Health inspection·January 13, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few the 3rd floor and saw resident laying on the floor. V13 said there was food sitting on the table. He said walker was farther away from the bed and close to the closet. He said R1 got up from the wheelchair, lost her balance and fell. V13 said there was indication that R1 hit her head against the floor because of the bruise and skin tear on forehead. He Informed the doctor and R1 was transferred to the hospital. V13 stated R1 was admitted in the hospital with diagnoses of subdural hematoma. He stated he can't remember if R1 was toileted, did not check if R1 was wearing a proper footwear. V13 said R1 was high for fall, if R1 was placed near the nurse's station and if walker was accessible or within reach to R1 then fall might have been prevented. On 1/12/25 at 1:11pm V14 (Certified Nursing Assistant / CNA) stated has been working with R1 who can speak minimal English. He said he was working with R1 on 11/13/24. R1 came back from out on pass and was served dinner in her room. V14 said R1 was sitting up in wheelchair, call light was within reach and instructed to call for help. V14 stated he went for his break and was informed that R1 fell and was about to be transferred to the hospital. V14 stated R1 would usually eat in the dining room, and she is high risk for fall. V14 said if resident was placed in the dining room, by the nurse's station, or if R1 had called for help, the fall might have been prevented. On 1/12/25 at 1:59pm V15 (Certified Nursing Assistant / CNA) stated she had worked with R1 but was not the assigned CNA during the fall incident on 11/13/24. V15 said she heard R1 was moaning or something, saw R1 laying on the floor on her stomach , face down with a bruise and some blood on the floor. She said nurse was informed immediately. V15 stated I don't believe R1 had any shoes on because I saw her shoes on the floor. R1 was wearing socks and might have slid. V15 stated R1's walker was by the radiator/ closet and not accessible to the R1. V15 said R1 is high risk for falls. V15 said she is always eating in the dining room. If the resident was in the dining room ,closer to the nurse's station, or maybe if R1 was using a proper footwear, the fall might have been prevented. On 1/12/25 at 2:37pm V3 (ADON / Assistant Director of Nursing) stated has been working in the facility since 2015. V3 stated she was informed by the nurse that R1 fell and had Bruise and skin tear on forehead. V3 said R1 was transferred to the hospital with a diagnosis of a subdural hematoma. She said the initial report was sent to state agency. V3 stated R1 is high risk for falls. The fall could have prevented, if R1 was place in common area like dining room or nurse' station for close supervision. Care plan date initiated on 2/24/23 documented in part: R1 at High risk for falls related to weakness. History of falls on: 5/17/2023, 12/19/2023, 7/15/2024, 11/13/2024. Care plan interventions included but not limited to: R1 to use walker. Ensure R1 is wearing appropriate footwear when ambulating. Care plan date initiated 1/18/24 documented in part: R1 have an ADL self-care/ mobility performance (functional abilities) deficit. Eating: R1's usual performance is supervision. Fall-initial occurrence note dated 11/13/24 documented in part: R1 had an un-witnessed fall in resident room on 11/13/2024 8:00 PM. Forehead bruised. Nurses Note dated 11/14/2024 showed in part: confirmed R1's hospital admission with Admitting Diagnosis: SUBDURAL HEMORRHAGE. R1's CT (computer tomography) head wo contrast result dated 11/13/24 documented in part: Impression: Stable narrow caliber interhemispheric acute subdural hematoma. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145999 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145999 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Niles 6601 West Touhy Avenue Niles, IL 60714 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 - Actual harm Residents Affected - Few R1's hospital records by V5 (HOSPITAL PHYSICIAN) history and physical notes dated 11/14/24 documented in part: R1 with mechanical fall in the nursing home. Was found on the floor, fall was unwitnessed. Frontal head contusion and bruising along the left hand and wrist. CT head with slim interhemispheric acute subdural hematoma. R1 is somnolent and complaining of neck pain. Waking up on and off on sternal rub and going back to sleep. Could not answer any of the subjective answer. V4 (Nurse Practitioner / NP) progress note dated 11/20/24 documented in part: R1 was readmitted to the hospital 11/13-11/17 due to a fall, unwitnessed. R1 was found to have interhemispheric SDH (Subdural hematoma). Facility's incident report dated 11/19/24 documented in part: R1 was last observed sitting in wheelchair eating her dinner, stood up, lost her balance, and fell to the floor. R1 had bruise and skin tear on the front / middle of the forehead and was sent to hospital with diagnosis of Subdural Hematoma. Facility's fall prevention policy dated 11/21/17 documented in part: 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. Assistive devices such as walkers and canes will be placed within reach of those residents. The resident will be reminded as needed to call for assistance before attempting to ambulate. Residents who require staff assistance will not be left alone after being Footwear will be monitored to ensure the resident has proper fitting shoes and / or footwear is non-skid. Prior to the survey date of 1/12/25 the facility took the following actions to correct the deficient practice. Surveyor did observation, interview and record review and found the following action plans in place: 1. R1 was supervised by staff every 15 minutes and placed by the common area for close monitoring. R1's log monitoring every 15 minutes from 11/17/24 to 1/11/25. 2. R1 was evaluated by therapy upon readmission on [DATE]. 3. V2 (DON) and V3 (ADON) in-serviced all staff on the facility's fall policy and individualized interventions. 4. Care plans updated with new interventions. 5. Fall assessment was completed upon readmission on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145999 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145999 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Niles 6601 West Touhy Avenue Niles, IL 60714 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 6. Level of Harm - Actual harm R1 had no further fall after incident on 11/13/24. Residents Affected - Few 7. V2 (DON) and V3 (Assistant Director of Nursing) stated that they discuss fall and interventions at morning meeting with IDT (interdisciplinary team). 8. Facility did a wide audit to ensure high risk residents care plans and interventions are up to date. 9. The facility's Quality Assurance Committee has monitored compliance through the daily and weekly internal Quality Assurance process. QA tool from 11/18/24 to 1/10/25 reviewed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145999 If continuation sheet Page 4 of 4