Inspection·October 23, 2024

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Nurse Assistant) notified V8, LPN/(Licensed Practical Nurse) that R1 had a bump on his head that was bleeding. Note indicates V4, CNA stated he received in report from V6, CNA that R1's head was bleeding all night. Note indicates V8, Nurse immediately entered R1's room and assessed R1. Note indicates a palm-size raised bruise was noted to the back of R1's head with a laceration noted to the center of the bump with blood dripping. Note indicates quarter-size drops of blood were noted to multiple areas of R1's pillowcase. Note indicates when asked, R1 stated he fell last night at 10:30pm with complaints of pain to the back of his head. Note indicates R1 was then transferred to the hospital for evaluation. Hospital Emergency Department (ED) Report dated 9/28/24 at 6:52am indicates R1 was found to have a bruise on the back of his head that had a small amount of blood. Note indicates R1 stated he may have had a seizure and fallen last night. Hospital Report indicates R1 was diagnosed with a Scalp Contusion. On 10/18/24 at 11am V8, LPN stated during report from V3, LPN on the morning of 9/28/24, V3 stated I don't have anything new to tell you (regarding R1). V8 stated she was never told R1 fell or had bleeding from his head. V8 stated she didn't find out until V4, CNA told her about R1. On 10/22/24 at 10:10am R1 was sitting in his room watching television. R1 was able to recall falling and hitting his head. At that time a linear approximately 4cm (centimeter) dark pink, slightly scabbed area to the posterior top part of R1's head was noted. On 10/22/24 at 11:46am V6, CNA stated On Friday night (9/27/24) I found (R1) sitting on the floor leaning against his bed. When (R1) laid down I noticed a small amount of blood on his head. I told the nurse (V3) and she did somewhat of an assessment and wiped the blood away with one of R1's tissues. She said he was Ok. She never started neuro checks or anything else. V6 stated R1's head continued to bleed all night The other CNA (V7) noticed it too. The nurse was aware. It was not right. I told my boss (V1, Administrator) exactly what happened. On 10/22/24 at 11:22am V4, CNA stated he came on shift and got a brief report and was told R1 had hit his head when he fell the night before, but it stopped bleeding. V4 stated he went to see R1 and noticed blood scatted on his pillow case. V4 stated he saw swelling and a knot on R1's head and It was still dribbling blood at that time. V4 stated he immediately went and told the V8,LPN who also had just received morning report. V3 stated that she had received no information about R1 in report and had no idea what happened to R1. V3 stated that V6, CNA (from night shift) stated that she told the V3 (night nurse) R1's head was still bleeding. On 10/22/24 at 12:30pm V3, LPN stated that V10, CNA told her that R1 (on 9/27/24) was on the floor. V3 stated she went to R1's room and R1 said he didn't fall. V3 stated R1 has behaviors of putting himself on the floor. V3 stated a short while later V6, CNA told her there was a small amount of blood on R1's head. V3 stated shehad already looked at R1's head and there was no swelling, and that she wiped the area with one of R1's tissues. V3 stated she didn't believe R1 fell and thought it was R1's behaviors so she didn't do neurological checks. V3 stated she didn't notify the physician and didn't notify R1's family. V3 stated R1's POA (Power of Attorney) said she doesn't want to hear about his Bullcrap so she didn't bother her. V3 stated R1 denied falling, but could not explain how he got on the floor. V3 stated she was aware of R1's seizure diagnosis but believed it was one of R1's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145021 If continuation sheet Page 2 of 6 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 10/23/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few behaviors. V3 stated she didn't hear from R1 or the CNA's for the rest of the night so she didn't check on R1 again during the night. On 10/22/24 at 12:50pm V7, CNA stated that she went to see R1 shortly after he fell. V7 stated that R1 told her he fell but he seemed ok. V7 stated there was blood on his pillow and it looked like he hit his head. V7 stated that she reported what she saw to the nurse (V3) and told her there was blood and (V3) said she already assessed R1. V7 stated I don't think she (V3) went back in to see him. On 10/22/24 at 2:15pm V1, Administrator stated staff should not disregard and not follow the fall protocol just because someone has behaviors. On 10/23/24 at 4:32pm V11, Medical Director stated there should be a policy and the staff should follow the policy for what to do when someone falls and when someone hits there head. V11 stated Staff should not minimize or disregard incidents because someone has behaviors, but should actually do more to make sure they are ok. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145021 If continuation sheet Page 3 of 6 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 10/23/2024 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to assess, document and provide pain management for one resident (R2) of three residents reviewed for change in condition. Residents Affected - Few This failure resulted in no pain management provided for 7 hours after R2 fell and sustained a left hip fracture Findings include: Facility Policy/Pain Management and assessment dated [DATE] documents: Evaluation and Assessment: Comprehensive pain assessment tool will be completed upon admission, transfer or onset of new pain which includes: Quality of pain (e.g. burning, aching, numbness) Pain intensity (numeric, visual analog scale, or nonverbal behavior, changes in function observation) Changes in mood state (e.g. depression, anxiety) Location and/or radiation of pain Factors that palliate or provoke pain Characteristics of pain (i. e., stable, progressive, crescendo) Facility Policy/Change in Condition Procedure dated 9/21/2022 documents: The following guidelines will be utilized as appropriate to each situation and change in condition: Full assessment by nursing staff including but not limited to: Full Vital signs (Temperature, Pulse, Respirations, Blood Pressure and Oxygen Saturation) Level of consciousness; Respiratory status including last bowel movement and urine properties Functional status, Pain Glucose test if diabetic or decrease in level of consciousness. Progress Note dated 9/27/24 at 11:59pm indicates (R2) on floor, sitting on his bottom. (R2) claims he was looking for his remote. Vital signs within normal limits, no injuries, moves all extremities within normal limits. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145021 If continuation sheet Page 4 of 6 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 10/23/2024 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 0697 Level of Harm - Actual harm Residents Affected - Few Progress Note dated 9/28/24 at 7am indicates R2 complained of hip pain 10/10 after fall last evening. Note indicates (R2) fell at 11:59pm 9/27/24, now complaining of pain and left leg appears to be externally rotated. No other progress notes or documentation regarding R2 was found between 9/27/24 at 11:59pm and 9/28/24 at 7am. Hospital ED (Emergency Department) Final Report Note dated 9/28/24 at 11:14am presented to the ED with left hip pain-swelling, stating he fell last night with pain persisting this AM. Note indicates R2 has a past surgical history of right hip fracture. Risk Management Incident Report dated 9/27/24 at 11:51pm indicates Level of Pain (post fall): Alert; wheelchair bound. Report does not include any actual documentation of R2's pain post fall. On 10/22/24 at 11:40am V6, CNA stated that she was sitting at the nurse station and heard a loud thud. V6 stated she left the nurses station and followed the sound of the thud and saw R2 on the floor in front of the sink. V6 stated R2's room is almost right next to the nurse station, R2's television is above the sink and R2 said he was trying to turn the television on. V6 stated she called V3, LPN who came in and barely did an assessment of R2 and then helped her get R2 back into his wheelchair. V6 stated she was holding the top half of R2 and V3 was holding his bottom half. V6 stated R2 was complaining of pain while they were trying to get him into the chair. V6 stated that night R2 would complain of pain and yell Ow! every time they turned and changed him when he was in bed, especially when turned to the left side. V6 stated R2 really couldn't roll onto the left side. V6 further stated When I found (R2) on the floor, he was completely on his left hip/side. He must have hit hard because the sound I heard from the nurses station was loud. V6 stated she did notify V3 about R2's pain throughout the night. On 10/22/24 at 12:30pm V3, LPN stated that she went to R2's room when she heard he was found on the floor. V3 stated that she and V6, CNA manually picked R2 up and put him in his wheelchair. V3 stated (R2) had no complaints of pain. V3 stated I rely on the CNA's to tell me. It was a busy night, I didn't reassess him. I gave (R2) meds in the morning (not for pain), he took it ok. There is not a spot to document pain on the Neuro sheet. I should've put in a progress note about R2's pain assessment. On 10/18/24 at 11:30am V5, LPN (Licensed Practical Nurse) stated she was told in report in the morning of 9/28/24 that R2 had an unwitnessed fall during the night (of 9/27/24) and was on neuro(logical) checks. V5 stated a CNA came to tell her that while she was providing cares to R2, he was complaining of pain on his left side. V5 stated the night nurse (V3) didn't say anything to her in report about R2 being in pain during the night. V5 stated she had another nurse (V8) came into R2's room and they both agreed R2 needed to go to the hospital for evaluation. V5 stated R2 was in a great deal of pain especially with any movement. No documentation of R2's pain at time of fall or anytime between time of fall at 11:59pm through 7am the following morning (9/28/24) was found or presented. No assessment or interventions to relieve R2's pain from after he fell was found or presented until the morning of 9/28/24 at 7am. Medication Administration Record (MAR) dated September 2024 indicates no pain medication was administered during the night of 9/27/24 through 9/28/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145021 If continuation sheet Page 5 of 6 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 10/23/2024 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 0697 Current Care Plan has no focus/problem area identifying R2's pain or interventions for pain management. Level of Harm - Actual harm On 10/22/24 at 10am R2 was sitting in his room in his wheelchair with a distressed facial appearance. R2 stated his back hurt and he wanted to lay down. R2 became teary-eyed while speaking. R2 stated this latest hip fracture was much more painful than his previous (right) hip fracture. R2 was unable to recall anything else from the night he fell (on 9/27/24) other than he was trying to turn on the television. Residents Affected - Few At that time V5, LPN came in to assess R2 and stated that R2 is easily emotional especially when in pain. On 10/23/24 at 4:30pm V11, Medical Director stated there can be severe pain associated with a hip fracture, especially with movement. V11 stated there should be a policy to assess for pain after a fall and the policy should be followed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145021 If continuation sheet Page 6 of 6