Inspection·April 18, 2023

F 0689 Level of Harm - Actual harm Residents Affected - Few Report further documents, under Notes, At approximately (7:00 am), (R2's) legs gave out during a transfer from her bed to her wheelchair. (R2) had no complaint of pain, and no physical abnormalities were noted. (R2) was assisted into her wheelchair and taken to therapy. (R2) was noted to have a bruise and (right lower extremity) was tender to touch. Physician and family representative were notified. Received a physician's order for x-ray of the right leg. X-ray results indicate acute to subacute fracture of the proximal tibia and fibula. Physician was notified of diagnostic results and gave new order to send the resident to the (emergency department) for evaluation and treatment. (R2) returned the same day with an immobilizer on and instructions to follow up with orthopedics. A Progressive Disciplinary Form, dated 2/10/23, documents V3 received a written discipline for pivot transferring R2 independently, when R2 was to be transferred with two staff and a mechanical lift. emergency room Records, dated 2/09/23, document R2 presented after sustaining a ground level fall and developing tenderness and swelling to the proximal right lower leg. Hospital x-ray results document R2 as having mildly displaced, comminuted and impacted proximal right tibial metaphysis fracture and probable mildly displaced fracture of the fibular head. On 4/17/23 at 12:14 pm, R2 was observed lying in bed with an immobilizer brace on her right leg. At that time, R2 explained on 2/09/23, V3 entered her room and had her sit on the side of the bed. V3 told R2 that they were going to stand and transfer to the wheelchair. R2 stated, I told (V3) I wasn't ready to transfer like that. Therapy hadn't cleared me to transfer that way, but (V3) insisted. I tried again to tell her 'No' and they use a lift, but everything went so fast. (V3) told me to put my hand on the arm of the wheelchair and (V3) pulled me up and I fell forward to my knees. R2 stated V3 was not using a gait belt. R2 indicated the nurse on duty assessed her leg. R2 stated she had some discomfort in the right lower leg, but it wasn't horrible, so she went on to her scheduled therapy session. R2 stated the Physical Therapist noticed bruising on her lower right leg and an x-ray was ordered that day, which found a fracture. On 4/18/23 at 10:55 am, V5 (Physical Therapist) confirmed on 2/09/23, when R2 presented to Therapy after her fall, R2 was complaining of pain in the right leg and there was bruising and swelling to the area below the right knee. V5 only worked R2's left leg that day and R2 was seen by the facility's Nurse Practitioner right after her Therapy Session. On 4/17/23 at 12:28 pm, V2 (Director of Nursing) stated they did determine that V3 had improperly transferred R2 on 2/09/23 and she should have been transferred from the bed to the wheelchair using a mechanical lift. V2 indicated V3 was disciplined for performing an improper transfer and received education. Prior to the survey date of 4/18/23, the facility had taken the following actions to correct the non-compliance: A. On 2/13/23, a facility wide audit was completed to ensure all resident's [NAME] reflected their correct current transfer status. B. On 2/10/23, all direct care staff received education regarding safety during transfers and the need to utilize the [NAME] to identify each resident's transfer status. C. On 2/16/23 and ongoing, Management has conducted random observations of direct care staff performing transfers to ensure proper technique and transfer status was followed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145039 If continuation sheet Page 2 of 4 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 145039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Healthcare of Peoria 5600 Glen Elm Drive Peoria, IL 61614 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 - Actual harm D. Beginning 2/16/23, Management will audit four residents weekly for four weeks to ensure all transfers are being performed as identified in the resident's [NAME]. This will be verified by interviews with staff and the residents on how the residents are being transferred in comparison to their transfer status in the Plan of Care and [NAME]. Residents Affected - Few E. On 2/16/23, a monitoring system was implemented to ensure all new residents have a Clinical Mobility Assessment completed and their transfer status added to the [NAME] for staff to reference. The Electronic Medical Record documents R1 was admitted to the facility on [DATE] with the diagnoses of Cerebral Infarct, Lack of Coordination, Abnormal Gait and Mobility, Seizure Disorder and Abnormal Posture. A Minimum Data Set assessment dated [DATE], documents R1 is cognitively intact, requires the extensive assistance of one staff for transfers, is not steady and can only stabilize with staff assistance when moving from surface to surface/seated to standing. A Fall Risk Assessment, completed on 2/18/23, failed to identify R1 as a potential fall risk, despite R1's history of Seizure Disorder and Abnormal Gait/Mobility. Progress Notes, dated 3/9/2023, document R1 had a witnessed fall in the shower room after resident was reaching for item(s) at time of the fall. Progress Notes document R1 sustained a hematoma on her head as a result of the fall and was sent to the Emergency Room, with all testing results returning negative. A Fall Report, dated 3/09/23, documents (R1) was observed on floor in front of (wheelchair) in center of shower stall leaning on her left side/arm. (R1) was naked due to having just finished a shower. (R1) was wet and slid out of (wheelchair) onto the floor. (R1) was assessed and had hematoma to back of her head and abrasion to her left scapula. (R1) assisted back to (wheelchair) by two staff members and then into bed. (R1) was sent to the (emergency department) to (evaluate) and treat due to being on blood thinners. (R1) came back from the (emergency department) with (no new orders). Neuros (Neurological checks) and fall vitals started. Care Plan updated to shower with two assist. On 4/17/23 at 2:02 pm, R1 was sitting up in her wheelchair in her room. R1 had obvious impairment to the function of her left side as a result of a recent stroke. At that time, R1 explained what happened when she fell on 3/09/23 in the shower room. R1 stated V4 (Certified Nursing Assistant) helped shower her and when it was over, V4 was helping transfer her to her wheelchair from the shower chair. R1 indicated V4 did not use a gait belt at any point while transferring her in the shower room. R1 stated, I was still wet, and the floor was wet, and I slid right out of my wheelchair. R1 stated she hit the back of her head on the tile and her left arm was hurting afterwards. R1 stated the nurse working came into the shower room to help V4 get her up off the floor, which is when they pulled her up by her arms. R1 stated the staff did not use a gait belt when getting her up off the floor and she was naked at the time. R1 stated staff usually put towels on the ground if it is wet and dry her off better before transferring her to the wheelchair after a shower. On 4/17/23 at 1:52 pm, V6 (Registered Nurse) stated V4 had summoned her to the shower room on 3/09/23, as R1 had fallen. V6 stated, when she entered the shower room, R1 was on the floor, naked and still wet, in front of her wheelchair. V6 stated she could feel a bump on the back of R1's head immediately after the fall. On 4/17/23 at 2:57 pm, V7 (Care Plan Coordinator) stated she interviewed R1 after she fell on 3/09/23, to determine the circumstances behind the fall. V7 stated R1 told her that her bottom was still wet and she slid out of the wheelchair, hitting her head. V7 stated R1 was very concerned about hitting her head and indicated she had not been dried off before being transferred. V7 stated she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145039 If continuation sheet Page 3 of 4 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 145039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Healthcare of Peoria 5600 Glen Elm Drive Peoria, IL 61614 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 - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete interviewed V4 after the fall, as well. V7 indicated V4 told her R1 was leaning forward in her wheelchair, trying to grab a towel and fell. V7 stated she did not believe R1's hematoma to the back of the head was consistent with that scenario, but nothing more was questioned for the investigation of the fall. On 4/17/23 at 1:53 pm, V4 (Certified Nursing Assistant) stated R1 fell from her wheelchair in the shower on 3/09/23 when she was leaning forward to grab a towel that was on the shower bar. V4 described R1 sliding out of the wheelchair onto the floor as she leaned forward, and her wheelchair cushion sliding out with her. On 4/18/23 at 10:25 am, V4 was interviewed again for more details regarding R1's fall. V4 stated she was in the last shower stall of the shower room and had transferred R1 from her wheelchair to the shower chair for her shower. V4 indicated she did not use a gait belt to transfer R1 from one chair to the other, because R1 was naked. After showering R1, V4 stated she dried off R1, but indicated R1 was still a little wet. V4 then transferred R1, naked and without a gait belt, back to her wheelchair from the shower chair. V4 stated, as she was backing R1 out of the shower stall, R1 leaned forward and slid out of the wheelchair. V4 stated she was unsure how R1 hit the back of her head during the fall. V4 asked for help from V6 to get R1 up off the floor. V4 stated they did not use a gait belt to get R1 up, because she was naked and R1 has a stoma that was exposed on her abdomen. V4 was questioned as to what she could have done to possibly prevent R1's fall and make her environment safer. V4 concluded that she could have made sure R1 was totally dry and could have put a hospital gown on R1 to utilize a gait belt when transferring her and getting her up off the floor. Event ID: Facility ID: 145039 If continuation sheet Page 4 of 4