Inspection·April 30, 2025

F 0582 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinator/Social Services) provide the residents with the NOMNC forms. When this surveyor asked V22 and V24 about their ABN form, V22 stated that the form looked familiar, but V22 does not provide it to the residents and V24 stated V24 has never seen the ABN form before. V22 stated V23 (Business Office Manager) would be the one to go over the financial aspect of the discharge process with residents. On 4/30/25 at 12:26 PM, V23 said he does not complete or provide the residents with an ABN form. V23 did say he goes over the financial portion of the discharge, but V23 does not document these interactions anywhere. On 4/30/25 at 12:34 PM, V24 said when V24 provides the residents with the NOMNC form, V24 is not in attendance. Facility Advance Beneficiary Notices policy dated 12/23 states, It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage . 5. The current CMS (Centers for Medicare and Medicaid)-approved version of the forms shall be used at the time of issuance to the beneficiary (resident or resident representative). Contents of the form shall comply with related instructions and regulations regarding the use of the form. a. For Part A items and services, the facility shall use the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), Form CMS-1005. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145024 If continuation sheet Page 2 of 13 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 145024 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Pinecrest 414 South Wesley Avenue Mount Morris, IL 61054 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure activity of daily living (ADL) assistance was provided for a dependent resident for 1 of 19 residents (R40) reviewed for ADLs in the sample of 19. Residents Affected - Few The findings include: R40's admission Record dated April 29, 2025, shows she was admitted to the facility on [DATE], with diagnoses including major depressive disorder, osteoarthritis, and alzheimer's disease. R40's Care Plan initiated January 6, 2025, shows R40 has an ADL self-care performance deficit. On April 28, 2025, at 10:06 AM, V4 and V5 Certified Nursing Assistants (CNA) went into R40's room to provide incontinence care. R40 told V4 and V5, I'm wet. V4 CNA told this surveyor that R40 was a get up. Meaning R40 should have been gotten up by night shift early in the morning. V4 removed R40's incontinence brief. There was a thick incontinence pad inside of R40's incontinence brief. Both the pad and R40's incontinence brief were saturated with dark urine from front to back. V4 said she did not know why R40 had an incontinence pad plus an incontinence brief on. V4 also said she does not know when R40's incontinence brief was last changed. On April 29, 2025, at 12:28 PM, V7 CNA said incontinence care should be done at least every two hours so the residents skin stays dry. It helps to prevent sores. V7 said an incontinence pad should not be place with an incontinence brief. R40's Minimum Data Set (MDS) dated [DATE], shows, she does not have any history of refusing cares. R40 is occasionally incontinent of urine and is dependent on staff for toileting and personal hygiene. The facility's Activities of Daily Living (ADLS) policy revised December 1, 2024, shows, A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145024 If continuation sheet Page 3 of 13 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 145024 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Pinecrest 414 South Wesley Avenue Mount Morris, IL 61054 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 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to initiate a pre-surgical order for a resident prior to his abdominal surgery. The facility failed to implement treatment orders for a resident with compression fractures of her spine. These failures apply to 2 of 19 residents (R43 and R390) reviewed for quality of care in the sample of 19. Residents Affected - Few The findings include: 1. R43's admission Record showed R43 was admitted to the facility on [DATE] with diagnoses of dementia, Alzheimer's Disease, atrial fibrillation (a-fib), and long-term use of anticoagulation medications. R43's current care plan showed R43 was cognitively impaired related to his diagnoses of dementia and Alzheimer's Disease. R43's December 2024 Medication Administration Record (MAR) showed R43 was prescribed Pradaxa 150mg (milligrams), give one tablet twice a day for anticoagulation therapy related to his diagnosis of a-fib. On 4/28/25 at 1:15 PM, V14 (Family of R43) stated, My biggest concern is the lack of communication at the facility. (R43) was a scheduled to have (abdominal) hernia surgery in December (2024). It was originally scheduled for December 11th (2024). When I visited him a few days before the surgery, I found out that they never stopped his blood-thinning medication. They were supposed to stop the medication for three days prior to his surgery. (V15 Nurse for R43's Surgeon) faxed all his pre-op (operation) orders and instructions to them (the facility) at the end of November (2024). Since they didn't stop his medication, we had to reschedule (R43's) surgery. A fax dated 11/27/24, sent from R43's surgeon's office to a fax number at the facility, contained R43's pre-op instructions, orders, and date of the surgery. It showed R43's hernia surgery was scheduled for 12/11/24. The fax showed, Surgery date and pre-op instructions .Please hold (R43's) Pradaxa for 3 days prior to surgery . A progress note dated 12/9/24 for R43 showed R43's hernia surgery was rescheduled for 12/13/24 due to R43's Pradaxa medication not being held three days prior (12/8/24-12/11/24) to his original surgery date of 12/11/24. R43's December 2024 MAR showed R43 was given both doses of his Pradaxa on 12/8/24 and 12/9/24. On 4/29/25 at 12:50 PM, V1 Administrator stated, As far as I can tell, it looks like the doctor's office faxed us (R43's) pre-op date and instructions on November 27th (2024) but we either couldn't find them or didn't get them. There are many (fax) machines here in the facility They re-faxed the orders to us on December 9th (2024) . On 4/30/25 at 10:52 AM, V8 Assistant Director of Nursing was shown the fax, dated 11/27/24 from R43's surgeons office, along with the number of the fax that R43's orders were sent to on that date. V8 stated, That's the fax number to the machine by where our receptionist sits. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145024 If continuation sheet Page 4 of 13 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 145024 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Pinecrest 414 South Wesley Avenue Mount Morris, IL 61054 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 On 4/29/25 at 10:10 AM, V15 (Nurse for R43's Surgeon) stated she herself faxed R43's pre-op orders, instructions, and confirmed surgery date of 12/11/24 to the facility on [DATE]. On 4/30/25 at 8:23 AM, V15 (Nurse for R43's Surgeon) stated, I know someone from the facility had gotten my initial fax (on 11/27/24) because someone called from the facility on December 6th (2024) to schedule (R43's) two-week post-op appointment for his December 11th surgery. I have it documented in (R43's) chart . V15 was unable to remember the name of the employee from the facility that called on 12/6/24. V15 stated, On December 9th, (V14 Family of R43) called me to tell me they had never held his Pradaxa, so we had to reschedule his surgery. I called the facility and whoever I spoke with told me the fax that I had originally sent had gone to some reception desk at the facility. I then re-faxed the information I had initially sent to the facility on November 27th, which showed a new surgery date of December 13th . 2. R390's admission Record showed R390 was admitted to the facility on [DATE]. R390's hospital discharge instructions and orders dated 4/4/25 showed R390 had a diagnosis of compression fractures to her spine. The orders showed R390 was admitted to the facility with an order for R390 to wear a back brace, for treatment of her spinal fractures, when out of bed. R390's April 2025 Order Summary Report showed an order for R390 To wear back brace when OOB (out of bed) and active. Back brace to be off when in bed. On 4/28/25 at 8:57 AM, R390 was seated in the recliner in her room. No brace was noted to R390's back. On 4/28/25 at 12:30 PM, R390 remained seated in the recliner in her room. No brace was noted to R390's back. On 4/29/25 at 9:00 AM, R390 was seated in the recliner in her room, visiting with family. No brace was noted to R390's back. On 4/29/25 at 9:15 AM, V17 Licensed Practical Nurse stated, (R390) does have a brace for her back she is supposed to wear when she is out of bed. I believe it's because she has fractures in her back. The facility's Consulting Physician/Practitioner Orders (undated) showed, Consulting physician/practitioner orders are those orders provided to the facility by a physician/practitioner other than the resident's attending physician or physician/practitioner who is acting on behalf of the attending physician . For consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will . Follow facility procedures for verbal or telephone orders including noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145024 If continuation sheet Page 5 of 13 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 145024 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Pinecrest 414 South Wesley Avenue Mount Morris, IL 61054 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R40's admission Record dated April 29, 2025, shows she was admitted to the facility on [DATE], with diagnoses including bilateral osteoarthritis of knees, anemia, major depressive disorder, osteoporosis, and alzheimer's disease. R40's Care Plan initiated December 30, 2024, shows R40 has had an actual fall related to poor balance and unsteady gait. Sensor alarm place in chair and bed for safety. R40 's Fall Risk Evaluation dated March 24, 2025; shows she has had 1-2 falls in the past three months. R40's gait/balance is not checked and does not contain a total fall risk score. On April 28, 2025, at 10:06 AM, V4 and V5 Certified Nursing Assistants (CNAs) transferred R40 from her bed to her chair. V4 and V5 were holding onto a gait belt, but R40 did not bear any weight on her legs. V4 and V5 transferred R40 to her wheelchair by lifting R40 via the gait belt. R40 needed to be scooted back into the wheelchair and V4 and V5 lifted R40 back by holding under her arms and her legs. R40's bed alarm did not sound when R40 was transferred into her wheelchair nor was a wheelchair alarm applied to her chair. R40's Skin Wound Notes dated March 31, 2025, shows R40 experienced a skin tear during a transfer. R40's Nurses notes show on April 24, 2025, R40 was lowered to the ground by a (CNA) while in the resident bathroom. Resident states her knees quit working. On April 28, 2025, R40 lost her balance during a shower and had to be assisted back in her shower chair by the CNA and R40 experienced another skin tear. On April 30, 2025, at 10:02 AM, V3 CNA said if a resident seems weak before transferring, then she notifies the nurse. V3 said if residents are not bearing weight, then the nurse and therapy needs to re-evaluate them. V3 said if a resident is not bearing weight, then the resident or staff could get injured. V3 said the R40 does not bear weight to her legs. V3 said that R40 has been a very tough transfer. The facility's Safe Resident Handling/Transfers policy revised on December 1, 2024, shows, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. The resident's mobility needs will be addressed on admission and reviewed quarterly, after a significant change in condition or based on direct care staff observations or recommendation. Based on observation, interview and record review the facility failed to ensure residents were transferred in a safe manner for 2 of 19 residents (R30 and R40) reviewed for safety and supervision in the sample of 19. The findings include: 1. R30's Fall Risk Evaluation dated 4/15/25 showed R30 was at risk for falls due to her history of falls, decreased muscular coordination, and use of ambulatory assistive devices. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145024 If continuation sheet Page 6 of 13 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 145024 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Pinecrest 414 South Wesley Avenue Mount Morris, IL 61054 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R30's Restorative assessment dated [DATE] showed R30 required the assistance of one staff member for transfers and toileting. On 4/28/25 at 9:45 AM, R30 was seated in a recliner in her room. R30 told V18 Certified Nursing Assistant (CNA) that she needed to go to the bathroom. V18 CNA transferred R30 from the recliner to a wheelchair by holding onto the waistband of R30's pants and lifting R30 out of the recliner. V18 then wheeled R30 into the bathroom. V18 transferred R30 from the wheelchair to the toilet by holding onto the waistband of R30's pants. No gait belt was used by V18 CNA for either of R30's transfers. On 4/29/25 at 11:35 AM, V19 CNA stated R30 requires the assist of one person for all transfers which means we use a gait belt when transferring her. The facility's Use of Gait Belt policy (undated) showed, It is the policy of this facility to use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145024 If continuation sheet Page 7 of 13 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 145024 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Pinecrest 414 South Wesley Avenue Mount Morris, IL 61054 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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents with dementia received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for 2 of 12 residents (R73 and R76) reviewed for dementia care in the sample of 19. Residents Affected - Few The findings include: 1. R73's admission Record dated April 29, 2025, shows R73 was admitted to the facility on [DATE], with diagnoses including neurocognitive disorder with lewy bodies, alzheimer's disease with early onset, anxiety disorder, major depressive disorder, dementia, and a history of falling. R73's Care Plan revised on November 1, 2024, shows, R73 exhibits resistance to cares: (refusing/resisting medication, refusing/resisting activities of daily living assistance, refusing/resisting food and/or fluids; refusing requests to get out of bed, refusing to cooperate with care plan objectives) related to psychiatric illness, severe mental illness, dementia, fear/paranoia, misunderstanding caregiver requests. Create a warm, safe, and inviting environment for care. Emphasize dignity. Emphasize soothing, kind, slow, and compassionate speech. Give resident time to respond verbally and physically. If attempts to redirect are unsuccessful, try switching staff. Remind resident that they are safe, and staff will protect them. Staff to have a wheelchair with them when resident is showing signs of being resistive to cares. On April 28, 2025, at 11:14 AM, V5 Certified Nursing Assistant (CNA) said, Come on [R73] lets go to the bathroom. V5 held R73 hand and guided him to stand up. V4 CNA was standing behind R73. R73 was planting his feet and not walking. V5 was attempting to slowly guide R73 by holding his hand. V4 had both of her hands to R73's back and was pushing R73 towards the bathroom with both of her hands and her body. It took V4 and V5 more than a few minutes to walk R73 to the bathroom as he did not want to walk. On April 29, 2025, at 12:28 PM, V7 CNA said if R73 is not walking somewhere, then she would get a chair so he could sit down. V7 said time should be given to R73 and then re-approach him later. V7 said she sometimes offers R73 snacks or dances with him to help him reach his destination. V7 said it takes R73 a while to get to a destination, he just needs time. 2. R76's admission Record dated April 29, 2025, shows she was admitted to the facility on [DATE], with diagnoses including dementia, anxiety, contusion of scalp, restlessness and agitation, and dementia. R76's Care Plan initiated October 10, 2024, shows R76 may exhibit resistance to cares: Create a warm, safe, and inviting environment for care. Emphasize dignity. If attempts to redirect are unsuccessful, try switching staff. Staff will assist with ambulation as needed with use of assistive devices and give the resident as many choices as possible about care and activities was initiated September 27, 2024. On April 28, 2025, at 11:25 AM, R76 was sitting in the units dining room. R76 kept trying to stand up and walk. V4 CNA stood behind R76, place V4's hands onto R76's shoulders and said hey down and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145024 If continuation sheet Page 8 of 13 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 145024 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Pinecrest 414 South Wesley Avenue Mount Morris, IL 61054 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 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few guided R76 to sit back down into the chair and walked away. At 11:29 AM, R76's was continuing to stand and try to walk. The unit manager took R76 for a walk around the unit and then brought R76 back to the dining room and R76 sat down to eat her lunch. On April 29, 2025, at 8:30 AM, V7 CNA was walking the unit with R76 because R76 was continuing to stand up and attempting to walk. On April 29, 2025, at 12:28 PM, V7 said if R76 is trying to stand then staff should try and involve R76 in an activity or take R76 for a walk. The facility's Dementia Care Policy dated December 1, 2024, shows, It is the policy of this facility to provide the appropriate treatment and services to every resident who displays signs of or is diagnoses with dementia, to meet his or her highest practicable physical, mental, and psychosocial well-being. Individualized, non-pharmacological approaches to care will be utilized, to include meaningful activities aimed at enhancing the resident's well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145024 If continuation sheet Page 9 of 13 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 145024 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Pinecrest 414 South Wesley Avenue Mount Morris, IL 61054 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to address an irregularity found by the pharmacist during the monthly medication review for 1 of 5 residents (R73) reviewed for drug regimen review in the sample of 19. The findings include: R73's admission Record dated April 29, 2025, shows R73 was admitted to the facility on [DATE] with diagnoses including neurocognitive disorder with lewy bodies, alzheimer's disease with early onset, anxiety disorder, major depressive disorder, dementia, and a history of falling. R73's Medication Regimen Review Prescriber Recommendation (MRR) dated March 11, 2025, shows, Resident is receiving quetiapine and furosemide but has not had any recent labs evaluated. Please consider: CMP (Comprehensive Metabolic Panel) now and every six months thereafter. The recommendation was signed off by the physician and says the order was faxed to lab on March 21, 2025, by a licensed practical nurse. R73's Medication Regimen Review Prescribe Recommendation dated April 15, 2025, shows, Lab results missing: Prescriber checked to get CMP now and every six months per MRR recommendation from March 2025. However, results are not available, and lab order has not been entered. Please enter order if still indicated by provider. The facility's Advanced Practical Nurse signed off the order and wrote April 21, 2025: Schedule for next lab day if not already done. The facility staff signed, Ordered for April 23, 2025. R73's Order Summary Report dated April 30, 2025, +\| which includes discontinued orders show that no CMP lab draw was ordered in March 2025. An + 06.2 3++3602 |order for CMP to be completed next available lab day and every six months was entered on April 21, 2025. On April 30, 2025, at 10:45 AM, V8 Assistant Director of Nursing (ADON) said she did not see an order entered for R73's labs for March. V8 said the order was entered April 2025. The facility's Medication Regimen Review policy revised December 1, 2024, shows, Facility staff shall act upon all recommendations according to procedure for addressing medication regimen review irregularities. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145024 If continuation sheet Page 10 of 13 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 145024 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Pinecrest 414 South Wesley Avenue Mount Morris, IL 61054 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 - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident's medication labeling was legible for 1 of 19 residents (R32) reviewed for medication storage and labeling in the sample of 19. The findings include: R32's Order Summary Report dated April 30, 2025, shows she was admitted to the facility on [DATE], with diagnoses including heart disease, unsteadiness on feet, convulsions, dementia, alzheimer's disease, and anxiety disorder. On April 30, 2025, at 9:53 AM, there was a blue bottle that contained white round pills in the locked memory care unit medication cart. R32's name was legible on the pill bottle label. The medication name was illegible and so was the full dispensed date. V20 Licensed Practical Nurse said she did not know what medication it was, but believed it was a hospice medication. On April 30, 2025, at 10:45 AM, V8 Assistant Director of Nursing (ADON) said medications should be legible and if they are not, then it should be replaced. The facility's Labeling of Medications and Biologicals Policy revised December 1, 2024, shows, All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. Medication labels must be legible at all times. Any medication label that is soiled, incomplete, illegible, worn, of makeshift must be returned and replaced by the issuing pharmacy, not merely covered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145024 If continuation sheet Page 11 of 13 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 145024 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Pinecrest 414 South Wesley Avenue Mount Morris, IL 61054 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, and record review the facility failed to ensure pureed pork was pureed to a pudding-like consistency. This applies to 4 of 4 residents (R390, R60, R339, R1) reviewed for pureed diets in the sample of 19. The findings include: Facility provided list of residents on a pureed diet shows R390, R60, R339, and R1 receive pureed diets. On 4/28/25 at 10:04 AM, V13 (Cook) started the puree process for the pureed pork. V13 measured out and weighed enough pork for four servings of pureed pork. V13 placed the pork into a blender pitcher with broth and started to puree the pork. At 10:09 AM, V13 stopped the blender and tested the consistency. V13 said it wasn't quite ready at that time and that the pork tends to be a little stringy and more difficult to puree. At 10:10 AM, V13 stopped the blender, tested it a second time and said it was much better. V13 placed the pureed pork into a food service pan and into the oven. On 4/28/25 at 10:11 AM, the first finished batch of pureed pork appeared to be lumpy as V13 scooped it into the food service pan. On 4/28/25 at 10:14 AM, V13 began the second batch of pureed pork and weighed out enough for three servings. V13 placed the pork into a blender pitcher with broth and started to puree the pork. At 10:15 AM, V13 stopped the blender and tested the pureed pork and said it was not quite ready. At 10:16 AM, V13 stopped the blender, tested the pureed pork again, and said it was good. On 4/28/25 at 9:58 AM, V13 said the consistency of the purees should be a pudding-like consistency. On 4/28/25 at 1:00 PM, the facility provided test tray of pureed pork was stringy, not fully blended, and required chewing. On 4/28/25 at 1:12 PM, V12 (Food Service Director) agreed that the pureed pork was stringy and not of an appropriate texture. Facility Puree Food Preparation policy dated 12/1/2023 states, . Puree means that all food has been ground, pressed and/or strained to a consistency of a soft, smooth, thick paste similar to a thick pudding. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145024 If continuation sheet Page 12 of 13 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 145024 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Pinecrest 414 South Wesley Avenue Mount Morris, IL 61054 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 ensure staff wore the required personal protective equipment (PPE) when providing care to a resident on enhanced barrier precautions for 1 of 19 residents (R63) reviewed for infection control in the sample of 19. Residents Affected - Few The findings include: R63's face sheet printed on 4/28/25 indicated R63 had a feeding tube. On 04/28/25 at 09:35 AM, there was a sign on R63's door indicating R63 was on enhanced barrier precautions. The sign indicated staff must wear gloves and gowns for high-contact resident care activities such as changing an incontinence brief or assisting with toileting. On 04/28/25 at 09:35 AM, R63 was in bed connected to his tube feeding. V10 (Certified Nursing AssistantCNA) and V11 (CNA) entered the room to provide incontinence care and changed R63's incontinence brief as it was soiled with urine. V10 and V11 had gloves on but no gown. V10 and V11 both touched the tubing of R63's tube feeding while providing incontinence care. On 04/28/25 at 10:01 AM, V10 said for a resident on enhanced barrier precautions staff should wear gloves and gowns when providing care. On 04/29/25 at 11:29 AM, V8 (Infection Control Nurse) said a resident with an implanted medical device such as a tube feeding would be on enhanced barrier precautions. V8 said staff should wear gloves and gowns when providing incontinence care to a resident on enhanced barrier precautions. R63's Care Plan with an initiated date of 5/7/24 showed R63 required enhanced barrier precautions because of a tube feeding. Listed under interventions was for staff to wear the necessary PPE when preforming high contact care activities. The facility's Enhanced Barrier Precautions policy with a reviewed date of 12/1/24 showed enhanced barrier precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistance organisms that employs targeted gown, and gloves use during high contact resident care activities. High contact care activities included changing briefs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145024 If continuation sheet Page 13 of 13