyor reminded V3 that the surveyor was not a resident in the facility, V3 stated, Yes but we are all still at risk to fall. Surveyor asked if this rationale was in their fall risk policy, V3 stated, No it is not. [DATE] 12:50 PM, follow up interview with V9 (ADON) stated, I was the fall nurse but (V2-DON) has kind of taken over so we are all involved in fall program. In our morning meeting we discuss our falls and discuss how the resident fell, how fall happened, and what can we do to prevent from happening again. Surveyor asked how this information gets conveyed to staff, V9 stated, It is conveyed to front line staff by a shift report. We transfer the fall intervention to the [NAME] (electronic note card). Surveyor asked how this information is given to agency staff, V9 stated, Every time we have agency they go through an orientation pack. It talks about the [NAME] and we talk about falls, change of condition and this packet is given to agency staff. Surveyor asked V9 to go through the orientation packet provided to agency staff to show where this information is, V9 It says Falls identification but no it doesn't have preventative fall measures, it just directs agency staff to go to the [NAME]. It instructs the staff when residents have already experienced a fall or found to have fallen. Surveyor asked how this would be considered fall prevention if it instructs on what to do after a fall and not before a fall happens, V9 stated, I see what you mean, fall prevention starts before a fail; so I would fix this or I would add to make sure you provide safety to make sense of this direction. Surveyor asked when the last time a fall inservice training was conducted. V9 stated, The first week of December I think but I can't be sure. Surveyor asked whether if any information was provided to nurses on the 24 hour report about residents, V9 stated, We got rid of that because it was inaccurate. We throw out the 24 report at the end of each shift and they shred it. On [DATE] at 2:30 PM in a follow-up interview, V2 (director of nursing) stated to the survey team during that all residents in the facility are considered fall-risk residents. V2 added that everyone is at risk for falls and stated, We are all at risk for falls. I can fall at anytime, you can fall at any time (referring to survey team) just like residents can fall. Surveyors reminded V2 that the surveyors were not residents in the facility and not cared for by her staff. A fall risk assessment for R1 dated [DATE] showed that the resident was at no risk for falls contradicting V2 (DON) and V9's (ADON) statements that everyone including surveyors are considered a fall risk. A fall risk assessment for R3 on [DATE], [DATE], and [DATE] all showed the resident to be at no risk for falls, and again contradicting V2 and V9's statement that everyone including surveyors are at risk for falls. On 2/21 at 11:50 AM, V19 (nurse manager/infection control) stated, My main focus is infection control. I help the nurses with relaying lab results and I generally help out on the floor. For fall related injuries our DON handles that but we talk about it in the clinical meeting every day. Surveyor asked if there was a fall prevention program the facility followed, V19 stated, (V2) can give you more information on that than me. Surveyor asked how the facility ensured the staff including agency staff are provided the information, V19 stated, When they get the endorsement sometimes they are told this information. I don't know if they get this information because I'm not there on shift change. Surveyor asked if she was part of the interdisciplinary team V2 was referring to, V19 stated, Yes I am. Surveyor asked if she should know more about the fall prevention program as she is part of the IDT, V19 stated, Yes. On 2/21/ 24 at 12:35 PM, V20 (staffing coordinator) stated,We usually give a packet for agency staff to check off on. The nurses are responsible for checking to see if the agency nurse signed off on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145994 If continuation sheet Page 13 of 25 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 145994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067 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 0658 Level of Harm - Minimal harm or potential for actual harm the packet. There is no place to check off on the packet that the agency nurse signed off on it to verify. The agency nurse get the packet and they work the same day. Surveyor asked if agency staff get training when they first start at the facility, V20 stated, No I don't think they're given actual inservice except for what's in the orientation packet. I just know we give them the packet before they work here and they sign it, then work the floor. Residents Affected - Few On [DATE] at 2:18 PM, V21 (RN) stated, I think V9 (ADON) did the last inservice training for falls. They also do this every week or every other week, I ' m not sure but they tell us this when we're on the floor as a one on one training. Surveyor asked who does this one to one training, V21 stated, (V9-ADON) does this. Surveyor asked when the last fall prevention inservice was conducted and by whom, V21 stated, January and monthly, I'm not really sure but it was with the ADON. Surveyor asked who the designated fall prevention nurse was, V21 stated, That would be (V9). (Based on interviews, V9 (ADON is not the designated Fall Prevention Nurse). Surveyor asked how he determines which residents are at risk for falls when he comes on his shift, V21 stated,When I do my rounds first and do the endorsement with incoming nurses. It is written down on the list of 24 hours report. Surveyor asked to provide the 24 hour record to surveyors, V21 stated, They took out the 24 hour report. We get endorsement from nights and then we shred it. ( There were no inservice training records provided to the survey team conducted by the ADON or other as stated by V21). Facility policy dated [DATE] titled Fall Prevention Program reads in part, Purpose: To assure the safety of all residents in thee facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality assurance programs will monitor the program to assure ongoing effectiveness. Fall incident reports will be reviewed, and quality issues identified to assure the on-going effectiveness of prevention program. A care plan for fall prevention will be implemented and maintained to assure the safety of residents who are at risk. The IDT will meet to review all resident falls that have occurred. Fall incident reports will be studied to determine any significant factors that may have caused the fall and to identify additional fall prevention strategies. The DON and nurse mangers and/or designee will be responsible for implementing and communicating resident-specific recommendations from the IDT to the nursing staff assigned to the resident. The nursing staff will be responsible for assuring the recommendations are followed through. Fall prevention strategies will be utilized for all residents at risk for falls including individualized interventions in accordance with the assessed needs of each resident. Residents will be evaluated after a fall has occurred in an attempt to identify any causative factors that need correction. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145994 If continuation sheet Page 14 of 25 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 145994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067 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 - Few 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 provide adequate supervision and monitoring of residents at risk for falls and with a history of falls for 4 (R1, R3, R4, R6) of 5 residents reviewed for accident hazards in the sample. The facility also failed to follow the plan of care to prevent future falls and failed to train staff (including agency staff) on fall risk interventions. Findings include: On [DATE] at 10:30 AM, V2 (Director of Nursing/DON) presented survey team with their fall incidents log in the past 60 days which showed 56 unwitnessed falls and 3 witnessed falls (averaging nearly 1 fall per day). V2 informed the survey team that she was in charge of managing falls in the facility along with her IDT (interdisciplinary team) which consisted of her assistant director of nursing and nurse managers. 1. R1 is a [AGE] year-old with diagnoses of respiratory failure with hypoxia, type 2 diabetes, congestive heart failure, gait abnormality, and cardiomyopathy. Care plan dated [DATE] reads in part, R1 is at risk for falls. The resident has balance or walking impairments. The resident experiences weakness. The resident takes medications that may cause dizziness, loss of balance, or impair judgement. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Interventions: Fall risk evaluation. Refer to therapy for screen/evaluation and treatment as indicated. Assist and encourage the resident in wearing non-skid footwear when out of bed. Keep bed in lowest position acceptable by the resident when the resident is in bed. Remind to request assistance when getting up if need. Remind resident to sit away from edge of mattress when sitting on the bed. Remind resident to request staff assistance with transfers out of bed. On [DATE] at 03:06 AM V26 (Agency Registered Nurse/RN) wrote in part, Health Status Note: called by the CNA (Certified Nursing Assistant) to the room saying the patient is on the floor. Nurse immediately responded, found the patient sitting on the floor, close to the bed, back supporting the bed, with leg extended. patient is alert and oriented stated that she did not hit her head. Patient was assessed before moving, level of consciousness at baseline, no change, range of motion within normal limits. Vital signs stable, no new pain, no injury/ redness noted at this time, Neurological check initiated, Primary physician is notified. Will endorse to morning nurse to notify social service. On [DATE] at 02:41 AM, V27 (Agency Nurse) wrote in part, [DATE] at 02:41 AM Event Note: Resident was observed on the floor in left side lying position & rubbing her right hip/leg area. Resident stated she fell & when writer asked how it happened, she said she can't remember. Also asked if she hit her head, she did (sic) pointing on her forehead. Resident unable to move her right leg, also said she has pain on the right hip/leg 10/10. Noted a bump with mild bruising to her forehead. Notified doctor and called 911. Applied ice pack to bump on forehead & stayed with resident till paramedics came. On [DATE] at 07:55 AM, V31 (Licensed Practical Nurse/LPN Nurse Manager) wrote in part, Health Status Note: Nurse spoke with hospital nurse. Resident is being transferred to alternate hospital for orthopedic surgery. Resident has a pelvic fracture. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145994 If continuation sheet Page 15 of 25 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 145994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067 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 Efforts to reach V27 (Agency nurse) for interview were left with unreturned messages. Level of Harm - Minimal harm or potential for actual harm On [DATE] at 12:09 PM, V26 (Agency RN) stated, Yes I remember R1, she was alert but forgetful and ambulates with some assistance and she spoke a little English. I would say her gait was very unsteady and she was tall skinny and weak and was supposed to use a cane. I think she was a fall risk, but I don't remember anyone telling me this. I'm agency here if you didn't know that so I have to figure things out on our own here. Surveyors asked if she received any training or orientation from the facility about fall risk interventions or if the facility identified any residents who were at risk for falls before the start of her shifts. V6 stated, No. I've never received any training like that. I remember they just gave me this thick stack of papers (V6 describing the thickness with her hand) when I first started, and I was supposed to read through it all and sign when I was done. Surveyor asked if she knew what she was signing. V6 stated, It was pretty much some directions on how to get into (electronic medical records) and where everything was. Surveyors asked if there were any topics related to the care of the residents. V6 stated, Not that I can remember. Surveyors asked if the facility conducted any regular in-service training during her time working at the facility. V6 stated, The only time was the in-service today it was conducted by the wound nurse which was general in-service. Surveyor asked what she meant by general in-service. V6 stated, It was the wound nurse, so she mentions stuff about turning and repositioning I remember, but she just passed around a signature sheet and we all signed it. Surveyor asked if there was any in-service training specific to fall prevention. V6 stated, Not that I recall. Residents Affected - Few On [DATE] at 11:15 AM, V30 (Family Member) stated, My mom died on my birthday and it's because this facility does not know how to care for people. I was called that my mom was found on the floor, and they sent her to the hospital because she was in a lot of pain and the hospital told me she had a hip fracture. She was in a lot of pain. My mom was sent to one hospital and transferred to another one. She died unnecessarily on week later. The surgeon put in another pacemaker for her heart, but the trauma of the fall contributed to her death. Surveyor asked if this was the first time her mother fell. V30 stated, No, in fact she had just fallen several days prior to this one and no one told me until she fell the second time when she was sent to the hospital. Hospital records dated [DATE] at 10:02 AM written by V29 (emergency room Doctor) reads in part, Patient arrived via emergency medical services from facility following being found on floor. Unwitnessed fall. Does not recall how got to floor. Positive for hematoma to mid forehead. Positive for pain and deformity to right hip with decreased range of motion. reports increased pain. Problem list: Atrial fibrillation, Blunt head injury, right Hip fracture. 2. R3 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including but not limited to Type 2 Diabetes Mellitus; Chronic Diastolic Heart Failure; Chronic Kidney Disease; Hyperlipidemia; Spinal Stenosis; Essential Hypertension; Cognitive Communication Deficit; and Dizziness and Giddiness. According to R3 ' s MDS (Minimum Data Set) assessment dated [DATE] under section C, R3 has BIMS (Brief Interview of Mental Status) score of 12 indicating impaired cognition. According to R3 ' s MDS (Minimum Data Set) assessment dated [DATE] under section GG, R3 required Partial/Moderate Assistance with sit-to-stand and toilet transfers. According to record review, R3's Fall care plan dated [DATE] reads in part, Anticipate and meet (R3's); Be sure (R3's) call light is within reach and encourage (R3). No intervention pertaining to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145994 If continuation sheet Page 16 of 25 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 145994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067 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 monitoring noticed. Level of Harm - Minimal harm or potential for actual harm According to record review, R3's Fall risk assessment dated [DATE] reads in part, (R3) at low risk for falls. Residents Affected - Few On [DATE] at 11:31 AM observed R3 sitting up in the bed. Surveyor noticed bilateral bruising around R3's eyes. R3 stated, I got up to the bathroom, tripped and fell down. I think it was last week. I went to the hospital, and they said I broke my hip. When I came back to the facility, they told me I can walk, but only with assistance, and put 20% of weight on my left leg. Surveyor noticed R3's demeanor to be quiet and sad, surveyor clarified how is R3 feeling. R3 stated, I'm depressed and looked away. Surveyor observed bed in the lowest position, no fall mats, reaching device laying on recliner, out of R3's reach; call light in the nightstand ' s drawer, out of R3's reach; room cluttered and dark. On [DATE] at 3:53 PM Surveyor observed R3 in his room, sitting in the wheelchair, in the bathroom. R3 said, I think I need to go to the bathroom; I'm going to poop myself. Surveyor observed call light in R3's nightstand ' s drawer. Call light not initiated upon surveyor entrance to R3's room. On [DATE] between 9:00 AM and 4:00 PM, in 3 separate attempts, surveyor called V28 (Licensed Practical Nurse). V28 did not answer, voicemail was left. On [DATE] at 12:21 PM V2 (Director of Nursing/Fall coordinator) related the following in summary: R3 is pretty impulsive, likes to get up on his own and do things for himself. R3 usually transfers with 1 person assistance. R3 is able to use a call light. At the time of the incident (on [DATE]), R3 got dizzy, lost his balance, and fell. R3 was transferred out to the hospital due to head and left side pain. Hospital records showed left femur fracture. Prior to the fall on [DATE], R3 was not a fall risk resident. Surveyor clarified if R3 has history of falls that would place him at risk for falls. V2 responded, R3 had another fall on [DATE] and on [DATE]. That would put him at a risk for falls. I think R3 ' s care plan interventions are appropriate to prevent him from falling. Progress note written by V28 (Licensed Practical Nurse) dated [DATE] at 12:51 AM reads in part, During shift report, heard loud noise from R3's room and R3 screamed for help. Immediately, writer and certified nursing assistant in the room. R3 lying on the floor on his left side. R3 with raised area to left side of forehead. Left knee abrasion and right-hand abrasion in between fingers. R3 stated, I started walking toward bathroom to take a dump, I felt dizzy and fell down. Upon full body assessment ROM (range of motion) WNL (within normal limits), R3 assisted back to level of comfort. First aid to areas of injury given. Ice pack placed on forehead r/t (related to) raised area. Left knee cleansed with NSS (normal saline solution) and (antibiotic ointment) applied. Right hand cleansed with NSS, (antibiotic ointment) applied. Neurological checks initiated. Peri care and toileting provided. 911 called, R3 taken to (local) hospital for further f/u (follow up). Final Facility Reported Incident report dated [DATE] at 12:33 PM reads in part, Investigation/Conclusion: R3 ' s experienced change in condition which resulted in sudden change in plane. R3 was admitted to the (local) hospital. Hospital record dated [DATE] authored by V32 (ER Doctor) reads in part, (R3) was apparently trying to transfer from chair to the toilet and did not have any help. He felt dizzy and hit forehead on the ground; also, c/o (complaining of) right knee pain with a bruise to the right knee; some left knee abrasion; soreness to the left shoulder. He had severe pain in the left hip after the fall. X-ray (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145994 If continuation sheet Page 17 of 25 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 145994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067 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 Pelvis 1 or 2 views: Left femoral greater trochanter avulsion fracture. Level of Harm - Minimal harm or potential for actual harm 3. R4 is a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Unspecified Dementia; Essential Hypertension; Hyperlipidemia; Muscle Weakness; Cardiomegaly; Alzheimer's Disease; and Personal History of Transient Ischemic Attack. Residents Affected - Few R4's MDS (Minimum Data Set) assessment dated [DATE] under section C, R4 has BIMS (Brief Interview of Mental Status) score of 12 indicating impaired cognition; Under section GG, R4 required Partial/Moderate Assistance with sit-to-stand transfers. R4's Fall care plan dated [DATE] reads in part, Be sure (R4's) call light is within reach and encourage (R4) to use it for assistance as needed. Place floor mats on the floor beside the bed. According to record review, R4 ' s Fall risk assessment dated [DATE] reads in part, (R4) is at high risk for falls. On [DATE] at 11:20 AM R4 was not in the room. Fall mats and wheelchair were stored in R4's bathroom. On [DATE] at 3:52 PM R4 was asleep. Bed in the lowest position, but no fall mats were on the floor and fall mats remained stored in the bathroom. Call light was placed on the nightstand, out of R4's reach. 4. R6 is an [AGE] year old with diagnosis of Parkinson's disease, dementia, delusional disorder, and anxiety disorder. A facility reported fall incident on [DATE] by V2 (DON) reads in part, Upon making rounds when arrived at 11:00 PM, CNA informed that resident (R6) had blood on the floor of the room and was scooting around on the floor. I went to assess the resident's condition and noticed some specks of dried blood on the floor. Noticed dried blood on the back right side of resident's head. Resident was alert and oriented times 1. Resident is very confused and very fidgety. Resident mumbling incoherent words and moved all extremities without any signs of pain. Once stabilized, left the room and proceeded to call 911. V2's root cause analysis reads, (R6) has tendencies to attempt self-transfers and will at times attempt to transfer herself out of bed or from her wheelchair. Staff will place the resident in areas of high staff visibility for closer supervision when awake. Fall care plan dated [DATE] reads in part, (R6) is at risk for falls. The resident has impaired cognition and impaired safety awareness due to dementia and Parkinson's. The resident has balance impairments. The resident has a history of falls. The resident experiences weakness. The resident takes medications that may cause dizziness, loss of balance, or impair judgement (psychotropic). The resident has vision impairments. She can be impulsive and does things on her own. Has tendency to reach for things on the floor, at nurse's station, or at the table in the dining room. With periods of restlessness due to Parkinson's and dementia. Goal: Prevent a serious fall related injury. Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Fall risk evaluation. Assist the resident in wearing non-skid footwear when out of bed. Keep bed in lowest position when the resident is in bed; Place floor mattress on the floor beside the bed while resident is in bed; Ensure proper positioning when seated in wheelchair and remind resident not to lean forward when in wheelchair. Keep resident in areas of high staff visibility for closer supervision when awake, High back wheelchair for positioning. Offer group activities for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145994 If continuation sheet Page 18 of 25 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 145994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067 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 resident to attend as she allows. Level of Harm - Minimal harm or potential for actual harm On [DATE] at 10:15 AM, R6 was in her room with the door fully closed. R6 was observed lying in bed awake and flailing her arms and appeared agitated. The room was dark with no lights on and with drapes that were closed. A heater was blowing air directly toward the resident who was immediately adjacent to the heater. Per care plan, R6 should have been placed in a high visibility area when the resident was awake. Residents Affected - Few V10 (Agency Nurse) was at the other wing of the unit and was asked about R6. V10 stated, This is only my second day here. I have 2 CNAs today, I think. I don't know who they are. Surveyor asked if the residents she took care of today were considered at risk for falls. V10 stated, I don't know which residents are fall risk, sorry. Surveyor asked if she was told by anyone from the facility before she started her shift anything about her residents. V10 stated, No I wasn't told anything special, why? Surveyor asked if she received any in-service training before taking on a shift at the facility. V10 stated, No, I didn't get any in-services. It's only my second day here. Surveyor asked if she recalled anything in orientation or if she received orientation. V10 stated, We don't get orientation, I'm agency. I pick up a shift, the facility accepts, and I work the floor. Surveyor asked how she would know anything about each resident. V10 stated, I try to write it down on a sheet. Surveyor asked if would receive any endorsement from the outgoing nurse. V10 stated, No, I came late today so I didn't see the nurse before me. Surveyor asked specifically about R6, V10 looks at her resident roster and stated, Yes she's mine but I can't tell you much about her. I just know which room she's in and she's mine today. On [DATE] at 10:30 AM the doors to R6 were once again closed and resident was observed awake in a bed. V10 was again observed on the same wing and asked if she obtained any endorsement from the outgoing nurse. V10 stated, No the nurse didn't tell me anything this morning because she was gone when I got here. On [DATE] at. 11:18 am V2 (DON) stated I am in charge of falls. When we have a fall I determine the root cause, update the plan of care with appropriate interventions. I type up the summary of any fall and meet with my IDT (interdisciplinary team) which consist of all the dept heads, but clinical team are my ADON and nurse managers. They know who fell and generally speaking, they know what the interventions are. Surveyor asked if there are any in-service training conducted related to fall prevention. V2 stated, Yes we in-service on falls and the last time was right around first week of December and it was on a variety of topics. Surveyor asked what the specifics were regarding this fall in-service training. V2 stated, It points out where to locate fall intervention which located on the (electronic medical note cards). It shows to our agency nurses know how to access the (electronic medical note cards). Surveyor asked if there are actual fall interventions provided to staff including agency nurses. V2 stated, No, it just directs them to the specific resident's (electronic medical note cards) with that information. Surveyor asked if she maintained a list of residents at risk for falls. V2 stated, I maintain list of residents who fell, but I don't have a list of residents at risk for falls that I provide staff to. Surveyor asked how agency nursing staff are provided the information necessary for them to identify residents at risk for falls. V2 stated, When agency nurses start here, we have a packet that they are supposed review and usually they sign off when they receive the packet that they've read the packet. Surveyor asked about agency CNA staff. V2 stated, CNAs are also given in a binder to review and it is in the employee lounge. Surveyor asked if the orientation packets provided to agency staff are reviewed by her or any of her nurse managers prior to agency staff coming on board. V2 stated, They are just given a packet, but no one goes through it with them. We just trust they did it. Surveyor asked how she ensured agency nursing staff knew how to care for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145994 If continuation sheet Page 19 of 25 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 145994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067 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 - Few residents in the facility they are unfamiliar with. V2 stated, I can't ensure that, they should know this. Surveyor asked if agency nurses are provided any information about the resident's fall risk status during shift-to-shift endorsements. V2 stated, We don't put this down on the 24-hour report because we got rid of it because it's not reliable but only except if it's a new admission. Surveyor clarified if the shift-to-shift reports were written anywhere or if it was a verbal endorsement. V2 stated, No the nurses do write down the endorsements from shift to shift, but these 24-hour reports don't get maintained and are shredded at the end of the day so I can't show you any past ones. On [DATE] at 10:30 AM, V9 (ADON) was observed walking the units and was asked about falls. V9 stated, I don't know which residents are fall risk residents. I'd have to check their (electronic note card). Surveyor asked if she had to look up every resident's record every time a nurse cares for a resident to determine if they were at risk for falls. V9 stated, Yes. Surveyor asked how that would be considered preventative fall interventions if her nurses cannot identify which residents were at risk or high risk for falls. V9 stated, Well, all our residents our fall risk residents. Every one of us is considered a fall risk including you (referring to the surveyor). Surveyor clarified her rationale to determine everyone including surveyors were at risk for falls. V9 stated, Yes, you (referring to the surveyor) can fall at any time, just like I can fall. Surveyor reminded V9 that the surveyor was not a resident in the facility. V9 stated, Yes but we are all still at risk to fall. Surveyor asked if this rationale was in their fall risk policy. V9 stated, No it is not. [DATE] 12:50 PM, follow up interview with V9 (ADON) stated, I was the fall nurse but (V2 DON) has kind of taken over so we are all involved in fall program. In our morning meeting we discuss our falls and discuss how the resident fell, how fall happened, and what can we do to prevent from happening again. Surveyor asked how this information gets conveyed to staff. V9 stated, It is conveyed to front line staff by a shift report. We transfer the fall intervention to the (electronic note card). Surveyor asked how this information is given to agency staff. V9 stated, Every time we have agency, they go through an orientation pack. It talks about the (electronic medical note cards) and we talk about falls, change of condition and this packet is given to agency staff. Surveyor asked V9 to go through the orientation packet provided to agency staff to show where this information is. V9 stated It says Falls identification but no it doesn't have preventative fall measures, it just directs agency staff to go to the (electronic medical note cards). It instructs the staff when residents have already experienced a fall or found to have fallen. Surveyor asked how this would be considered fall prevention if it instructs on what to do after a fall and not before a fall happens. V9 stated, I see what you mean, fall prevention starts before a fall. So, I would fix this, or I would add to make sure you provide safety to make sense of this direction. Surveyor asked when the last time a fall in-service training was conducted. V9 stated, The first week of December I think but I can't be sure. Surveyor asked whether if any information was provided to nurses on the 24-hour report about residents. V9 stated, We got rid of that because it was inaccurate. We throw out the 24-hour report at the end of each shift and they shred it. On [DATE] at 2:30 PM in a follow-up interview, V2 (DON) stated to the survey team during that all residents in the facility are considered fall-risk residents. V2 added that everyone is at risk for falls and stated, We are all at risk for falls. I can fall at any time, you can fall at any time (referring to survey team) just like residents can fall. Surveyors reminded V2 that the surveyors were not residents in the facility and not cared for by her staff. A fall risk assessment for R1 dated [DATE] showed that the resident was at no risk for falls contradicting V2 (DON) and V9's (ADON) statements that everyone including surveyors are considered a fall risk. A fall risk assessment for R3 on [DATE], [DATE], and [DATE] all showed the resident to be at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145994 If continuation sheet Page 20 of 25 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 145994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067 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 - Few no risk for falls, and again contradicting V2 and V9's statement that everyone including surveyors are at risk for falls. On 2/21 at 11:50 AM, V19 (Nurse manager/Infection Control) stated, My main focus is infection control. I help the nurses with relaying lab results, and I generally help out on the floor. For fall related injuries our DON handles that but we talk about it in the clinical meeting every day. We normally have a morning meeting and then the clinical meeting starts. We discuss any admissions, diagnoses, what the residents are here for; and we discuss incidents. We discuss what the factors are, how it occurred, if call light was within reach and what interventions are in the plan. Surveyor asked if there was a fall prevention program the facility followed. V19 stated, (V2) can give you more information on that than me. We do interventions and update the program, but I do not know exactly about the fall program. (V2) makes sure all interventions are there, what the fall protocol, and if the patient fell, why that fall occurred, so we make a plan, so it doesn't happen. We then update the information in the (electronic medical note cards) for CNA to see. The agency nurses have access to it too in the (electronic medical note cards). Surveyor asked how the facility ensured the staff including agency staff are provided the information. V19 stated, When they get the endorsement sometimes, they are told this information. I don't know if they get this information because I'm not there on shift change. Surveyor asked if she was part of the interdisciplinary team V2 was referring to. V19 stated, Yes I am. On 2/21/ 24 at 12:35 PM, V20 (Staffing Coordinator) stated, We usually give a packet for agency staff to check off on. The nurses are responsible for checking to see if the agency nurse signed off on the packet. There is no place to check off on the packet that the agency nurse signed off on it to verify. The agency nurse get the packet and they work the same day. Surveyor asked if agency staff get training when they first start at the facility. V20 stated, No I don't think they're given actual in-service except for what's in the orientation packet. I just know we give them the packet before they work here and they sign it, then work the floor. On [DATE] at 2:18 PM, V21 (RN) stated, I think V9 (ADON) did the last in-service training for falls. They also do this every week or every other week, I'm not sure but they tell us this when we're on the floor as a one-on-one training. Surveyor asked who does this one-to-one training, V21 stated, (V9-ADON) does this. Surveyor asked when the last fall prevention in-service was conducted and by whom. V21 stated, January and monthly, I'm not really sure but it was with the ADON. Surveyor asked who the designated fall prevention nurse was. V21 stated, That would be (V9). (Based on interviews, V9 ADON is not the designated Fall Prevention Nurse). Surveyor asked how he determines which residents are at risk for falls when he comes on his shift. V21 stated, When I do my rounds first and do the endorsement with incoming nurses. It is written down on the list of 24 hours report. Surveyor asked to provide the 24-hour record to surveyors. V21 stated, They took out the 24-hour report. We get endorsement from nights and then we shred it. (There were no in-service training records provided to the survey team conducted by the ADON or other as stated by V21). Facility policy dated [DATE] titled Fall Prevention Program reads in part, Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality assurance programs will monitor the program to assure ongoing effectiveness. Fall incident reports will be reviewed, and quality issues identified to assure the on-going effectiveness of prevention program. A care plan for fall prevention will be implemented and maintained to assure the safety of residents who are at risk. The IDT will meet to review all resident falls that have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145994 If continuation sheet Page 21 of 25 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 145994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete occurred. Fall incident reports will be studied to determine any significant factors that may have caused the fall and to identify additional fall prevention strategies. The DON and nurse mangers and/or designee will be responsible for implementing and communicating resident-specific recommendations from the IDT to the nursing staff assigned to the resident. The nursing staff will be responsible for assuring the recommendations are followed through. Fall prevention strategies will be utilized for all residents at risk for falls including individualized interventions in accordance with the assessed needs of each resident. Residents will be evaluated after a fall has occurred in an attempt to identify any causative factors that need correction. Event ID: Facility ID: 145994 If continuation sheet Page 22 of 25 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 145994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on observations, interviews, and record review, the facility failed to ensure that nursing staff (including agency staff) have the necessary competencies, skill sets, and training required to prevent falls and assure resident safety. This failure applied to 3 (R1, R2, and R3) of 3 residents reviewed for staff competence and has the potential to affect all 117 residents currently in the facility. Findings include: On 2/20/24 at 9:45 AM, V2 (Director of Nursing/DON) presented the survey team with the total number of 117 residents currently residing in the facility. On 02/20/2024 at 10:48 AM V4 (Agency Registered Nurse) stated I work for an agency, and this is the first time I'm in this facility. The night shift nurse gave me verbal hand off report to familiarize me with the residents. I can also check resident specific needs in electronic medical record under (electronic note card). None of my residents have special needs. Surveyor clarified if V4 (agency RN) had any residents under fall risk. V4 responded: I have two residents who are at risk for falls, R4 and R5. On 02/20/2024 at 11:23 AM V5 (Certified Nursing Assistant/CNA) stated I've been working here for about three years. I'm pretty familiar with residents. For example, R3 is able to use a call light, uses urinal and needs assistance if needs to have a bowel movement or get dressed. R3 recently fell and hurt his hip. Before, we used gait belt to assist him, now he needs more assistance. R3 is not at risk for falls as far as I know. If we have a resident at risk for falls, we make sure bed is in the lowest position, there are fall mats at bed side, and we monitor those residents closer. We have fall risk resident list, we used to have a hard copy list in the binder, but now, we look it up in the electronic medical record under (electronic note card). V5 (CNA) unable to log in to electronic medical record. Unable to confirm fall risk resident list. On 02/20/2024 at 11:51 AM V7 (Registered Nurse/RN) stated there is no binder with residents' information, all information is available in electronic medical record under (electronic note card). V7 (RN) opened random electronic medical record, (electronic note card). (Electronic note card) was blank, no information available pertaining to resident's needs. On 2/21/24 at 11:18 AM V2 (Director of Nursing) stated we in-service on falls and the last time was right around first week of December 2023. Surveyor asked what the specifics were regarding this fall in-service training. V2 stated, It points out where to locate fall intervention which are located in the (electronic note card). It shows to our agency nurses how to access the (electronic note card). Surveyor asked if there are actual fall interventions provided to staff including agency nurses. V2 stated, No, it just directs them to the specific resident's (electronic note card) with that information. Surveyor asked if she maintained a list of residents at risk for falls. V2 stated, I maintain list of residents who fell, but I don't have a list of residents at risk for falls that I provide to staff. Surveyor asked how agency nursing staff are provided the information necessary for them to identify residents at risk for falls. V2 stated, When agency nurses start here, we have a new hire packet that they are supposed review and sign off when they receive the packet to confirm that they've read the packet. Surveyor asked about agency CNA staff. V2 stated, CNAs are also given binder to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145994 If continuation sheet Page 23 of 25 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 145994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many review, it is available in the employee lounge. Surveyor asked if the orientation packets provided to agency staff are reviewed by her or any of her nurse managers prior to agency staff coming on board. V2 stated, They are just given a packet, but no one goes through it with them. We just trust they read it. Surveyor asked how V2 ensured agency nursing staff knew how to care for the residents in the facility they are unfamiliar with. V2 stated, I can't ensure that, they should know this. Surveyor asked if agency nurses are provided any information about the resident's fall risk status during shift-to-shift endorsements. V2 stated, We don't put this down on the 24-hour report because we got rid of it because it was not reliable unless for new admission. Surveyor clarified if the shift-to-shift reports were written anywhere or if it was a verbal endorsement. V2 stated, No, the nurses do write down the endorsements from shift to shift, but these 24-hour reports don't get maintained and are shredded at the end of the day, so I can't show you any past ones. On 2/21/24 at 10:30 AM V9 (Assistant Director of Nursing/ADON) was observed walking the units and was asked about falls. V9 stated, I don't know which residents are fall risk residents. I'd have to check their (electronic note card). Surveyor asked if she had to look up every resident's record every time a nurse cares for a resident to determine if they were at risk for falls. V9 stated, Yes. Surveyor asked how that would be considered preventative fall interventions if her nurses cannot identify which residents were at risk or high risk for falls. V9 stated, Well, all our residents are fall risk residents. Every one of us is considered a fall risk, including you (referring to the surveyor). Surveyor clarified her rationale to determine everyone including surveyors were at risk for falls, V9 stated, Yes, you (referring to the surveyor) can fall at any time, just like I can fall. Surveyor reminded V9 that the surveyor was not a resident in the facility. V9 stated, Yes, but we are all still at risk to fall. Surveyor asked if this rationale was in their fall risk policy. V9 stated, No, it is not. On 2/21/24 at 12:35PM V20 (Staffing coordinator) stated we usually give a packet for agency staff to check off on it. The nurses are responsible for checking to see if the agency nurse signed off on the packet; however, there is no place on the packet to check off that the agency nurse went over it, and it is verified. The agency nurse gets the packet, and they work the same day. Surveyor asked if agency staff obtain any training. V20 stated, No, I don't think they're given actual in-service training, but what's in the packet. I just know we give them the packet before they work here, and they sign it. Surveyor clarified if there is a system to determine staffing needs. V20 stated, We use system that tells us how many staff members we need based on census; it does not include acuity though. We use about 50% of agency staff comparing to regular staff. We usually have more regular staff on the morning shift, evening is mostly agency, and night shift is mostly regular staff regarding CNAs. Regular nurses work mostly in the morning and afternoon, and two out of three nurses on night shift are form agency. New agency staff gets new hire packet that they need to review and sign off before the beginning of first shift. The nurse supposed to verify that agency staff went through the packet. On 2/21/24 at 12:50 PM Surveyor conducted a follow up interview with V9 (ADON) who stated, I was the fall nurse but V2 (DON) has kind of taken over, so we are all involved in fall program. We discuss our falls in our morning meeting. We discuss how residents' fell, how fall happened, what can we do to prevent it from happening again. Surveyor asked how this information gets conveyed to staff. V9 stated It is conveyed to front line staff by shift report. We transfer the intervention to (electronic note card) and to the nurse on the floor, to let them know there are new interventions. Every time we have agency staff, they go through orientation packet. We also talk about (electronic note card). The new hire packet is given to agency staff, but nobody verifies whether they read it and familiarize themselves with it. Surveyor asked V9 to go through packet with surveyor to show where fall (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145994 If continuation sheet Page 24 of 25 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 145994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many prevention is discussed. V9 pointed out that the packet describes falls' identification but does not list preventative fall measures. It directs agency staff to go to (electronic note card). Surveyor asked about last fall in-services provided to staff. V9 (ADON) stated, Last time we had fall in-service was first week of December (2023), I think, but I can't be sure. Surveyor asked to see shift to shift report and/or 24-hour report. V9 (ADON) said, We got rid of 24-hour report because it was inaccurate. We maintain shift-to-shift report, but it gets shredded at the end of each shift. On 2/21/24 at 2:18 PM V21 (Registered Nurse) who related the following in summary: I think V9 (ADON) did the last in-service training for falls. They do this every week or every other week, I'm not sure, but they tell us this when we're on the floor as a one-on-one training. Surveyor asked who does this one-to-one training. V21 stated, V9 (ADON) does this. Surveyor asked when the last fall prevention in-service was conducted and by whom. V21 stated, January (2024) and monthly. I'm not sure but it was with V9. Surveyor asked who the designated fall prevention nurse was. V21 guessing, That would be V9? V21 (RN) does not appear to know. (V9 is not the fall nurse). Surveyor asked how V21 determines who is at risk for falls when he comes on his shift. I do my rounds first and endorsement with incoming nurses. It is written down on the list of 24 hours report. V21 asked to provide the record to surveyors, They took out the 24-hour report. We get endorsement from nights and then we shred it. On 2/22/24 at 2:30 PM in a follow-up interview, V2 (DON) stated to the survey team during interview that all residents in the facility are considered fall-risk residents. V2 added that everyone is at risk for falls. V2 stated, We are all at risk for falls. I can fall at any time, you can fall at any time just like residents can fall. According to record review, daily schedules from 12/01/2023 to 02/20/2024 show that facility uses about 50% of agency staff on daily basis. Education attendance record dated 12/05/2023 reads in part, Topic: Resident Care/(electronic note card). Summary of Education: Please check (electronic note card) before providing care to residents. Purpose: To have knowledge of resident needs and preferences. Goal: To provide the optimal safe care possible for residents. No mention of fall prevention interventions. Per record review, there is no in-service conducted by V9 (ADON) weekly or monthly as stated by V21 (RN). Facility Agency Orientation: Illinois Handbook (no date) reviewed. No fall prevention interventions listed; falls section pertains to post-fall interventions only. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145994 If continuation sheet Page 25 of 25