Inspection·October 20, 2023

F 0550 waits are long than hoped. Level of Harm - Minimal harm or potential for actual harm The facility's Resident Council meeting minutes, dated 9/28/23, document, Old Business: Bathroom wait times ongoing especially after mealtime. New Business: Nursing - longer waits for toileting after meals especially at night. They don't see night crew in evenings. Residents Affected - Few On 10/19/23, at 10:45 am, V2 Director of Nursing/DON confirmed the Resident Council meeting minutes state there is an ongoing issue with bathroom wait time. V2 stated that the expectation is for the call device to be answered and acknowledged in five minutes, 15 minutes top for answering it to assist with a need like toileting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145151 If continuation sheet Page 2 of 18 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 145151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Mendota 1201 First Avenue Mendota, IL 61342 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. 2. The current Order Summary Report for R59 documents a physician order, dated 7/24/23 for antipsychotic medication Quetiapine 37.5 mg (milligrams) at bedtime related to Mood Affective Disorder. Residents Affected - Few The Pharmacy Recommendation for R59, dated 8/8/23, documents, Antipsychotic Justification needed for R59's use of Quetiapine. An appropriate diagnosis must accompany each antipsychotic order, and it must also have documented justification for continued use. This recommendation lists new diagnosis as: Behavioral and Psychological Symptoms of Dementia (BPSD). The current Care Plan for R59 documents, R59 is receiving an antipsychotic medication related to mood disorder. On 10/20/23 at 11:15 am, V4 CPC (Care Plan Coordinator) confirmed R59's current Antipsychotic Care Plan documents a diagnosis of Mood Disorder. V4 CPC stated she was unaware of the 8/8/23 Pharmacy Recommendation with new diagnosis for R59's Quetiapine. V4 CPC stated V2 DON (Director of Nursing) does all the Pharmacy Recommendations and did not notify her of the new diagnosis or she would have updated it. Based on observation, interview, and record review, the facility failed to revise resident Care Plans for two (R17 and R59) of 18 residents reviewed for Care Plans in a sample of 24. Findings include: The facility's undated Comprehensive Care Plans policy, documents, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .Policy Explanation and Compliance/Guidelines: 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 1. On 10/17/23, at 10:44am, R17 was lying in bed with oxygen flowing per nasal cannula via oxygen concentrator with a humidifier bubbler in use. R17's current POS includes a diagnosis of Chronic Diastolic (Congestive) Heart Failure with an order dated 3-22-23 for oxygen as needed. R17's current Care plan does not include any cares for R17's oxygen humidifier and tubing. On 10/20/23, at 11:12am, V4 Care Plan Coordinator stated the cares for R17's oxygen is not on R17's Care Plan and should be. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145151 If continuation sheet Page 3 of 18 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 145151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Mendota 1201 First Avenue Mendota, IL 61342 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement pressure ulcer prevention interventions for a resident identified at risk of skin breakdown and failed to complete weekly skin assessments for one of one resident (R8) reviewed for pressure ulcers in the sample of 24. This failure resulted in R8 developing unstageable pressure ulcers to R8's bilateral heels. Residents Affected - Few Findings include: The facility's undated Pressure Injury Prevention and Management Policy documents, Policy - This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. Avoidable is defined as, The resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. A section titled Policy Explanation and Compliance Guidelines documents, 2. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. 3. Assessment of Pressure Injury Risk: a. Licensed nurses will conduct a pressure injury risk assessment, using the (Pressure Ulcer Risk Assessment) tool, on all residents upon admission/re-admission, weekly x (times) four weeks, then quarterly or whenever the residents' condition changes significantly. 4. Interventions for Prevention and to Promote Healing a. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. b. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). c. Evidenced based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include but are not limited to: i. Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.); ii. Minimize exposure to moisture and keep skin clean, especially of fecal contamination; iii. Provide appropriate, pressure-redistributing, support surfaces; iv. Provide non-irritating surfaces; and v. Maintain or improve nutrition and hydration status, where feasible. f. Interventions will be documented in the care plan and communicated to all relevant staff. g. Compliance with interventions will be documented in the weekly summary charting. 5. Monitoring: a. The RN (Registered Nurse) Unit Manager, or designee, will review all relevant documentation regarding skin assessments, pressure injury risks, progression towards healing, and compliance at least weekly, and document a summary of findings in the medical record. The facility's undated Skin Assessment Policy documents, It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment. This policy further documents Compliance Guidelines as, 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145151 If continuation sheet Page 4 of 18 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 145151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Mendota 1201 First Avenue Mendota, IL 61342 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 0686 Level of Harm - Actual harm R8's admission Record documents R8 was most recently admitted to the facility on [DATE] with diagnoses to include: Type 2 Diabetes Mellitus, Age-Related Osteoporosis, Need for Assistance with Personal Care, Unspecified Dementia, Chronic Kidney Disease Stage 3B, Heart Failure, Unspecified Urinary Incontinence and Weakness. Residents Affected - Few R8's Minimum Data Set Assessment, dated 8/23/23 documents, R8 has moderately impaired cognition; is at risk of developing pressure ulcers/injuries; requires extensive assistance by two (plus) persons physical assist in the areas of bed mobility, transferring, dressing, toileting, and personal hygiene. R8's current Care Plan documents, R8 is at risk for skin breakdown due to limited mobility, incontinence, diagnosis of diabetes and chronic kidney disease; R8 has an ADL (Activities of Daily Living) self-care performance deficit related to Dementia, Impaired balance, Limited Mobility, Disc Degeneration, Osteoporosis and Osteoarthritis; Needs assist to turn and reposition at least every two hours and as needed; Requires extensive assistance of one to reposition in recliner chair; R8 has cognitive impairment; and is malnourished. R8's Predicting Pressure Ulcer Risk Evaluation, dated 7/21/23, documents R8 is at risk for developing pressure ulcers. This same Pressure Ulcer Assessment contains Clinical Suggestions for pressure ulcer prevention interventions to be implemented. R8's clinical suggestions are all blank and not marked as implemented on this evaluation tool. R8's Predicting Pressure Ulcer Risk Evaluation, dated 8/22/23, documents R8 is at moderate risk for developing pressure ulcers. A section titled Activity documents R8 is Chairfast: Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. A section titled Mobility documents R8 is Very limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. A section titled Nutrition documents R8 Probably Inadequate: Rarely eats a complete meal and generally eats only about 1/2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. A section titled Friction and Shear documents Problem: Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. This Pressure Ulcer Assessment has Clinical Suggestions for pressure ulcer prevention interventions to be implemented. R8's clinical suggestions are all blank and not marked as implemented on this evaluation tool. R8's Mini Nutritional assessment dated [DATE] documents the following: R8 is bed/chair bound and R8 is with severe dementia or depression. R8's Progress Note dated 9/11/23 at 1:21 am documents, (R8) continues to receive (hospice) services for heart failure. Periods of lethargy. Dependent upon all aspects of care. Transfers per (two) staff assist and (mechanical) lift. Mobility and positioning per (geriatric)-chair propelled by staff. (Two) staff assist required with bathing, personal hygiene, dressing, toileting, and post-use hygiene cares. (Bowel and bladder) incontinence with brief worn. Staff assist of one with feeding. Intake varies. R8's Progress Note dated 10/16/23 and written by V14 (Registered Nurse) documents R8 continues with (local hospice) for CHF (Congestive Heart Failure); transfers with two assist and (mechanical lift); Uses (reclining chair with wheels) for mobility, assist of one to two with bathing, dressing, and grooming; Assist of two with toilet use and post-use hygiene; Incontinent of bowel and bladder with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145151 If continuation sheet Page 5 of 18 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 145151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Mendota 1201 First Avenue Mendota, IL 61342 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 0686 brief worn at all times. Level of Harm - Actual harm R8's Client Coordination Notes Report dated 10/17/23 and written by V12 (Hospice Aide) documents, During this (visit, I) found a very large blister on (R8's) left hill (heel), black in the middle . (Manager, V13) notified of changes. Residents Affected - Few R8's Client Coordination Notes Report dated 10/18/23 and written by V13 (Hospice RN) documents, (R8) is a [AGE] year-old living (at present facility) with primary diagnosis of CHF (Congestive Heart Failure) with senile degeneration of the brain. This same note documents (R8) was asleep in her (mobility) chair; R8 would mumble occasionally; R8 is a total assist with her ADLs (Activities of Daily Living); R8 will not eat without being fed, and even then, only taking in 25% (percent). (V12) had called earlier and said (R8's) left heel had a blister on it from pressure. Heel protectors were ordered and new wound care order. It was covered with Hydrogel at this visit. R8's Progress note written by V14 (Registered Nurse) on 10/17/23 at 7:44 pm documents, Hospice CNA (V12) summoned this nurse to (R8's) room. Hospice CNA (V12) notified Hospice RN (V13) awaiting call back. (R8) presents with a left (heel) ulcer black colored noted to heal (heel). Treatment in place for foam boarder dressing M/W/F (Monday, Wednesday, Friday) and PRN (as needed) until healed. (Pressure Ulcer Preventative soft boots) in place for left foot. R8's Wound Observation Tool dated 10/17/23 documents, R8 has a (facility) acquired ulcer measuring four centimeter by three centimeter area to R8's left heel. R8's Care Plan was revised on 10/18/23 to include R8 had a wound to R8's left heel. There are no interventions added for pressure relieving device to R8's heel(s). R8's Physician Order Sheet dated October 2023 documents an order for (pressure relieving) boots at all times to left foot with an order start date of 10/17/23. R8's Progress Note dated 10/19/23 at 7:25 pm states, (Hospice) CNA/Certified Nursing Assistant noted a pressure sore starting to R8's right heel when giving (R8) a bath. Dark soft area (one centimeter in diameter) noted with surrounding skin red. Hospice to bring air mattress and (pressure relieving boot) applied with new order for skin prep. R8's Wound Observation Tool dated 10/19/23 documents R8 developed a (facility) acquired pressure area to R8's right heel discovered on 10/19/23. This same Tool documents R8's pressure ulcer as a dark circle measuring one centimeter by one centimeter. On 10/17/23 at 10:35 am, R8 was observed in R8's bedroom, sitting upright in a (wheeled mobility) chair with R8's knees bent and R8's feet flat, directly on the chair rest. No chair cushion was noted to R8's chair or pressure relieving interventions were noted to R8's bilateral heels. On 10/17/23 at 12:06 pm, R8 was observed in R8's (wheeled mobility) chair inside her room. R8 remained upright in her chair with her knees bent and feet resting directly on the footrest. R8 appeared asleep and did not respond when surveyor knocked on her open door. No chair cushion was noted to R8's chair or pressure relieving interventions were noted to R8's bilateral heels. On 10/17/23 at 2:30 pm, R8 was observed lying in bed on her back. R8's feet were not elevated off the bed and no pressure relieving devices were in place. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145151 If continuation sheet Page 6 of 18 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 145151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Mendota 1201 First Avenue Mendota, IL 61342 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 0686 Level of Harm - Actual harm Residents Affected - Few On 10/18/23 at 10:30 am, R8 was noted to be in R8's (wheeled mobility) chair. R8 was sitting slightly reclined with her knees bent and feet flat on the footrest of her chair. No chair cushion was noted to R8's chair or pressure relieving interventions were noted to R8's bilateral heels. On 10/19/23 at 11:28 am, R8 was noted to be in bed with facility staff performing incontinence care. At this time, an approximate two centimeter by one centimeter open area was noted to R8's right heel. 10/19/23 at 1:23 pm V2 (Director of Nursing) confirmed R8 is at moderate risk for developing pressure ulcers; R8's left heel pressure ulcer was discovered on 10/17/23; R8 was ordered a heel protector for R8's left foot only; R8 developed a new pressure ulcer to R8's right heel on 10/19/23; pressure reducing interventions had not been implemented prior to R8's bilateral heel skin breakdown; and R8 did not have a chair cushion to offload pressure when R8 was out of bed. V2 stated V2 ordered offloading supplies today (10/19/23) and R8 now has bilateral heel protectors. At this time, V2 verified skin assessments should be performed by the nurses weekly. V2 verified V2 was only able to provide one Weekly Skin Assessment conducted by a licensed nurse which was dated 8/27/23. As of 10/20/23, R8's medical record did not contain documentation that weekly skin assessments were completed on R8 since R8's admission to the facility other than the one obtained on 8/27/23 and R8's medical record did not contain documentation that pressure ulcer prevention interventions were implemented for R8's bilateral heels prior to the development of R8's pressure ulcers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145151 If continuation sheet Page 7 of 18 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 145151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Mendota 1201 First Avenue Mendota, IL 61342 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 Residents Affected - Few 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 observation, interview, and record review, the facility failed to ensure a physician ordered assistive device was used for a resident's contracted hand for one (R36) of one resident reviewed for contractures in a sample of 24. Findings include: On 10/17/23 at 10:29am and 10/18/23 at 11:44am, R36 sat in a wheelchair of her doorway without any assistive device in R36's contracted right hand. R36's current Physician Order Sheet/POS includes an order dated 6/28/22: Place rolled up washcloth to right hand BID (twice per day) as tolerated. On 10/19/23 at 11:18am, V8 Certified Nursing Assistant/CNA confirmed that V8 was taking care of R36 yesterday and the day before. V8 stated she didn't know R36 needed any assistive device in R36's hand. V8 stated, I'm a float and work prn (as needed). V8 stated she did not place one in R36's hand or offer it either of those days that V8 took care of R36. R36's Treatment Order Administration/TAR sheet, dated 10/1/23-10/31/23, does not include any direction for signing off on R36 wearing an assistive device in her right hand. On 10/19/23 at 11:25am, V3 Assistant Director of Nursing/ADON, stated, (R36) will refuse the assistive device at times, but staff should still offer it. (R36) should be wearing it or at least at least attempted to be worn by staff offering it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145151 If continuation sheet Page 8 of 18 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 145151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Mendota 1201 First Avenue Mendota, IL 61342 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its policy and procedure for obtaining weights on new admissions for three of three residents (R116, R117 and R366) reviewed for new admissions in the sample of 24. Residents Affected - Few Findings include: The facility's undated admission of a Resident policy and procedure documents, The admission process is intended to obtain all the information possible about the resident, for the development of comprehensive plans of care, and to assist the resident in becoming comfortable in the facility. Residents are admitted to the facility under orders of the attending physician. The facility's undated admission Checklist documents upon arrival to the facility the CNA (Certified Nursing Assistant) get HT (height) and weight and Weight daily x3 (times three) days then weekly x4 (times four) weeks, then monthly in the computer task area. The facility's undated Weight Monitoring policy and procedure documents, A comprehensive nutritional assessment will be completed upon admission on residents to identify those at risk for unplanned weight loss/gain or compromised nutritional status. Assessments should include the following information: a. General appearance (e.g., robust, thin, obese, or cachectic). b. Height. c. Weight. d. Food and fluid intake. e. Fluid loss or retention. f. Laboratory/Diagnostic Evaluation. A weight monitoring schedule will be developed upon admission for all residents and Newly admitted residents - monitor weight weekly for 4 weeks. On 10/19/23 at 1:21 pm, V2 DON (Director of Nursing) stated new admission residents should be weighed every day for three days, then weekly for four weeks, and then monthly. Weights are documented on the MAR (Medication Administration Record) or in the Vital and Weight tab in the computer system. 1. The Face Sheet for R116 documents R116 was admitted to the facility on [DATE]. The Weight and Vitals Summary for R116, documents a weight was obtained for R116 on 10/10/23, 10/11/23 and 10/18/23. This Summary does not include a day three admission weight on 10/12/23. On 10/19/23 at 1:21 pm, V2 DON (Director of Nursing) stated there should be more weights than what is documented in R116's medical record. V2 DON stated, (R116) is a new admission and should have had weights done for the first three days and then weekly. 2. The Face Sheet for R117, documents R117 admitted to the facility on [DATE]. The current Order Summary Report for R117, documents a physician order dated 9/27/23 to do Weekly weights x4 (times four) weeks every Wednesday for 4 (four) weeks. The MAR dated 9/1/23 through 9/30/23 and the Weight Summary for R117, documents there were no weights obtained during the first three days of R117's admission to the facility. The Weight and Vitals Summary for R117 documents the initial weight for R117 was obtained on 9/30/23, four days after R117 admitted to the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145151 If continuation sheet Page 9 of 18 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 145151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Mendota 1201 First Avenue Mendota, IL 61342 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 10/19/23 at 1:22 pm, V2 DON confirmed R117 was not weighed until day four of being admitted to the facility. 3. R366's current Face sheet documents R366 admitted to the facility on [DATE]. R366's Weights and Vitals Summary documents weights were obtained on the following days: 10/3/23, 10/4/23, and 10/6/23. As of 10/19/23, R366's medical record did not contain documentation that a third daily weight was obtained on 10/5/23 or that weekly weights were obtained thereafter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145151 If continuation sheet Page 10 of 18 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 145151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Mendota 1201 First Avenue Mendota, IL 61342 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 follow its oxygen policy for changing oxygen equipment and failed to ensure a resident's oxygen humidity bottle was not empty while in use for one resident (R17) of two residents reviewed for oxygen in a sample of 24. Residents Affected - Few Findings include: The facility's undated Oxygen Administration policy documents, 5. Change humidifier bottle when empty, every 72 hours or per facility policy, or as recommended by the manufacturer. Use only sterile water for humidification. The facility's undated Oxygen Concentrator policy documents, Policy: The purpose of this policy is to establish responsibilities for the care and use of oxygen concentrators. Policy Explanation and Compliance Guidelines: 5. Care of the Concentrator: c. Nurse responsibilities: i. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. ii. Change humidifier bottle when empty, every seventy-two hours, or as recommended by the manufacturer. On 10/17/23, at 10:44am, R17 was in bed with oxygen infusing per nasal cannula at two liters per minute via oxygen concentrator. R17's oxygen humidity bottle is dated 10-4-23 and is empty. R17's current Physician Order Sheet/POS includes a diagnosis of Chronic Diastolic (Congestive) Heart Failure with an order dated 3-22-23 for oxygen as needed. On 10/17/23, at 11:09am, V4 Care Plan Coordinator confirmed that R17's humidity bottle is dated 10-4-23 and empty. V4 stated that it should not be empty and denied knowing the timeframe for changing out oxygen humidity bottles. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145151 If continuation sheet Page 11 of 18 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 145151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Mendota 1201 First Avenue Mendota, IL 61342 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to assess a dialysis access site; failed to monitor a dialysis resident's weight per physician order; and failed to ensure communication between the dialysis center and the facility was maintained for one (R116) of one resident reviewed for dialysis in the sample of 24. Residents Affected - Few Findings include: The facility's undated Hemodialysis policy and procedure documents, This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to the meet the special medical, nursing, mental, and psychosocial needs of residents receiving Hemodialysis. This will include: Ongoing assessment and oversight of the resident before, during and after dialysis treatments, including monitoring of the resident's condition during treatments, monitoring for complications, implementation of appropriate interventions, and using appropriate infection control practices; and Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. The licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form or other form, that will include, but not limit itself to: a. Timely medication administration (initiated, held or discontinued) by the nursing home and/or dialysis facility; b. Physician/treatment orders, laboratory values, and vital signs; c. Advance Directives and code status; specific directives about treatment choices; and any changes or need for further discussion with the resident/representative, and practitioners; d. Nutritional/fluid management including documentation of weights, resident compliance with food/fluid restrictions or the provision of meals before, during and/or after dialysis and monitoring intake and output measurements as ordered; e. Dialysis treatment provided and resident's response, including declines in functional status, falls, and the identification of symptoms that may interfere with treatments; f. Dialysis adverse reactions/complications and/or recommendations for follow up observations and monitoring, and/or concerns related to the vascular access site; g. Changes and/or declines in condition unrelated to dialysis; h. The occurrence or risk of falls and any concerns related to transportation to and from the dialysis facility. The Nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications. The nurse will ensure that the dialysis access site (e.g., AV (arteriovenous) shunt or graft) is checked before and after dialysis treatments and every shift for patency by auscultating for a bruit and palpating for a thrill. If absent, the nurse will immediately notify the attending physician, dialysis facility and/or nephrologist. On 10/17/23 at 2:00 pm, R116 was sitting up in a stationary chair in his room with a visible shunt to his left arm. R116 stated he goes to the dialysis center three times a week on Monday, Wednesday and Fridays and pointed to the visible shunt to his left arm. R116 stated R116 is supposed to be weighed in the mornings before R116 goes to dialysis. R116 stated the nurses at the dialysis center take care of his shunt. On 10/19/23 at 10:03 am, R116 stated no one at the facility does anything with his dialysis shunt or checks it for bruit and thrill. R116 stated, Only dialysis does that when I go. The current Order Summary Report for R116, dated 10/1/23 through 10/31/23, documents the following physician orders obtained on 10/10/23 and to start on 10/18/23: Assess Dialysis access sight to left arm before and after treatment for Patency by Auscultating for a bruit and palpate for a thrill. If either are absent notify physician and (Dialysis Center) two times a day every Monday, Wednesday, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145151 If continuation sheet Page 12 of 18 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 145151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Mendota 1201 First Avenue Mendota, IL 61342 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Friday; Assess Fistula to left arm for redness, swelling or phone after dialysis treatment at bedtime every Monday, Wednesday, Friday; Weight 3x (three times) per week in the morning every Monday, Wednesday, Friday. This same Order Summary Report documents a physician order dated 10/10/23: Weight 3x (Three times) per week in the morning every Monday, Wednesday and Friday. The Weight and Vitals Summary for R116, documents weights were obtained for R116 on 10/10/23, 10/11/23 and 10/18/23. This Summary does not include R116's dialysis weights were obtained on 10/13/23 or 10/16/23. The MAR (Medication Administration Record) for R116, dated 10/1/23 through 10/31/23 documents the start date of assessing R116's shunt, checking for bruit and thrill, and obtaining R116's weight as 10/18/23. As of 10/18/23 at 3:00 pm, R116's MAR did not contain documentation that assessments of R116's dialysis shunt, checking of bruit or thrill, or weights have been completed or documented. On 10/19/23 at 1:01 pm, V1 Administrator provided and confirmed the undated Dialysis Communication Form is the form the facility uses for communication between the facility and the Dialysis center on dialysis days. The Medical Record for R116 does not include any Dialysis Communication Forms having been completed for R116 or returned from the Dialysis Center. On 10/19/23 at 12:24 pm, V2 DON confirmed the physician order for R116's dialysis care was entered on 10/10/23 with a start date of 10/18/23. V2 DON stated the orders were entered incorrectly and should have started on 10/10/23 which is why it wasn't done until 10/18/23. On 10/19/23 at 1:21 pm, V2 DON stated there should be more weights than what is documented in the weight tab or on R116's MAR because R116 is a new admission and should have had weights done for the first three days, then weekly and then on dialysis days and should be documented in the weight tab and on the MAR. On 10/19/23 at 2:55 pm, V2 DON stated she has not been able to locate any Dialysis Communication forms for R116 and cannot say if the form was sent or returned to the facility. V2 DON confirmed the form should be sent with R116 when he leaves for his treatment and returned when R116 comes back from the center. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145151 If continuation sheet Page 13 of 18 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 145151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Mendota 1201 First Avenue Mendota, IL 61342 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 0760 Ensure that residents are free from significant medication errors. 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 physician ordered medications were administered as ordered for two (R59 and R117) of four residents reviewed for medication administration in the sample of 24. Residents Affected - Few Findings include: The facility's undated, Medication Administration policy and procedure documents, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Review MAR (Medication Administration Record) to identify medication to be administered. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. Administer medication as ordered in accordance with manufacturer specifications. Correct any discrepancies and report to nurse manager. The facility's undated, Medication Errors policy and procedure documents, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. Significant medication error means one which causes the resident discomfort or jeopardizes his/her health and safety. To prevent medication errors and ensure safe medication administration, nurses should verify the following information: a. Right medication, dose, route, and time of administration; b. Right resident and right documentation. 1. On 10/17/23 at 9:30 am, R59's bedroom door held a Contact/Droplet Isolation sign with a bin of PPE (Personal Protective Equipment) to the left of the entrance of R59's room. R59 was lying in bed watching television. The Face Sheet for R59 documents, a diagnosis of COVID-19 with onset date of 10/12/23. The Point of Care Testing Log documents, R59 tested positive for COVID-19 on 10/12/23. The Progress Note for R59, dated 10/12/23, documents, Facility testing done today. (R59) was rapid COVID tested, and results were positive. (R59) has had increase in confusion and congestion. R59 was moved to another room and placed in transmission-based isolation and a new medication order was obtained. The current Order Summary Report for R59 documents a physician order, dated 10/13/23 to administer Molnupiravir 200 mg (milligrams); Give 4 (four) capsules by mouth two times a day every 5 (five) day(s) for COVID until 10/18/23 taken orally every 12 hours of 5 days. The pharmacy Packing Slip, dated 10/13/23, documents the pharmacy sent 40 (forty) capsules of Molnupiravir 200 mg capsules to the facility for R59. The medication cart held a medication bottle for R59 labeled with quantity of 40 Molnupiravir 200 mg capsules with directions to administer four capsules (800 mg) by mouth twice daily for five days. The MAR (Medication Administration Record) for R59, dated 10/1/23 through 10/31/23, documents, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145151 If continuation sheet Page 14 of 18 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 145151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Mendota 1201 First Avenue Mendota, IL 61342 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Molnupiravir Oral Capsule 200 mg; Give 4 capsules by mouth two times a day every 5 day(s) for COVID until 10/18/23 taken orally every 12 hours of 5 days. This MAR documents R59 received 4 capsules on 10/13/23 and 10/18/23. On 10/18/23 at 4:00 pm, a prescription bottle for R59, labeled Molnupiravir 200 mg capsules, quantity of 40 capsules and instructions to give four capsules twice a day for 5 days was noted. The capsules inside the prescription bottle were counted with V2 DON (Director of Nursing); 32 capsules were remaining in the bottle. V2 DON confirmed the pharmacy sent 40 capsules and confirmed the label directions and stated that R59 should have gotten four capsules twice a day for 5 days and only received four capsules one time on the first day on 10/13/23 and four capsules this morning (10/18/23). V2 DON stated she called R59's physician who stated the medication is out of the time frame to be given for COVID-19 and does not want the medication restarted. 2. The Face Sheet for R117, documents R117 admitted to the facility on [DATE] with diagnoses of aftercare following joint replacement surgery, Osteonecrosis, Sepsis due to Methicillin susceptible Staphylococcus Aureus, Bacterial Pneumonia, Bacteremia and COVID-19 with onset date of 10/12/23. The current Order Summary Report for R117 documents a physician order, dated 9/27/23 as: Heparin Sodium Injection Solution 5000 units/ml (milliliter); Inject 1 ml subcutaneously every 8 hours for Post procedure for 28 days with stop date of 10/25/23. The MAR (Medication Administration Record) for R117, dated 9/1/23 through 9/30/23 and 10/1/23 through 10/31/23, document R117 to receive Heparin 5000 unit/ml; Inject 1 ml subcutaneously every 8 hours for Post procedure for 28 days at 12:00 am, 8:00 am, and 4:00 pm. These MARs indicate R117 did not receive the physician ordered Heparin at 12:00 am on 9/29/23, 9/30/23, 10/1/23, and 10/13/23 through 10/17/23. On 10/20/23 at 12:55 pm, V2 DON (Director of Nursing) reviewed R117's current Order Summary Report, September, and October MARs, and confirmed R117 should be getting Heparin three times a day at midnight, 8:00 am, and 4:00 pm. V2 DON stated she was not aware that R117 was not receiving his midnight dose of Heparin, looks like there were two nurses who were not giving it, and would investigate these as medication errors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145151 If continuation sheet Page 15 of 18 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 145151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Mendota 1201 First Avenue Mendota, IL 61342 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to perform hand hygiene prior to exiting a positive COVID-19 resident room for one (R48) of five residents reviewed for transmission-based precautions in the sample of 24. Residents Affected - Few Findings include: The facility's undated Standard Precautions Infection Control policy and procedure documents, All staff are to assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Therefore, all staff shall adhere to Standard Precautions to prevent the spread of infection to residents, staff and visitors. Standard Precautions refer to the infection prevention practices that apply to all residents, regardless of suspected or confirmed diagnosis or presumed infection status. This includes hand hygiene, selection and use of PPE (e.g., gloves, gowns, facemasks, respirators, eye protection), respiratory hygiene and cough etiquette, safe injection practices, environmental cleaning and disinfection, and reprocessing of reusable resident medical equipment. Hand hygiene is a general term for cleaning our hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand run (ABHR). Personal protective equipment, or PPE, refers to protective items or garments worn to protect the body or clothing from hazards that can cause injury and to protect residents from cross-transmission. The facility's undated, Hand Hygiene policy and procedures documents, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. The undated, hand hygiene table, documents hand hygiene is to be performed After touching blood, body fluids, secretions, excretions, contaminated items; before and after removing PPE; between resident contacts; and before meals and after using the restroom. The Face Sheet for R48, documents R48 admitted to the facility on [DATE] and COVID-19 was added to Diagnosis Information with an onset date of 10/13/23. The COVID-19 Rapid point of care test result for R48 documents, R48 tested positive for COVID-19 on 10/13/23. The current Order Summary Report for R48 documents a physician order, dated 10/13/23, Strict Isolation Droplet and Contact for COVID-19 positive. On 10/17/23 at 10:26 am, R48 was sitting in a wheelchair in her room with a wheeled walker in front of her. R48's bedroom door held a Contact/Droplet Sign with a bin of PPE (personal protective equipment) just outside of R48's room. V7 Physical Therapist, dressed in an isolation gown, N95 mask, face shield and gloves was providing R48 with therapy services. After transferring R48 from a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145151 If continuation sheet Page 16 of 18 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 145151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Mendota 1201 First Avenue Mendota, IL 61342 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wheelchair to the recliner, V7 walked to the open door, removed her PPE (in order of: gloves, gown, face shield, and N95 mask) and exited R48's room without performing hand hygiene. V7 reached into the PPE bin outside of R48's room, retrieved a non-surgical mask, applied the mask and proceeded to walk down the hallway, passing two hand sanitizer containers positioned on the right side of the hallway wall and one hand sanitizer container on the left side of the hallway wall without using. V7 Physical Therapist turned right off the hallway and entered the therapy room where other staff were working. On 10/17/23 at 10:45 am, V7 Physical Therapist stated she worked with R48 on transfers this morning in R48's room. V7 stated R48 is in isolation for COVID-19 and confirmed she did not wash her hands after removing her soiled PPE or prior to leaving R48's room and should have. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145151 If continuation sheet Page 17 of 18 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 145151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Mendota 1201 First Avenue Mendota, IL 61342 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 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on observation, interview, and record review the facility failed to ensure the designated Infection Control Preventionist completed the specialized training in infection prevention and control. This failure has the potential to affect all 66 residents residing in the facility. Findings include: The facility's current Infection Control Line List for COVID-19 documents, as of 10/14/23, 14 residents have tested positive for COVID-19 with outbreak beginning on 10/8/23. As of 10/19/23 there are 18 residents who have tested positive for COVID-19. On 10/17/23 at 9:00 am, signage was posted on the facility entrance door indicating the facility was experiencing an outbreak of COVID-19. A table to the right of the facility entrance held surgical masks and an automatic dispenser of hand sanitizer was positioned next to the table. On 10/17/23 at 9:15 am, V1 Administrator stated the facility is in a COVID-19 outbreak and V3 ADON (Assistant Director of Nursing) was the designated facility's ICP (Infection Control Preventionist). V3 ADON/ICP was responsible for the facility's Antibiotic Stewardship Program. On 10/20/23 at 9:22 am, V3 ADON stated she is the Infection Preventionist for the facility and does all the antibiotic stewardship and tracking of infections. V3 stated she has not taken the Infection Control Class yet. On 10/20/23 at 10:16 am, V2 DON stated she did take the Infection Control Course but has not yet taken the exam. On 10/20/23 at 9:55 am, V1 Administrator stated the ICP Certificates are in the Infection Control Book. V1 Administrator stated V3 ADON/ICP has not signed up for the class yet and V2 DON took the class and has not yet taken the test. The facility's Infection Control Logbook does not contain an Infection Control Infection Preventionist Certificate for V3 ADON/ICP. The Resident Census and Condition of Residents (Centers for Medicare and Medicaid Services/CMS 672) form, dated 10/17/23, documents 66 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145151 If continuation sheet Page 18 of 18