Inspection·January 13, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop a plan of care for three (R1, R28, and R33) of 16 residents reviewed for care planning in the sample of 16. Findings include: The facility's Comprehensive Care Plan Policy and Procedure, revised 6/25/2020, documents An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. 1. R28's Face Sheet, documents R28 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Initial Smoking Evaluation was completed on 6/14/21 and was re-evaluated again on 9/14/22. On 1/11/23 at 10:56 am, R28 stated she does like to go outside and smoke sometimes. On 1/11/23 at 12:01 pm, V2 DON (Director of Nursing) stated the resident who smoke are all independent except for R28 who requires some assistance to get up and to go outside. On 1/12/23 at 9:35 am, R28 stated the staff got her up yesterday and took her outside to smoke. The current Care Plan for R28 does not document that R28 is a smoker or list any interventions for smoking. On 1/12/23 at 10:05 am, V4 CPC (Care Plan Coordinator) stated I must have missed that, it was before me, so I wasn't aware (R28) didn't have a Care Plan for smoking. 2. On 1/10/23 at 10:38 AM, R33 was noted to be lying in bed with eyes closed. A pole was near the head of R33's bed where a tube feeding bottle was hanging. An indwelling urinary catheter bag was noted to be hanging from the right side of R33's bed with yellow urine containing white strands. R33's current Physician Order Sheet documents the following orders: Change (urinary) Catheter drainage bag weekly every evening shift on Wednesday; Flush indwelling urinary catheter with 60 ml/milliliters 0.9% (percent) NS/Normal Saline BID (twice a day) for irrigation; Catheter Care every shift and as needed for infection control; Enteral feedings, Glucerna 1.2 at 75 milliliters/ml an hour and flush (water) 100 ml an hour for 16 hours a day through gastrostomy tube via feeding pump and Gentamicin Sulfate Ointment 0.1 % (percent). Apply to G-Tube (Gastrostomy Tube) site topically every day shift for preventative. Clean with soap and water, apply ointment, cover with split gauze. R33's Hospice Physician Interim Orders Sheet on 12/19/22 documents a clinical update of R33 to the physician for signs and symptoms of urinary tract infection/UTI to which an order for Cipro 500 milligrams/mg twice a day for seven days was received. R33's Medication Administration Record/MAR, dated 12/1/22-12/31/22 documents R33 received Ciprofloxacin HCL/Hydrochloride 500 mg two times a day for seven days for UTI. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145021 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 145021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Macomb Post Acute Care Center 8 Doctors Lane Macomb, IL 61455 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 01/10/23 at 11:18 AM V8 (Registered Nurse) entered R33's room to perform indwelling urinary catheter care. V8 stated that R33 recently finished an antibiotic for a UTI and that R33's urine had an increased amount of mucous threads that was still clogging R33's catheter at times and the catheter was requiring irrigation. At this time, V8 irrigated R33's urinary catheter. On 1/10/23 at 12:08 PM, V8 (Registered Nurse) administered R33's afternoon medications via R33's Gastrostomy Tube. At this time, V8 stated that R33 receives tube feedings from 4:00 PM-8:00 AM every day. V8 stated that R33 can also take food orally, but R33 most always refuses. As of 1/10/23, R33's current Care Plan did not contain documentation that a care plan was developed with interventions for R33's indwelling urinary catheter or R33's Gastrostomy Tube. On 1/12/23 at 10:10 AM, V4 (Care Plan Coordinator) verified that a Care Plan area was not developed for R33's indwelling urinary catheter with recent history of UTI or R33's Gastrostomy Tube. V4 stated, It just got missed. It's on there now. 3. The facility's Wandering and Elopement Assessment and Prevention Policy and Procedure, revised 12/22/22, states, All residents in this facility shall be assessed for risk of elopement/unsafe wandering to ensure their safety and prevention from elopement. Procedure: Facility uses a multi-faceted approach to prevent elopement: 1. Environmental controls, such as but not limited to: b. Alarmed Bracelets. 4. Appropriate interventions per individualized plan of care based on the resident's assessment may include but are not limited to: b. (Electronic Wandering Monitoring Device) application c. Care Plan developed for elopement/unsafe wandering. On 1/12/23 at 10:00 AM, R1 was sitting in R1's room in a recliner chair. V8 (Registered Nurse) pulled down R1's sock, exposing an electronic wandering device monitor to R1's left ankle. V8 stated that R1 wanders throughout the facility and that R1 is confused. R1's current Order Summary Report documents an order for the following: (Name of electronic wandering monitor device) applied to left ankle every shift for safety. Notify DON/Director of Nursing/ADON/Assistant Director of Nursing if device is not working properly and to check electronic wandering monitor device's battery every night shift with an order start date of 9/23/22. R1's Wandering/Elopement Risk Assessment, dated 9/23/22, documents R1 is at high risk for wandering/elopement. This same form documents R1 is cognitively impaired, has a pertinent diagnosis that increases R1's risk for elopement, R1 persistently states in a hostile or aggressive manner that R1 wants to leave the unit or will find a way to leave, R1 wanders aimlessly and R1 has risk factors that increase R1's risk for elopement. As of 1/12/23, R1's current Care Plan did not contain documentation that a care plan was developed with interventions for R1's wandering/elopement risk or for R1's use of an electronic wandering monitoring device. On 1/12/23 at 10:10 AM, V4 (Care Plan Coordinator) verified that a Care Plan area was not developed for R1's wandering/elopement risk or for R1's use of an electronic wandering monitor device. V4 stated that V4 was not aware of R1's electronic wandering monitor device and stated that it should be on R1's Care Plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145021 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 145021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Macomb Post Acute Care Center 8 Doctors Lane Macomb, IL 61455 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to revise a plan of care for two (R28 and R33) of 16 residents reviewed for care planning in the sample of 16. Findings include: The Facility's Comprehensive Care Plan Policy and Procedure, revised [DATE], documents Care plans are revised as changes in the resident's condition dictate. Care plans are reviewed at least quarterly. The Facility's Quarterly Review Policy and Procedure for Care Plans, revised [DATE], documents Each resident's care plan shall be reviewed at least quarterly. The Care Planning/Interdisciplinary Team is responsible for maintaining care plans on a current status. The Care Planning/Interdisciplinary Team is responsible for the periodic review and updating of care plans. 1. The current Care Plan for R28 documents a Focus area for R28 initiated on [DATE] as Right elbow with blanchable redness and on [DATE] a Focus area was initiated as Denuded tissue on right and left buttocks related to shearing, thin skin, sliding up and down in bed, poor appetite, incontinence. This same Care Plan documents an initiated Focus area on [DATE] documenting (R28) chooses to be a full code and a Focus area initiated on [DATE] as: My current diet is CCHO (carbohydrate-controlled diet)/mechanical soft. The Order Summary Report for R28, dated [DATE] documents a physician's order for DNR (Do Not Resuscitate) and a signed POLST for DNR as of [DATE]. This same Report documents a physician order for Regular diet Mech (mechanical) soft: Chopped/Advanced/Soft and Bite Sized texture, Regular/Thin consistency, ice cream with lunch and supper as of [DATE]. On [DATE] at 11:10 am, R28 stated, I definitely don't want them to do anything (CPR-Cardiopulmonary Resuscitation) at this time. I had changed my mind last spring and I don't want them to do anything. R28 stated someone told her once what happens when CPR is performed, and she (R28) doesn't want any of that. On [DATE] at 9:35 am, R28 stated she does not have a sore on her buttock right now, but it does get sore from time to time. R28 stated the staff are good about keeping an eye on her buttocks and her elbows to make sure they don't get sores. R28 stated when her bottom gets sore, she turns onto her right side and so far, she has been good. R28 raised both of her arms up revealing no wounds and rolled to her right side and revealed no wounds to her buttocks. On [DATE] at 9:30 am, R28 was in bed with breakfast tray in front of her with a regular sausage patty on her plate that one fourth of had been eaten. R28 stated she cannot eat the sausage because it is too tough. R28 stated they are supposed to cut it up or grind it up but sometimes they don't. The Meal Ticket for R28, dated [DATE] Breakfast, documents Diet: Regular; Diet Texture: Dental Soft (Mech Soft); Diet Other: Gravy on all potatoes, magic cup with lunch and supper. This ticket documents R28 was to receive Ground Sausage with gravy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145021 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 145021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Macomb Post Acute Care Center 8 Doctors Lane Macomb, IL 61455 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On [DATE] at 9:45 am, V2 DON (Director of Nursing) confirmed R28 should be receiving a mechanical soft diet with ground meat with gravy and should not have received a regular sausage patty. V2 also stated R28 does not have any wounds at this time but there was a time when R28 had redness to her elbows and her buttocks and have all resolved. On [DATE] at 10:05 am. V4 CPC (Care Plan Coordinator) confirmed R28's contains Focus areas for skin wounds, R28's diet order was incorrect, and R28's code status was documented as a Full Code. V4 CPC stated R28 does not currently have any wounds, R28's diet order was changed on July of 2021, and R28's code status was changed to a DNR on [DATE]. V4 CPC stated she did not start the CPC position until May and the corrections needing revised were before my time. 2. The facility's Skin Prevention, Assessment and Treatment Policy and Procedure, revised [DATE], documents residents identified as high risk for pressure ulcer development should have appropriate interventions to manage the risks on the resident's Care Plan. This same policy also documents the Risk Management Committee should review residents with wounds weekly for progress, interventions, and care plan revision as appropriate. R33's Pressure Ulcer Risk Assessment Tool, dated [DATE], documents R33 is at moderate risk for developing pressure ulcers. R33's current Physician Orders documents wound treatment orders for R33's known pressure ulcers. The facility's Weekly Wound Tracking Wound Log documents R33 is being monitored for current pressure ulcer wounds to R33's bilateral hips, right shoulder, bilateral heels, coccyx and left foot. On [DATE] at 10:51, V8 (Registered Nurse) entered R33's room to provide cares. V8 began with changing R33's pressure ulcer wounds to R33's left foot, toes, heels and coccyx. R33's left foot was noted to have several open areas with thick tan drainage noted. R33's bilateral heels were noted to be blackened and scabbed. R33's current Care Plan documents R33 is at risk for alteration in skin integrity. As of [DATE], R33's Care Plan was not updated to include R33's current pressure ulcer wounds, interventions or treatments. On [DATE] at 10:10 AM, V4 (Care Plan Coordinator) verified that R33's Care Plan should have been updated to include R33's actual impaired skin integrity with interventions and it did not. V4 stated, They (wounds) should have been on there (R33's Care Plan). They are on there now. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145021 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 145021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Macomb Post Acute Care Center 8 Doctors Lane Macomb, IL 61455 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 ensure staff wash hands after removing soiled gloves and before placing clean gloves while performing pressure ulcer wound care and failed to document weekly skin assessments per facility policy for one of two residents (R33) reviewed for pressure ulcers in the sample of 16. Residents Affected - Few Findings include: The facility's Clean Dressing Change Policy, revised, 12/5/22, states, Policy: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing and frequency of changes. 7. Wash hands and put on clean gloves. 8. Place a barrier cloth or pad next to the resident, under the wound to protect the bed linen and other body sites. 9. Loosen the tape and remove the existing dressing. If needed to minimize skin stripping or pain, moisten with prescribed cleansing solution or use adhesive remover to remove tape. 10. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. 11. Wash hands and put on clean gloves. 12. Cleanse the wound as ordered, taking care to not contaminate other skin surfaces or other surfaces of the wound (i.e., clean outward from the center of the wound). Pat dry with gauze. 14. Wash hands and put on clean gloves. 15. Apply topical ointments or creams and dress the wound as ordered. Protect surrounding skin as indicated with skin protectant. 16. Secure dressing. [NAME] with initials and date. (Add time if dressing is more than once daily.) 17. Discard disposable items and gloves into appropriate trash receptacle and wash hands. 18. Return resident to a comfortable position. Place call light within reach. Open door, blinds, or curtains if desired by resident. The facility's Skin Prevention, Assessment and Treatment Policy, revised 5/2/22, states, 5. All residents should have their skin integrity examined thoroughly at least weekly by a licensed nurse to identify existing pressure ulcers. a. Findings from the weekly skin assessment should be documented by the licensed nurse on a skin progress note. The facility's Standard Precautions Policy, revised 1/6/21, states, Policy: It is the facility's policy that standard precautions will apply to the care of all residents in all situations regardless of their suspected or confirmed infection disease process. Standard Precautions assume all blood, body fluids and secretions/excretions, non-intact skin and mucous membranes may contain transmissible infectious agents. Procedure: Handwashing 1. After touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn; 2. Immediately after gloves are removed, between resident contacts and when otherwise indicated to avoid transfer of microorganisms to other residents or environments; and 3. Between tasks and procedures on the same resident to prevent cross-contamination of different body sites. Gloves Use: 1. Staff will wear clean non-sterile gloves: a. when touching blood, body fluids, secretions, excretions, and contaminated items; and b. before touching mucous membranes and broken skin. 3. Gloves will be removed promptly after use, before touching non-contaminated items and environmental surfaces and before going to another resident. 4. Hands should be washed immediately after removal of gloves to avoid transfer of microorganisms to other residents or environments. The facility's Hand Washing Policy and Procedure, revised 11/5/19, states, Hand washing is an integral part of an effective infection control program. Its purpose is to reduce the risk of blood borne illness and prevent cross contamination. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145021 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 145021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Macomb Post Acute Care Center 8 Doctors Lane Macomb, IL 61455 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. On 1/10/22 at 10:51, V8 (Registered Nurse) entered R33's room to provide cares. V8 began changing R33's pressure ulcer wounds to R33's left foot, toes, heel and coccyx. V8 removed R33's old wound dressing to R33's entire left foot which was noted with a tan drainage on the gauze and placed it in the trash receptacle. At this time, a half-dollar sized open area with a yellowish-gray center and reddened surrounding was noted to the top of R33's left foot. R33's left posterior toes and in between the toes were noted with reddened open areas. The pad of skin under the toes of R33's left posterior foot was noted to have an opened area with active red drainage. After removing the soiled dressing, V8 removed V8's soiled gloves and without hand washing prior, placed on new gloves. V8 then cleansed R33's wound at the top of R33's left foot with wound cleanser. V8 removed the soiled gloves and without hand washing, placed on clean gloves. V8 continued to clean R33's left foot, toes, and heel wounds. V8 again, removed V8's soiled gloves and without hand washing, placed on clean gloves. At this time, V8 milked a thick, tan creamy substance from the open wound on the top of R33's left foot. V8 stated R33 is on an antibiotic for a wound infection. V8 cleansed off the thick drainage, removed soiled gloves and without hand washing, placed on clean gloves. V8 then removed R33's wound packing from the packaging, placed it in R33's left foot and toes wound beds and removed soiled gloves. Without hand washing, R33 placed on clean gloves and applied skin protective wipes to R33's right and left heels which were noted to be fully blackened and scabbed. V8 then removed V8's soiled gloves, and without hand washing, moved R33's heel protection boots and opened R33's bedroom door to speak to a staff member on the other side. V8 then placed on clean gloves without hand washing. V8 placed a protective foam dressing over the wound packing, wrapped R33's left foot in a gauze roll, reached into V8's right front packet and pulled out a roll of tape. V8 removed V8's gloves, did not wash V8's hands and then secured the gauze roll with a piece of tape. Without hand washing, V8 placed a new pair of gloves on and secured R33's heel protection boots in place. At 11:06 AM, V7 (Certified Nursing Assistant) entered R33's room to assist V8. After V7 and V8 cleansed R33's buttocks and coccyx area of liquid incontinent stool, touched soiled incontinence brief and wipes, V8 removed V8's soiled gloves and placed a clean pair of gloves on with no hand washing prior. V8 then removed R33's coccyx wound dressing which was noted to have been soiled with stool. V8 changed V8's soiled gloves with no handwashing in between. V8 continued to cleanse R33's coccyx wound, remove soiled gloves, placed clean gloves, and place wound treatment to the center of R33's coccyx wound bed with no hand washing occurring at any time. V8 then removed V8's gloves and did not wash V8's hands. With V8's ungloved, unwashed hands, V8 placed a foam adhesive bandage over R33's coccyx wound, touching R33's surrounding skin that was just wiped of liquid stool with V8's bare hands. V8 then lowered R33's bed with the remote control and then performed hand hygiene. R33's Hospice Physician Interim Orders Sheet (undated) documents a clinical update on R33 to the physician for possible skin infection to toes and a request for an antibiotic to which a signed order for Keflex 500 milligrams/mg three times a day for seven days was received on 12/30/22. R33's December 2022 and January 2023 Medication Administration Record (MAR) document Cephalexin 500 mg tablet was given three times a day for infection from 12/31/22-1/10/23. On 1/10/23 at 11:38 AM, V8 verified that V8 did not wash V8's hands in between glove changes at any time during R33's wound dressing changes or after R33's incontinence care. V8 stated, I should have washed my hands before putting on new gloves each time. I was rushing. 2. R33's Pressure Ulcer Risk Assessment Tool, dated 12/20/22, documents R33 is at moderate risk for developing pressure ulcers. R33's current Physician Orders documents wound treatment orders for R33's known pressure ulcers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145021 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 145021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Macomb Post Acute Care Center 8 Doctors Lane Macomb, IL 61455 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 R33's Treatment Administration Record (TAR) for November 2022 documents an order for weekly skin checks every Tuesday for preventative care. This order has a start date of 7/12/22. R33's TAR for December 2022 documents an order for weekly skin checks every Tuesday for preventative care. This order has a start date of 7/12/22 and an end date of 12/26/22. R33's December 2022 TAR documents a new order for Body Audits daily for skin observation. This order has a start date of 12/27/22. R33's TAR for January 2023 documents an order for daily body audits with a start date of 12/27/22 and no end date. As of 1/11/23, R33's medical record did not contain weekly skin assessment notes for the following days: 11/8/22, 11/15/22, 11/22/22, 11/29/22, 1/3/23 or 1/10/23. On 1/11/23 at 12:00 PM, V2 (Director of Nursing) stated skin checks should be documented with an associated assessment in the resident's medical record, either in assessments or a progress note at least every week. At this time, V2 verified R33's weekly skin assessment documentation was not documented in R33's medical record and should be. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145021 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 145021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Macomb Post Acute Care Center 8 Doctors Lane Macomb, IL 61455 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview and record review, the facility failed to change a resident's indwelling urinary catheter bag as ordered by the physician, failed to perform hand hygiene and wear gloves during indwelling urinary catheter care and failed to flush an indwelling urinary catheter as ordered by the physician for one of one resident (R33) reviewed for urinary catheters in the sample of 16. Findings include: The facility's Catheter Flush Policy and Procedure, revised 1/13/22, states, It is the policy of this facility and to ensure catheter irrigation is performed with comfort for the resident. Procedure Interpretation and Implementation: Irrigation of the catheter will provide comfort for the resident and allows the bladder to drain. 1. Verify Physician Order. 13. Remove gloves and wash hands. The facility's Catheter Care Policy and Procedure, revised 1/13/22, states, Staff will maintain consistent and adequate hygiene standards for residents with an indwelling catheter in order to maintain comfort, function, and prevent infection and other complications. Procedures: 1. Gather Equipment. 5. Wash hands and apply clean gloves. 11. Dispose of contaminated items in designated containers. 12. Remove gloves and perform hand hygiene. The facility's Standard Precautions Policy, revised 1/6/21, states, Policy: It is the facility's policy that standard precautions will apply to the care of all residents in all situations regardless of their suspected or confirmed infection disease process. Standard Precautions assume all blood, body fluids and secretions/excretions, non-intact skin and mucous membranes may contain transmissible infectious agents. Procedure: Hand Washing 1. After touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn; 2. Immediately after gloves are removed, between resident contacts and when otherwise indicated to avoid transfer of microorganisms to other residents or environments; and 3. Between tasks and procedures on the same resident to prevent cross-contamination of different body sites. Glove Use: 1. Staff will wear clean non-sterile gloves: a. when touching blood, body fluids, secretions, excretions, and contaminated items; and b. before touching mucous membranes and broken skin. 3. Gloves will be removed promptly after use, before touching non-contaminated items and environmental surfaces and before going to another resident. 4. Hands should be washed immediately after removal of gloves to avoid transfer of microorganisms to other residents or environments. The facility's Hand Washing Policy and Procedure, revised 11/5/19, states, Hand washing is an integral part of an effective infection control program. Its purpose is to reduce the risk of blood borne illness and prevent cross contamination. R33's Hospice Physician Interim Orders Sheet on 12/19/22 documents a clinical update on R33 to the physician for signs and symptoms of urinary tract infection/UTI to which an order for Cipro 500 milligrams/mg twice a day for seven days was received. R33's Medication Administration Record/MAR, dated 12/1/22-12/31/22 documents R33 received Ciprofloxacin HCL/Hydrochloride 500 mg two times a day for seven days for UTI. R33's current Physician Order Sheet documents the following orders: Change (urinary) Catheter (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145021 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 145021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Macomb Post Acute Care Center 8 Doctors Lane Macomb, IL 61455 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few drainage bag weekly every evening shift on Wednesday; Flush indwelling urinary catheter with 60 ml/milliliters 0.9% (percent) NS/Normal Saline BID (twice a day) for irrigation; and Catheter Care every shift and as needed for infection control. On 01/10/23 at 11:18 AM V8 (Registered Nurse) entered R33's room to perform indwelling urinary catheter care. V8 stated that R33 recently finished an antibiotic for a UTI and that R33's urine had an increased amount of mucous threads that was still clogging R33's catheter at times and the catheter was requiring irrigation. At this time, V8 withdrew normal saline from a sterile bottle. The syringe was noted to filled with a little bit less than 50 ml of NS. At this time, V8 stated V8 was instilling 47 ml of saline into R33's urinary catheter to flush it. V8 removed the urinary catheter from the tubing/bag and connected the syringe to flush the catheter. After completing the flush, V8 reconnected the catheter and the tubing/bag and immediately removed the glove to V8's right hand. No hand hygiene was performed. V8 then manipulated R33's urinary catheter tubing with V8's ungloved, unwashed right hand to drain the urine from the catheter into the bag. A large return with approximately 700 ml of yellow urine with thick, white strands was noted in the catheter tubing and the catheter bag. At this time, V8 verified that R33's urinary catheter bag was dated 12/28/22 and R33's catheter securement device to R33's right thigh was dated 12/28/22. V8 stated that the catheter bags and securement devices are changed weekly at the same time. On 1/10/23 at 11:38 AM, V8 verified that V8 did not wash V8's hands after handling R33's urinary catheter and verified that V8 touched R33's urinary catheter bag and tubing with ungloved, unwashed hands. V8 stated that R33's urinary catheter was supposed to be flushed with 60 ml of Normal Saline, not 47 ml. V8 stated, All of the saline kept falling back into the bottle. We are supposed to use 60 ml. V8 stated that R33's urinary catheter bag and securement device was supposed to be changed last on 1/4/23 since it is every week. At this time, V8 verified the urinary bag was not changed as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145021 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 145021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Macomb Post Acute Care Center 8 Doctors Lane Macomb, IL 61455 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview and record review the facility failed to perform hand hygiene and maintain glove use during Gastrostomy Tube Care and failed to cleanse a Gastrostomy Tube as ordered by the physician for one of one resident (R33) reviewed for Gastrostomy tubes in the sample of 16. Findings include: The facility's Feeding Tube Dressing Change Policy and Procedure, revised 1/13/22, states, It is the policy of this facility to provide Gastrostomy and Jejunostomy site care to decrease the risk of infection. 3. Wash hands and put on clean gloves. 4. Using gauze pads and ordered cleanser, gently clean the area immediately surrounding the tube and continue working outward in a circular fashion. Be sure to clean under the bolster. 6. Pat dry after cleaning. 7. Place a dressing around the site as ordered. 10. Remove gloves and wash hands. The facility's Standard Precautions Policy, revised 1/6/21, states, Policy: It is the facility's policy that standard precautions will apply to the care of all residents in all situations regardless of their suspected or confirmed infection disease process. Standard Precautions assume all blood, body fluids and secretions/excretions, non-intact skin and mucous membranes may contain transmissible infectious agents. Procedure: Handwashing 1. After touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn; 2. Immediately after gloves are removed, between resident contacts and when otherwise indicated to avoid transfer of microorganisms to other residents or environments; and 3. Between tasks and procedures on the same resident to prevent cross-contamination of different body sites. Gloves Use: 1. Staff will wear clean non-sterile gloves: a. when touching blood, body fluids, secretions, excretions, and contaminated items; and b. before touching mucous membranes and broken skin. 3. Gloves will be removed promptly after use, before touching non-contaminated items and environmental surfaces and before going to another resident. 4. Hands should be washed immediately after removal of gloves to avoid transfer of microorganisms to other residents or environments. The facility's Hand Washing Policy and Procedure, revised 11/5/19, states, Hand washing is an integral part of an effective infection control program. Its purpose is to reduce the risk of blood borne illness and prevent cross contamination. R33's current Physician Order Sheet documents the following order: Gentamicin Sulfate Ointment 0.1 % (percent). Apply to G-Tube (Gastrostomy Tube) site topically every day shift for preventative. Clean with soap and water, apply ointment, cover with split gauze. On 1/10/23 at 12:08 PM, V8 (Registered Nurse) administered R33's afternoon medications via R33's G-Tube. V8 washed hands and placed on gloves. V8 then squeezed a small amount of R33's Gentamicin ointment onto a gauze square and used the gauze to spread the Gentamicin ointment around R33's G-Tube site. V8 did not cleanse R33's G-Tube site with soap and water prior to placing the antibiotic ointment. V8 then removed V8's gloves and placed a clean, split gauze dressing over R33's G-Tube site with V8's unwashed, ungloved hands. On 1/10/23 at 12:15 PM, V8 stated, I should have washed my hands and put on gloves before placing (R33's) clean G-Tube dressing. Any time in between cares, you should wash your hands and I didn't. At this same time, V8 verified that R33's G-Tube site was not cleansed with soap and water before the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145021 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 145021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Macomb Post Acute Care Center 8 Doctors Lane Macomb, IL 61455 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 0693 topical medicine and dressing was applied. V8 stated, I should have. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145021 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 145021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Macomb Post Acute Care Center 8 Doctors Lane Macomb, IL 61455 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 ensure oxygen tubing and humidifier bottle were dated when initiated and the humidifier bottle contained distilled water for one (R91) of three residents reviewed for respiratory services in the sample of 16. Residents Affected - Few Findings include: The facility's Oxygen Administration and Storage Policy and Procedure, revised 3/8/2022, documents: Purpose: To ensure staff follow safety guidelines and regulation for storage and use of oxygen. Procedure: 1. Verify provider's order for the procedure. 2. In cases of emergency, oxygen may be administered as a nursing intervention until a physician order may be obtained . 12. Label the tubing connected to the oxygen cylinder with time and date . 15. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through . General Guidelines: 7. The humidifier bottle is to be labeled with the date of application and changed weekly if refillable. Emergency Oxygen Administration: It is the Nurse's responsibility to provide emergency administration of oxygen when it is necessary for the care of a resident . 3. The nurse will then call the provider as soon as reasonable to obtain a provider's order. There is no oxygen administration order on R91's Order Summary Report, dated 1/12/23. On 1/10/23 at 12:06 pm, R91 was lying in bed with oxygen being administered at 4L (liters per minute) via nasal cannula with small amount of water in humidifier bottle that was not bubbling. There was no date on the oxygen tubing or the humidifier bottle. On this same date at 2:00 pm, R91's oxygen tubing and humidifier bottle remained without a date and the humidifier bottle was empty. On 1/11/23 at 11:50 am R91's oxygen tubing and humidifier bottle remained undated, and the humidifier bottle remained empty. On 1/11/23 at 12:30 pm, R91's undated oxygen tubing had been removed and was hanging over R91's dresser and the undated empty humidifier bottle remained attached to the oxygen concentrator. On 1/12/23 at 9:15 am, R91 was sitting up in a recliner chair with oxygen on at 4 liters, the humidifier bottle remained empty, and the bottle and tubing were not dated. On 1/12/23 at 9:20 am, V5 LPN (Licensed Practical Nurse) stated R91 was sent out to the local hospital yesterday for an evaluation and returned later in the day and is still receiving 4 liters of oxygen. V5 LPN stated all the humidifier bottles and oxygen tubing are to be changed by third shift Nurses on Fridays, all oxygen tubing and bottles should be dated when they are placed, and the humidifier bottles should always have distilled water in them. During medication administration to R91, V5 LPN confirmed R91's humidifier bottle and tubing should have a date on them as to when they were placed and R91's humidifier bottle should have distilled water in it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145021 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 145021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Macomb Post Acute Care Center 8 Doctors Lane Macomb, IL 61455 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 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. Based on observation, interview, and record review the facility failed to serve a physician ordered diet to one (R28) of two residents reviewed for nutrition in the sample of 16. Residents Affected - Few Findings include: The Face Sheet for R28, documents R28 was admitted to the facility with the following diagnoses: Type 2 Diabetes Mellitus, Atypical Facial Pain, Temporomandibular Joint Disorder, Articular Disc Disorder of Temporomandibular Joint, Dysphagia and Other Symptoms and Signs Concerning Food and Fluid Intake. The Order Summary Report for R28, dated 1/12/23, documents a Physician Order was obtained on 11/29/21 for R28 as Regular Diet, Mech Soft: Chopped/Advanced/Soft and Bite Sized Texture, Regular/Thin consistency, ice cream with lunch and supper. The Breakfast meal ticket for R28, dated 1/12/23, documents R28 breakfast menu including Ground Sausage w(with)/gravy. On 1/12/22 at 9:35 am, R28 was in her room eating breakfast. R28 had a plate with scrambled eggs and a whole sausage patty and no gravy. On 1/12/22 at 9:38 am, R28 stated she cannot chew the sausage because it is too tough and is supposed to have her meat ground and sometimes gets it with gravy. On 1/12/22 at 9:45 am, V2 DON (Director of Nursing) looked at R28's Breakfast meal ticket and stated R28 is supposed to have ground meats with gravy and should not have received a whole sausage patty. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145021 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 145021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Macomb Post Acute Care Center 8 Doctors Lane Macomb, IL 61455 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to wash hands after removing gloves during incontinence care for one of one resident (R33) reviewed for bowel and bladder in the sample of 16. Residents Affected - Few Findings include: The facility's Standard Precautions Policy, revised 1/6/21, states, Policy: It is the facility's policy that standard precautions will apply to the care of all residents in all situations regardless of their suspected or confirmed infection disease process. Standard Precautions assume all blood, body fluids and secretions/excretions, non-intact skin and mucous membranes may contain transmissible infectious agents. Procedure: Handwashing 1. After touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn; 2. Immediately after gloves are removed, between resident contacts and when otherwise indicated to avoid transfer of microorganisms to other residents or environments; and 3. Between tasks and procedures on the same resident to prevent cross-contamination of different body sites. Gloves Use: 1. Staff will wear clean non-sterile gloves: a. when touching blood, body fluids, secretions, excretions, and contaminated items; and b. before touching mucous membranes and broken skin. 3. Gloves will be removed promptly after use, before touching non-contaminated items and environmental surfaces and before going to another resident. 4. Hands should be washed immediately after removal of gloves to avoid transfer of microorganisms to other residents or environments. The facility's Hand Washing Policy and Procedure, revised 11/5/19, states, Hand washing is an integral part of an effective infection control program. Its purpose is to reduce the risk of blood borne illness and prevent cross contamination. On 1/10/23 at 11:06 AM, V7 (Certified Nursing Assistant) entered R33's room to assist V8 (Registered Nurse) with cares. At this time, R33 was noted to be incontinent of liquid stool. V7 cleansed R33's buttocks area of the liquid stool with wet wipes. V7 picked up the soiled incontinence brief and soiled wet wipes directly with V7's gloved hands, disposed of the items into the trash and then removed soiled gloves. Without handwashing, V7 placed on clean gloves. V7 noticed a single soiled wipe that had fallen out of R33's incontinent brief onto R33's bed pad. With V7's left, gloved hand, V7 picked up the stool covered wipe and placed it into the trash. V7 then removed the soiled glove from V7's left hand and without performing hand hygiene, placed a new glove onto V7's left hand. V7 then continued to cleanse the remaining stool from R33's buttocks, groins and scrotum. V7 removed V7's soiled gloves and placed on new gloves without performing hand hygiene. V7 then assisted in placing a clean incontinence brief under R33 and assisted V8 in turning R33 from side to side. V7 removed gloves and exited R33's room without performing hand hygiene. On 1/10/23 at 11:35 AM, V7 stated, I should have washed my hands (between glove changes and after cares) but I didn't. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145021 If continuation sheet Page 15 of 15