Inspection·June 5, 2024

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hand soiled glove and an ungloved right hand. V8 then removed the left-hand glove and performed hand washing. Without donning gloves, V8 began to cut a piece of Calcium Alginate to fit the center of R1's open wound, touching the wound covering with V8's bare hands. V8 then placed a glove to V8's left hand, exited R1's room wearing the glove to V8's left hand, returned wearing the same glove to V8's left hand and then placed a glove on V8's right hand. No handwashing or glove changes occurred upon V8's return to R1's bedroom. V8 then proceeded to place the Calcium Alginate to R1's left foot wound and dress the wound. V8 then removed V8's soiled gloves and without handwashing, V8 adjusted R1's left foot, handed R1 R1's sock, and placed items in the trash. V8 exited R1's bedroom carrying the bottle of wound cleanser, walked up the hallway to the nursing station where V8 then performed hand hygiene. On 6/4/24 at 2:05 PM, V8 verified V8 did not change gloves or perform hand hygiene after removing R1's soiled left foot dressing and before cleaning R1's left foot wound. V8 stated, I don't think I should have because I was still touching a dirty wound. At this time, V8 verified V8 should not have touched R1's Calcium Alginate with V8's bare hands. V8 stated, I was trying to barely touch it, but I should have worn gloves. V8 verified V8 did not immediately wash V8's hands after performing wound care and before touching clean items in R1's room and should have. On 6/5/24 at 2:04 PM, V1 (Administrator/Registered Nurse) and V2 (Director of Nursing) in a joint interview, V1 and V2 both stated V8 should have immediately removed V8's soiled gloves and washed V8's hands before cleansing R1's wound. V1 and V2 stated V8 should not have touched R1's Calcium Alginate with V8's bare hands. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145021 If continuation sheet Page 2 of 10 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 06/05/2024 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, interview, and record review, the facility failed to ensure a resident had physician orders and a diagnosis for use of an indwelling urinary catheter and failed to ensure a resident's indwelling urinary catheter did not come in direct contact with the ground for one of two residents (R4) reviewed for indwelling urinary catheters in the sample of seven. Findings include: The facility's Policy and Procedure: Indwelling Catheter dated 12/29/23 documents the physician's order for indwelling urinary catheters will note the size French and bulb inflation (milliliters). R4's Hospital Records Discharge Orders document R4 discharged from the hospital on 5/23/24 after management of a femur fracture with repair. These same Hospital Records do not document an order for R4 to admit to the skilled nursing facility with an indwelling urinary catheter. R4's admission Record documents R1 admitted to the facility on [DATE]. R4's current Physician Orders do not document an order for R4's indwelling urinary catheter, size French, or bulb inflation. R4's current Care Plan documents R4 with the presence of an indwelling urinary catheter and that R4 is currently on antibiotic therapy related to urinary tract infection. R4's Nursing Progress Note dated 5/29/24 states, Urine obtained and sent to lab. (R4) has been yelling out, attempting to hit staff, throwing items. R4's Urine Culture Result dated 5/31/24 documents an abnormal result of greater than 100,000 colony-forming unit per milliliter Escherichia coli. This same laboratory results documents an order for R4 to start Macrobid 100 milligrams twice a day for ten days. On 6/4/24 at 12:30 PM, R4 was sitting up in wheelchair in the front lobby of the skilled nursing facility. R4's indwelling urinary catheter drainage bag was noted in a dignity bag covering hanging from the underside of R4's wheelchair. The tubing of R4's indwelling urinary catheter was noted to be resting directly on the ground. Dark amber colored urine was noted in the tubing with thick brown sediment. On 6/4/24 at 12:46 PM, V6 (Certified Nursing Assistant) pushed R4 in R4's wheelchair out of the facility and across the parking lot to a nearby office for a scheduled appointment. R4's indwelling urinary catheter tubing remained directly touching the ground and was dragging across the pavement of the parking lot and the road. On 6/5/24 at 9:10 AM, R4 was lying in R4's bed in R4's room. R4's indwelling urinary catheter bag and tubing was resting directly on the floor to the left side of R4's bed. R4's urine remained a dark amber color. No dignity bag covering was in place on R4's catheter bag at this time. On 6/5/24 at 9:13 AM, V10 (Certified Nursing Assistant/CNA) entered R4's bedroom. V10 noted R4's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145021 If continuation sheet Page 3 of 10 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 06/05/2024 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 indwelling urinary catheter bag and tubing resting directly on the floor. At this time, V10 picked R4's indwelling urinary catheter bag off the floor and hung it to the side of R4's bed and using a plastic clip that was located around the tubing of R1's catheter, clipped the tubing to the fitted sheet on R4's bed, so the tubing was not directly touching the ground. At this time, V10 stated R4's indwelling urinary catheter bag and tubing should not have any direct contact with the ground. V10 stated R4 does not like having the catheter and that R4 frequently attempts to pull it out. On 6/5/24 at 2:04 PM, V1 (Administrator/Registered Nurse) and V2 (Director of Nursing) in a joint interview, both stated R4's indwelling urinary catheter bag and tubing should never come into direct contact with the ground. V1 and V2 also stated they were looking into the reasoning for R4's indwelling urinary catheter. V1 verified R4 did not come to the facility with orders for an indwelling urinary catheter and R4 did not have a diagnosis to justify the use of an indwelling urinary catheter. V1 stated R4 is always attempting to pull her catheter out, so V1 is looking into getting it discontinued. V1 and V2 verified R4 is currently receiving antibiotic treatment for a urinary tract infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145021 If continuation sheet Page 4 of 10 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 06/05/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure walk-in coolers in the kitchen maintained a temperature of less than 40 degrees Fahrenheit/F and that food in refrigerators were kept at a temperature of 41 degrees Fahrenheit or below. This failure has the potential to affect all 50 residents residing in the facility. Findings include: The facility's Policy and Procedure Refrigerators and Freezers revised 11/15/21 states, Policy Statement: The facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Policy Interpretation and Implementation: 1. Acceptable temperatures should be 35 degrees F to 40 degrees F for refrigerators and less than 0 degrees F for freezers. 5. The supervisor will take immediate action if temperatures are out of range. Actions necessary to correct the temperatures will be recorded on the tracking sheet, including the repair personnel and/or department contacted. The facility's Policy and Procedure Food Temperatures revised 11/5/21 states, Policy Statement: Food will be stored in accordance with local, state, and federal guidelines. Policy Interpretation and Implementation: 2. Food in refrigerators will be kept at 41 degrees F or below. An Electronic/E-mail Communication from V1 (Administrator) to V14 (Chief Operating Officer) on 5/9/24 at 3:30 PM states, Our walk-in cooler is running at 45 degrees (F), and we just received both of our trucks today. They put coolant in it twice in the last two weeks, 4 lbs. (pounds) the first time and then 10 days later 3.5 lbs. We don't want our food to go bad. What do we do? On 5/9/24 at 4:42 PM, V14 responded that V16 (Corporate Maintenance Director) is off the rest of the week, but that V16 is working on someone to work up a repair quote. An Electronic/E-mail Communication from V16 on 5/14/24 at 10:03 AM documents that a (Name of Electrical, Plumbing, and Heating Company) had been contacted to get the facility on their schedule to look at walk-in (cooler). An Electronic/E-mail Communication from V1 to V14, V15 (Purchasing), V16, and V4 (Dietary Manager) on 5/15/24 at 2:53 PM states, Just an update our walk-in is running at 43 degrees (F) today. An Electronic/E-mail Communication response from V16 to V1, V4, V14, and V15 on 5/15/24 at 1:56 PM states, Why are we still trying to use it? (Name of Electrical, Plumbing, and Heating Company) is going to get us on the schedule as soon as possible. On 5/15/24 at 2:56 PM, V1 (Administrator) responded, We have no other option. Everything won't fit in the reach in and somethings we can't freeze. On 5/15/24 at 1:58 PM, A second Electronic/E-mail Communication from V16 stated, We can't keep throwing money away on putting freon (in) it. We are trying to get it fixed as soon as we can. On 5/15/24 at 3:07 PM, V1 responded, I understand that. I just don't know what to do. An Electronic/E-mail Communication from V16 on 5/16/24 at 10:18 AM states, (Name of Electrical, Plumbing, and Heating Company) is working on a quote to repair walk-in should have it today. An Electronic/E-mail Communication from V17 (Employee at Name of Hired Electrical, Plumbing, and Heating Company) on 5/17/24 at 11:31 AM states, That's good enough for me to schedule someone to look at it. I will work it into our schedule to check out the problem and price repairs next week, as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145021 If continuation sheet Page 5 of 10 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 06/05/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many soon as someone can get to it, probably the middle of next week is the soonest we could. Did you say it was a walk-on cooler? A Price Quote from (Name of Electrical, Plumbing, and Heating Company) dated 5/23/24, states, We are pleased to offer the following work to be done: We will remove the old evaporator coiled and condensing unit. We will install the following new equipment with new copper line set: (Name Brand) Condensing Unit and Air ECM (Electronically Commutated Motor) with Intelligen Controller. The total cost for all parts material and labor will be $10, 218.00 (dollars). Everything is in stock with our supplier and takes 3-5 (three to five) days to receive. On 6/4/24 at 10:04 AM, a tour of the kitchen was conducted with V4 (Dietary Manager). V5 (Temporary Maintenance Director) was also present in the kitchen. At this time, the walk-in coolers digital temperature outside the door was reading 44 degrees F. At this time, V4 stated, We just got done cleaning breakfast, so that door has been opened, so it's reading higher than normal. At this time, V4 and V5 were asked if there have been any known issues with any of the refrigerators or freezers not working as they should. V4, quietly responded, Oh, yeah. and V5, pointing to the walk-in cooler that was reading 47 degrees, stated, That one right there. V4 and V5 both stated the walk-in cooler has not been working correctly for at least a month and a half. V5 stated, They tried dumping freon in it over and over, but that was an easy fix and it's not working anymore. V4 stated, The walk-in freezer is on the other side of the walk-in cooler, so I keep the freezer door opened to keep the walk-in cooler at temperature. V4 stated, Once the door stays closed for a period of time, it will cool down. V5 stated, It (walk-in cooler) needs a new condenser. It's not working. At this time, a prepared cup of milk on a drink cart was observed. V4 checked the temperature of the milk and it read 44.1 degrees F. On 6/4/24 at 11:01 AM, a follow-up visit was made to the kitchen with V4. At this time, the walk-in cooler digital temperature read 47 degrees F. On 6/4/24 at 11:10 AM, V9 (Dietary Aide/Cook) toured the walk-in cooler with this writer. At this time, the walk-in cooler contained the following items: 55-four ounce/oz. containers of fruit yogurt; 123 eggs; A cardboard box of sliced cheese; Four-One Gallon containers of Mayonnaise; Six individual containers of pear fruit cups; One-Five Pound Vacuum sealed portion of Diced Beef; A metal pan containing leftover Tuna Noodle Casserole dated 5/31/24; One container of Thickened Dairy Supplement; One vacuum sealed 15 pound package of Corned Beef Brisket; a metal pan of gelatin dessert; one chocolate cream pie; four gallons of milk; a variety of drink pitchers labeled: Apple Juice, Lemonade; Cranberry Juice, and Tea; and two unopened boxes of ham. On 6/4/24 at 11:20 AM, V9 removed one yogurt cup, the pan of tuna noodle casserole, and poured a glass of milk into a plastic cup and set it on a counter in the kitchen. With a digital thermometer, V9 checked the temperature of the three items: The fruit yogurt cup read: 41.9 degrees F; The tuna noodle casserole read 42.6 degrees F; and the glass of milk read 41 degrees F. V9 stated, I am going to have to tell (V4) these temperatures are too high, we can't serve this. It has to be 41 degrees F or less, and it's not. On 6/4/24 at 11:26 AM, the walk-in cooler continued to read 47 degrees F. On 6/4/24 at 11:32 AM, the drink cart container one gallon of milk and the variety of fruit juices was removed from the walk-in cooler and brought out to the main dining room to be served. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145021 If continuation sheet Page 6 of 10 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 06/05/2024 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 0812 On 6/4/24 at 11:36 AM, V18 (Resident Aide/RA) poured three glasses of milk and gave them to R2. Level of Harm - Minimal harm or potential for actual harm On 6/4/24 at 11:40 AM, R2 took a drink out of one of the milk glasses that were given to her. At this time, R2 stated, It is actually colder than it usually is. Months ago, I was given chocolate milk that was spoiled. Residents Affected - Many On 6/4/24 at 11:52 AM, the digital temperature gage outside the walk-in cooler was reading 46 degrees F. At this time, V9 was observed disposing of the tuna noodle casserole into the trash and the yogurt cups had been disposed of as well. V9 stated, We have to get rid of this. We can't use that cooler anymore. We are taking everything out of there. On 6/4/24 at 1:29 PM, R1 stated, Oh, the food is disgusting. They serve warm milk. It's bad. On 6/5/24 at 9:22 AM, a tour of the kitchen was conducted. V4 (Dietary Managaer) stated, We have shut it down (walk-in cooler). It's not working. Everything is out of there. We shut it down last night. The digital thermometer outside the walk-in cooler read 51 degrees F. At this time, V4 was observed removing the vacuum sealed package of corned beef brisket from the walk-in cooler and placing it into the freezer. V4 stated, I still had this (corned beef brisket) in there (walk-in cooler). I just put it in the freezer to keep it cool until I can make room in the stand-up fridge. At this time, V4 stated V4 refused to check the internal temperature of the corned beef brisket due to its vacuum seal. V4 stated, I don't know when I am serving this. If I open the seal, I will have to serve it. I know the temperature is fine because I keep that freezer open, and I keep the meat in the back of the walk-in cooler. When asked why V4 was continuing to use a walk-in cooler that was not operating correctly, V4 stated, What do you want me to do? I don't have anywhere else to put all of this food. There is no room in the other refrigerators. No other food items were observed in the walk-in cooler. On 6/5/24 at 12:00 PM, V1 (Administrator) stated the Corned Beef Brisket was disposed of into the trash and would not be served to any residents. V1 stated the walk-in cooler will not be used until it is repaired. The Resident Room Roster dated 6/4/24 documents 50 residents currently reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145021 If continuation sheet Page 7 of 10 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 06/05/2024 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 upon observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions for residents with open wounds, indwelling urinary catheters, and peripherally inserted central catheters/PICC for three of six residents (R1, R4 and R6) reviewed for Enhanced Barrier Precautions in the sample of seven. Residents Affected - Few Findings include: The facility's Policy and Procedure Enhanced Barrier Precautions dated 3/27/24 states, Policy: It is the policy of this facility that Enhanced Barrier Precautions (EBP) are used to prevent transmission of infectious organisms spread by direct or indirect contact with the patient or the patient's environment. They are a strategy in nursing homes to decrease transmission of CDC (Centers for Disease Control and Prevention) targeted and epidemiologically important MDROs (Multidrug-Resistant Organisms) when contact precautions do not apply. EBP is used during high-contact care activities for residents with chronic wounds or indwelling medical device, regardless of MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply. The website https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html states, What is the definition of indwelling medical device? An indwelling medical device provides a direct pathway for pathogens in the environment to enter the body and cause infection. Examples of indwelling medical devices include, but are not limited to, central vascular catheters (including hemodialysis catheters, peripherally-inserted central catheters/PICCs), indwelling urinary catheters, feeding tubes, and tracheostomy tubes. The guidance advises using Enhanced Barrier Precautions for the care and use of indwelling medical devices. How is 'care and use' defined? The presence of an indwelling device is a major risk factor for being colonized with or acquiring a MDRO. Therefore, the safest practice would be to wear a gown and gloves for any care (e.g., dressing changes) or use (e.g., injecting or infusing medications or tube feeds) of the indwelling medical device. The CDC's (Centers for Disease Control and Prevention) Enhanced Barrier Precautions door signage states, STOP. Everyone must: Clean their hands including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activities: Device care of use of: central line, urinary catheter, feeding tube, tracheostomy; Wound Care: any skin opening requiring a dressing. On 6/4/24 at 9:15 AM, V1 (Administrator) stated that the facility only has one resident (R7) currently in the facility with Enhanced Barrier Precautions implemented. R1's Progress Note signed and dated by V13 (Advanced Nurse Practitioner) on 6/4/24 at 1:37 PM documents R1 is currently receiving intravenous (IV) antibiotics through a PICC Line for treatment of recent diagnoses of Gangrene, Osteomyelitis, and Necrotizing Fasciitis to R1's left foot. This same note documents R1 receives daily wound care to R1's left foot. R1's current Care Plan states, I (R1) have a PICC line and am at risk for opportunistic infection to enter my body and intervention of Educate resident on reason for Enhanced Barrier Precautions. R4's current Care Plan documents R4 with the presence of an indwelling urinary catheter and that R4 is currently on antibiotic therapy related to urinary tract infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145021 If continuation sheet Page 8 of 10 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 06/05/2024 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 R6's Baseline Care Plan dated 5/25/24 documents R6 with the presence of an indwelling urinary catheter. Level of Harm - Minimal harm or potential for actual harm On 6/4/24 at 12:30 PM, R4 was sitting up in wheelchair in the front lobby of the skilled nursing facility. R4's indwelling urinary catheter drainage bag was noted in a dignity bag covering hanging from the underside of R4's wheelchair. Residents Affected - Few On 6/5/24 at 10:00 AM, R6 was observed coming inside from the smoking patio. R6's indwelling urinary catheter drainage bag was noted in a dignity bag covering hanging from the underside of R6's wheelchair. On 6/4/24 at 12:36 PM, R1, R4, and R6's bedrooms were observed. R1 and R6's rooms were next door to each other and R4's bedroom was directly across the hall from R1 and R6. At this time, R1, R4, and R6's bedroom doors did not contain the CDC's Enhanced Barrier Precautions door signage. No bins containing personal protective equipment were located outside R1, R4, or R6's bedroom. On 6/4/24 at 1:41 PM, R1 was sitting up in a chair in R1's room. R1 stated R1 has a Peripherally Inserted Central Catheter (PICC Line) that R1 is receiving IV (intravenous) antibiotics through for a wound infection to R1's left foot. At this time, R1 was receiving a dose of antibiotics through R1's right upper arm PICC line. R1 stated the staff has never worn a gown while performing treatments to R1's PICC Line or R1's left foot wound. On 6/4/24 at 1:48 PM, V7 (Registered Nurse) entered R1's room to respond to a beeping alarm coming from R1's IV pump. At this time, V7 disconnected R1's IV tubing from R1's PICC line and then proceeded to flush R1's PICC line with a Normal Saline 10 milliliter flush. V7 did not wear a gown during the care of R1's PICC line. On 6/4/24 at 1:53 PM, V8 (Registered Nurse) entered R1's bedroom to change R1's left foot wound dressing. V8 removed R1's soiled dressing. Dark brown drainage was noted to have soaked through the center of R1's dressing. A dime-sized open area was noted to the posterior lateral side of R1's left foot. V8 cleansed R1's wound with a spray cleanser and proceeded to place Calcium Alginate in R1's wound bed. V8 did not wear a gown during R1's entire wound care treatment. On 6/4/24 at 2:05 PM, V8 verified did not maintain Enhanced Barrier Precautions/EBP during R1's wound care. V8 stated R1 did not have enhanced barrier precautions ordered. V8 stated V8 did not know if R1 should have EBP implemented. On 6/5/24 at 9:13 AM, V10 (Certified Nursing Assistant/CNA) entered R4's bedroom. V10 noted R4's indwelling urinary catheter bag and tubing resting directly on the floor. At this time, V10 picked R4's indwelling urinary catheter bag off the floor and hung it to the side of R4's bed and using a plastic clip that was located around the tubing of R1's catheter, clipped the tubing to the fitted sheet on R4's bed. V10 stated R4 did not have Enhanced Barrier Precautions implemented and stated, The nurses order that. On 6/4/24 at 2:09 PM, V3 (Infection Preventionist) stated that R7 was the only resident in the facility with EBP implemented. V3(Assistant DON/Infection Preventionist) verified R1 currently had a PICC line and a wound to R1's foot. V3 stated V3 did not think R1's wound was open, and R1's PICC line alone wasn't a reason to implement EBP. At this time, V3 also verified R4 and R6 had indwelling urinary catheters but did not have EBP implemented because they did not have more than one reason for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145021 If continuation sheet Page 9 of 10 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 06/05/2024 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few EBP to be implemented. V3 stated V3 did not think an indwelling urinary catheter alone was a reason to implement EBP. V3 stated you would know if a resident had EBP implemented by the sign posted on their door and the bin of personal protective equipment/PPE outside of their door. On 6/5/24 at 9:10 AM, R1, R4, and R6's bedroom doors remained without the CDC's Enhanced Barrier Precautions door signage and no bins containing personal protective equipment were located outside of their bedrooms. On 6/5/24 at 2:04 PM, V1 (Administrator/Registered Nurse) and V2 (Director of Nursing) in a joint interview verified R1, R4, and R6 did not have EBP implemented. V2 stated, Gowning every time they need catheter care or do wound dressings? I would have to talk to (V3) about that. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145021 If continuation sheet Page 10 of 10