Inspection·April 17, 2025

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 4/15/2025 at 2:00 PM, V7 (Cook) stated, We (dietary staff) do not give (R52) double portions with his meals. If (R52) asks for seconds, we would give them to him. I am not aware of (R52) having a physician's order to get double portions at meals. On 4/16/25 at 9:21 AM, V2 (Director of Nursing) confirmed R52's dietary order documents double portions with lunch and dinner meals and that those double portions should be served without R52 having to ask. Event ID: Facility ID: 145021 If continuation sheet Page 2 of 7 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 04/17/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure a multidose tuberculin vial was dated when opened. This failure has the potential to affect all 60 residents residing in the facility. Findings include: The Facility's Storage, Labeling of OTC (over the counter) Medication, Destruction and Disposal of Medication policy, dated/revised November 9th, 2021, documents, Purpose: To ensure that medications and biological are stored in a safe, secure storage and safe handling. Medications requiring refrigeration should be stored in the refrigerator located in the drug room at the nurse's station. Medications should be stored separately from food and must be labeled. Please refer to package insert for specific temperature requirements of medication. On 4/16/25 at 9:30 AM V3 (LPN/Licensed Practical Nurse) opened the refrigerator located in the medication room. On the top shelf of the door in the refrigerator was one vial of Aplisol (Tuberculin) units/0.1 ml (milliliter). Vial was opened, one fourth of the way full, and was not dated when opened. V3 verified the vial was opened and not dated. V3 verified the vial of (Tuberculin) is used for all residents residing in the facility. On 4/15/25 at 9:40 AM V3 stated (Tuberculin) should be dated once opened and discarded after 30 days of opening. The facility's CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Application for Medicare and Medicaid Form 671 dated 4-14-25 and signed by V1/Administrator documents 60 residents currently reside within the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145021 If continuation sheet Page 3 of 7 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 04/17/2025 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 0806 Level of Harm - Minimal harm or potential for actual harm Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, interview, and record review the facility failed to offer food substitutions of similar nutritive value. These failures have the potential to affect all 60 residents residing within the facility. Residents Affected - Many Findings include: The facility's CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Application for Medicare and Medicaid Form 671 dated 4-14-25 and signed by V1/Administrator documents 60 residents currently reside within the facility. The Substitution policy dated 12/30/24, documents Food Substitutions will be made as appropriate or necessary. Policy Interpretation and Implementation 1. The food services manager, in conjunction with the clinical dietitian, may make food substitutions as appropriate or necessary. The food services shift supervisor on duty will make substitutions only when unavoidable. 2. The food services manager will maintain an exchanged list identifying the seven (7) exchanges of food groups. When in doubt about an appropriate substitution, the food services manager will consult with the dietitian prior to making substitutions. 3. Resident' likes and dislikes will be considered when making substitutions. 4. All substitutions are noted on the menu and filed in accordance with established dietary policies. Notations of substitutions must include the reason for the substitutions. 6. The dietician will provide feedback on appropriate substitutions as necessary. The facility's Menus dated 4-13-25 through 4-19-25 document there is only one vegetable and one entree option daily for lunch and supper. The facility's Substitution Menu does not include a vegetable option. The Lunch/Dinner Substitute Menu only includes the option of applesauce, corn dog, hot dog, cottage cheese, or grilled cheese. On 4-14-25 at 12:01 PM V7 (Cook) was serving mixed vegetables and spaghetti with meat sauce to all residents. V7 stated, There are no substitutes offered in place of the mixed vegetables. We (facility) staff do not offer a substitution for vegetables. The only substitutes we offer every day for the main entrees are hot dogs, corn dogs, or grilled cheese. On 4-14-24 from 12:00 PM through 12:50 PM the lunch meal was observed in the main dining room. All residents were served mixed vegetables. On 4-14-25 at 12:05 PM R9 was served spaghetti and meat sauce, cake, mixed vegetables, and a bread stick. R9 pointed at the mixed vegetables and stated to V3 (LPN/Licensed Practical Nurse), I don't like those. V3 stated to R9, Let me turn your plate around so you don't have to look at them (mixed vegetables). On 4-14-25 at 12:35 PM R13, R27, R32, R36, R37, and R40 were in the dining room and ate everything on their plate except for the mixed vegetables. R13, R27, R32, R36, R37, and R40 all verified that they do not like mixed vegetables and are never offered a substitute for vegetables at meals. On 4-15-25 from 12:05 PM through 12:30 PM the lunch meal was observed in the main dining room. All residents were served steamed broccoli. R13, R32, R36, and R40 did not eat the broccoli and were not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145021 If continuation sheet Page 4 of 7 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 04/17/2025 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many offered a substitute. R13, R32, R36, and R40 also verified they do not get substitutes offered for the main entree except for the same options of a corn dog, hot dog, or grilled cheese. On 4-15-25 at 1:40 PM during a resident group meeting, R1, R10, R13, R15, R17, R20 and R45 all stated they are given one choice for lunch and supper and then if they want something different, they can choose from a hot dog, corn dog, or grilled cheese. At this time all the residents confirmed there are not any vegetable substitutions or alternate choices. R45 stated he has watched residents just push their vegetables aside if they don't like them but there isn't ever a second option offered for vegetables. On 4-15-25 at 2:45 PM, R51 stated, (R51) does not feel like they have any options on the dietary menus. The institutional like food and canned vegetables are not enough. We are given one choice and if that is something you don't like they have a few options to choose from which is a corn dog, hot dog, or grilled cheese. I've had a corn dog a few times, you can only eat so much of that. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145021 If continuation sheet Page 5 of 7 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 04/17/2025 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 complete and record cool down temperatures for meat that was prepared ahead and stored in the facility's refrigerator for future use, ensure facial hair was appropriately restrained within a hair net while in the kitchen, ensure a gallon of milk's temperature was kept below 41 degrees Fahrenheit, and ensure the sanitation buckets had the appropriate amount of quaternary ammonium. These failures have the potential to affect all 60 residents residing within the facility. Findings include: The facility's CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Application for Medicare and Medicaid Form 671 dated 4-14-25 and signed by V1/Administrator documents 60 residents currently reside within the facility. The Food Temperature policy dated 12/30/24, documents Food will be stored in accordance with local, state, and federal guidelines. Policy Interpretation and Implementation 1. Food will be stored in accordance with local, state, and federal guidelines. 3. Food in refrigerators will be kept at 41-degrees F (Fahrenheit) or below. 6. Food items will be cooled from 135-70 degrees F within 2 (two) hours and from 70-41 degrees F or below within 4 (four) additional hours. 8. Food items being cooled will be checked and if food items do not meet the required cooling timeframe, will be heated to 135-degree F and the re-cooling process restarted. The Personnel Adherence to Sanitary Procedures policy dated 12/30/24, documents Food service personnel shall follow appropriate sanitary procedures. Policy Interpretation and Implementation 1. In addition to employee personnel policies, food services and dietary personnel will be required to adhere to the following sanitary standards: a. Hair nets or approved hats, covering all the hair, must be worn at all times while on duty. The Cleaning Dining Room Tables or Food Service Carts policy dated 3/23/24, documents To maintain sanitary dining room table and food surfaces. Policy Interpretation 3- Bucket Procedure 1. Prepare 3 (three) buckets: soapy water, plain water, and sanitizing solution. 2. Use a clean cloth in each bucket and keep cloth with the proper bucket. 3. After each meal, when dishes are removed, wipe table with soapy water, including edges. a. When cart is emptied, wipe with soapy water. 4. Rinse with plain water-if necessary, per manufacturer's guidelines. 5. Wipe with sanitizing solution diluted according to manufacturer's directions for food contact surfaces. 6. Permit to air dry. Cleaning of Dining Room Tables, Chairs, Food Surfaces, and Carts 1. Use detergent water and a clean cloth in each bucket and keep the cloth with the proper bucket. 2. Wipe tabletop, under side, top edges, and legs. 3. With another bucket, wipe chairs including seat, arm, and legs. 4. Rinse with plain water (if required per manufacture's guidelines) 5. Wipe with food safe sanitizing solution diluted according to manufacturer's directions for food contact surfaces for the appropriate amount of time. 6. Allow to air dry. The Manufacturer's instructions for Quat (Quaternary Ammonium Compounds) Sanitizer, (not dated) documents Direction for Use - Use Quat Sanitizer (200 ppm/parts per million active) for sanitizing and cleaning of equipment and utensils in food processing, dairy industry, bars, restaurants, institutional kitchens, meat and poultry processing plants. Prior to application, remove gross food particles and soil by a pre-wash, pre-scrape, or pre-flush, and when necessary, pre-soak. Thoroughly wash or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145021 If continuation sheet Page 6 of 7 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 04/17/2025 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 flush equipment or utensils with a good detergent or compatible cleaner followed by a potable water rinse before applying sanitizer. Apply QUAT Sanitizer to pre-cleaned hard non-porous surfaces with cloth, mop sponges, or sprayer or by immersion. Surfaces must remain wet for 60 seconds. Drain thoroughly and allow to air dry before reuse. On 4-14-25 from 9:33 AM to 10:03 AM a tour was completed in the kitchen and dining room. During this tour, V5 (Dietary Aide) was washing all dining room tables with wash clothes that were submersed in a red sanitizing bucket of water. V5 tested the water within the sanitizing bucket for Quaternary Ammonium using a Quaternary Ammonia Strip. The strip read zero PPM of Quaternary Ammonium. The container holding the Quaternary Ammonia testing strips stated 200-400 PPM was the normal range of Quaternary Ammonia. V6 (Dietary Aide) was washing dishes and had a full beard that was not restrained with a hair net. On the top shelf of the three-drawer refrigerator there was a plastic bag dated 4-10-25 containing 12 cooked sausage patties, a plastic bag dated 4-13-25 containing 14 cooked chicken breasts, and a plastic bag dated 4-9-25 containing two cooked polish sausages. There were no cool-down logs located within the kitchen for the cooked sausage patties, cooked chicken breasts, or cooked polish sausages. On 4-14-25 at 9:45 AM (V5) stated, I did not fill the sanitizing bucket. (V6/Dietary Aide) filled the bucket. On 4-14-25 at 10:00 AM V6 stated, I did not add any sanitizer to the sanitizing bucket. I did not know I was supposed to. I did not know I have to wear a hair restraint over my beard. On 4-14-25 at 10:15 AM V4 (Dietary Manager) verified there are no cool-down logs for the cooked sausage, polish sausage, and chicken breasts located in the refrigerator. V4 stated, We (kitchen staff) do not do cool-down logs when storing leftovers. The health department gave me cool-down logs last week, but I have not started to do them yet. (V6) should be wearing a hair net over his beard while in the kitchen and the sanitizing bucket should have had sanitizer. On 4-14-25 at 12:13 PM V4 calibrated a thermometer and inserted the thermometer into a gallon of skim milk that was in a wash tub in the main dining room. The milk was sitting on top of ice. The temperature of the milk was 49 degrees Fahrenheit. V4 (Dietary manager) stated, Whoever put the milk out here should have put ice all the way up on the outside of the milk to keep the milk cool. The milk should have a temperature of 41 degrees (Fahrenheit) or below. On 4-15-25 at 2:10 PM V10 (Dietary Aide) was in the kitchen washing dishes and V11 (Dietary Aide) was prepping meals. Both V10 and V11 had full beards that were not restrained with hair nets. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145021 If continuation sheet Page 7 of 7