Inspection·October 13, 2023

F 0575 Level of Harm - Potential for minimal harm Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. Based on observation, interview and record review, the facility failed to post State Agency contact information. This failure has the potential to affect all 113 residents in the facility. Residents Affected - Many Findings include: On 10/11/23 at 10am, Resident group meeting was held with 16 residents. Six residents (R8, R14, R27, R43, R63, R93), including the Resident Council President (R8), all stated they did not know where the State Agency information was posted. On 10/11/23 and 10/12/23 State Agency information was only posted in the foyer area of the facility. The foyer access was only accessible by going through double doors to enter the foyer from within the facility, or entrance/exit doors on the other side of the foyer. On both days of observation, the foyer area was mostly accessed by visitors, vendors, and staff. This area was not consistently accessed by the majority of residents in the facility. On 10/12/23 at 1:15pm, V1 Administrator toured the facility and acknowledged that there were no other State Agency signs posted within the facility and stated The State Agency posters should be posted with the Ombudsman posters. At that same time, Ombudsman information posters were posted in several units throughout the facility. Resident Census and Conditions Report form, dated 10/10/23, indicates there are 113 residents in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145039 If continuation sheet Page 2 of 17 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 10/13/2023 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 0655 Level of Harm - Minimal harm or potential for actual harm Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 10/10/23 at 11:10am and 10/12/23 at 9:19am, R309's CPAP was on the right side of her bed. Residents Affected - Few On 10/10/23 at 11:10am, R309 stated I take care of my own CPAP and wear it at night, I have had it since I got here. R309's current care plan does not have R309's CPAP documented. On 10/13/23 at 1:02 PM, V2 RN/Registered Nurse DON/Director of Nursing verified R309's care plan did not include her CPAP use. Based on observation, interview, and record review, the facility failed to develop a baseline care plan for a resident's anticoagulant and insulin medications (R359) and a resident's CPAP/continuous positive airway pressure machine (R309) for two of 25 residents (R309 and R359) reviewed for care plans in the sample of 45. Findings include: The facility's 24 Hour (Interim) Care Plan Policy revised 02/21 states, Purpose: To provide guidelines for completion of a 24-Hour (Interim) Plan of Care for newly admitted residents. A 24-Hour Care Plan guides provision of care from the time of the resident transfer/admission until the Interdisciplinary Care Plan is completed. Policy: Based on information obtained during the admission process an Interim care plan will be developed as soon as possible after admission. Responsibility: It is the responsibility of the Interdisciplinary Team (IDT) to develop the Interim Care Plan. It is the responsibility of the Charge Nurse/Care Plan Coordinator to complete an Interim Care Plan on all newly admitted residents. Procedure: 1. An Interim Care Plan will be developed as soon as possible after initial admission. 2. The Interim Care Plan will be based on Physicians Orders and Nursing admission Assessment. 3. The Interim Care Plan will guide all resident care until the Interdisciplinary Care Plan is developed. This same policy documents the Interim Care Plan should include resident medications. 1. R359's current admission Record documents R359 admitted to the facility on [DATE]. R359's current Medication Review Report documents an order for Insulin Aspart Subcutaneous Solution Pen-Injector 100 units/ml (per milliliter) per sliding scale with an order start date of 10/3/2023, and an order for the anticoagulant medication Warfarin Sodium 6 milligram tablet via Gastrostomy Tube with an order start date of 10/3/2023. R359's Baseline Care Plan, dated 10/3/2023, Section D documents Medications Resident is Taking. The boxes Insulin and Anticoagulants are not marked. On 10/11/23 at 9:00 AM, V14 (Licensed Practical Nurse) entered R359's bedroom and administered three units of insulin subcutaneously to R359's right lower quadrant. As of 10/11/23, R359's Interim Care Plan did not document R359's insulin, or anticoagulant medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145039 If continuation sheet Page 3 of 17 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 10/13/2023 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 0655 Level of Harm - Minimal harm or potential for actual harm On 10/12/2023 at 11:29 AM, V2 (Director of Nursing) stated insulin and anticoagulant medications should be documented on the resident's baseline care plan by the admitting nurse. At this time, V2 verified R359's base line care plan did not document R359's insulin, or anticoagulant medications. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145039 If continuation sheet Page 4 of 17 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 10/13/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on record review and interview the facility failed to maintain an accurate Care Plan for one resident (R12) of 25 reviewed for care plan accuracy in a total sample of 45. Residents Affected - Few Findings Include: The Facility's Care Plan policy dated 6/23 documents each resident will have a plan of care to identify problems, needs and strengths that will identify how the interdisciplinary team will provide care. The resident care plan is the tool used to coordinate all care provided to the resident to be sure care is necessary, appropriate and planned to meet the individual needs of the resident consonant with the physicians plan of care. On 10/10/23 at 10:30 AM, R12 stated (Staff) don't ever get me up. I would like to be out and about more. They say I refuse but I have never refused to get up. I have never refused anything. R12's Current Care Plan, dated 8/15/22, documents (R12) has a behavior of refusing to be turned and to get up from bed. R12's medical record does not contain any documentation regarding R12 ever refusing to get out of bed or refusing to be turned while in bed. R12's MDS (Minimum Data Set), dated 8/11/23, documents R12's BIMS (Brief Interview for Mental Status) Score to be 15/15 indicating R12 is cognitively intact. R12's MDS also documents no mood or behavior problems. On 10/11/23 at 2:00 PM, V2 (Director of Nursing) confirmed that R12's medical record did not contain any documentation of refusal to get out bed or be turned and re-positioned in bed. R12's Current Care Plan, dated 8/15/22, documents (R12) has a behavior of refusing all supplements/enhanced foods, and has weight loss as a result. R12's Current Physician Order Sheet, dated October 2023, documents Enhanced cereal every breakfast, and enhanced potatoes every lunch time. R12's medical record does not contain any documentation regarding R12 ever refusing her enhanced foods or supplements. On 10/11/23 at 1:30 PM V7 (Dietary Manager) stated (R12) does not like protein shakes, other supplements she will accept. Her care plan is wrong. R12's Current Care Plan, dated 8/15/23, documents (R12) has a behavior of refusal of medications. R12's medical record does not contain any documentation regarding R12 ever refusing any medications. On 10/11/23 at 2:00 PM V2 DON confirmed that R12's medical record did not contain any documentation of R12's refusal to take medications. V2 stated I don't know where that came from. It needs to come (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145039 If continuation sheet Page 5 of 17 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 10/13/2023 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 0657 off the care plan. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145039 If continuation sheet Page 6 of 17 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 10/13/2023 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 0688 Level of Harm - Minimal harm or potential for actual harm Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on interview and record review, the facility failed to perform recommended exercises for one (R12) of four residents reviewed for mobility in a total sample of 45. Residents Affected - Few Findings Include: The Facility's Range of Motion dated 9/2018 documents the purpose of the policy is to provide resident with limited range of motion appropriate treatment and services to increase or prevent further decrease range of motion. Policy: all residents will be assessed on admission and quarterly, or more often as a change of condition warrants, for risk factors for development of contractures. A program will be developed based on the resident's unique risk factors and involving formalized therapy as applicable. Any ROM will be reflected in the interdisciplinary care plan and will be systematically and consistently followed. It is the responsibility of the CNA (Certified Nurse Aide) to perform exercises as identified. R12's Therapy to Nursing Recommendations, dated 8/25/22, documents Passive Range of Motion to (Both) Lower Extremities 2-3 times per week to prevent contracture formation. Encourage Active Range of motion to (Both) Upper Extremities as tolerated. R12's Electronic Medical Record, dated 9/30/23, documents under Task: Range of Motion. Nursing to encourage resident to participate in PROM (Passive Range of Motion) to (Both) LE (Lower Extremities) 3 times per week and AROM (Active Range of Motion) to (Both) UE (Upper Extremities). On 10/10/23, V16 (R12's Family Member/Health Care Power of Attorney) stated (R12)'s insurance only pays for her to get skilled therapy for so many days per year, otherwise she is dependent on (Facility Staff) to exercise her legs for her, and they do not do that on a regular basis. On 10/10/23 at 11:00 AM, R12 stated I need to be exercising my body, especially my legs because I have MS (Multiple Sclerosis). They (Staff) don't exercise me at all. On 10/11/23 at 10:15 AM, V17 (Certified Nurse Aide) stated (in the presence of R12) I can only do her exercises when we have enough staff, usually we do not. I don't have time today. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145039 If continuation sheet Page 7 of 17 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 10/13/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions were maintained for a resident with a Gastrostomy Tube/G-Tube and the facility failed to wear gloves while administering medications through a G-Tube for one of three residents (R359) reviewed for gastrostomy tubes in the sample of 45. Findings include: The facility's Tube Feeding (Administration of Medication) Policy dated 8/2017 states, Procedure: 4. Wash hands. Apply gloves. The facility's Gloves (Use) Policy revised 8/20 states, Policy: Gloves will be used per Standard Precautions, isolation precautions, and according to the CDC/Centers for Disease Control and Prevention Guidelines. Gloves will be worn to prevent the spread of infection and disease to residents and employees, protect wounds from contamination, protect hands from potentially infectious materials, and to prevent exposure to the HIV/Human Immunodeficiency Virus (AIDS) acquired immunodeficiency syndrome and Hepatitis B viruses from blood or body fluids. Procedure: 4. Nonsterile gloves should be used primarily to prevent the contamination of the employee's hands when providing treatment or services to the resident and when cleaning contaminated surfaces. 7. When to Use Gloves: A. When touching excretions, secretions, blood, body fluids, mucous membranes, or non-intact skin. C. When cleaning up spills or splashes of blood or body fluids. The facility's Enteral Tube Feeding Policy dated 8/23 states, Procedure: 4. Wash hands. Apply gloves. The facility's Enhanced Barrier Precautions (EBP) policy dated 10/21/2022 states, General: EBP expand the use of PPE (Personal Protective Equipment) and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs (Multi Drug Resistant Organisms) to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices, regardless of MDRO colonization, as well as, for residents with MDRO infection or colonization. Policy: EBP requires the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Use of eye protection may be necessary when splash or spray may occur, but it is not necessary in other situations. High contact resident care activities requiring gown and glove use among residents that trigger EBP use include Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator. The Centers for Disease Control and Prevention/CDC's Enhanced Barrier Precautions Door Sign documents: 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 following high-contact resident care activities including providing hygiene and device care (Feeding Tube). R359's admission Note, dated 10/03/2023, documents R359 is NPO (Nothing by Mouth) with continuous tube feedings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145039 If continuation sheet Page 8 of 17 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 10/13/2023 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 0693 R359's Skilled Nursing Charting Note, dated 10/04/2023, documents R359 intakes calories via G-Tube. Level of Harm - Minimal harm or potential for actual harm R359's current Physician Order Sheet documents the following: R359's NPO status, R359's G-Tube care, Jevity 1.5 at 60 milliliters/ml per hour continuously, and Enhanced Barrier Precautions in place during high-contact care activities that provides opportunities for transfer of MDROs from/to high risk residents with wounds and/or indwelling medical device that are at especially high risk for both acquisition of and colonization of MDROs. Residents Affected - Few On 10/11/2023 at 9:20AM, The CDC's Enhanced Barrier Precautions sign was taped on the outside of R359's door. At this time, without wearing a gown or gloves V14 (Licensed Practical Nurse) entered R359's room to administer R359's prepared G-Tube (Gastrostomy Tube) medications. Without wearing a gown or gloves, V14 performed the following: disconnected R359's tube feeding, connected a bolus syringe to R359's G-Tube, aspirated for G-Tube contents, administered R359's medications flushing with water in between each one, primed the tubing of a new tube feeding bottle, and reconnected R359's tube feeding to R359's G-Tube. Upon V14 initially disconnecting R359's tube feeding, gastric contents splattered out of R359's G-Tube where V14 was holding the tube with an ungloved hand. On 10/11/2023 at 9:26AM, without handwashing, V14 swiped the hair from the left side of her face touching her cheek with V14's soiled hand. On 10/11/2023 at 9:39AM, V14 verified V14 did not wear gloves or gown while administering R359's G-Tube medications, or while connecting/disconnecting R359's tube feedings. V14 stated that V14 does not wear gloves when administrating G-Tube medications. On 10/12/2023 at 12:25PM, V4 (Registered Nurse/Infection Preventionist) verified V14 should have worn gloves and a gown prior to entering R359's room, and when managing R359's G-Tube. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145039 If continuation sheet Page 9 of 17 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 10/13/2023 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to obtain orders for a CPAP (Continuous Positive Airway Pressure) use for one (R309) of one residents reviewed for oxygen use in a sample of 45. Residents Affected - Few Findings include: Facility Oxygen Administration, revised 2/21, documents Oxygen therapy will be administered to the resident only upon the written order of a licensed physician. R309's facility record documents an admission date of 10/2/23, and R309 has the diagnosis of Obstructive Sleep Apnea. R309's Inventory of Personal Effects, undated, documents CPAP. R309's Medication Review Report dated 10/11/23 has no documented orders for R309's CPAP. On 10/10/23 at 11:10am and 10/12/23 at 9:19am, R309's room had an oxygen sign on door, and R309's CPAP was on the right side of her bed. On 10/10/23 at 11:10am, R309 stated I take care of my own CPAP and wear it at night, I have had it since I got here. On 10/12/23 at 9:40am, V11 Licensed Practical Nurse/LPN stated I don't work midnights so I would not sign off on the CPAP. There is no order for (R309's) CPAP. On 10/12/23 at 10:00am, V3 RN/Registered Nurse ADON/Assistant Director of Nursing stated, I don't have an order for (R309's) CPAP, it must be a home machine, and I will get the settings and get an order in for her. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145039 If continuation sheet Page 10 of 17 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 10/13/2023 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 0697 Provide safe, appropriate pain management for a resident who requires such services. 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 a physician ordered narcotic medication for pain control was available on admission for one (R260) of three residents reviewed for pain in a sample of 45. Residents Affected - Few Findings include: The facility's Management of Pain policy, revised 8/19, documents Policy: Our mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. The purpose of this policy is to accomplish that mission through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. We will achieve these goals through: Promptly and accurately assessing and diagnosing pain. Increasing comfort and reducing depression and anxiety in residents. On 10/10/23, at 10:15am, R260 is lying in bed with a cast noted to his right leg. R260 stated the following: (On admission) I had to wait for pain medication (Oxycodone) to get here. It is the only pain medicine that works for me. I came here last Monday (October 2) from the hospital after surgery on my fractured right ankle. My pain was at a six (out of 10). R260 stated I had to wait quite a while and felt like sh**. My pain went up to an eight. That night wasn't funny. R260's current Physician Order Sheet/POS includes a primary diagnosis of fracture of right lower leg, closed fracture, and a secondary diagnosis of fracture of upper and lower end of unspecified fibula, closed fracture. R260's Minimum Data Sheet/MDS, dated [DATE], documents R260 is cognitively intact. R260's After Visit Summary/AVS, dated 9/18/23 - 10/2/23, documents a physician order for Oxycodone 10mg two tablets every six hours as needed for pain. On 10/12/23, at 1:15pm, V1 Administrator confirmed the admission time for R260 was at 11:55am on 10/2/23. R260's Nursing admission Assessment, dated 10/2/23, documents R260 has pain in his right lower leg (front) rated 7/10. R260's Medication Administration Record/MAR, dated October 2023, documents R260's pain level was 8/10 on evening shift 10/2/23 and 8/10 on day shift 10/3/23. The facility's billing report from the medication dispensary, dated 10/12/23, documents that V4 Infection Control Preventionist retrieved Oxycodone 10mg four tablets from the dispensary to give to R260 on 10/3/23 at 11:09am. The facility's Proof of Delivery List Report dated 10/12/23, documents R260's Oxycodone 10mg tablets were delivered on 10/3/23 at 3:06pm. On 10/13/23, at 9:15am, V15 Licensed Practical Nurse/LPN confirmed that R260 admitted just before noon on 10/10/23 with a fractured leg. V15 stated the following: There was a hang up with the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145039 If continuation sheet Page 11 of 17 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 10/13/2023 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few pharmacy receiving the script (for R260's Oxycodone). They have to have it physically in their hands. I faxed it as soon as (R260) got here, but for some reason they weren't receiving it. (R260) rated his pain a seven (on the pain scale 0-10). The hospital sent a script for the Norco (Hydrocodone) but didn't send any signed script for the Oxycodone. (R260) said that Tylenol would do nothing and said that the Norco (Hydrocodone) won't do much for his pain either. (R260) preferred Oxycodone which is the only thing that helps his pain. It wasn't until I read (R260's) AVS (After Visit Summary) that I saw (R260) had an order for Oxycodone, but no script for it .There is a lack of communication between the doctor, pharmacy and us when trying to get a signed script. (R260's) dose of 10mg two tablets was not in our (medication dispensary) so we had to get a doctor order for (R260's) dose in order to pull it from the (medication dispensary). By this time, it was the following day when (R260) got the Oxycodone. On 10/13/23, at 10:05am, V2 Director of Nursing/DON stated that a lot of times they have to fight with the doctor and the pharmacy and sometimes even the hospital to get signed scripts for narcotics. The doctor often won't sign it because they haven't seen the resident yet so will come in the next day and sign it. It shouldn't be this long of a wait time to get the signed script and the medication here especially for a noon admission. We try to get the liaison to be sure there are signed scripts, but it doesn't always happen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145039 If continuation sheet Page 12 of 17 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 10/13/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an appropriate indication for use of an antipsychotic medication for one resident (R25) with a diagnosis of Dementia and failed to ensure prn (as needed) physician orders for an anti-anxiety medication did not exceed 90 days for one resident (R92) of five residents reviewed for unnecessary medications in the sample of 45. Findings include: Facility Policy/Antipsychotic Drugs dated 8/2017 documents: Residents will not receive antipsychotic medications unless they have one or more of the following specific conditions: Schizophrenia Schizo-Affective Disorder Delusional Disorder Psychotic Mood Disorders (including Mania and Depression with Psychotic features) Acute Psychotic Episodes Brief Reactive Psychosis Schizophreniform Disorder Atypical Psychosis Tourette's Syndrome Huntington's Disease Organic Mental Syndromes (Delirium, Dementia, Amnestic) with associated psychotic and/or agitated behaviors which: Have been qualitatively and objectively documented, are persistent, and not caused by preventable reasons. Causing the resident to present a danger to self or others, continuously scream, yell or pace, if these behaviors cause an impairment in functional capacity, or experience psychotic symptoms (hallucinations, paranoia, delusions) but not exhibited as dangerous behaviors. Facility Policy/Psychotropic Medication Protocol dated/revised 2/2021 documents: Residents shall only be given antipsychotic drugs when clinically indicated according to appropriate diagnosis and physician's order. 1. On 10/10/23 and 10/11/23, R25 was in the Memory Care dining room during activities and meals. R25 would periodically yell out vocalizations. Yelling behavior was not loud, was not constant, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145039 If continuation sheet Page 13 of 17 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 10/13/2023 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 0758 did not appear to disrupt the milieu. Level of Harm - Minimal harm or potential for actual harm Current Medical Diagnosis list indicates R25 has a diagnosis of Alzheimer's Disease dated 1/1/23, Dementia with Other Behavioral Disturbance dated 1/1/23, and Bipolar Disorder dated 8/24/22 (diagnosed at [AGE] years old). Residents Affected - Few Current Physician Orders indicate R25 was admitted in 2018, is [AGE] years old, and receives quetiapine (antipsychotic) 25mg (milligrams) at bedtime for behaviors related to Dementia with Other Behavioral Disturbance, and Bipolar Disorder (Unspecified) dated 5/12/23. Consent for Psychotropic Medication(s), dated 9/6/22,1/30/23, and 5/12/23, for administration of quetiapine to R25 do not have a diagnosis or indication for use included in any of the consents. R25's Current Care Plan indicates R25 receives antipsychotic medications related to Bipolar disorder (date initiated 12/10/21) with a target date/revision for 12/20/23. R25's Care Plan does not include specific antipsychotic medication administered, or target behaviors requiring the use of an antipsychotic medication. R25's Current Care Plan also indicates R25 is at risk for a behavior problem related to Dementia, Bipolar Disorder, Depression, Anxiety, and Mood Affective Disorder. This same Care Plan indicates R25 has yelling behaviors related to Dementia, Bipolar disorder, Depression, Anxiety, and Mood Affective Disorder. R25's Psychiatric Progress Note, dated 8/17/23 and 9/18/23, indicates R25 is receiving hospice services and does not appear to respond to internal stimuli, and no other symptoms of psychosis were reported such as auditory or visual hallucinations. On 10/12/23 at 10:30am, V21 Memory Care Director/RN (Registered Nurse) stated (R25) can't see or hear. Her only behavior is yelling out she has no psychosis. 2. R92's Current Physician's Orders indicate R92 has orders to receive alprazolam (antianxiety) 0.5mg every eight hours as needed for GAD (Generalized Anxiety Disorder) related to Anxiety Disorder for 90 days, with a date ordered 9/15/23. R92's MAR (Medication Administration Record) indicates R92 received alprazolam 0.5mg on 10/2/23, 10/5/23, 10/6/23, 10/10/23 and 10/11/23. R92's Progress Notes also indicate alprazolam was given on the identified dates in October. R92's MAR or progress notes do not describe the behaviors R92 was exhibiting requiring the use of alprazolam. R92's Behavior tracking record indicates R92 was agitated on 10/9/23, 10/11/23 and 10/12/23; and angry on 10/12/23. R92's Current Care Plan indicates R92 receives an antianxiety medication related to anxiety disorder. This Care plan does not indicate specific behaviors requiring the use of antianxiety medication. On 10/12/23 at 10:40am, V12 Memory Care Director/RN stated that the nurse administering a prn (as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145039 If continuation sheet Page 14 of 17 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 10/13/2023 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 0758 needed medication) should be documenting the actual behaviors in the nurse progress notes. Level of Harm - Minimal harm or potential for actual harm On 10/13/23 at 11:45pm, V3 ADON (Assistant Director of Nursing) stated We increased R92's alprazolam to every four hours today and I noticed the order was for 90 days. I knew that wasn't right so we changed the order (dated 10/13/23) to 14 days. V3 also stated that the nurse administering a prn should document in the progress note. V3 was unable to provide any documentation explaining the reason alprazolam was being administered to R92 and was unable to justify the increase to every four hours from every eight hours. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145039 If continuation sheet Page 15 of 17 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 10/13/2023 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to obtain physician ordered laboratory results for one of 25 residents (R359) reviewed for physician orders in the sample of 45. Residents Affected - Few Findings include: The facilities Anticoagulant Therapy Policy dated 08/02/2017, states, Policy; All residents on anticoagulant therapy shall have their medications monitored monthly, unless otherwise ordered by a physician. Procedure: 1. All residents on Coumadin should have an order for a monthly prothrombin time (unless ordered sooner by MD/Medical Doctor.) R359's current admission Record documents R359's diagnoses to included but not limited to: Permanent Atrial Fibrillation, Heart Failure, and Peripheral Vascular Disease. R359's Medication Review Report, dated 9/04/2023 to 10/31/2023, documents R359 is currently prescribed the blood thinning medication Warfarin Sodium daily for DVT (Deep Vein Thrombosis) prevention. This same report documents an order for an INR (International Normalized Ratio) to be obtained on 10/10/23. As of 10/11/2023 at 12:45PM, R359's PT (Prothrombin Time)/INR/Coumadin (Warfarin) Flowsheet did not document a PT/INR lab result for 10/10/23. On 10/11/2023 at 12:45PM, V4 (Registered Nurse) verified R359's PT/INR was not obtained on 10/10/23 and should have been. V4 stated V4 changed R359's order to be obtained on 10/11/23 since the order was not completed on 10/10/2023. V4 stated V4 would obtain R359's PT/INR result now. On 10/11/23 at 1:20 PM, after obtaining R359's PT/INR result, V4 stated that R359's PT/INR resulted back as high and R359's Coumadin will be held for two days. R359's PT (Prothrombin Time)/INR/Coumadin (Warfarin) Flowsheet on 10/11/23 documents a PT result of 49.9 seconds and documents a Normal PT equals 10-13 seconds. R359's INR result is documented as 4.8. This same sheet on 10/11/23, documents Dose Change: Hold times two days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145039 If continuation sheet Page 16 of 17 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 10/13/2023 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on interview and record review, the facility failed to consistently offer/provide bedtime snacks to six residents (R8, R14, R27, R43, R63, R93) which include the Resident Council President (R8) of 16 residents reviewed for bedtime snacks in the sample of 45. Findings include: Facility policy/Bedtime Snacks dated 8/2017 documents: To ensure that residents are offered bedtime snacks daily. All residents within the facility shall be offered a snack at bedtime. Charge Nurse and Nursing Assistants will offer snacks to all residents every evening prior to bedtime. On 10/11/23 at 10am, Resident group meeting was held with 16 residents. Six residents (R8, R14, R27, R43, R63, R93) including the Resident Council President (R8) stated they were not consistently offered or provided with bedtime snacks. R8, R63 and R93 stated the kitchen puts out snacks at the nurse's station but the CNA's don't consistently offer or pass out. R63 stated there have been two residents who will take all of the snacks back to their room and the staff don't replace them. On 10/12/23 at 2:40pm, V19 CNA (Certified Nurse Assistant) identified herself as a 2nd shift CNA. At that time V19 stated she's usually on break when the snacks need to be passed I'm not usually around to do that. The snacks are set out at the nurse's station. If they ask, I'll bring it to them. On 10/12/23 at 2:45pm, V20 CNA stated certain residents automatically get snacks and the other snacks are saved for residents who might have blood sugar problems. On 10/12/23 at 2:50pm, V18 LPN (Licensed Practical Nurse) stated sometimes residents come from other units to get snacks before bed because there are a couple residents who will take all the snacks for themselves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145039 If continuation sheet Page 17 of 17