Inspection·November 14, 2024

F 0676 Level of Harm - Minimal harm or potential for actual harm On November 13, 2024, at 12:11 PM V15 (Registered Nurse) stated she has taken care of R31 in the past and was taking care of her today, and she was not aware R31 was hard of hearing. Surveyor asked if she has seen resident with hearing aids in her ears. V15 said she has occasionally seen R31 with hearing aids in her ears. V15 stated the Certified Nursing Assistants (CNA) puts them in for the residents. V15 stated R31 has never asked V15 to put her hearing aids in. Residents Affected - Few On November 13, 2024 at 12:13 PM, V16 (CNA) stated she is caring for R31 today and has been assigned to her a lot in the past. V16 stated she has never helped R31 put her hearing aids in. V16 stated it has been a while since she has seen R31 with her hearing aids in. On November 13, 2024, at 4:02 PM, R31 still had no hearing aids in her ears. R31 stated after surveyor left earlier in the day, the nurse came in and said she would put her hearing aids in, but she had to go pass a medication first. R31 stated she thinks it was around 2:00 PM. R31 stated V15 did not put her hearing aids in. R31 stated that the nurse also said she would let the morning shift know to put R31's hearing aids in for her. R31's Progress note written by V15 on November 13, 2024 at 5:37 PM showed the following: Nurse asked resident if she had her hearing aids in, resident stated no. Nurse asked why she did not have her hearing aids and resident replied because no one ever mentions it, or ask me if I want them put in. Explained to the resident that she needs to ask the staff and hit her call light any time help is needed with inserting hearing aids. On November 13, 2024 at 4:06 PM, V3 (Assistant Director of Nursing) residents who need assistance with putting on their hearing aids have orders to that effect and/or it is in their care plan. V3 stated she expects her staff to follow the care plan and assist residents who require assistance with putting on their hearing aids. V3 stated the nurse, or the CNA can assist the resident in putting their hearing aids in. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146170 If continuation sheet Page 2 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2024 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 assist residents identified as needing assistance with eating, personal hygiene and grooming. This applies to 4 of 5 residents (R16, R42, R50 and R51) reviewed for ADL (activities of daily living) in the sample of 15. Residents Affected - Some The findings include: 1. R50 had multiple diagnoses including malignant neoplasm of the stomach, severe protein-calorie malnutrition, cerebral infarction and Barret's esophagus with low grade dysplasia, based on the face sheet. R50's significant change in status MDS (minimum data set) dated September 3, 2024 showed the resident was cognitively intact. The same MDS showed R50 required assistance from the staff with eating and personal hygiene. R50's active order summary report showed on August 27, 2024, the resident was admitted to hospice care due to malignant carcinoid tumor of the stomach. On November 12, 2024 at 10:40 AM, R50 was sitting in his wheelchair inside the main dining room. R50 had accumulation of long facial hair and his fingernails were long, jagged with black substances under some of the nails. R50 stated he needs the staff's assistance with shaving, and fingernails trimming and cleaning. On November 12, 2024 at 12:42 PM, R50 was sitting in his wheelchair, inside the main dining room. R50 was served regular textured meal consisting of lasagna, green beans and a garlic bread. R50 was also served a cup of coffee, a scoop of ice cream and a nutritional supplement in an open carton. R50's meal and drinks were untouched. At 1:00 PM, V12 (Licensed Practical Nurse) moved R50's wheelchair to allow another resident to pass behind him (R50), then placed R50 back to face his dining table. During time, R50's lunch meal and drinks remained untouched, but V12 did not encourage or cued resident to eat and/or drink. At 1:13 PM, V13 (CNA/Certified Nursing Assistant) asked R50 if he was done eating but did not attempt to encourage or cue the resident to eat, since R50's lunch meal and drinks remained untouched. During the same time, V14 (CNA) came and asked R50 if he was done eating. R50 responded yes then V14 started wheeling the resident away from his dining table towards the dining room door. At this time V14 was stopped and V2 (DON/Director of Nursing) was called by the surveyor. V2 was led to R50's dining table and shown the untouched meal and drinks of the resident. V2 poured the nutritional supplement from the carton into a cup and gave it to R50 and the resident drank 100% of the nutritional supplement. V2 placed R50 in-front of his table and started to cue and assisted the resident with feeding. With the assistance of V2, R50 took at least three bites of lasagna, two bites of green beans, one bite of the garlic bread, a few sips of the coffee, a few small bites of ice cream (vanilla and the blue ice cream) and consumed 100% of the 2% milk in a cup which was additionally given to the resident by V2. On November 13, 2024 at 9:08 AM, R50 was sitting in his wheelchair by the front lobby. R50 had accumulation of long facial hair and his fingernails were long, jagged with black substances under some of the nails. V3 (ADON/ Assistant Director of Nursing) was present during the observation and acknowledged R50's facial hair needs shaving and the resident needs nail care from the staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146170 If continuation sheet Page 3 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm R50's active care plan initiated on August 27, 2024 showed the resident has an ADL self-care performance deficit. 2. R51 had multiple diagnoses including dementia without behavioral disturbance, Parkinson's disease and need for assistance with personal care, based on the face sheet. Residents Affected - Some R51's admission MDS dated [DATE] showed the resident was moderately impaired with cognition and required maximum assistance from the staff with personal hygiene. On November 12, 2024 at 10:21 AM, R51 was in bed, alert and verbally responsive. R51 had accumulation of long facial hair and his fingernails were long and jagged. R51 stated R51 wanted to have his fingernails trimmed and his facial hair shaved. V4 (CNA) was present and heard the request of R51. On November 13, 2024 at 9:10 AM, R51 was in bed, alert and verbally responsive. R51 had accumulation of long facial hair and his fingernails were long and jagged. V3 (ADON) was present during this observation and acknowledged R51's fingernails needed trimming and his facial hair needed shaving. According to V3, R51 needs the staff assistance with fingernails care and shaving to ensure grooming and hygiene. R51's active care plan initiated on October 16, 2024 showed the resident has an ADL self-care performance deficit and needs the staff assistance with ADLs. The same care plan showed multiple interventions including provision of assistance with personal hygiene. On November 13, 2024 at 2:50 PM, V2 (DON) stated it is part of the facility's nursing care and services to assist all residents needing assistance with ADLs including shaving/removal of unwanted facial hair and nail care. According to V2, all residents needing assistance with ADLs should be assisted by the staff to ensure and maintain the residents good hygiene and grooming. During the same interview, V2 stated based on her observation of R50 during the lunch meal on November 12, 2024, the resident needed a lot of cuing and assistance from the staff to eat and drink. According to V2, the staff should have provided cuing and assistance to R50 since his lunch meal and drinks were untouched to encourage and ensure the resident eat and drink to maintain and ensure nutrition and hydration. 3. R16's diagnoses on face sheet included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, contracture, left hand. R16's quarterly MDS dated [DATE] showed that R16 was severely impaired in cognition and dependent on staff for personal hygiene. On November 12, 2024 at 11:13 AM, R16 was seated in a reclining chair in dining room and was feeding self with her right hand. Some of R16's nails on right hand appeared very long (about 1/2 inch) and/or jagged and most nails had blackish substance underneath the nails. R16's left arm was tucked under blanket and not visible. R16 was unable to respond adequately to queries. On November 12, 2024 at 8:41 AM, R16 was seated in the dining room after breakfast. R16's nails on right hand remained long with blackish substance underneath the nails. R16's left arm remained tucked under the blanket. V5 CNA (Certified Nursing Assistant) who was in the dining room was asked to remove the blanket from the left arm and R16's thumb finger was noted to have a very long nail. The other four fingers were curled into the fist and the nails were not visible and R16 would not open her fingers. V5 was notified about R16's long fingernails and V5 stated that she will take care of it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146170 If continuation sheet Page 4 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2024 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 0677 R16's POS (Physician Order Sheet) initiated June 25, 2024 included: Trim nails and keep it short. Level of Harm - Minimal harm or potential for actual harm R16's care plan-initiated May 17, 2023 included that R16 has a deficit in ADL self-care performance related to diagnosis of Dementia, Anemia, Anxiety Disorder, Major Depressive Disorder, Glaucoma, and left hand contracture. Intervention for the same included that R16 is dependent on staff for personal hygiene. Residents Affected - Some 4. R42's EMR (Electronic Medical Record) showed R42 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease, major depression, periprosthetic fracture around internal prosthetic hip joint, subsequent encounter, hypertensive heart and chronic kidney disease with heart failure, generalized anxiety, muscle wasting and atrophy not elsewhere classified, and obstructive sleep apnea. R42 was admitted to hospice on October 5, 2024. R42's change of condition MDS (Minimum Data Set) dated October 15, 2024, showed R42 was cognitively impaired. R42 required substantial/maximal assistance for showering and personal hygiene. R42's care plan showed R42 was admitted to hospice care for diagnosis of Alzheimer's and is expected to have an overall unavoidable decline in function, nutrition, skin integrity, mood, and communication. Interventions included staff to adjust provisions of ADLs (Activities of Daily Living) to compensate for resident's changing abilities. R42's care plan showed R42 has a deficit in ADL self-care performance related to history of falling, osteoarthritis, pain, muscle wasting, and atrophy. Interventions showed R42 was dependent on staff for transfer to shower with mechanical lift and required substantial/maximal assistance for showering and personal hygiene. R42's shower sheets for the last two weeks provided by the facility on November 13 at 2: 30 PM, showed on October 30, 2024 there was no mention of nail care being provided. On November 4, 2024, there was no mention of nail care being provided. On November 6, 2024, there was no mention of nail care being provided. On November 11, 2024, showed R42 has scratches to the back of his left hand, on his left upper thigh, and a scab on his scalp. There was no mention of nail care being provided. On November 11, 2024, at 9:59 AM, R42 had whiskers on his cheeks and chin. R42 said he would like to be shaved. His nails were long and there was brown substance noted under them. On November 13, 2024, at 9:47 AM, R42 was in the small activity room asleep in his high backed chair with his head forward. There were whiskers still noted on his cheeks and chin and his nails were still long with brown substance under them. R42's hair has not been combed as evidenced by hair sticking up on top and sides and in the back the hair was parted and matted to his head with some hair going to the right and some hair going to the left. On November 13, 2024, at 12:20 PM, V2 (DON/Director of Nursing) said residents are offered two showers per week, per their schedule. R42's shower day is scheduled for Tuesday; day shift, and Friday; evening shift. The CNAs (Certified Nurse Assistant) will fill out the shower sheet and then the nurses must sign off on the sheets. On shower days the staff are to wash hair, do oral care, a skin assessment and notify the nurse if there are any issues, cut fingernails, if toenails are long, let nurse know so resident can get on podiatry list, and comb hair. Any refusal should be documented on the shower sheet. On a non-shower day, the CNAs should still be washing face and hands, grooming (oral care, shaving, and nail care) and any refusals should be documented. Facility provided their policy titled, [Name of the facility] Activities of Daily Living (ADLs) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146170 If continuation sheet Page 5 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm with a revision date of February 2024. The policy showed Care and services will be provided for the following activities of daily living: 1. Bathing and dressing, grooming and oral care 4. Eating to include meals and snacks Policy Explanation and Compliance Guidelines 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, personal and oral hygiene. Residents Affected - Some Facility provided their policy titled, [Name of the facility] Nail Care with a renewal/revision date of November 2023 showed, Policy: The purpose of this procedure is to provide guidelines for the provision of care to a resident's nail for grooming and health 3. Routine nail care and inspection of nails will be provided during ADL (Activity of Daily Living) care and on an ongoing basis. 4. Routine nail care, to include trimming and filing, will be provided on a regular schedule (such as weekly on Wednesday 3-11 shift). Nail care will be provided between scheduled occasions as the need arises. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146170 If continuation sheet Page 6 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to assess and provide splint to a resident, to prevent further reduction in ROM (range of motion). This applies to 1 of 1 resident (R38) reviewed for range of motion in the sample of 15. The findings include: R38 was admitted to the facility on [DATE]. R38 had multiple diagnoses including spastic hemiplegia affecting left dominant side, mild dementia with other behavioral disturbance and contracture of left hand muscle, based on the face sheet. R38's significant change in status MDS (minimum data set) dated November 1, 2024 showed the resident was moderately impaired with cognition. The MDS showed R38 had functional limitation in ROM on one side of both upper and lower extremities. The same MDS showed R38 required maximum to total assistance from the staff with most of her ADLs. On November 12, 2024 at 10:11 AM, R38 was sitting in her wheelchair outside of her room. R38 had left arm and hand weakness. R38 was not able to move her left hand and/or open her left fingers. R38 had no splint or positioning device in place. According to R38 she does not use any splint or positioning device on her left hand. On November 13, 2024 at 8:58 AM, R38 was sitting in her wheelchair inside her room. R38 had left hand weakness and was not able to move her left hand and/or open her left fingers. R38 had no splint or positioning device in place. V3 (Assistant Director of Nursing) was present during the observation and stated R38 had left hand contracture. V3 was prompted to have the therapy department screen R38 to determine the need for a splint or positioning device on the resident's left hand. On November 13, 2024 at 11:56 AM, V11 (Occupational Therapist) stated she screened R38 morning per request of the facility. V11 stated based on the screening, R38 had left hand contracture which included all her left finger joints and the resident also had left elbow contracture. V11 stated the contracture were partially stretchable and because of this she had recommended for R38 to use a left hand roll at all times as tolerated and should be removed during ADL (activities of daily living) care to prevent further contracture/stiffness and or deformity and to prevent skin breakdown. According to V11, she also recommended for R38 to use a left elbow orthosis at least six hours during the day also to prevent further contracture/stiffness and or deformity and to prevent skin breakdown. R38's Occupational Therapy problem identification checklist created by V11 on November 13, 2024 showed the resident was, Developing loss in range of motion due to contracture. The checklist showed, Recommended left hand roll and left elbow orthosis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146170 If continuation sheet Page 7 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2024 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to puree the maple glazed ham to pureed consistency for residents on pureed diets. This applies to 8 of 8 residents (R2, R3, R9, R23, R26, R45, R47, R159) reviewed for mechanically altered diets in the sample of 15. The findings include: On November 13, 2024 at around 10:50 AM, the pureed meal preparation of maple glazed baked ham done by V9 (Cook) was observed in the facility kitchen. V9 stated that she is preparing for 8 residents who are on pureed diets. The maple glazed baked ham was pre-sliced and still had the rind intact. V9 placed the sliced ham into the blender and added about a cup of [NAME] to the blender and pureed the mixture for about two minutes. V9 stated that she is adding the glaze for the flavor. V9 was seen opening the blender and testing the product during the process and then continued to puree the mixture. V9 then opened the lid and after tasting it. V9 stated that it was ready for service. The pureed product had small pieces of rind still visible in the mixture. On taste testing the product, the rinds were still intact and unable to be chewed and got stuck in the throat when swallowed. On November 13, 2024 at 10:55 AM, V10 (Dining Director) was notified that the pureed maple glazed baked ham was not safe to serve due to the presence of pieces of rind in it. V10 stated the pureed product should be like pudding consistency that can be swallowed without chewing. Facility 'Diet Type Report' printed on November 12, 2024 showed that R2, R3, R9, R23, R26, R45, R47 and R159 were on pureed consistency diets. Week at a glance menu (Week 1) included maple glazed baked ham for the lunch meal on November 13, 2024. Recipe for Pureed Maple Glazed Baked Ham included 'Place potion of prepared ham in food processor with hot broth and blend to a smooth consistency. Facility policy for Therapeutic Diets (issued September 1, 2021) included as follows: Guidelines: Mechanically altered diet means one in which the texture of the diet is altered. When the texture is modified, the type of texture must be specific and part of the physician' or delegated registered or licensed dietitian's order. Facility policy for Liberalized Diets (issued September 1, 2021) included as follows: Guidelines: 5. e. Pureed -Regular diet that is processed to a smooth, mashed potato or pudding consistency FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146170 If continuation sheet Page 8 of 8