Inspection·June 23, 2023

F 0623 Level of Harm - Minimal harm or potential for actual harm Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on interview and record review the facility failed to provide written notice of transfer to four residents (R8, R12, R36, and R49) of four residents reviewed for hospital transfer in the sample of 19. Residents Affected - Some Findings include: The progress notes for R8 on 4/14/23 at 12:33 AM indicates that she was transferred to a hospital due to shortness of breath and low oxygen levels. There is no indication that a notice of transfer was provided or sent. The progress notes for R12 on 3/22/23 at 10:00 PM indicates that she was transferred to a hospital for hyperventilating. There is no indication that a notice of transfer was provided or sent. The progress notes for R36 on 7/24/22, 12/11/22, and 3/25/23 indicates that he was transferred to a hospital for respiratory distress. There is no indication that a notice of transfer was provided or sent. The progress notes for R49 on 11/27/22 at 12:48 PM and 5/11/23 at 11:01 AM indicates that he was transferred to a hospital for evaluation after falls. There is no indication that a notice of transfer was provided or sent. On 6/22/23 at 11:49 AM V2 (Director of Nursing) said the family is notified by phone call of a hospital transfer. There is no written notice sent. On 6/23/23 at 10:10 AM V30 (Registered Nurse) said we do not send a notice of transfer we notify the family verbally. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146187 If continuation sheet Page 2 of 15 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 146187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Court Nursing & Rehab 1750 Elmhurst Road Des Plaines, IL 60018 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide written notice of bed hold to four residents (R8, R12, R36, and R49) of four residents reviewed for hospital transfer in the sample of 19. Findings include: The progress notes for R8 on 4/14/23 at 12:33 AM indicates that she was transferred to a hospital due to shortness of breath and low oxygen levels. There is no indication that a notice of bed hold was provided or sent. The progress notes for R12 on 3/22/23 at 10:00 PM indicates that she was transferred to a hospital for hyperventilating. There is no indication that a notice of bed hold was provided or sent. The progress notes for R36 on 7/24/22, 12/11/22, and 3/25/23 indicates that he was transferred to a hospital for respiratory distress. There is no indication that a notice of bed hold was provided or sent. The progress notes for R49 on 11/27/22 at 12:48 PM and 5/11/23 at 11:01 AM indicates that he was transferred to a hospital for evaluation after falls. There is no indication that a notice of bed hold was provided or sent. On 6/21/23 at 10:50 AM V1 (Administrator) said we never give a notice of bed hold. We must hold the bed for 10 days for Medicaid residents. We don't bill them. I think the notice of bed hold is in the contract. On 6/22/23 at 11:49 AM V2 (Director of Nursing) said there is no notice of bed hold. On 6/23/23 at 10:10 AM V30 (Registered Nurse) said we do not send a notice of bed hold; we notify the family verbally. Policy Bed Hold Notice Upon Transfer revised [DATE] At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the; bed-hold policy and addresses information explaining the return of the resident to the next available bed. 1.Before a resident is transferred to the hospital or goes on therapeutic leave, the facility will provide to the resident and/or representative written information that specifies: a. The duration of the state bed -hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility: b. The reserve bed payment policy in the state plan policy, if any. c. The facility policies regarding bed-hold periods to include allowing a resident to return to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146187 If continuation sheet Page 3 of 15 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 146187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Court Nursing & Rehab 1750 Elmhurst Road Des Plaines, IL 60018 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 0625 next available bed. Level of Harm - Minimal harm or potential for actual harm d. Conditions upon which the resident would return to the facility. Residents Affected - Some 2. In the event of an emergency transfers of a resident, the facility will provide within 24 hours written notice of the facility's bed-hold policies as stipulated in the State's plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146187 If continuation sheet Page 4 of 15 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 146187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Court Nursing & Rehab 1750 Elmhurst Road Des Plaines, IL 60018 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 Based on observation, interview and record review, the facility failed to provide necessary services to maintain personal hygiene for a resident who is unable to carry out toileting needs for one (R2) of one resident reviewed for activities of daily living in a sample of 19. Residents Affected - Few Findings include: On 06/21/2023 at 1:19PM during wound care observation, R2 was observed with two disposable briefs. R2 said that most of the time, staff put two disposable briefs on her because they said she wets fast and heavily. On 06/21/2023 at 1:27PM, V18 (Registered Nurse) stated that there should only be one disposable brief on the resident. On 06/21/2023 at 1:37PM, V2 (Director of Nursing) said that she expects staff to place only one disposable brief on incontinent residents. R2's Order Summary Report dated 6/21/2023 indicated admission date of 5/2/2023, diagnoses including anxiety disorder and retention of urine. Minimum Data Set Section G dated 5/8/2023 indicated R2 needs extensive assistance with toilet use. Braden Scale for Predicting Pressure Ulcer Risk dated 5/10/2023 indicated score of 13 with category of moderate risk, and clinical suggestions including utilize incontinent products after each incontinence period. Care plan reviewed and did not indicate rationale for placing two disposable briefs on R2. Facility unable to provide policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146187 If continuation sheet Page 5 of 15 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 146187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Court Nursing & Rehab 1750 Elmhurst Road Des Plaines, IL 60018 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete a root cause analysis of falls and develop effective interventions to prevent falls and injury for one resident (R49) of six residents reviewed for falls in the sample of 19. This failure resulted in R49 falling and sustaining fractures to the left 6th, 7th, and 8th ribs. Findings include: R49's medical record indicates that he had a fall on 11/27/22. The progress notes of 11/27/22 at 12:48 PM indicates that R49 was found on the bathroom floor in lying position, leaning against the wall. 911 was called and R49 was transferred to a hospital. He returned to the facility on [DATE]. A progress note by V31 (Nurse Practitioner) indicates that a CT (computerized axial tomography) scan revealed a small acute subdural hematoma on the right measuring two mm (millimeters). Repeat CT at 9PM revealed stable right frontal and left parietal infarcts, decreased density periventricular white matter bilaterally consisted with chronic small vessel ischemic changes. The previously noted two mm small subdural hematoma seen on the previous CT was not seen on the follow up study. The documentation of the fall provided by the facility did not contain a root cause analysis. The root cause analysis was requested. On 6/22/23 at 12:00 PM V22 (Care Plan Coordinator) said we discuss the falls in the morning meeting. The Director of Nursing, Assistant Director of Nursing, and Nurse Consultant update the Care Plan. I do not update those Care Plans. I do the initial Care Plan. I do not do the root cause analysis. On 6/22/23 at 12:20 PM V28 (Nurse Consultant) said we did not identify the root cause for R49 for the falls. That could impact the interventions. The interventions added to the Care Plan on 11/28/22 are neuro (neurological) checks per protocol, assist with ADLs (activities of daily living) as indicated. Monitor for seizures and follow seizure precautions. PT/OT (Physical Therapy/Occupational Therapy) evaluate and treat. A progress notes of 11/28/22 at 2:56 PM indicates a Fall Risk Evaluation score of 15 which means that R49 is at high risk for falls and should be on the fall prevention program. R49's medical record indicates that he had a fall on 5/11/23. The progress notes of 5/11/23 at 11:01 AM indicates that R49 was found on the floor of his room at around 8 AM. He was grimacing and shaking while up in the wheelchair. R49 was sent to the hospital for evaluation and treatment. V30 (Registered Nurse) said that she was in report and had not made rounds on R49. A (Certified Nursing Assistant/CNA) notified her that R49 was on the floor. A CT scan of the chest was performed at the hospital. IMPRESSION: 1. Acute fractures involving the posterior aspects of the left sixth, seventh, and eighth ribs. 2. Hemorrhagic left pleural effusion. No pneumothorax. 3. Air noted within the subcutaneous tissues of the left posterior chest wall at the fracture sites. 4. Nonspecific left upper lobe lung nodule. The intervention added to the Care Plan R49 returned to the facility on 5/14/23 is sent to the ER (Emergency Room) for evaluation c/o (complains of) pain increased shaking. Date initiated 5/22/23 On 6/23/23 at 10:20 AM V2 (Director of Nursing) said that the fall prevention program was to put a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146187 If continuation sheet Page 6 of 15 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 146187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Court Nursing & Rehab 1750 Elmhurst Road Des Plaines, IL 60018 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 yellow tag on the name plate for his room and put a yellow tag on his walker. Level of Harm - Actual harm On 6/23/23 at 10:10 AM V30 (Registered Nurse) said (R49) has a yellow tag on his door which means he's a fall risk. He is ambulatory but we check on him often, every two to three hours. Residents Affected - Few Policy: Fall Prevention Program revised [DATE] Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. 6. High Risk protocols: a. The resident will be placed on the facility's Fall Prevention Program. c. Provide interventions that address unique risk factors measured by the risk assessment tool: d. Provide additional interventions as directed by the resident's assessment, including but not limited to: i. Assistive devices ii. Increased frequency of rounds iii. Sitter if indicated iv. Medication regimen review v. Low bed vi. Alternate call system vii. Scheduled ambulation or toileting assistance viii. Family caregiver or resident education ix. Therapy services referral 9. When any r3esident experiences a fall, the facility will: e. Review the resident's care plan and update as indicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146187 If continuation sheet Page 7 of 15 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 146187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Court Nursing & Rehab 1750 Elmhurst Road Des Plaines, IL 60018 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to follow physician orders by failing to provide prescribed oxygen administration for one resident (R39) of two residents reviewed for oxygen administration in a sample of 19 residents. Residents Affected - Few Findings include: On 6/20/23 and 6/21/23 at 10:00am, R39 was observed sitting in her room watching television. R39 was observed at rest with 5 liters of oxygen through nasal cannular attached to a humidifier. On 6/21/23 at 10:00am, V18 (Registered Nurse) stated that R29 should be on 3 liters of oxygen when at rest. On 6/21/23 at 12:00pm, V2 (Director of Nursing) stated that the nurses should follow the physician orders. Physician orders dated 5/2/23 reads, continuous oxygen at 3L per nasal cannula at rest, 5L per nasal cannular with activity. Facility policy dated 2/2023 reads: Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preference. 1.Policy Explanation and Compliance Guidelines: Oxygen is administered under orders of a physician, except in the case of an emergency. 4. The resident's care plan shall identify the intervention for oxygen therapy, based upon the resident's assessment and orders . Care plan initiated 5/3/23 reads R39 has oxygen therapy related to diagnosis of hypoxemia. Interventions: administer oxygen as ordered. Follow oxygen precautions per facility protocol. Care plan initiated 5/17/23 reads, R39 has diagnosis of Congestive Heart Failure; recent diagnosis of Pleural Effusion; at risk for complications. Intervention: Administer Oxygen as ordered - see Electronic Medication Administration Record (EMAR). Observe for signs and symptoms of poor oxygen absorption. Notify MD of abnormal findings promptly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146187 If continuation sheet Page 8 of 15 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 146187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Court Nursing & Rehab 1750 Elmhurst Road Des Plaines, IL 60018 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure that it is free of medication error rate of five percent or greater. This deficiency applies to two (R11, R20) of eight residents observed for medication administration. Residents Affected - Few Findings include: During medication administration observation, two medication errors were observed out of 25 opportunities that resulted in an eight percent medication error rate. On 06/21/2023 at 11:15 AM during medication administration observation, V25 (Registered Nurse) was observed preparing to administer insulin aspart pen to R11 without priming it, and immediately pulling out the needle from the skin after pressing the plunger during administration of insulin. At 11:25 AM, V25 was again observed preparing to administer insulin aspart pen to R20 without priming it, and immediately pulling out the needle from the skin after pressing the plunger during administration of insulin. On 06/21/2023 at 3:40 PM, V2 (Director of Nursing) stated that during injection of insulin, pen needles should be held under the skin for a few seconds before removing it. On 06/22/2023 at 12:12 PM, V23 (Pharmacy Director of Clinical Services) stated that insulin pens should be primed with 2 units then the needle should be kept under the skin for 10 seconds before pulling out. She also added that if the needle was pulled out immediately after pressing the plunger, the resident could possibly not receive the correct dose. Facility Policy: Title: Insulin Pen Date Reviewed/Revised: February 2023 Policy: It is the policy of this facility to use insulin pens in order to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge. Policy Explanation and Compliance Guidelines: 6. Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir. 11. Procedure: h. Prime the insulin pen: i. Dial 2 units by turning the dose selector clockwise. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146187 If continuation sheet Page 9 of 15 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 146187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Court Nursing & Rehab 1750 Elmhurst Road Des Plaines, IL 60018 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete ii. With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. j. Injecting the insulin: v. While still pressing the plunger, keep the needle in the skin for up to 6-10 seconds and then remove the needle from the skin. Event ID: Facility ID: 146187 If continuation sheet Page 10 of 15 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 146187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Court Nursing & Rehab 1750 Elmhurst Road Des Plaines, IL 60018 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure that residents are free of significant medication errors for two (R11, R20) of eight residents observed for medication administration in a sample of 23. Residents Affected - Few Findings include: On 06/21/2023 at 11:15 AM during medication administration observation, V25 (Registered Nurse) was observed preparing to administer insulin aspart pen to R11 without priming it, and immediately pulling out the needle from the skin after pressing the plunger during injection of insulin. At 11:25 AM, V25 was again observed preparing to administer insulin aspart pen to R20 without priming it, and immediately pulling out the needle from the skin after pressing the plunger during injection of insulin. On 06/21/2023 at 3:40 PM, V2 (Director of Nursing) stated that during injection of insulin, pen needles should be held under the skin for a few seconds before removing it. On 06/22/2023 at 12:12 PM, V23 (Pharmacy Director of Clinical Services) stated that insulin pens should be primed with 2 units then the needle should be kept under the skin for 10 seconds before pulling out. She also added that if the needle was pulled out immediately after pressing the plunger, the resident could possibly not receive the correct dose. R11's Order Summary Report dated 06/21/2023 indicated admission date 05/21/2023, diagnoses including type 2 Diabetes Mellitus without complications, and order for Insulin Aspart 100 unit/milliliters (ml) inject 8 units subcutaneously (under the skin) with meals with order date of 05/21/2023. R20's Order Summary Report dated 06/21/2023 indicated admission date 01/12/2022, diagnoses including type 2 Diabetes Mellitus without complications, and order for Insulin Aspart FlexPen Subcutaneous Solution Pen-Injector 100 units/ml inject 5 units subcutaneously before meals with order date 05/26/2023. Facility Policy: Title: Insulin Pen Date Reviewed/Revised: February 2023 Policy: It is the policy of this facility to use insulin pens in order to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge. Policy Explanation and Compliance Guidelines: 6. Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146187 If continuation sheet Page 11 of 15 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 146187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Court Nursing & Rehab 1750 Elmhurst Road Des Plaines, IL 60018 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 0760 11. Procedure: Level of Harm - Minimal harm or potential for actual harm h. Prime the insulin pen: i. Dial 2 units by turning the dose selector clockwise. Residents Affected - Few ii. With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. j. Injecting the insulin: v. While still pressing the plunger, keep the needle in the skin for up to 6-10 seconds and then remove the needle from the skin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146187 If continuation sheet Page 12 of 15 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 146187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Court Nursing & Rehab 1750 Elmhurst Road Des Plaines, IL 60018 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 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure that one resident (R59) of 3 three residents reviewed for dental care in a sample of 19 received acute care for teeth pain. This failure resulted in resident experiencing teeth pain for at least 4 months without any treatment. Residents Affected - Few Findings include: On 06/20/23 12:08 PM R59 was sitting in the dining room waiting to be served dinner and stated he has pain and pointed to his bottom left teeth. Observed resident self-feeding a pureed diet. On 6/22/23 at 11:10 AM R59 stated his teeth hurt. On 6/22/23 at 10:51 AM V2 (DON) stated the dentist came in May of 2023 and didn't see anyone on the second floor. We will be looking for a new dentist to see residents. Review of Email by V2 on May 5th documents resident's on 2nd floor were not seen by Dentist. On 06/22/23 at 11:12 AM V25 (RN) stated R59 never complains of anything, except once he complained about 3-4 months ago about dental issues. He had pain in the mouth. V25 stated she referred R59 for a dental appointment. On 06/22/23 at 12:31 PM V15 (Social Service Director) stated usually the resident, family, or nurse would tell her if someone needs dental services. V15 stated she sent a referral about 6 months ago for R59 to be seen. V15 stated she doesn't remember who or why R59 was referred to the dentist. At the time he didn't have Medicaid and he didn't have a benefit for Dental. V15 stated R59 did not see a dentist. Normally, follow up would be with the dentist if someone who was supposed to be seen and not seen. V2 stated, the dental offices said they couldn't see him because they didn't accept his insurance. We usually give family an option to pay for dental care, however, V15 stated R59's family is not involved. On 06/22/23 02:38 PM V15 states she doesn't know why R59 was not seen in May. Review of R59's progress notes from June 2023 is absent of any nurses note about teeth pain. ` R59 orders document for the following order dated 1/27/23: Dental care as needed. Review of R59's care plan is absent of a dental care plan. On 6/23/23 at 9:52 AM V2 (DON) stated when a resident has tooth pain her expectations are to call the Doctor and inform them and refer to be seen by dentist. V2 stated she Expect the nurse to write a progress note indicating the level of pain and location of pain, and a consent to be seen by dentist. V2 stated even if there is a standing order for the dentist, the expectation would be for staff to notify the doctor. Teeth pain would be considered a change of condition. V2 stated a dental emergency depends on the level of pain. V2 stated, it would be significant for someone to have tooth pain for months. V2 stated, the resident should be assessed to determine urgency. V2 stated, at first notification of tooth pain a care plan would be warranted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146187 If continuation sheet Page 13 of 15 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 146187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Court Nursing & Rehab 1750 Elmhurst Road Des Plaines, IL 60018 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 0790 Level of Harm - Minimal harm or potential for actual harm The facility's Dental Services policy dated February 2023 document the following: It is the policy of this facility to assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care. Emergency Dental services includes services needed to treat an episode of acute pain in teeth, gums or palate; broken, or otherwise damaged teeth or any other problem of the oral cavity that required immediate attention by a dentist. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146187 If continuation sheet Page 14 of 15 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 146187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Court Nursing & Rehab 1750 Elmhurst Road Des Plaines, IL 60018 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 - Some 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 monitor in-room refrigerator temperatures for 4 residents (R21, R24, R34, and R63) of 4 reviewed for in-room refrigerators temperatures in a sample of 19. Findings include: On 6/20/23 at 11:04 AM R63 and R24's refrigerator was observed with no temperatures recorded on the log for the month of June 2023. On 6/20/23 at 11:15 AM R34's refrigerator was observed with one temperature recorded on the log for today and nothing from 6/1/23 through 6/19/2023. The mini refrigerator log is in a clear sleeve on the front of the refrigerator. R34 states she shares the refrigerator with R21 who her roommate is. On 6/21/23 at 9:55 AM in R63's room with V17 (Certified Nurse Assistant/CNA), V17 stated the CNAs don't check the refrigerator temperatures. Surveyor observed a temperature recorded for today and yesterday only. R63 states her and R24 share the refrigerator. On 6/21/23 09:59 AM with V5 (Staffing Coordinator) in R21 and R34's Room. Observed in-room refrigerator has a temperature recorded on the log for today and yesterday only. Observed food and drinks in the refrigerator. On 6/22/23 at 11:03 AM with V17 (CNA) in R63 and R24's room, observed no recording for temperatures for the night shift for refrigerators for today on R63 and R24's refrigerator that they share. Observed food and drinks in the refrigerator. On 6/22/23 at 11:45 AM V2 (DON) stated CNAs and nurses during night shift fill out temperature logs on refrigerators daily. On 6/22/23 at 11:03 AM V12 (Nurse) stated in-room refrigerators should be checked daily by night shift. On 6/22/23 at 2:45 PM V2 (DON) stated they do not have a policy for in-room resident refrigerators. V2 stated they will be working on a policy. The facility's Date marking for Food safety Policy documents the following: The facility adheres to a date marking system to ensure the safety of ready to eat, time/temperature control for safety food. Policy Explanation and Compliance Guidelines for Staffing: 1) refrigerated, ready to eat, time/temperature control for safety (i.e., perishable food) shall be held at a temperature of 41-degree Fahrenheit or less for a maximum of 7 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146187 If continuation sheet Page 15 of 15