Inspection·December 11, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few R1's safety. On December 10, 2025, at 1:00 PM, V6 (R1's Doctor) said R1's leg laceration was caused by the improper transfer. V6 said facility staff should be following proper procedure and use a gait belt when transferring a resident. On December 10, 2025, at 3:28 PM, V2 (DON/Director of Nursing) said facility staff should use a gait belt when transferring a resident. V2 said R1's care plan and medical record showed facility staff were to use a gait belt when transferring R1. V2 said V4 should have used a gait belt when transferring R1 from the toilet to the wheelchair. The facility's final report dated November 28, 2025, completed by V3 (ADON) showed, Complete Description of Occurrence: [R1] has BIMS (Brief Mental Score) of 13, has diagnosis of right sided hemiplegia, aphasia following cerebral infarction, osteoarthritis, and unspecified thrombocytosis. On Monday evening about [4:30 PM], resident was assisted by a CNA (Certified Nursing Assistant) from the toilet, and when attempting to sit back into the wheelchair her right foot was caught in the small tire of the right side of the wheelchair causing her right lower leg to swing forward once she was seated in the chair and bump into the frame of the wheelchair. The aide observed the injury and summoned the nurse to the bathroom. First aid was rendered, and pressure was applied to right lower leg laceration. Resident reported complaints of discomfort and [Physician] notified. Order received to transfer resident to emergency room for further evaluation and treatment. POA (Power of Attorney) made aware of incident and order to transfer to the emergency room, per POA request [local hospital] is first hospital of choice. EMS (Emergency Medical Services) notified of bypass request to [local hospital] and resident was transferred to [local hospital] ER (Emergency Room). Resident returned to the facility approximately [10:30 PM]. The resident was assessed and returned with 10 sutures to right lower leg with physician order to remove sutures in 10 days. Investigation being conducted. Final Investigation: On 11/25/2025 around [4:15 PM], [R1] was assisted to the bathroom. This aide reported entering the bathroom, asked if she was ready and she nodded. He placed a new brief around her legs, and as he stood on her right side, she used her left arm to pull herself up from the bathroom grab bar. While she stood, he cleaned her from behind, was in the process of pulling up her brief and pants, while pulling up her brief, she was turned to face the wall, to sit back in her wheelchair and while her chair was locked, the aide attempted to pull the wheelchair closer behind her legs. She sat back into the wheelchair and her right foot was against the front tire of the wheelchair causing her right leg (which is contracted) to swing forward and land back onto the frame of the wheelchair where the leg rest had been removed. When the aide had unlocked her chair to pull her out of the bathroom, there was blood on her right lower leg. The nurse was summoned to the room, and first aid was rendered. Pressure was applied and [Physician] notified, order was received to transfer resident to emergency room for further evaluation and treatment. POA made aware. Resident was transferred to [local hospital] per the request of the POA, because it is her hospital of choice. Resident returned to facility at approximately [10:30 PM], while at the emergency room resident was administered an Tdap (Tetanus, Diphtheria, and Pertussis) vaccine, x-ray of the right tibia and fibula which showed no acute abnormalities and right lower leg laceration was closed with 10 sutures. An order was received to monitor site for signs/symptoms of infection and remove sutures in 10 days. Per staff interviews, resident participates with transfers despite right sided hemiplegia. Currently, [R1] has no changes in her ADLs from the laceration and propels self on unit. Upon completion of the investigation, it was determined transfers would now be two person assist to help guide the residual affected side post stroke. In addition, Restorative Nursing will assess transfer/safety needs. Plan of care has been updated; treatment and monitoring orders are in place for right leg laceration aftercare. Facility to remove sutures in 10 days as ordered. R1's emergency room medical records dated November 24, 2025, showed R1 went to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146170 If continuation sheet Page 2 of 3 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 12/11/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete emergency room for a leg laceration which occurred while being transferred. The records continued to show R1's right leg laceration was 3 centimeters and required eight stitches. The facility's undated policy titled Use of Gait Belt showed Policy: It is the policy of this facility to use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety. Policy Explanation and Compliance Guidelines: 1. Each nursing department employee will be given a gait belt during orientation. 2. All employees will receive education on the proper use of gait belt during orientation and annually. 3. It will be the responsibility of each employee to ensure they have it available for use at all times when at work. Event ID: Facility ID: 146170 If continuation sheet Page 3 of 3