Inspection·June 15, 2022

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R57's facility Dietary Notes, dated 5/10/22 and signed by V19/Registered Dietician document, Unstageable Pressure Injury to left, medial heel (Measures) 0.5 CM X 1 CM. Noted RD recommendations for Prostat on last assessment, not implemented at this time. Recommendation: Recommend 30 ML (Milliliters) Prostat daily for 21 days to assist with wound healing. R57's facility Dietary Notes, dated 6/7/22 and signed by V19/Registered Dietician document, Stage 3 Pressure Injury to left medial heel. Noted (R57) with recent hospital stay. Noted RD recommendations for Prostat on last assessment, not implemented at this time. Recommendation: Recommend 30 ML (Milliliters) Prostat AWC daily for 21 days to assist with wound healing. R57's monthly Treatment Record, dated June 2022 includes the following physician orders: Daily Skin Check, Day shift. A review of document indicates the treatment as only being performed one day from June 1, 2022 to June 12, 2022. On 6/15/22 at 11:44 A.M., V11/Registered Nurse (RN) prepared to perform wound care for R57. With the assistance of V9/Certified Nursing Assistant (CNA), V11 rolled R57 to the right side. R57's coccyx area skin was discolored, with some denuded skin present. On 6/15/22 at 1:10 P.M., V2/Director of Nurses (DON) verified the missing daily skin checks for R57 and stated, I don't know why the Dietician's recommendations for the Prostat for (R57) were never implemented. We must have missed it (orders). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 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 145266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fondulac Rehabilitation and Health Care Center 901 Illini Drive East Peoria, IL 61611 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 - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide Range of Motion exercises for limited range of motion, for seven of seven residents (R6, R9, R35, R40, R49, R55 and R57) reviewed for range of motion, in a sample of 27. Findings Include: The facility policy, Restorative ADL (Activities of Daily Living) Programs, dated (revised) 01/02 directs staff, Restorative programs shall be planned for any resident with a reasonable likelihood for improvement in their functioning levels or to prevent a loss of function. Documentation or program implementation, follow through and individual resident progress towards goals will be done as follows: The Nursing Assistant performing the program as part of the daily care will document and initial the daily flow sheet as indicated for each restorative program. 1. On 06/12/22 at 10:29 A.M., R9 was seated in a reclining wheelchair, in a resident room. R9's bilateral hands were in a contracture position. R9's Minimum Data Set assessment, dated 6/9/21, documents R9 has functional limitation in range of motion impairment to both upper and lower extremities. R9's facility Range of Motion Assessment, last dated 3/15/22 documents that R9 is at High Risk for contracture development with contractures already present in bilateral upper and lower extremities. R9's current Care Plan, dated 2/3/20 includes the following Problem/Need: Range of Motion problem. Also included are the following Approach/Interventions: Active Range of Motion exercises twice daily. R9's Restorative Nursing Program Documentation, dated June 2022 documents staff failed to perform the required range of motion exercises seven times in the past twelve days. 2. On 6/12/22 at 9:46 A.M., R40 was lying in bed, sleeping. Contractures were present in R40's bilateral hips, legs and feet. R40's Minimum Data Set assessment, dated 5/9/22, documents R40 has functional limitation in range of motion impairments to both lower extremities. R40's Range of Motion Assessment, last dated 5/16/22 documents that R40 is at Moderate Risk for developing further contarctures, with moderate contractures already present in R40's lower extremities. R40's current Care Plan, dated 4/1/20 includes the following Problem/Need: Range of Motion problem. Also included are the following Approach/Interventions: Active Range of Motion exercises twice daily. R40's Restorative Nursing Program Documentation, dated June 2022 documents staff failed to performed the required range of motion exercises eight times in the past twelve days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 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 145266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fondulac Rehabilitation and Health Care Center 901 Illini Drive East Peoria, IL 61611 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 - Some 3. On 6/12/22 at 9:54 A.M., R55 was lying in bed, awake. At that time R55 was unable to recall staff performing range of motion exercises for her. Contractures were present in R55's bilateral hips, legs and feet. R55's Minimum Data Set assessment, dated 4/11/22, documents R55 has functional limitation in range of motion impairments to both lower extremities., requires the use of a wheelchair and is totally dependent on staff for most activities of daily living. R55's Range of Motion Assessment, last dated 3/9/22 documents that R55 is at Moderate Risk for developing further contarctures, with moderate contractures already present in R55's lower extremities. R55's current Care Plan, dated 9/22/20 includes the following Problem/Need: Range of Motion problem. Also included are the following Approach/Interventions: Active Range of Motion exercises twice daily. R55's Restorative Nursing Program Documentation, dated June 2022 documents staff failed to performed the required range of motion exercises seven times in the past twelve days. 4. On 6/12/22 at 10:05 A.M., R57 was asleep in bed. Contractures were present in R57's left shoulder, arm, hand, fingers, hip, knee and ankle. R57's Minimum Data Set assessment, dated 5/26/22, documents R57 has functional limitation in range of motion impairments to one side of both upper and lower extremities. R57's Range of Motion Assessment present in R57's Medical Record is incomplete. R57's current Care Plan, dated 5/24/22 includes the following Problem/Need: Range of Motion problem. Also included are the following Approach/Interventions: Active Range of Motion exercises twice daily. R57's Restorative Nursing Program Documentation, dated June 2022 documents staff failed to performed the required range of motion exercises eight times in the past twelve days. 6. R6's Profile Face Sheet documents diagnosis of Hemiplegia, affecting the right dominant side. R6's Care Plan documents Restorative Nursing Program- Range of Motion, Problem/Need to maintain current level of functioning. Goal- Will actively participate in moving/exercising joints with verbal cues twice daily thru next 90 days. R6's Restorative Nursing Program Documentation for 6/1/22 - 6/12/22, documents (R6) needs to perform AROM (Active Range of Motion) to upper and lower extremities twice daily to maintain current level of functioning. AROM was not performed on 6/1, 6/8, 6/11 and 6/12/22. AROM was performed once on 6/26/6/22. R6's Minimum Data Set assessment dated [DATE], Functional Status (Section G) documents R6 is a total dependence of one - two staff for Activities of Daily Living. Restorative Nursing Programs (Section O) documents R6 was receiving Range of motion (active). On 6/12/22 at 10:35 AM, R6 was lying in bed unable to reposition herself. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 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 145266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fondulac Rehabilitation and Health Care Center 901 Illini Drive East Peoria, IL 61611 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 7. R35's Medical Record, documents R35 has a diagnoses of Acute Ischemic Cerebrovascular Accident. Level of Harm - Minimal harm or potential for actual harm R35's Care Plan documents Restorative Nursing Program- Range of Motion, Problem/Need to maintain current functional ability. Will actively participate in moving/exercising joints with verbal cues twice daily thru next 90 days. Residents Affected - Some R35's Range of Motion (ROM) Assessment documents a score of 10 (Moderate). Treatment may include, but is not limited to basic ROM, positioning, turning, ambulating, as indicated by individual resident needs. R35's Restorative Nursing Program Documentation for 6/1/22 - 6/12/22, documents (R35) needs to perform AROM (Active Range of Motion) to upper and lower extremities twice daily to maintain current level of functioning. AROM was not performed on 6/1 and 6/8 - 6/12/22. AROM was performed once on 6/2- 6/6/22. R35's Minimum Data Set assessment dated [DATE], Functional Status (Section G) documents R35 is a limited assist of one staff for Activities of Daily Living and uses a wheelchair. Restorative Nursing Programs (Section O) documents R35 was receiving Range of motion (active). On 6/12/22 at 9:40 AM, V18 (Certified Nursing Assistant) was assisting R35 from his bed to his wheelchair. R35 was unsteady on his feet. On 6/15/22 at 10:00 A.M., V2/Director of Nurses (DON) stated, We (facility) do not have a Restorative Nurse. The CNAs (Certified Nursing Assistants) are supposed to do range of motion exercises for each resident on a program, two times daily and document it on the Restorative Nursing flow sheet. At that time, V2/DON confirmed the areas of blank documentation on their Range of Motion (ROM) flow sheets for R6, R9, R35, R40, R49, R55 and R57 and further stated, I don't know that the CNAs did range of motion (exercises) for those residents or not. 5. 06/15/22 09:59 AM R49's Range of Motion Assessment, dated 5/19/22, documents a score of 14 indicating that R49 is a moderate risk for contractures. This form documents that treatments may include, but is not limited to basic ROM (range of motion), positioning, turning, ambulating, as indicated by individual resident needs. R49's care plan documents a Restorative Nursing Program-Range of Motion-Problem/Need to maintain current functional ability. R49 will actively participate in moving/exercising joints with verbal cues twice daily through 90 days. Staff will assess and document Restorative participation and response to the program. R49's Restorative Nursing Program Documentation for June of 2022, has no documentation that R49's AROM to upper and lower extremities twice daily to maintain current level of functioning was not completed at all on 6/6/22. This form has no documentation of any AROM being completed a second time from 6/3/22 through 6/11/22. R49's Restorative Nursing Program Documentation indicates that R49 needs assist from staff for bed mobility such as side to side turning and repositioning. This form has no documentation that R49's bed mobility was not done on 6/6/22. This form also has no documentation that R49's bed mobility was not done from 6/3/22 through 6/11/22, on the second shift. R49's current care plan documents a Restorative Nursing Program-Range of Motion. On 6/14/22 V2 (Director of Nurses) verified that R49's were not signed out as being completed as required. V2 stated that V16, Licensed Practical Nurse/Minimum Data Set Nurse, sets up the restorative programs and the Certified Nursing Assistants are to follow up with the programs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 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 145266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fondulac Rehabilitation and Health Care Center 901 Illini Drive East Peoria, IL 61611 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to perform a resident bed to wheelchair transfer to minimize the risk of injury for one resident (R57) of three residents, reviewed for transfers, in a sample of 27. FINDINGS INCLUDE: The Facility's Fall Prevention policy (undated) documents, All staff must observe residents for safety. Interventions (fall) will be implemented for residents. New interventions will be written on the care plan. R57's current Physician Order Sheet, dated June 2022 documents that R57 was admitted to the facility on [DATE] with the following diagnoses: CVA (Cerebral Vascular Accident) with left sided weakness, Dementia, Aphasia and Delirium. R57's Minimum Data Set assessment, dated 5/26/22, documents R57 has functional limitation in range of motion impairments to one side of both upper and lower extremities. This same form documents that R57 is totally dependent on two staff members for bed to chair transfers. R57's current Care plan includes the following Problem/Need Area: (R57) is at high risk for falls. Also included are the following Approaches/Interventions: requires assistance of two (staff) and gait belt for all transfers. On 6/12/22 at 11:05 A.M., V9/Certified Nursing Assistant (CNA) prepared to transfer R57 from the bed to his wheelchair. V9 did not apply a gait belt or request assistance from another staff member, V9/CNA grabbed R57 under his arms and swung him around, dropping R57 into his chair. At that time, V9/CNA stated, Boy, you're heavy (R57). I'm glad I didn't drop you. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 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 145266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fondulac Rehabilitation and Health Care Center 901 Illini Drive East Peoria, IL 61611 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview and record review, the facility failed to minimize the risk of infection by keeping a urinary collection bag off of the floor and failed to place a urinary collection bag in a privacy bag for two of two residents (R13 and R57), reviewed for urinary catheters, in a sample of 27. FINDINGS INCLUDE: The facility policy, Urinary Drainage Collection Unit, dated (revised) 2/18 directs staff, To provide a sterile collection unit for urinary drainage to minimize entry of bacteria into the bladder. Hang the urinary drainage unit below the bladder level, not touching the floor. Keep urinary drainage bag in a catheter cover (dignity bag). 1. R57's current Physician Order Sheet, dated June 2022 includes the following diagnoses: Urinary Retention, Neurogenic Bladder, History of Urinary Tract Infection and Proteinuria. Also included are the following physician orders: Catheter change monthly with #16 Coude, 10 ML (Milliter) balloon and Supra Pubic Catheter Site Care every shift. On 06/12/22 at 9:15 A.M., R57 was lying in bed. A urinary catheter collection bag with yellow urine, was visible from the hallway. The urinary collection bag was laying on the floor. At that time, V9/Certified Nursing Assistant (CNA) verified the presence of the urinary collection bag on the floor. On 06/15/22 at 9:16 A.M., V57 was sleeping in bed. A urinary collection bag was visible from the hallway and was laying on the floor of R57's room. At that time, V11/Registered Nurse (RN) verified the collection bag visible from the doorway and stated, These girls (Certified Nursing Assistants) need to be careful with these (urinary collection bags) and make sure they are in a privacy bag and up off of the floor. 2, On 6/12/22 at 10:30am, R13 was in bed with the urinary drainage bag hanging on the side of R13's bed, touching the floor. R13 stated that the urinary drainage bag is always hanging there and touching the floor. R13 stated that the urinary drainage bad is never covered for privacy. On 6/12/22 at 11:45am, R13 was in the main dining area with the urinary catheter drainage bag hooked under the wheel chair, uncovered and dragging on the floor. On 6/15/22 at 11:00am, V11, Registered Nurse, stated that the urinary drainage bags are not covered and should be for privacy and infection control purposes. On 6/15/22 at 1:00pm, V2 Director of Nursing, verified that the urinary drainage bags are not to be touching the floor and are to be covered at all times, unless they are being emptied. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 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 145266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fondulac Rehabilitation and Health Care Center 901 Illini Drive East Peoria, IL 61611 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Based on observation, interview and record review the facility failed to provide behavioral health care services and develop individualized interventions/programs recommended in the PASRR (pre-admission screening and resident review) for one of one resident (R51) reviewed for behavioral health services in a sample of 27. Findings include: The Facility Assessment, dated March 2022, documents services and care we offer based on our Residents' need. Mental health and behavior to manage medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individual with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individual with depression, trauma/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities. This form also documents that the facility must have sufficient staff who provide direct services to residents with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. R51's Progress Notes, dated 1/5/22, document that R51 was admitted to the facility for aftercare, impaired mobility and ADL's (Activities of Daily Living), fall with a femoral shaft fracture, fracture of proximal end of the right humerus, fracture right ulna, nasal fracture, pelvic fracture, Schizoaffective disorder, Schizophrenia-paranoid type. Suicide and self-inflicted injuries by jumping from a high place and a fracture of the right foot. R51's Progress Notes, dated 1/7/22, documents that R51 removed his leg splint. On 1/8/22 R51 was sent to the local hospital for splint replacement. On 1/18/22 R51 was observed sticking a toothbrush inside his penis. On 5/20/22 the facility received a call stating that R51 was suicidal and wants to go to the hospital. R51 was sent to the hospital for an evaluation and all parties notified. R51's PASRR, dated 4/2/22, documents that R51's birthdate is 5/11/1979. This form also documents that R51 requires a structured environment such as socialization activities to diminish tendencies toward isolation and withdrawal. This form also documents that the nursing facility should monitor R51 for symptoms of isolation. This form documents the development, maintenance, and consistent implementation across settings of those programs designed to teach individuals daily living skills necessary to become more independent and self-determining including, but not limited to, grooming, personal hygiene, mobility, nutrition, vocational skill, health, drug therapy, mental health education, money management, and maintenance of the living environment. In addition, this form documents that a crisis intervention plan is necessary should R51 begin to have thoughts of hurting R51's self including an individual, group, and family psychotherapy so R51 can talk to someone about their feelings that led up to R51 jumping off of a high place. R51's current care plan documents an intervention for psychotherapy/psychiatry services. This form documents that R51 has risk factors that require monitoring and interventions to reduce the potential for self harm. The intervention for this is 15-minute checks. On 6/12/22 at 10:30am, R51 was lying in bed, holding a toothbrush straight up and down, on his abdomen, staring at it. At 1:30pm, R51 was in bed again, staring at the toothbrush he was holding on his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 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 145266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fondulac Rehabilitation and Health Care Center 901 Illini Drive East Peoria, IL 61611 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few abdomen. On 6/13/22 at 11:00am, R51 was in bed with the toothbrush in the same position. At 11:45pm, R51 was in the main dining area sitting at a table by himself. On 6/14/22 at 1:30pm, R51 was lying in bed holding the toothbrush on his abdomen, staring at it. On 6/14/22 at 1:00pm V17, Certified Nursing Assistant, stated that there are no residents being monitored with 15 minute checks. V17 stated that there is a sheet that is filled out for every 15 minute checks, in the binder at the nurses station. V17 demonstrated that the binder has no documentation of 15 minute checks for R51. On 6/14/22 at 1:15pm, V5, Licensed Practical Nurse, verified that no one in the facility is on 15 minute checks. V5 stated that R51 is not receiving any specialized psychotropic care, nor is he on any suicidal precautions. On 6/14/22 at 1:30pm, V2, Director of Nursing, stated that the facility does not offer any psychiatric services. V2 stated that the residents primary care physician manages all psychiatric medications. On 6/14/22 at 1:45pm, V15, Social Service Director, stated that R51 is not in any Psych. programs. V15 verified that the facility does not offer any psychiatric programming including those listed on R51's PASRR form. V15 stated that after R51 is finished with his therapy he will be discharged . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 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 145266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fondulac Rehabilitation and Health Care Center 901 Illini Drive East Peoria, IL 61611 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review, the facility failed to reconcile controlled medications for 29 of 29 residents (R1, R5, R6, R9, R12, R14, R18, R19, R21, R22, R24, R26, R28, R29, R31, R32, R33, R35, R36, R37, R38, R47, R48, R49, R52, R54, R209, R308 and R309) reviewed for medications, in the sample of 29. FINDINGS INCLUDE: The facility policy, Controlled Substances, dated (revised) 11/6/18 directs staff, It is the policy of the facility that all drugs listed as Schedule II drugs are subject to specified handling, storage, disposal and record keeping. Schedule II drugs are to be kept under two separate locks requiring two separate keys. A permanently affixed locked cabinet within the locked medication cart may be used for safe keeping. The Schedule II cabinet must remain locked and the Charge Nurse shall have the key in her possession at all times. Only Licensed Nurses will have access to Controlled Substances. A control sheet for each prescription will be initiated. The control sheet will contain: Resident's Name, ordering physician name, Issuing Pharmacy, Name and strength of drug, Quantity received and Date and time received. The drugs in Schedule II (and those in other schedules which have been restricted and stored in the Controlled Substance cabinet) will be counted and reconciled by the nurse coming on duty with the nurse that is going off duty. These records shall be retained for at least one year. R52's current Physician Order Sheet, dated June 2022 includes the following medications: Norco (controlled substance) 7.5/325 MG (Milligrams) Give 1 tablet by mouth every six hours for pain. On 6/12/22 at 11:34 A.M., V3/Licensed Practical Nurse (LPN) prepared to administer medications for R52. V3/LPN unlocked the A Hall Controlled Substance box, located in the A Hall Medication Cart, withdrew a medication punch card and punched one tablet of Norco 7.5/325 MG into a plastic medication cup. V3/LPN then opened the black A Hall Narc (Narcotic) Book and signed out the medication. At that time, the Shift To Shift Count Sheet, dated 6/1/22 through 6/30/22 documented twenty six missed shift to shift nursing narcotic counts. An inventory of the A Hall Controlled Substance box included controlled substances for (R1, R5, R9, R14, R18, R21, R22, R26, R31, R32, R33, R38, R47, R52, R54, R308 and R309). At that time, V3/LPN verified the missing shift to shift narcotic counts. On 6/12/22 at 11:45 A.M., the Shift To Shift Count Sheet, for the facility B Hall, dated 6/1/22 through 6/30/22 documented forty four missed shift to shift nursing narcotic counts. An inventory of the B Hall Controlled Substance box included controlled substances for R6, R12, R19, R24, R28, R29, R35, R36, R37, R48, R49 and R209. At that time, V4/Licensed Practical Nurse (LPN) verified the missing shift to shift narcotic counts. On 6/14/22 at 1:30 P.M., V2/Director of Nurses (DON) stated, The on-coming Nurse and the off-going Nurse are supposed to count all controlled medications for each (medication) cart, in the facility, and both sign the Controlled Substance Shift Count form. At that time, V2/DON verified the missing signatures and verified the facility nurses work eight hour shifts. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 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 145266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fondulac Rehabilitation and Health Care Center 901 Illini Drive East Peoria, IL 61611 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to follow manufacturer's warnings for administration of medications, for two residents (R36, R42) in the sample of twelve residents, reviewed for medication pass. This failure resulted in two medication errors out of thirty opportunities for error, for a 6.67% medication error rate. Residents Affected - Few FINDINGS INCLUDE: The facility policy, Medication Administration (revised 11/18/17) directs staff, Medications must be identified by using the seven rights of administration: right resident, right drug, right dose, right consistency, right time, right route and right documentation. 1.) R36's current Physician Order Sheet, dated June 2022 includes the following diagnosis: Diabetes Mellitus. This same document includes the following medication: Lispro Insulin 18 Units subcutaneous after meals. On 6/12/22 at 11:47 A.M., V4/Licensed Practical Nurse (LPN) prepared to administer medications to R36. V4/LPN withdrew an Insulin pen from the top of the medication cart, applied a needle and without following the printed manufacturer's warning of administering the Insulin after R36 had eaten, injected R36 with 18 Units of Lispro Insulin. At 12:30 P.M., R36 was served the noon meal. On 6/12/22 at 11:53 A.M., V4/LPN confirmed she did not follow the manufacturer's printed warnings when administering medications to R36. 2.) R42's current Physician Order Sheet, dated June 2022 includes the following diagnosis: Severe Protein Calorie Malnutrition. This same document includes the following medication: Ceravite take one tablet daily. On 6/13/22 at 8:24 A.M., V5/Licensed Practical Nurse (LPN) prepared to administer medications for R42. V5/LPN withdrew a medication card labeled as Ceravite. The printed manufacturer's warning label on the medication card stated, Take one tablet daily one hour before meals or 2 to 3 hours after meals. V5/LPN punched one tablet into a small plastic medication cup and despite the manufacturer's warning to administer the medication one hour prior to a meal, handed the plastic cup to R42, who had just finished eating the morning meal. R42 swallowed the medication with sips of water. On 6/13/22 at 8:30 A.M., V5/LPN confirmed she did not follow the manufacturer's printed warnings when administering medications to R42. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 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 145266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fondulac Rehabilitation and Health Care Center 901 Illini Drive East Peoria, IL 61611 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 Based on record review and interview the facility failed to do accuchecks (test for blood sugar levels) or give insulin to one resident (R36) of three residents reviewed for insulin in a sample of 27. Residents Affected - Few Findings include: The facility Medication Administration policy revised 11/18/17, documents Drug administration shall be defined as an act in which a single dose of a prescribed drug or biological is given to a resident by an authorized person in accordance with all laws and regulations governing such acts. The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container (including a unit dose container), verifying it was the physicians order, giving the individual dose to the proper resident, and promptly recording the time and dose given. Medications must be prepared and administered within one hour of the designated time or as ordered. R36's current medical record documents R36 has a diagnosis of Diabetes Mellitus. R36's Physician Order dated 6/1/22 - 6/30/22 documents ACCUCHECK (before meals and bedtime) daily at 8:00 AM, 11:00 AM, 4:00 PM, and 8:00 PM. Humulin R 100 units/ml (milliliters) 3ml vial (give per sliding scale Sub-Q (subcutaneous) four times a day) at 8:00 AM, 12:00 PM, 5:30 PM, and 8:00 PM. Lantus Pen 100 units/ml 3ml (inject 35 units Sub-Q once daily) at 7:00 AM. Insulin Lispro 100 unit/ml pen (inject 18 units Sub-Q three times daily after meals) at 8:00 AM, 12:00 PM, and 5:00 PM. Insulin Lispro 100 unit/ml pen (inject 16 units Sub-Q at bedtime) at 8:00 PM. R36's Medication Administration Record dated 6/1/22-6/30/22, documents the 8:00 AM ACCUCHECK on 6/10/22 was 231. This required 4 units of Humulin R 100 Units/ML(Milliliters) and there was no insulin documented as given. There were no ACCUCHECKS done at 11:00 AM, 4:00 PM, or 8:00 PM on 6/10/22 to determine the sliding scale required for Humulin R 100 units/ml insulin. There was no Humulin R 100 units/ml insulin given at 12:00 PM, 5:30 PM, or 8:00 PM on 6/10/22. There were no ACCUCHECKS done at 11:00 AM, 4:00 PM on 6/11/22 to determine the sliding scale required for Humulin R 100 units/ml insulin. There was no Humulin R 100 units/ml insulin given at 12:00 PM or 5:30 PM on 6/11/22. Lantus Pen 100 units/ml insulin (inject 35 units Sub Q once daily) was not given at 7:00 AM on 6/10/22. Lispro 100 unit/ml insulin pen (inject 18 units Sub Q three times a day) at 8:00 AM, 12:00 PM, and 5:00 PM. Lispro was not given at 8:00 AM on 6/10, 6/11, or 6/12/22. Lispro was not given on 6/8, 6/9, 6/10, or 6/12/22 at 12:00 PM. Lispro was not given on 6/8, 6/10, or 6/11/22 at 5:00 PM. Lispro 100 unit/ml insulin pen (inject 16 units Sub Q at bedtime) at 8:00 PM. Lispro was not given on 6/10/22 at 8:00 PM. Lantus 100 unit/ml insulin pen (inject 35 units Sub Q once daily) at 7:00 AM. Lantus was not given on 6/10/22. On 6/15/22 at 11:20 AM, R36 stated that she is on a sliding scale for insulin and is to have an accucheck done at 8:00 AM, 11:00 AM, 4:00 PM, and 8:00 PM daily to determine her insulin needs. R36 stated that on 6/9 and 6/10/22, V4 (Licensed Practical Nurse) did not do any accuchecks and did not give any insulin as ordered for R36. (R36) stated (V4/LPN) doesn't like me so she doesn't always give me my insulin. On 6/15/22 at 10:30 AM, V2 (Director of Nursing) stated The accuchecks and insulin should have been given for (R36). (V4/Licensed Practical Nurse) worked on the 10th (6/10/22) and (V11/Registered Nurse) worked on the 11th (6/11/22). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 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 145266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fondulac Rehabilitation and Health Care Center 901 Illini Drive East Peoria, IL 61611 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 On 6/15/22 at 11:55 AM, V4 (Licensed Practical Nurse) stated I think I did them (accuchecks and insulin for (R36). I made a mistake and didn't write them down. V11 (Registered Nurse) was not available for an interview. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 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 145266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fondulac Rehabilitation and Health Care Center 901 Illini Drive East Peoria, IL 61611 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to ensure a cooked pork roast was cooled to a safe temperature before storing in the refrigerator, open containers of food were covered to prevent contamination and labeled with the date opened, foods with expired dates were discarded, staff food was not stored in the refrigerator with residents' food, refrigerators were clean and without debris, and clean bowls in the kitchen were stored to prevent debris from falling into the eating surface. These failures have the potential to affect all 67 residents in the facility. Findings include: A Storage policy dated 10/2020 states, When using only part of a product, the remaining product should be in the original package or airtight container and labeled and dated. This policy also states, Do not leave serving utensils or tools in food containers. A Food from Outside Sources/Personal Food Storage policy dated 4/2017 states, All residents have the right to accept food brought to the facility by any visitor (s) and/or food from a facility garden, however, the food must be handled in a way to ensure resident safety. This policy states, Any suspicious or obviously contaminated food or beverage will be discarded immediately. Food and beverages will be labeled with the resident's name, food item, date. In addition, this policy states, Housekeeping staff, or designee shall clean and sanitize the refrigerators once a month or as required. A Food and Drug Administration (FDA) document dated as current documents that the FDA has rules for cooling food safely which includes, The FDA recommends that food be cooled from 135°F(Fahrenheit) to 41°F (57°C (Celsius) to 5°C) in six hours or less. This time limit helps prevent dangerous bacteria growth. In addition, this document states, Food must be cooled from 135°F to 70°F (57°C to 21°C) in two hours or less. In this range, bacteria can double in as little as 20 minutes (https://www.fsis.usda.gov/food-safety/safe-food-handling-and-preparation/food-safety-basics/how-temperatures-affect-food The faster food passes through this temperature range, the better. Food workers have the rest of the six hours to take food through the remaining temperature danger zone, from 70°F down to 41°F (21°C to 5°C). On 6/12/22 at 9:25a.m. V6 (Cook) was in the kitchen preparing the noon meal. There was a cooked roast on the food prep table which was wrapped in plastic. V6 stated the meat was a pork roast that was cooked yesterday. V6 stated that after the roast was cooked, it was refrigerated overnight and was going to be sliced and made into sandwiches as an alternative for the residents' lunch. V6 stated the facility no longer keeps cool down logs on cooked meat and, therefore, there is no documentation of the temperature the roast was when it was placed in the refrigerator or whether the FDA's two step method of cooling cooked food was utilized. V6 proceeded to take the internal temperature of the roast using a digital food thermometer. The internal temperature of the meat was 62.6F, well above the FDA's safe food refrigeration temperature of 41F. V6 stated she did not think the meat could have warmed up that much since the time she removed it from the refrigerator. V6 proceeded to open the cooler where cold food for residents' meals is stored. Inside the cooler was a rack with shelves which contained nine glasses of cranberry juice and five cups of diced peaches, one cup of pureed peaches, and one cup of thickened juice which were unlabeled and uncovered. There was an unsealed and partially used bag of lunch meat which was not labeled with opened date. There were two pitchers of juice which were unlabeled. V6 verified the food items in the refrigerator that were uncovered, partially used, and without labels. V6 closed the refrigerator and walked over to the steam table where there (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 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 145266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fondulac Rehabilitation and Health Care Center 901 Illini Drive East Peoria, IL 61611 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many was a table adjacent on top of which were four small disposable plastic cups which were uncovered and contained a purple substance under a brown substance. V6 stated these were peanut butter and jelly cups for residents. V6 verified the cups were uncovered and unlabeled. On a table next to the stove was a small plate containing a piece of toast which was uncovered. At 11:36a.m. V7 (Dietary Manager) opened the freezer in the facility's kitchen located across from the food preparation table. Inside the freezer was a partially consumed water bottle containing a pink liquid. V7 stated that staff's personal drinks are not supposed to be kept in that freezer. V7 proceeded to enter the dry storage room where there was a large plastic container of granulated sugar with the lid partially removed exposing the contents. V7 attempted to replace the lid but it did not fit over the container of sugar. There was a large plastic container of a powdered substance next to the sugar which also had the lid partially removed. The lid to this container was covered with the powdered substance. V7 stated the powder is used to thicken liquids for residents requiring thickened liquids in their diets. V7 proceeded to remove the lid and brushed off the powder into the waste basket. There was a smaller plastic nine by thirteen sized container which contained granulated sugar which was in clumps, and which contained a small scoop within the container on top of the sugar. V7 stated that was sugar used in the dining room when staff were serving drinks and which water had dripped into the container causing the sugar to clump. V7 stated she was saving that container of sugar to be used for residents again. Across from the sugar containers was a small food preparation table with additional containers of dry cereals. Also on the table was a stack of cereal bowls facing upward. V7 stated the bowls are kept like that so staff can easily fill the bowls when residents request cereal. There was brown and tan debris visible inside the top bowl in the stack. On a bottom shelve of the storage rack was a large electric food slicer which was uncovered and had visible debris just below where the blades were attached. V7 verified the slicer was being stored without a cover and stated she did not know where the debris on the slicer came from. On 6/13/22 at 1:00p.m. V18 (Housekeeping Supervisor) unlocked the residents' nourishment room door and opened the refrigerator containing stored residents' foods. The refrigerator interior was covered with dried liquids, pieces of paper and food debris. There were numerous food items which were partially used and unlabeled which included a small bottle of chocolate syrup, a large bottle of chocolate syrup, four jars of salsa of various sizes, a carton of milk, two bottles of Worcestershire sauce, a bottle of ketchup and mustard, Italian salad dressing, strawberry jelly, liquid coffee creamer, a vegetable drink, barbeque sauce, a liter of soda, a large bag of bacon pieces, an opened can of soda, a jar of relish, a container of sour cream, a bottle of liquid tea, a plastic water bottle. Also in the refrigerator was a partially eaten rotisserie chicken, wilted grapes, a container of margarine, an unsealed plastic bag with a sandwich with hard bread and an unknown brown substance between the bread, two commercially prepared sandwiches with labels instructing to use by 5/23/22, a commercially prepared macaroni and cheese container and a container of a tofu dish both labeled with a use by date of 5/23/22. Additionally, there was a partially used bottle of a nutritional supplement drink and a plastic container of food which V18 stated belonged to one of the nursing staff. V18 verified the contents of the refrigerator and stated that all the foods within the refrigerator should be labeled with the resident's names and date they were opened. V18 stated the expired food should have been discarded. V18 stated that facility staff are not supposed to store their food in the residents' nourishment refrigerator. At 1:15p.m. V1 (Administrator) entered the residents' nourishment room and verified the soiled condition of the refrigerator and verified that the contents were expired, not labeled, not completely covered, or belonged to nursing staff. V1 proceeded to open the freezer to examine the contents. Inside the freezer were four (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 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 145266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fondulac Rehabilitation and Health Care Center 901 Illini Drive East Peoria, IL 61611 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many therapeutic ice bags on top of which was a partially consumed fast-food chocolate drink laying on its side. There was a frozen dinner in a box, a chicken burrito, a pastry roll, a partially empty water bottle, an unwrapped partially eaten ice cream sandwich. None of these items were labeled with who they belonged to or when they were opened. Additionally, there were pieces of paper, food debris and drops of frozen brownish liquid all over the interior of the freezer. V1 verified the freezer was soiled and contained expired, unlabeled and open partially consumed foods. V1 also verified there was a partially consumed fast food chocolate drink laying on top of therapeutic ice bags used in medical treatments for residents. V1 stated that the refrigerator and freezer needed to be cleaned and expired or unlabeled foods discarded. V1 stated that therapeutic ice bags should not be stored in the refrigerator with food. On 6/15/22 at 9:00a.m. and 1:00p.m. V1 stated that the facility no longer keeps cool down temperatures on cooked roasts because all cooked foods are supposed to be consumed the same day they are cooked. V1 stated that if there are any leftovers of foods such as a cooked pork roast, that food is offered to staff for their meals that same day. V1 stated the cooked pork roast that had an internal temperature of 62.6F the day after it was cooked should have been discarded and not saved to serve to residents. A Resident Census and Conditions of Residents form dated 6/12/22 and signed by V16 (Minimum Data Set Coordinator) documents that at the time of the survey 57 residents resided in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 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 145266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fondulac Rehabilitation and Health Care Center 901 Illini Drive East Peoria, IL 61611 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews the facility failed to ensure staff wore masks covering their noses and mouths while in the resident areas of the facility. This failure has the potential to affect all 57 residents in the facility. Residents Affected - Many Findings include: A COVID-19 Control Measures policy dated as revised 2/21/22 states, Anyone entering the facility must wear a facemask. On 6/12/22 at 9:15a.m. V4 (Licensed Practical Nurse/LPN) walked from the residents' hallway through the facility's dining room to the side entrance of the building without wearing a face mask. V4 proceeded to talk with visitors who just entered the building before walking back through the dining room into the patient hallway where the nurses' desk was located. At 9:40a.m. V3 (LPN/Infection Preventionist) was standing behind the nurses' station which was centrally located between the three resident hallways. V3 was wearing a facemask which was placed under her chin and not covering her nose or mouth. V3 stated that staff are supposed to wear a facemask covering their noses and mouths while in the facility. During this conversation, V3 maintained her mask under her chin without adjusting it to cover her nose and mouth. On 6/14/22 at 11:00a.m. V9 (Certified Nurse Aide/CNA) was standing at the end of the residents' hall. V9's mask was under V9's chin and not covering V9's nose or mouth. At that time, V9 proceeded to walk from the end of the residents' hall past the nurses' station, through the residents' dining room to exit the side door while wearing V9's mask under V9's chin. At 1:30p.m. V9 was standing in the dining room in the presence of residents who were eating popsicles for a snack. V9 had removed V9's mask and was also eating a popsicle in the presence of these residents. On 6/15/22 at 10:15a.m. V9 and V10 (CNA) were seated at the end of a residents' hall. V9's facemask was below V9's chin and not covering V9's mouth or nose. V11 (Registered Nurse) was standing next to V11's medication cart on the same residents' hall as V9 and V10. V11 was wearing a facemask under V11's chin and not covering V11's nose or mouth. V11 proceeded to talk to a visitor then talk to V9 and V10 while continuing to wear the facemask under V11's chin. On 6/15/22 at 11:00a.m V2 (Director of Nurses) stated that the facility requires all staff to wear face masks to cover their noses and mouths while working in resident areas of the facility as an infection control measure to prevent the potential spread of COVID-19. V2 stated that V9 should not have removed V9's facemask to eat a popsicle in the presence of residents in the dining room. V2 stated that V4 should not have walked through the facility without a facemask. V2 stated that V3 and V11 should not have been in the residents' hall or at the nurses' station without wearing a mask over their noses and mouths. A Resident Census and Conditions of Residents form dated 6/12/22 and signed by V16 (Minimum Data Set Coordinator) documents that at the time of the survey 57 residents resided in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 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 145266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fondulac Rehabilitation and Health Care Center 901 Illini Drive East Peoria, IL 61611 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 0886 Perform COVID19 testing on residents and staff. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to have documented efforts to obtain COVID-19 laboratory test results within 48 hours or that it attempted to contact its local and state health departments for assistance with timely COVID-19 laboratory testing. These failures have the potential to affect all 57 residents in the facility. Residents Affected - Many Findings include: A COVID-19 Testing policy dated 6/4/20 gives as its purpose, To identify asymptomatic cases, to confirm infection symptomatic cases, to evaluate quality indicators, to follow-up on infection control programs and to support decision making. On 6/12/22 at 10:16a.m. and 6/14/22 at 2:00p.m. V2 (Director of Nurses) stated the facility recently had an outbreak of COVID-19 among its staff and residents. V2 stated that the facility's community transmission levels are high, and the facility was already testing unvaccinated staff two times weekly using a point of care (POC) rapid test. V2 stated that on 5/16/22 the facility had its first case of COVID-19 at which time they began a broad testing program for all residents and staff two times weekly to continue for two weeks following the last positive COVID-19 test. V2 stated the facility continued testing staff using the POC rapid test but used a laboratory (Lab) to perform PCR (Polymerase Chain Reaction) testing for all residents twice weekly. V2 stated that since 5/16/22 the lab has not given the facility results within 48 hours on multiple occasions. V2 stated that the facility's corporate office has been informed but no other measures have been attempted. V2 stated the facility's corporate office does not allow for residents to have POC rapid testing which would ensure the facility can determine a resident's COVID-19 status within 15 minutes. V2 stated that the facility's local and state health departments have not been contacted for assistance with this matter. V2 provided a compilation of residents' PCR test results which documents that residents' PCR testing performed 5/23/22 were not returned to the facility until 6/2/22; results of residents' PCR testing performed 5/26/22 were not returned to the facility until 6/2/22; results of residents' PCR testing performed 5/30/22 were not returned to the facility until 6/2/22; results of residents' PCR testing performed 6/2 22 were not returned to the facility until 6/6/22; results of residents' PCR testing performed 6/9/22 were not returned to the facility until 6/14/22. A Resident Census and Conditions of Residents form dated 6/12/22 and signed by V16 (Minimum Data Set Coordinator) documents that at the time of the survey 57 residents resided in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 If continuation sheet Page 18 of 18