Inspection·January 26, 2024

F 0550 3. On 1/23/24 at 12:15 PM, V17 (CNA) was observed feeding R33 and R56 at the same time. Level of Harm - Minimal harm or potential for actual harm R33's Face Sheet showed diagnoses of Alzheimer's disease, chronic pain, dementia with behavioral disturbances, generalized anxiety disorder and a history of falling. R33's January 2024 physician orders for a general pureed textured diet with regular thin liquids and nutritional supplements three times per day. The care plan dated 1/4/24 stated R33 has a self-care performance deficit and requires substantial / maximal staff assistance with eating and is at risk for altered nutritional status. Interventions showed R33 should be observed for signs of pocketing, choking, coughing, drooling or holding food in her mouth. Residents Affected - Some R56's Face Sheet showed diagnoses of senile degeneration of the brain, adult failure to thrive, and dysphagia (difficulty swallowing). R56's physician's orders include general pureed diet with nectar thick liquids. R56's care plan dated 12/9/23 states she has self-care performance deficit and is dependent on staff for eating. R56 is at risk for altered nutritional status and should be observed for pocketing, choking, coughing, drooling or holding food in her mouth. On 1/25/24 at 10:13 AM, V2 DON (Director of Nursing) stated CNAs should be feeding one person at a time so they can pay attention to each resident individually in a normal manner. V2 added that CNAs should notice how each resident is chewing, swallowing, and eating their food and should not be distracted from the resident they are assisting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146170 If continuation sheet Page 2 of 16 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 146170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Gardens Nsg & Rehab 212 Airport Road North Aurora, IL 60542 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure a resident's code status was consistent throughout the medical record to accurately reflect a resident's end of life choice. This applies to 1 of 25 residents (R9) reviewed for advanced directives in a sample of 25. Findings include: R9's Face Sheet showed diagnoses of chronic atrial fibrillation, diabetes, hypertension, and history of venous thrombosis and embolism (blood clot). R9's MDS (Minimum Data Set) dated [DATE] shows R9 is cognitively intact. R9's advance directive care plan (initiated [DATE]) showed Pursuant to resident rights and the individual's desire to retain control and autonomy over their health care decisions, [R9] has executed/completed . POLST: Practitioner Order for Life-Sustaining Treatment. The Goal in the care plan (initiated [DATE]) showed [R9's] wishes for DNR status, as specified in their advance directive documents, will be honored and clearly delineated in the medical record, in compliance with state law. Interventions (initiated [DATE]) showed Inform caregivers of code status. R9 signed a POLST (Practitioner Order for Life-Sustaining Treatment) form on [DATE], selecting NO CPRDo Not Attempt Resuscitation (DNR). R9's Active (Physician) Orders as of [DATE] showed a [DATE] order of Attempt Resuscitation/CPR . Farther down on the orders, it showed a [DATE] order that read DNR. Immediately below that order, another order showed a [DATE] order for Full treatment: Primary goal of sustaining life by medically indicated means. In addition to treatment described in Selective Treatment and Comfort-Focused Treatment, use intubation, mechanical ventilation and cardioversion as indicated. Transfer to hospital and/or intensive care unit if indicated. Further down is a [DATE] order that read POLST-Do Not Attempt Resuscitation/DNR. The banner at the top of R9's EMR (Electronic Medical Record) showed all the orders combined, showing Code Status: Attempt Resuscitation/CPR (selecting CPR means Full Treatment in Section B is selected). DNR. Full Treatment: Primary goal of sustaining life by medically indicated means. In addition to treatment described in Selective Treatment and Comfort-Focused Treatment, use intubation, mechanical ventilation and cardioversion as indicated. Transfer to hospital and/or intensive care unit if indicated. POLST- Do Not Attempt Resuscitation/DNR. On [DATE] at 9:42 AM, V15 RN (Registered Nurse) caring for R9 stated a resident's code status can be located on the Medication Administration Record, doctors' orders, admission records or the banner at the top of the EMR. V15 stated R9's banner was confusing because the verbiage says two different things, stating R15 had two different orders and they needed to be clarified. On [DATE] at 10:03 AM, V10 CNA (Certified Nursing Assistant) the code status for residents is found in the EMR or by asking the nurse. On [DATE] at 10:08 AM, V17 CNA stated resident code status is in the EMR. V17 stated if she were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146170 If continuation sheet Page 3 of 16 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 146170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Gardens Nsg & Rehab 212 Airport Road North Aurora, IL 60542 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 0578 confused by the code status, she would ask the nurse. Level of Harm - Minimal harm or potential for actual harm On [DATE] at 10:13 AM, V2 D.O.N (Director of Nursing) stated staff look for resident's code status in the banner at the top of the EMR or the physician orders. V2 stated the previous order to attempt resuscitation should have been removed by the person updating the order. V2 verified R9's POLST says DNR, adding the two orders are confusing, and the resident's wishes should be honored. Residents Affected - Few The facility policy Communication of Code Status dated 2/2023 states It is the facility's policy to adhere to residents' rights to formulate advanced directives. In accordance with these rights, the facility will implement procedures to communicate a residents' code status to those individuals who need to know this information. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146170 If continuation sheet Page 4 of 16 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 146170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Gardens Nsg & Rehab 212 Airport Road North Aurora, IL 60542 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to implement a resident's pressure ulcer intervention in a timely manner. This applies to 1 of 7 residents (R53) reviewed for pressure ulcer in a sample of 25. Residents Affected - Few The findings include: On 1/23/24 at 11:20 AM, R53 was in bed resting. No low air-loss mattress was present. On 1/24/24 at 11:45 AM, V3 (ADON/Assistant Director of Nursing) performed wound care treatments to R53's bilateral buttocks. V3 said that R53 had bilateral DTI (deep tissue injuries) to her buttocks. V3 stated wound rounds are done weekly with the nurse practitioner and R53's wounds were measured on Monday, 1/22/24. V3 stated R53's DTI had purplish discoloration, there was no drainage, and she had a skin tear to her left buttock. On 1/24/24 at 11:45 AM, no low-air loss mattress was present on R53's bed. On 1/25/24 at 12:42 PM, R53 was in her room eating her lunch. No low air-loss mattress was present. R53's EMR (Electronic Medical Records) showed diagnoses of cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and type 2 diabetes mellitus with unspecified complication. R53's MDS (Minimum Data Set) of 11/6/23 shows R53 is at risk for developing pressure ulcers/injuries and she had MASD (Moisture Associated Skin Damage). R53's Weekly Skin Check of 12/21/23 shows that there was redness to R53's left gluteal fold. R53's Weekly Skin Check of 1/4/24 shows that there was redness to R53's coccyx area and excoriation to the left lower leg. R53's Weekly Skin Check of 1/18/24 shows that R53 had rashes, erythema to sacrum. R53's Weekly Wound Documentation (1/22/24) shows that R53 had DTI, the date acquired was 1/21/24, wound measurements to left buttocks showed length 2 cm, width 2 cm, depth 0 cm; wound measurement to right buttocks length 3cm, width 1cm, depth 0 cm; Peri- wound tissue with mild MASD. The special equipment/preventive measures for the DTI were Calazime Skin Protectant External paste, low air-loss mattress ordered 1/21/24 by hospice, arrived 1/24/24. On 1/25/24 at 2:06 PM, V21 (Hospice Clinical Director) said they were not notified until 1/23/24 (two days later) that R53 needed a low air-loss mattress, and they delivered the mattress on 1/24/24. On 1/25/24 at 1:35 PM, V3 (ADON) said R53's air loss mattress was ordered on 1/21/24 when the DTI was discovered, and air loss mattress came in yesterday (1/24/24). R53 was currently on the air loss mattress. On 1/25/24 at 1:44 PM, V2 (Director of Nursing) said R53 was just placed on the low air loss mattress about five minutes ago. Progress notes from wound care provider of 1/22/24 documents R53 has history of pressure wounds, and active problems of pressure-induced deep tissue damage of the right and left buttock. On 1/25/24 at 1:03 PM, V2 (DON/Director of Nursing), said they do weekly skin checks on R53 and that R53 has had the MASD on and off and has been treated with zinc oxide and A & D ointment since 9/27/23. V2 said that on 1/18/24, there was redness noted to R53's sacrum and on 1/21/24, DTI was discovered and R53 was seen by the nurse practitioner on 1/22/24. V2 said R53 was on hospice and on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146170 If continuation sheet Page 5 of 16 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 146170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Gardens Nsg & Rehab 212 Airport Road North Aurora, IL 60542 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1/25/24, there was an order for R53 to have an air loss mattress. V2 said the hospice provides the air loss mattress, and it usually gets to the facility within 24 hours once the order is placed. On 1/25/24 at 1:40 PM, V19 (Clinical Director/Consultant) said R53 was currently on the air loss mattress, hospice usually brings the mattress within 24 hours from when it is ordered. V19 said they could always order the low air loss mattress from another company, and it would arrive at the facility the same day or next day if the order came was placed at night. The facility's Pressure Injury Prevention and Management policy (revised 10/2022) states that the facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146170 If continuation sheet Page 6 of 16 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 146170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Gardens Nsg & Rehab 212 Airport Road North Aurora, IL 60542 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interview and record review, the facility failed follow up and document pharmacist recommendations made during the monthly medication review. This applies to 3 of 5 residents (R4, R12 and R26) reviewed for unnecessary medications in a sample of 25 residents. Findings include: 1. R4's medical history includes Chronic Pulmonary Obstructive Disease, Dementia, Peripheral Vascular Disease, Major Depressive disorder, and Hypertension. R4's progress notes from the pharmacist were reviewed for the prior twelve months. On 2/27/23, 3/20/23, 8/30/23 and 11/30/23 the pharmacist documented in the EMR (Electronic Medical Record). MMR (Monthly Mediation Review) completed: irregularity noted. See Consultant's report. No details regarding the irregularity were found in the R4's EMR. The facility did not provide any copies of the consultant reports or physician response to recommendations. 2. R12's medical history includes Chronic Respiratory failure, Dementia, Bipolar Disorder, Recurrent Depressive Disorder, Generalized Anxiety Disorder, Chronic Pain and History of falling. R12's progress notes from the pharmacist were reviewed for the prior twelve months. On 1/30/23, 2/6/23, and 5/22/23 the pharmacist documented progress note in the EMR stated MMR (Monthly Mediation Review) completed: irregularity noted. See Consultant's report. No details regarding the irregularity were found in the R12's EMR. The facility did not provide any copies of the consultant reports or physician response to recommendations. 3. R26's medical history includes Parkinson's Disease, Dementia, Major Depressive Disorder, Anxiety Disorder and History of Falling. R26's MMR (Monthly Medication Review) consultant report dated 10/13/23 post fall review recommendations - if antipsychotic therapy is necessary consider a non-dopamine antagonist. The facility did not provide the physician response to the recommendation made by the pharmacist. 1/25/24 at 4:25 PM, V2 DON (Director of Nursing) stated the pharmacist documents the MMR (Monthly Medication Review) was completed in each resident EMR (Electronic Medical Record). The pharmacist document is no irregularities were found or irregularities, see report. V2 stated the pharmacist recommendation reports come to her. V2 stated there is a form with all recommendations provided to the medical director and the medical director addresses concerns for him. V2 stated there are nursing recommendations and physician recommendations that they review themselves. If recommendations are related to psychotropic medications, they are sent to the psych services. V2 stated she sometimes get verbal orders from the physician or nurse practitioner. V2 stated the pharmacy recommendations are not scanned into the EMR. V2 stated she scans the recommendations back to the pharmacist, so he is aware of what has been addressed. The facility undated policy Medication Regime Review states the facility is responsible for ensuring that all clinical records are available for review. For facilities that utilize an eMAR (Electronic Medication Record) system, the consultant pharmacist's review will be in the eMAR system. The consultant pharmacist will document in the progress notes section if any recommendations are made, and the note will be electronically signed. The facility undated policy Distribution of Medication Regimen Review Report states the attending (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146170 If continuation sheet Page 7 of 16 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 146170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Gardens Nsg & Rehab 212 Airport Road North Aurora, IL 60542 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 0756 Level of Harm - Minimal harm or potential for actual harm physician and /or medical director will document their review and response to the recommendations made by the consultant pharmacist directly on the medication regimen review report form or in the medical record. If the physician disagrees with the recommendations or no change is to be made, the physician must document the rational in the resident's medical record. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146170 If continuation sheet Page 8 of 16 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 146170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Gardens Nsg & Rehab 212 Airport Road North Aurora, IL 60542 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to appropriately store and secure medications safely for 4 residents (R13, R19, R61, & R315) in a sample of 25. Findings include: 1. On 01/24/24 at 1:30 PM, R315's oxycodone 5mg medication punch card was observed with the #7 pill slot punched open and a pill inside. V15 (Nurse), who was said she did not know the facility's policy for when a control medication is punched open, but she would not discard the medication because it didn't hit the floor and if she were to discard the medication, she would have to get a second nurse and they may not be available. R315's EHR (Electronic Health Record) showed that she is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including unilateral primary osteoarthritis of right knee. R315's physician's order dated 1/12/24 showed oxycodone HCl Oral Tablet 5 MG Give 1 tablet by mouth every 6 hours as needed for moderate-severe pain rated 4-6 2. On 01/24/24 at 1:30 PM, R19's Lorazepam 0.5mg medication punch card was observed with the #12 pill slot punched open, with tape over it and a pill inside. On 1/25/24 at 11:37 AM, R19's Lorazepam 0.5mg medication punch card was observed with the #3 pill slot punched opened with a pill inside. V2 DON (Director of Nurses) who was present at the time, said the medication needs to be disposed of. R19's EHR showed that she is an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including bilateral primary osteoarthritis of hip, and generalized anxiety disorder. R19 did not have an active order for the Lorazepam 0.5mg. R19's last order for Lorazepam 0.5mg was on 10/22/23 for lorazepam 0.5mg every 8 hrs. as needed for anxiety with and end date of 11/5/23. On 01/25/24 11:27 AM, V2 DON (Director of Nurses) said her expectations are that there is to be no taping closed of controlled medications. V2 said she told the nurses they need to get a second nurse to dispose of the medication. V2 said this is done to prevent drug diversion. On 1/24/23 at 1:42 PM, V11 (Nurse) said if a narcotic punch card is open, the pill should be discarded/wasted with another nurse. V11 said she would not tape it back up. V11 said she did not know the facility's policy. The facility's 3.3 Controlled Substances policy (date 12/2018) showed medications classified by the FDA as controlled substances have high abuse potential and may be subject to special handling storage and record keeping. All controlled substances will be dispensed in a tamper resistant container designed for easy counting of content. 3. On 1/23/24 at 11:13 AM, R61 was resting in bed in her room. R61 had tube of Triamcinolone Acetonide 0.1% cream on her bedside table. On 1/24/24, at 11:34 AM, the Triamcinolone cream was still on R61's bedside table. On 1/25/24 at 10:05 AM, the Triamcinolone cream was still present on R61's bedside table. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146170 If continuation sheet Page 9 of 16 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 146170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Gardens Nsg & Rehab 212 Airport Road North Aurora, IL 60542 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R61's POS (Physician Order Sheet) shows order for Triamcinolone Acetonide External Cream 0.1% apply to affected area topically every 12 hours as needed for rash with redness and itching. R61 did not have an order for medication to be stored in the resident room. 4. On 1/23/24 at 11:21 AM, R13 had a tube of Trolamine Salicylate 10% Arthritis pain relieving cream and a tube of Iodosorb Cadexomer Iodine gel tube on the cabinet in her room. At 11:32 AM, R13 said she uses the arthritis cream because she has arthritis but does not use the Iodosorb cream. On 1/24/24 at 11:35 AM, arthritis cream and the Iodosorb cream were on R13's cabinet. On 1/25/24 at 10:07 AM, both creams were still on R13's cabinet. Review of R13's current POS shows that there were no orders for Iodosorb or the Arthritis pain relieving cream and or to have medications stored in resident's room. On 1/25/24 at 10:49 AM, V2 (DON/Director of Nursing) said R13 and R61 do not have orders for medications to be stored in their rooms. The facility's Medication Storage policy (revised 2/2023) states to ensure all medications are stored in pharmacy and/or medication rooms, stored in locked compartments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146170 If continuation sheet Page 10 of 16 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 146170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Gardens Nsg & Rehab 212 Airport Road North Aurora, IL 60542 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide thickened liquids as ordered by the Physician for a resident with aspiration precautions. This applies to 1 of 6 residents (R267) reviewed for diet texture in a sample of 25. The findings include: The EMR (Electronic Medical Record) showed R267 was admitted to the facility on [DATE], with multiple diagnoses which included cerebrovascular disease affecting the right dominant side and with right oropharyngeal dysphagia, pneumonia, chronic obstructive pulmonary disease, and asthma. R267's 1/22/2024 Minimum Data Set showed he was cognitively intact. R267's risk for altered nutritional status care plan dated 1/17/2024 showed multiple interventions including, Observed for document report PRN any s/sx of dysphagia: Pocketing, Choking, Coughing, Drooling, holding food in mouth, several attempts at swallowing, Refusing to eat, Appears concentered during meals .Provide, serve diet as ordered. R267's Order Summary Report showed a 1/18/2024 diet order for a general diet with pureed texture and nectar consistency liquids. On 1/23/2024 at 12:08 PM, R267 was in the dining room for lunch and started to cough while drinking a cup of coffee. V9 (Certified Nurse Assistant/CNA) said R267 had difficulty swallowing and he was supposed to receive thickened liquids and a pureed diet. V9 stirred and inspected R267's cup of coffee, which showed it was a thin consistency. V9 said she thought the thickener had not settled and moved the cup to the side. V9 then returned and removed the cup of coffee away from R267. V6 (CNA) provided R267 with a new cup of thickened coffee. V6 said she thickened R267's coffee to a honey-thick consistency. On 1/24/2024 at 3:56 PM, V8 (Speech Language Pathologist/SLP) said she was treating R267 for dysphagia and he had swallowing precautions. V8 said R267 had a history of lots of respiratory problems, including a previous tracheotomy. V8 said R267's diet was pureed with nectar thick liquids and if not received as ordered, he could aspirate. V8 said staff should have followed R267's diet on his meal ticket, which shows he should receive thickened liquids. On 1/25/2024 at 9:35 AM, V2 (Director of Nursing/DON) said she expects CNAs to read the resident's meal ticket and follow the ordered diet. V2 continued to say R267 should have been served the correct consistency of thickened liquids as ordered, and if not provided, he could aspirate, get pneumonia or sepsis, or die. The facility's policy, titled Swallowing Evaluation Protocol not dated, showed Policy Specifications: 1. The speech language pathologist will assess the resident for dysphagia and make recommendations to the physician for proper food consistency and fluid thickness. A physician's order is needed for food consistency changes .4. Appropriate information on safe swallow strategies for the resident is readily available to nursing and dining room staff. This information, provided to staff by the speech pathologist, will be included on the tray card or ticket or in an appropriate form available to staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146170 If continuation sheet Page 11 of 16 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 146170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Gardens Nsg & Rehab 212 Airport Road North Aurora, IL 60542 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to properly label, date, seal, and store food items in the kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 1/23/24 documents the total census was 64 residents. On 1/23/24 at 11:06 AM, V12 (Dietary Manager) 63 residents eat from the facility kitchen. On 1/23/24 starting at 10:13 AM, the facility kitchen was toured in the presence of V12 (Dietary Manager) and V13 (Dietary Manager-in-Training). The following was found: Walk-in refrigerator: 1. Two large bins of pre-cooked roast beef in silver bins, one tray stacked on top of the other, dated 1/22/24. Both trays had tin foil on the top and was not sealed. The foil was broken with meat exposed in both containers. Drips of brown liquid were present on the tinfoil of the bottom tray. 2. Ten trays of fruits in small pre-portioned bowls. V13 said they were pears and strawberries and cream. None of the ten trays were labeled or dated. Dry Storage: 3. A 22-quart bin of brown sugar without a label or date. 4. A 27-pound box of maraschino cherries with five 4 pound 8 ounce containers inside. Three of the containers were sticky with red substance leaked on the outside and the bottom and top of the box. 5. A 6-pound 12 ounce can of pineapple tidbits with a large dent on the circulation rack for resident consumption. On 1/24/24 at 12:36 PM, V12 (Dietary Manager) said all foods need to be labeled and dated so residents do not get served expired foods. V12 said all foods need to be sealed to prevent contamination and/or cross-contamination. V12 said it is not okay to stack the silver food bins, one on top of the other, because of the risk of cross contamination from the contents of one pan spilling into the other. V12 said all dented food cans should be removed from circulation because of the risk of botulism. V12 said if food from a dented can is served to the residents, residents can get sick and/or the quality of the food can be affected. The facility's policy titled, Quick Resource Tool: Receiving issued 9/1/21 states, Standard: Safe food handling procedures for the time and temperature control will be practiced in the transportation, delivery, and subsequent storage of all food items. Guidelines: .4. All canned goods will be appropriately inspected for dents, rust or bulges. Damaged cans will be segregated and clearly identified for return to vendor or disposal, as appropriate. 5. All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146170 If continuation sheet Page 12 of 16 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 146170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Gardens Nsg & Rehab 212 Airport Road North Aurora, IL 60542 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm The facility's policy titled, Quick Resource Tool: QRT Food Storage issued 9/1/21 states, Standard: . All time/temperature control for safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. Guidelines: .5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination . Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146170 If continuation sheet Page 13 of 16 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 146170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Gardens Nsg & Rehab 212 Airport Road North Aurora, IL 60542 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 0882 Level of Harm - Minimal harm or potential for actual harm Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on interview and record review, the facility failed to have a designated certified Infection Preventionist (IP) who was responsible for the facility's Infection Prevention and Control Program (IPCP). Residents Affected - Many This affects all 64 residents in the facility. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 1/23/24 documents the total census was 64 residents. On 01/24/24 at 12:10 PM, V2 DON (Director of Nurses) said the facility no longer has an IP. V2 said she believed that the IP quit around the end of September 2023 and the facility has not hired anyone to fill the position since. V2 said she does some of the ICPC along with the facility's nurse consultant. V2 said she is not certified as an IP. On 01/25/24 at 09:42 AM, V19 (Nurse Consultant) said she did the screening, education, and offering of the flu and /covid-19 for the staff at the facility but she was not certified as an IP. The facility's Infection Preventionist policy (date 11/14/22) showed the facility will employ one or more qualified individuals with responsibility for implementing the facility's infection prevention and control program. The facility will ensure the IP (Infection Preventionist) is qualified by education, training, experience or certification. The facility's Payroll Action form for V22 (Facility's former IP) showed her resignation date of 11/13/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146170 If continuation sheet Page 14 of 16 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 146170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Gardens Nsg & Rehab 212 Airport Road North Aurora, IL 60542 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain kitchen equipment in safe operating condition. This applies to all residents residing in the facility, and all staff and visitors that come to the facility. Residents Affected - Many The findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 1/23/24 documents that the total census was 64 residents. On 1/23/24 at 10:59 AM, the hotbox electrical cord in the kitchen was observed frayed/damaged at both ends with wires exposed. The end of the cord that attached to the electrical plug was frayed, and the end of the cord that attached to the hot box was also frayed, exposing wires underneath at both ends. V12 (Dietary Manager) said she put in a work order about a month ago to V14 (Maintenance Director) to replace the hot box cord. On 1/24/24 at 10:36 AM, V14 (Maintenance Director) said the work order to replace the hotbox cord was never put in writing so he did not know when he was first told by V12 (Dietary Manager) that it needed to be replaced. V14 said he thought it was a few weeks ago when he was notified by V12 that the hotbox cord needed to be replaced. On 1/24/24 at 12:36 PM, V12 said she remembered telling V14 about the hot box cord issue around the beginning of December and the fraying had progressively gotten worse since then. V12 said the frayed cord is an electrical fire risk and potential harm of electrical shock if someone touched the exposed wires or tried to move the equipment without realizing it was damaged. The facility's policy titled, Electrical Safety Precautions Policy dated February 2023 states, Policy: To assure that all personnel are aware of electrical safety precautions to be followed when performing tasks associated with position responsibilities. Policy specifications: .7. Worn, cut, frayed, spliced, exposed, or burned power cords should be reported .18. All defective equipment, outlets, electrical cords, etc., should be tagged to prevent use by others . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146170 If continuation sheet Page 15 of 16 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 146170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Gardens Nsg & Rehab 212 Airport Road North Aurora, IL 60542 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview and record review, the facility failed to ensure lint was removed from the facility's dryers, posing a fire hazard. This applies to all residents residing in the facility, all staff, and visitors that come to the facility. The findings include: On 01/24/24 at 10:26 AM, all four clothes dryers were observed with clothes in them and with lint on the screens, from about an eighth to a half inch thick. Each dryer had a front panel at the bottom of the dryer, and when removed, two piles of lint were noted inside each dryer. The sizes of the piles all ranged from six to eighteen inches across, four to six inches high, and three to six inches deep. V20 (Director of Housekeeping) said all the dryers were fire hazards because of the lint in them. V20 said the dryers are to be cleaned every two hours and he believed they had not been cleaned that day at all. The facility lint trap log showed that the lint traps had not been cleaned for the last two days, 1/23/24 and 1/24/24. The lint trap log starts at 6 AM and runs through 6 AM. As of 1/24/24 at 10:26 AM, the log showed last time the lint had been cleaned from the dryers was on 1/22/24 at 10 AM, two days earlier. The log also showed that no lint had been cleaned from the dryers on 1/12/24 & 1/15/24. The log showed that on the days that lint was cleaned from the dryers, it was only cleaned twice in the 24-hour day, on dates of 1/1/24 1/11/24, 1/13/24 - 1/14/24, 1/16/24 -1/22/24. On 01/24/24 at 01:43 PM, V14 (Maintenance Director) said lint should be clean after three loads and an accumulation of lint in a dryer is a fire hazard. V14 said the facility's policy is to clean after every three loads, then nightly and monthly with shop vac. The facility's dryer manual, Tumble Dryers 50-pound capacity 75 pound capacity (date April 2019) page 14 showed, to avoid fire and explosion, keep surrounding areas free of flammable and combustible products. Regularly clean the cylinder and exhaust tube should be cleaned periodically by competent maintenance personnel. Daily remove debris from lint screen filter and inside of filter compartment. The facility's Dryer Safety policy (no date) showed that the lint screen must be brushed and cleaned every 2 hours if not, the screen will become packed with lint. When this occurs, the warm air moving through the system is blocked, raising the temperature in the basket and causing a potentially dangerous situation (i.e., where one spark on lint can cause a fire). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146170 If continuation sheet Page 16 of 16