Inspection·August 4, 2023

F 0576 Ensure residents have reasonable access to and privacy in their use of communication methods. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to deliver mail six days a week. This has the potential to affect all 62 residents residing in the facility. Residents Affected - Many Findings include: Long Term Ombudsman Program Resident Rights for People in Long-term care Facilities, dated 12/04, documents Your facility must deliver your mail to you promptly. On 8/03/23 at 10:05 AM, a resident council meeting was conducted in the sunroom. During the resident council meeting, R39, R42, R33, and R11 were asked if they got mail delivered on Saturdays and during the week. R39, R42, R33, and R11 all stated they did not get mail delivered on weekends, and if a package was delivered on Saturday they had to wait until Monday when V13 Activity Director came back to work because V13 is who delivers the mail and packages and only works Monday through Friday. On 8/03/23 at 10:50 AM, a tour of the facility was taken, and a paper was posted in the clear glass display case at the nurse's desk that documents All mail that is available to be handed out will be given to activities by 1:00pm for distribution. Exceptions for the weekends, when there may not be anyone available. On 08/04/23 at 11:25 AM V13 Activities stated, I work Monday thru Friday from 8:30 to 4:30pm and pass the mail/packages after management takes out their financial information. R39, R41, R33, and R11's medical records document they are moderately impaired and cognitively intact for cognition. Resident Census and Conditions form, dated 8/2/23, documents 62 resident live in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 If continuation sheet Page 2 of 34 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 08/04/2023 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 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Potential for minimal harm Based on observation, interview and record review, the facility failed to post and have reports from the most recent survey of the facility available. This has the potential to affect all 62 residents residing in the facility. Residents Affected - Many Findings include: Long Term Ombudsman Program Resident Rights for People in Long-term care Facilities, dated 12/04, documents Your facility must let you see reports of all inspections by the Illinois Department of Public Health. On 8/03/23 at 10:05 AM, a resident council meeting was conducted in the sunroom. During the resident council meeting, R39, R42, R33, and R11 were asked if they knew where the state survey book was located at the facility. R39, R41, R33, and R11 were unaware of where the state survey book was located because it was located in the front lobby at one time, but it had been removed quite a while ago when the lobby was remodeled. On 8/03/23 at 10:50 AM, a tour of the facility was taken and unable to find the state survey binder. A paper posted in the clear glass display case at the nurse's desk documents state survey results are available for residents and visitors to view in the front lobby, however no binder or results of state inspection found in the lobby. On 8/03/23 at 11:50 AM, a tour of the facility was conducted with V1 Administrator and she verified the facility did not have the state survey book in the lobby. I have it in my office because it was not updated, they remodeled the lobby and it hasn't had a place to go since the remodel, and I suppose it will go on the table when we take off the magazine. R39, R41, R33, and R11's medical records document they are moderately impaired and cognitively intact for cognition. Resident Census and Conditions form, dated 8/2/23, documents 62 resident live in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 If continuation sheet Page 3 of 34 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 08/04/2023 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a physician's order was obtained for code status (Do Not Resuscitate/DNR) for one resident (R419) of 26 residents, in a total sample of 26 residents reviewed for DNR Physician orders. FINDINGS INCLUDE: Facility policy, entitled Advance Directive, Revised [DATE], documents, 4. Any decision made by the resident shall be indicated in the chart in a manner easily understood by all staff. Advance directives specifying full code/attempt resuscitation/CPR [Cardio-Pulmonary Resuscitation] or the absence of determination shall be recorded as a Full Code. Those residents indicating Do Not Attempt Resuscitation/DNR shall be recorded as DNR. Staff must be aware of any requests for limited Medical Interventions shall be recorded appropriately on the care plan. DNR or requests for comfort measures only shall be recorded as signifying DNR-Comfort. Code status shall also be recorded on the resident's Physician Order Sheet. R419's IDPH [Illinois Department of Public Health] Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form, signed by R419 on [DATE], and R419's physician on [DATE], document: Section A: Attempt Resuscitation/CPR has the box and lined out with error written and the Do Not Attempt Resuscitation/DNR is marked with an X; and Section B: Full Treatment has the box with a lined out with error written and the Comfort Focused Treatment is marked with an X. R419's Physician's Orders sheet, for [DATE] to [DATE], document under the Code Status section as R419 being a *** FULL CODE ***. On, [DATE], at 8:40 AM, V2/Director of Nursing confirmed V2's expectation is R419's Physician's Order Sheet should have been updated to reflect R419's change in code status to DNR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 If continuation sheet Page 4 of 34 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 08/04/2023 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 0585 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on interview and record review, the facility failed to inform residents of their rights and where/whom to file a grievance. This has the potential to affect all 62 residents residing in the facility. Residents Affected - Many Findings include: Facility Resident Grievances/Complaints, revised 11/1/17, documents It is the policy to actively encourage residents and their representatives to voice grievances and complaints on behalf of themselves or others. The facility shall provide contact information including: grievance official name, business address, business phone, a reasonable timeframe for completing the review of the grievance. On 8/03/23 at 10:05 AM, a resident council meeting was conducted in the sunroom. During the resident council meeting, R39, R42, R33, and R11 were asked if they knew who their grievance official was and how to file a grievance. R39, R41, R33, and R11 were unaware of who their grievance official was and stated there was no posting they were aware of on who to file a grievance to. On 8/03/23 at 10:50 AM, a tour of the facility was taken, and no postings were found on how to file a grievance and where/whom was responsible for assisting with filing a grievance for residents. On 8/03/23 at 11:50 AM, a tour of the facility was conducted with V1 Administrator and she verified the facility did not have any postings on how to file a grievance and where/whom was responsible for assisting with filing a grievance for residents. R39, R41, R33, and R11's medical records document they are moderately impaired and cognitively intact for cognition. Resident Census and Conditions form, dated 8/2/23, documents 62 resident live in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 If continuation sheet Page 5 of 34 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 08/04/2023 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm 2. The POS (Physician's Orders Sheet) for R56, dated August 2023, documents R56's diagnoses as: Left MCA (middle cerebral artery) stroke, right flaccid Hemiplegia. This same POS documents Physician orders for: Isosource (Dense Complete Nutrition Formula with Fiber) 1.5 calorie to infuse at 120 ml (milliliters) per hour via gastrostomy tube using enteral feeding pump for 12 hours; flush gastrostomy feeding tube with 200 ml of water three times daily during enteral feeding; regular mechanical soft, very moist diet, with nectar thick liquids orally; Med Pass (nutritional supplement) 60 ml by mouth three times daily; and Mighty Shake (nutritional supplement) 4 ounces by mouth three times daily. Residents Affected - Few On 8/2/23 at 12:42 PM, R56 was sitting in a wheelchair in the dining room eating a mechanical soft diet. On 8/3/23 continuous observation between 8:00 AM through 8:30 AM, R56 was sitting in the dining room and ate 100% of breakfast tray served. On 8/3/23 at 12:20 PM, R56 was sitting in a wheelchair and eating noon meal. On 8/4/23 at 7:50 AM, V1 DON (Director of Nursing) stated R56 has been refusing his gastrostomy tube feedings but does have an oral diet and eats meals in the dining room. The Quarterly MDS (minimum data set) assessment for R56, dated 7/13/23, documents R56 with a feeding tube and does not include diet or liquids being received orally. This same MDS documents R56 with no swallowing concerns identified. Based on interview and record review, the facility failed to submit correct MDS (Minimum Data Set) assessments for two residents (R5 and R56) reviewed for MDS correctness in a sample of 26. Findings include: The facility's Comprehensive Assessment/MDS (Minimum Data Set) Policy, dated 11/1/17, documents: It is the policy of (facility) to comprehensively assess and periodically reassess each resident admitted to this facility. The results of this resident assessment shall serve as the basis of determining resident strengths, needs, goals, life history and preferences to develop a comprehensive plan of care for each resident with the goal of attaining or maintaining the resident's highest practicable physical, mental, and psychosocial well-being. 1. R5's current Physician Orders, dated 8/1/23, documents R5 has a diagnosis of Bipolar; R5's current Physician Orders does not document a diagnosis of Post Traumatic Stress Disorder/PTSD. R5's MDS (Minimum Data Set), dated 5/15/23 Section I Active Diagnoses, does not document R5's diagnosis of Bipolar but does document (with a checkmark at 16100) a diagnosis of PTSD (Post Traumatic Stress Disorder). On 8/4/23 at 10:30 AM, V5 Minimum Data Set/MDS/Care Plan Coordinator stated, (R5) does not have PTSD; the MDS diagnosis of PTSD was an error on my part; I shouldn't have checked that, and I did not put a checkmark at (R5's) diagnosis of Bipolar and I should have; that was an error on my part. I will correct those today. At this time, V5 also stated, We have gotten a signed Progress Note (dated 8/4/23) from (V14/Physician Assistant) stating that (R5) does not have a diagnosis of PTSD. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 If continuation sheet Page 6 of 34 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 08/04/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The facility's AIM (Assess, Intercommunicate, Manage) for Wellness form for R23, dated 5/14/23, documents the nurse entered the resident room and resident was sitting on the springs of the unoccupied bed in her room. R23 had her legs drawn up underneath her and was only dressed in a bra and underwear and was asking the nurse not to leave her alone. R23 was unable to state her name and had increased confusion. R23 was sent to the local hospital emergency room for an evaluation of her altered mental status. The Progress Note for R23, dated 5/14/23 at 7:30 AM, documents R23 was sent to and admitted to the local hospital. The Progress Note dated 5/17/23 at 6:00 PM, documents R23 was readmitted to the facility. The facility's AIM for Wellness form for R23, dated 5/21/23 documents R23 was in bed all day with eyes closed, not responding to verbal stimuli, not speaking, not eating, not taking medications, and not following verbal commands. R23 was sent to the local hospital for an evaluation for altered mental status. The Progress Note for R23, dated 5/21/23 at 5:00 PM, documents R23 was sent to the local emergency room for an evaluation. The Progress Note dated 5/22/23 at 1:14 PM, documents R23 returned to the facility. The current Care Plan for R23, does not include R23's hospitalizations or risk for re-hospitalization. On 8/3/23 at 11:06 AM, V1 Administrator confirmed a Hospitalization Care Plan was not developed for R23 and should have been and stated the residents Care Plans are generic, sloppy and have not updated. 4. The POS (Physician's Orders Sheet) for R56, dated August 2023, documents R56's diagnoses as: Left MCA (middle cerebral artery) stroke, right flaccid Hemiplegia. This same POS documents Physician orders for: Isosource (Dense Complete Nutrition Formula with Fiber) 1.5 calorie to infuse at 120 ml (milliliters) per hour via gastrostomy tube using enteral feeding pump for 12 hours; flush gastrostomy feeding tube with 200 ml of water three times daily during enteral feeding; regular mechanical soft, very moist diet, with nectar thick liquids orally; Med Pass (nutritional supplement) 60 ml by mouth three times daily; and Mighty Shake (nutritional supplement) 4 ounces by mouth three times daily. On 8/02/23 at 12:42 PM, R56 was sitting up in a wheelchair in the dining room eating lunch. On this same date at 2:42 PM, R56 was lying in bed with gastrostomy tube visible at edge of shirt and tied in a knot. On 8/03/23 from 08:00 AM through 8:30 AM and at 12:20 PM, R56 was sitting in a wheelchair in the dining room feeding self-meal. On 8/4/23 at 7:50 AM V1 Administrator confirmed R56 refuses to allow the use of his gastrostomy feeding tube for nutrition or medications and has a physician order for an oral diet. V2 DON also stated the facility started talking with R56's physician about possibly getting the feeding tube out due (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 If continuation sheet Page 7 of 34 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 08/04/2023 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 0656 to R56's refusals. Level of Harm - Minimal harm or potential for actual harm The facility's monthly weight book documents the following date and weights for R56 as: [DATE].6 pounds; [DATE].0 pounds; [DATE].2 pounds; April 136.7 pounds; May 141.1 pounds; June 141.8 pounds; and July 144.1 pounds. Residents Affected - Some The RD (Registered Dietitian) Note for R56, dated 7/7/23, documents a recommendation for Physician consult related to R56's refusal of gastrostomy tube. The Dietary Quarterly Note for R56, dated 4/11/23, documents R56 refuses gastrostomy tube nutritional feeding a lot, Mighty Shakes ordered, and R56 with aphasia (without speech) and the RD monitoring weights and labs. The QA (Quality Assurance Notes) for R56, document meetings being held and include R56 refusal of gastrostomy tube feedings. The current Care Plan for R56, does not document a Nutritional Care Plan and R56 at Risk for weight loss or fluctuation in weights was developed for R56. On 8/3/23 at 11:06 AM, V1 Administrator confirmed a Care Plan was not developed for R56's risk of weight loss due to his refusals of Gtube feedings and there should be. V1 Administrator stated the residents' Care Plans are generic, sloppy, and have not been updated. Based on observation, interview and record review, the facility failed to develop a person-centered plan of care for four of 16 residents (R23, R29, R37, R56) reviewed for care plans in the sample of 26. Findings include: The facility's Comprehensive Care Planning Policy, revised 7/20/22, states, 4. Comprehensive Care Plans shall strive to describe a. The resident's preferences, choices, and goals to the extent possible to assist in attaining or maintaining the resident's highest practicable quality of life. b. The resident's medical, nursing, physical, mental, and psychosocial needs and preferences. c. Person centered measurable objectives and timeframes for ease of evaluating resident progress toward achieving goals. 8. Communication of the Care Plan contents is paramount to the success of consistent care delivery. 1. R37's Face sheet documents R37 was admitted to the facility on [DATE]. R37's Cumulative Diagnosis Log documents R37 as a smoker. The facility's Smoking List documents R37 as a current smoker in the facility. R37's Smoking assessment dated [DATE] documents R37 as a supervised smoker. On 8/2/23 at 12:55 PM, R37 stated R37 is a current smoker. R37 stated R37 does not always have cigarettes available but R37 smokes when R37 can. As of 8/3/23 at 9:00 AM, R37's current Care Plan did not document any information regarding R37 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 If continuation sheet Page 8 of 34 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 08/04/2023 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 0656 being a current smoker in the facility. Level of Harm - Minimal harm or potential for actual harm On 8/3/23 at 10:51 AM V5 (Care Plan Coordinator) verified R37's current Care Plan did not contain any documentation regarding R37's smoking status and it should. V3 stated, It's on there now. Residents Affected - Some 2. On 8/02/23 at 9:30 AM, R29's left arm was edematous. R29 stated she has a blockage and needs a stent put in place. R29's left arm has a compression sleeve in place from hand all the way up to the shoulder and was on 4 liters of oxygen per nasal cannula. R29's current physician orders, dated 7/21/23, documents Refer to vascular due to blockage in the left arm. R29's current care plan does not have her left arm edema or oxygen use noted on the problem/need area with a goal and interventions. On 8/03/23 at 9:30 AM V6 Licensed Practical Nurse/LPN stated (R29) has a referral to (local) vascular surgeon in November 2023 and uses oxygen when she gets short of breath. On 8/4/23 at 10:25 AM, V5 Care plan coordinator verified R29 did not have edema or her oxygen marked on her care plan under its own problem/need area, and should be with a goal and interventions in place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 If continuation sheet Page 9 of 34 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 08/04/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. The POS (Physicians Orders Sheet) for R43, dated [DATE], documents R43 with diagnoses of Anxiety, Bipolar Disorder, Depression, and Physical Deconditioning. This same POS lists the following psychotropic medications physician orders: Divalproex Sodium ER (Extended Release) 500 mg (milligrams) twice daily; Lorazepam 1 mg at bedtime; Lorazepam 0.5 mg twice daily; Risperidone 1 mg three times a day; and Sertraline (Zoloft) HCL (hydrochloride) 100 mg nightly. A physician order, dated [DATE], documents admit R43 to local hospice service with no hospitalizations or labs. On [DATE] at 11:35 AM and 2:42 PM and on [DATE] at 8:00 AM and 10:24 AM, R43 was sitting up in a high back reclining wheelchair with a mechanical lift transfer sling underneath her. On [DATE] at 3:44 PM, R43 was transferred from the high back reclining wheelchair to her bed with a mechanical lift via the sling. On [DATE] at 3:45 PM, V6 LPN (Licensed Practical Nurse) stated R43 used to be in a regular wheelchair and would propel herself but stopped doing that quite a while ago. R43 hasn't been able to walk or transfer and is total care for her cares. V6 LPN stated R43 is transferred with a mechanical lift and went on Hospice due to decline in her condition and only behavior V6 LPN is aware of is anxiety at times. The fall investigation for R43, dated [DATE], documents R43 attempted to get up unassisted and lost balance falling to the floor with intervention to ensure R34 is positioned correctly in the chair and to Use (high back reclining) chair instead of standard wheelchair for more support. The Hospice Note for R43, dated [DATE], documents R43 was provided a high back reclining wheelchair. The current Care Plan for R43 was not revised to include the use of R43's psychotropic medications with R43's identified targeted behaviors and interventions; Was not revised with R43's use of a high back reclining wheelchair; Was not revised to include resident centered hospice services and interventions. This same Care Plan was not revised and still documents: Assist for transfers and ambulation; and attempt more frequent lab draws. On [DATE] at 11:06 AM, V1 Administrator confirmed R43's Care Plan was not revised, and the residents Care Plans are generic, sloppy, and have not updated. 6. The POS (Physicians Orders Sheet) for R56, dated [DATE], documents the following diagnoses: Left MCA (middle cerebral artery) Stroke, right Flaccid Hemiplegia, Cerebral Edema, Aphasia and Depression. This same POS lists the following orders: Iso-Source (Dense Complete Nutrition Formula with Fiber) 1.5 Cal (calorie) 120 ml (milliliters) per electronic feeding pump for 12 hours; 200 ml water flush three times daily during feeding; 30 ml water flush before and after medications; Med Pass (nutritional supplement) 60 ml three times daily; Mighty Shake (nutritional supplement) 4 ounces three times daily; Cleanse and change split sponge daily; Regular mechanical soft - very moist diet with nectar thick liquids On [DATE] at 10:00 AM, R56 refused to be interviewed, raised left arm, and waved arm toward door and grunted for surveyor to leave the room. On [DATE] at 12:42 PM, on [DATE] at 8:00 AM and 12:20 PM, R56 was sitting in a standard wheelchair in the dining room with his right arm flaccid resting next to him in his lap and was eating a mechanical soft diet. On [DATE] at 2:42 PM, and on [DATE] at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 If continuation sheet Page 10 of 34 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 08/04/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 10:20 AM and 3:40 PM, R56 was lying in bed on his back with a visible gastrostomy feeding tube tied in a knot at edge of shirt. R56 refused to allow surveyor to see his Gtube insertion site. On [DATE] at 7:50 AM V2 DON (Director of Nursing) stated R56 was on Hospice but was taken off sometime last year because he was doing better, and therapy was initiated. Restorative Rehabilitation picked him up after therapy. V2 DON stated R56 refuses to allow his gastrostomy feeding tube to be used, flushed, or cleaned and will tie the tube in a knot. V2 DON confirmed R56 uses a standard wheelchair and no longer uses the high back reclining wheelchair. On [DATE] at 8:37 AM, V4 LPN (Licensed Practical Nurse) stated R56 refuses Gtube feedings and flushes and hasn't let anyone do anything with his Gtube for a long time. R56 will take his medications by mouth but will refuse them sometimes too. V4 LPN stated, I am really surprised he hasn't tried to yank it (Gtube) out yet. On [DATE] at 7:58 AM and 8:01 AM, V9 and V10 CNA's (Certified Nursing Assistants) respectively stated R56 refuses to participate in his restorative programs and won't allow staff to do any of his restorative programs. The Progress Notes for R56, dated April through [DATE], document R56's refusal of Gtube cares, feedings, flushes, and medications and R56 tying his Gtube in a knot to prevent use. The Quarterly Dietary Note, dated [DATE], documents R56 refuses his Gtube feedings a lot. The RD (Registered Dietitian) Note, dated [DATE], documents R56 continues to refuse Gtube feedings at times, weight trending up due to weight loss last month. The RD Note, dated [DATE], documents R56's continued refusal of Gtube feedings, flushes, and Nurse confirming and recommendation for physician consult related to R56's continued refusal of Gtube feeding and flush. The Dietary Services Communication form for R56, dated [DATE], documents R56 with Gtube feeding and oral diet, R56 refusing all Gtube feeding and water flushes. Recommend MD (medical doctor) consult related to Gtube feeding and water flush refusals. The facility Laboratory testing forms for R56, dated [DATE], document R56's refusal of labs and document to redraw on [DATE] with no other laboratory results in R56's medical record. The Social Service Notes for R56, document R56 admitted to the facility on [DATE] and signed hospice service contract on [DATE]. The Social Service Note, dated [DATE], documents R56 was discontinued from hospice due to family wanting therapy services and on [DATE] R56 was refusing Gtube feedings, eating most meals in the dining room with appetite varying, refusing to wear helmet, and propelling own wheelchair independently. The current Care Plan for R56 was not revised to include: R56's refusal of Gtube care, feedings, water flushes, and medications; R56 ties Gtube in a knot to prevent use; Refusing Restorative programing; Refusal of oral medications at times; No longer uses a high back reclining wheel chair and uses a standard wheel chair; Refuses to wear helmet when up; Consumes oral diet only; Weight fluctuations and risk for weight loss; and refusal of laboratory testing. On [DATE] at 11:06 AM, V1 Administrator confirmed R56's Care Plan was not revised and should have been to include and/or remove R56's: Refusal of Gtube cares, feedings, and flushes; Tying Gtube in a knot to prevent use; wheelchair use and not high back reclining wheel chair use; Refusal of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 If continuation sheet Page 11 of 34 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 08/04/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm restorative programming; Refusal to wear helmet while up; and Refusal of laboratory testing. V1 Administrator also stated the residents Care Plans are generic, sloppy, and have not been updated. Based on observation, interview, and record review, the facility failed to review and revise a care plan for six (R29, R38, R68, R419, R43, and R56) of 26 residents reviewed for care plan revision in a sample of 26. Residents Affected - Some Findings include: Facility policy, entitled Comprehensive Care Planning, revised [DATE], document, The following procedures shall be utilized in the development and maintenance of care plans: 1.b. The Care Plan shall be revised as necessary when the needs/problems and care and services specified in the plan of care no longer reflect those of the resident. 1. R29's Physician Order Sheet (POS), dated [DATE]-[DATE], documents Kidney Disease Stage Three. On [DATE] at 9:30 AM, R29 had was in bed with a right chest port in place with a dressing dated [DATE]. R29 stated she gets her Dialysis thru her right chest port on Tuesday, Thursday, and Saturday at a (local) Dialysis center, and has been on Dialysis for one year. On [DATE] at 9:30 AM, V6 Licensed Practical Nurse/LPN stated (R29) goes to Dialysis Tues, Thurs, and Sat in East Peoria. R29's current care plan has no documentation specifying R29's Dialysis location, frequency, or daily weights. On [DATE] at 10:25 AM, V5 Care plan coordinator verified R29 did not have R29's Dialysis care plan individualized to her care, and it should be. 2. R38's POS, dated [DATE]-[DATE], documents Fluoxetine 40mg/milligrams daily, and Olanzapine 10mg at bedtime. R38's current care plan has no documentation specific to R38's behavior monitoring while taking an antidepressant and antipsychotic. On [DATE] at 10:25 AM, V5 care plan coordinator verified R38 did not have R38's mood and behavior care plan individualized to his care, and it should be. 3. R56's current care plan has no documentation specific to R56's behavior monitoring while taking an antidepressant and antipsychotic. R56's current physician order sheet, dated 8/1-[DATE], documents Haloperidol 0.5mg by mouth daily at noon and Haloperidol 10mg by mouth twice a day for mood disorder; Zoloft 25mg by mouth daily for depression; and Benztropine 2mg by mouth twice a day for mood disorder. R38's current care plan has no documentation specific to R38's behavior monitoring while taking an antidepressant and antipsychotic. On [DATE] at 10:25 AM, V5 care plan coordinator verified R56 did not have R56's mood and behavior (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 If continuation sheet Page 12 of 34 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 08/04/2023 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 0657 care plan individualized to their care, and it should be. Level of Harm - Minimal harm or potential for actual harm 4. R419's IDPH [Illinois Department of Public Health] Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form, signed by R419 on [DATE], and R419's physician on [DATE], document: Section A: Attempt Resuscitation/CPR [Cardio-Pulmonary Resuscitation] has the box and lined out with error written and the Do Not Attempt Resuscitation/DNR is marked with an X; and Section B: Full Treatment has the box x'd with a lined out with error written and the Comfort Focused Treatment is marked with an X. Residents Affected - Some R419's current care plan, not dated, document, No Advanced Directives Chosen-Resident will be resuscitated; Resident has chosen to be resuscitated. If found unresponsive-begin CPR. On, [DATE], at 8:40 AM, V2/Director of Nursing confirmed V2's expectation is R419's Care Plan should have been updated to reflect R419's change in code status from Full Code/Attempt CPR to DNR. V2 confirmed R419's Code Status was changed, from Attempt CPR to DNR, while V2 was on vacation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 If continuation sheet Page 13 of 34 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 08/04/2023 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. Based on observation, interview and record review the Facility failed to document a completed admission Smoking Assessment in R219's Medical Chart for one Resident (R219) of 12 reviewed for Smoking in a sample of 26. Findings include: Facility Resident Smoking Policy, undated, documents that each Resident whom chooses to smoke will have a Smoking Assessment completed prior. Facility Smoking and Vaping Policy, revised 10/27/22, documents: the Facility works to provide appropriate care for Residents keeping safety and comfort in mind; implementation of the Smoking Safety Risk Assessment will be conducted once the Resident indicates they may want to smoke; and development of the Resident Smoking Contract will be completed by the Social Service Designee and the Resident. Facility Residents Who Smoke List, undated, documents R219 as a smoker. R219's admission Nursing Assessment, dated 7/19/23, documents that R219 is alert/oriented and has an orthopedic cast to the right wrist/forearm. R219's current Care Plan, documents R219 has chosen to continue smoking. On 8/2/23, during the hours of 9:00 AM and 3:00 PM, R219's Medical Chart did not document a Resident Smoking Assessment. On 8/3/23, during the hours of 7:45 AM and 3:00 PM, R219's Medical Chart did not document a Resident Smoking Assessment. On 8/2/23, at 9:03 AM, R219 was smoking on the designated Facility Smoking Patio. On 8/3/23, at 9:00 AM, R219 was smoking on the designated Facility Smoking Patio. On 8/3/23, at 9:03 am, R219, via electronic application (cell phone app) that translates Chinese to English, stated, I go outside and smoke about two to three times a day. On 08/03/23, 9:18 AM, V5 (Minimum Data Set/MDS) stated, I was on vacation when R219 admitted to the Facility. Honestly, the nurses should be completing the assessments upon admission, and then I do them quarterly when I do the (MDS's), but I help the nurses out and usually end up doing all of them. Do you see this huge stack of assessments (sitting in a storage rack on V5's desk)? I bet there are at least twenty-five of them in this stack and R219's is probably in here. I am trying to get caught up on, I am so far behind. On 08/03/23, at 9:15 AM, V2 (Director of Nursing/DON) stated, I was at a work training on the day that (R219) admitted to the Facility. That is the day that the nurse had three admissions all at once and got behind. I try and help them get assessments and paperwork completed, but I was gone that day, then I went on vacation for a week. The assessments should be in the Resident charts, but we have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 If continuation sheet Page 14 of 34 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 08/04/2023 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 had so many problems with medical records and nursing that we are playing catch up on all of the Resident Assessments. (V8/Social Service) sometimes does the Smoking Assessments, but she is not here this week, she is on vacation. We probably should have completed the Smoking Assessment for (R219's) safety, especially since he has a cast on his arm. I do not see a Resident Smoking Contract for (R219) in his chart either. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 If continuation sheet Page 15 of 34 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 08/04/2023 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 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 observation, interview and record review, the Facility failed to follow Physician Orders for Resident weights for one (R219) of 26 Residents reviewed for Weights in a sample of 26. Residents Affected - Few Findings include: Facility Resident Weight Monitoring Policy, revised 9/2008, documents: it is the policy of the Facility that the Resident weights are recorded and monitored at least monthly; new admission weight is obtained within 24 hours of admit; weights and re-weigh results are recorded by nursing staff on the Report of Monthly Weight Form in the medical record; Residents who have been determined by the Weight Committee to be increased risk for weight loss will be put on weekly weights for at least four weeks; and all new admissions and re-admissions will be weighed weekly for at least four weeks. R219's Physician Order Sheet/POS, dated 7/19/23, documents that R219 admitted to the facility on [DATE]. The POS also documents an order, on 7/19/23, for daily weights for three days, then every week for four weeks. R219's Treatment Administration Record/TAR, dated 7/19/23 through 7/31/23, documents an order on 7/19/23 for Daily Weights for three days, then every week for four weeks. The TAR does not document R219's daily weight on 7/19/23, 7/20/23 or 7/21/23. The TAR does not document R219's weekly weight on 7/26/23. Facility Monthly Weight Grid, dated 8/2022 through 7/2023 (provided on 8/2/23 by V2/Director of Nursing), does not document an entry with R219's name or weight record. On 8/3/23, at 11:26 AM, V2 (Director of Nursing) stated, Our policy says that all new admissions are supposed to be weighed upon admission, then for the first three days after admission, then weekly for four weeks. The weights are supposed to be signed off on the 'TAR (Treatment admission Record). I am not sure where they recorded (R219's) weights, but they should be on his 'TAR,' especially since there is a designated spot for them to log it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 If continuation sheet Page 16 of 34 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 08/04/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to meet the professional standards of quality care to ensure required care and services were provided for residents receiving enteral nutritional feedings for two (R29 and R56) of two residents and failed to implement a physician referral for a resident who is refusing gastrostomy tube cares, feedings, and flushes for one (R56) of two residents reviewed for gastrostomy tubes in the sample of 26. Findings include: The facility's Daily Cleansing of G/J/Peg Tube Site policy and procedure, dated 4/2007, documents It is the policy of (the facility) to provide care and services to the resident with a gastrostomy or Jejunostomy tube to maintain the site in clean and safe manner as to minimize the risk of infection. This policy documents the procedure for cleansing the tube site. The Facility Conformance with physician medication orders, reviewed 9/27/17, documents A complete and accurate listing of current medication orders will be maintained on the residents Physician Order Sheet. The facility's Quality Assurance Nursing Care - Gastric/Feeding Tube policy and procedure, revised 4/2007, includes the following documentation: Diagnosis supports tube requirement (Speech or Swallow Evaluation);Continued need is supported by MD (medical doctor) documentation; Care Plan reflects interventions for care, maintenance, feeding ad medications; Care Plan addresses reason for tube; Care Plan addresses psychosocial needs of altered eating pattern; Care Plan addresses risks of aspiration, diarrhea, vomiting, dehydration, and metabolic abnormalities; TAR (Treatment Administration Record) reflects sit care/monitoring; Tube is properly positioned/secured; Residual is checked/recorded; Flushes are performed as ordered; Site care is done - documented daily; No S&S (signs and symptoms) of infection at the insertion site. 1. The POS (Physicians Orders Sheet) for R56, dated August 2023, documents the following diagnoses: Left MCA (middle cerebral artery) Stroke, right Flaccid Hemiplegia, Cerebral Edema, Aphasia and Depression. This same POS lists the following physician orders: Iso-Source (Dense Complete Nutrition Formula with Fiber) 1.5 Cal (calorie) 120 ml (milliliters) per electronic feeding pump for 12 hours; 200 ml water flush three times daily during feeding; 30 ml water flush before and after medications; and Cleanse and change split sponge daily. On 8/02/23 at 12:42 PM, on 8/3/23 at 8:00 AM and 12:20 PM, R56 was sitting in a standard wheelchair in the dining room eating a mechanical soft diet with nectar thick liquids. On 8/2/23 at 2:42 PM, and on 8/3/23 at 10:20 AM and 3:40 PM, R56 was lying in bed on his back with his gastrostomy feeding tube tied in a knot visible at edge of shirt. R56 refused to allow surveyor to see his Gtube insertion site. During this investigation, between 8/2/2023 and 8/4/2023, R56 refused his Gtube feeding, flushes, and cares. On 8/3/23 at 8:37 AM, V4 LPN (Licensed Practical Nurse) stated R56 refuses his Gtube (gastrostomy tube) feedings and flushes and hasn't let anyone do anything with his Gtube for a really long time. V4 LPN stated, I am really surprised (R56) hasn't tried to yank it (Gtube) out yet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 If continuation sheet Page 17 of 34 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 08/04/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm On 8/4/23 at 7:50 AM, V2 DON (Director of Nursing) stated R56 refuses to allow his gastrostomy feeding tube to be used, flushed, or cleaned and will tie the tube in a knot so that no one can use it. V2 DON stated the facility began talking with R56's Physician on 7/11/23 about R56's refusals and of possibly getting the Gtube removed. V2 DON also stated the facility has been trying to find the Physician who put the Gtube in, but so far have not been able to figure that out. Residents Affected - Few R56's Medical Record does not contain documentation that a Speech or Swallow Evaluation was completed, Physician supported documentation for the continued use of R56's feeding tube. The facility's monthly weight log documents the following dates and weights for R56 as: [DATE].6 pounds; [DATE].0 pounds; [DATE].2 pounds; April 136.7 pounds; May 141.1 pounds; June 141.8 pounds; and July 144.1 pounds. These weights indicate R56 with 7.91% weight loss in 30 days from January to February 2023; 5.85% weight loss in 30 days from March to April 2023; and 6.75% weight in three months from January to April 2023. The RD (Registered Dietitian) Note for R56, dated 5/9/23, documents R56 refusing Gtube feedings at times. Weight trending up appropriately due to weight loss last month. The RD Note, dated 7/7/23, documents R56 meets estimated nutrient needs with current Gtube feeding order. Noted R56 refusing tube feeding at this time. Nurse confirms resident refusing tube feedings, all medications, and does not allow staff to flush the tube. RD recommendation was to obtain a Physician consult related to R56's refusal of Gtube feedings and flushes. The Progress Notes for R56, dated April 2023 through August 2023 document R56's continuous refusals of Gtube use for feedings, flushes and medication, including R56 tying Gtube in a knot to prevent use. The Progress Notes do not include documentation of R56's insertion site or that cares were provided and does not document whether there are signs and symptoms of infection. The Progress Notes do not include Physician documentation supporting the continued use of R56's Gtube. The current Dietary Care Plan for R56, dates a problem area on 4/11/23 as R56 has history of refusing Gtube feedings with weight documented as 135 pounds. This Care Plan does not reflect interventions for care and maintenance, feeding and medications, reason for the Gtube, pyschosocial needs of altered eating pattern and does not address the risks of aspiration, diarrhea, vomiting, dehydration, or metabolic abnormalities. On 8/4/23 at 8:15 am, V2 DON confirmed the facility does not have any documentation regarding the facility efforts to address R56's Gtube concerns and refusals. 2. On 8/02/23 at 9:30 AM, R29 had an empty bag of tube feeding on an IV pole with a pump dated 8/1/23 with an expiration of 8/3/23. At that same time R29 was in bed with a right chest port in place. R29 stated she gets her tube feeding thru her right chest port and it runs for 12 hours from about 7 PM till 7 AM. R29 stated six years ago her small intestine was taken out due to an infection. R29's Physician Order Sheets (POS), dated 8/1-8/31/23, has no documentation R29 gets a tube feeding, what time it is supposed to run over, or the amount to be infused. On 8/03/23 at 9:30 AM, V6 Licensed Practical Nurse/LPN stated Pharmacy provides us with the tube feeding bag, it runs for 12 hours at night, and I don't see her tube feeding orders on her physician order sheet and it should be. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 If continuation sheet Page 18 of 34 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 08/04/2023 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 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 have oxygen orders on one (R29) of one resident reviewed for oxygen in a sample of 26. Residents Affected - Few Findings include: Facility Conformance with physician medication orders, reviewed 9/27/17, documents A complete and accurate listing of current medication orders will be maintained on the residents Physician Order Sheet. On 8/02/23 at 9:30 AM, R29 was in bed and had 4 liters of oxygen on via nasal cannula. R29 stated she has oxygen only because she had a hard time breathing due to excess fluid. R29 was able to answer questions but becomes short of breath with talking. R29's Physician Order Sheets (POS), dated 8/1-8/31/23, has no documentation R29 is on oxygen. On 8/03/23 at 9:30 AM, V6 Licensed Practical Nurse/LPN stated I don't see (R29's) oxygen orders on her physician order sheet and it should be. (R29) wears oxygen for comfort at night, and as she needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 If continuation sheet Page 19 of 34 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 08/04/2023 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 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 have Dialysis orders, failed to obtain a daily weight, and failed to coordinate communication between the Dialysis facility and the nursing home on one (R29) of one resident reviewed for Dialysis in a sample of 26. Residents Affected - Few Findings include: Facility Conformance with physician medication orders, reviewed 9/27/17, documents A complete and accurate listing of current medication orders will be maintained on the residents Physician Order Sheet. Facility Outpatient Dialysis Services Agreement, dated 3/17/07, documents The Nursing Facility shall ensure that all appropriate medical and administrative information accompanies all residents at the time of transfer to the Dialysis Unit. The parties will mutually develop a written protocol governing specific responsibility's, policies and procedures to be used in rendering Dialysis services to residents including the development and implementation of a resident's care plan relative to the provision of Dialysis services. The Nursing Facility will provide for the interchange of information useful or necessary for the care of the resident and will inform the Dialysis unit of a contact person at the nursing facility whose responsibilities include oversight of provision of care of the patient at the Nursing Facility. R29's Physician Order Sheet (POS), dated 8/1/31-8/31/23, documents Kidney Disease Stage Three. R29's Physician Order Sheets (POS), dated 8/1-8/31/23, has no documentation R29 is on Dialysis, and no daily weights. R29's current medical record has no documentation R29 is on Dialysis, no daily weights documented, and no regular communication sheets or documentation in nursing notes from R29's Dialysis provider. On 8/02/23 at 9:30 AM, R29 had was in bed with a right chest port in place with a dressing dated 8/1/23. R29 stated she gets her Dialysis through her right chest port on Tuesday, Thursday, and Saturday at a (local) Dialysis center, and has been on Dialysis for one year. On 8/03/23 at 9:30 AM, V6 Licensed Practical Nurse/LPN stated (R29) goes to Dialysis Tues, Thurs, and Sat in East Peoria. They weigh her there, we do not weigh her daily here, but we should be, or should be getting the communication from Dialysis. Dialysis updates us if we need it, but we do not communicate every day she goes, and we do not send a communication form to them. We get paperwork monthly from them on the labs and draw labs when ordered. We don't weigh her daily, I don't have a daily weight sheet in my MAR/Medication Administration Record or TAR/Treatment Administration Record for her, and the CNA's/Certified Nurse Aides document the monthly weights in a binder here at the nurse's station. We probably need to be weighing her daily, she gets Dialysis three days a week and they don't communicate weights, and we need to start doing daily weights on her because she has been gaining. I don't see any orders in her medical record for her Dialysis days and where she goes, and it should be. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 If continuation sheet Page 20 of 34 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 08/04/2023 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on record review and interview, the facility failed to ensure a Registered Nurse/RN was staffed eight hours per day, every day in July 2023. This failure has the potential to affect all residents residing in the facility on those days. FINDINGS INCLUDE: The facility's Nurse Staffing Schedule, for July 2023, document the facility failed to staff a Registered Nurse on July 8, 9, 25, and 28, 2023. On 8/4/2030, at 11:38 AM, V2/Director of Nursing confirmed the facility did not provide a RN for at least 8 hours on July 8, 9, 25, and 28, 2023. V2 confirmed resident census, on the aforementioned days, was 61, 61, 65, and 64, respectively. Resident Census and Conditions form, dated 8/2/23, documents 62 resident live in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 If continuation sheet Page 21 of 34 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 08/04/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 8/2/23 at 11:35 AM, 11:54 AM, 2:42 PM, on 8/3/23 at 8:00 AM and 10:24 AM R43 was sitting up in a reclining wheelchair with no behaviors noted. On 8/3/23 at 3:44 pm, R43 was transferred from her high back reclining wheelchair to her bed with no behaviors noted. The Quarterly MDS for R43, dated 7/13/23, documents R43's cognition is severely impaired, R43 is mildly depressed with delusions with no identified behaviors. R43 receives antipsychotic, antianxiety, and antidepressant medication daily. The current Behavior Care Plan for R43 documents R43 has history of displaying inappropriate behavior and/or resisting care/services with diagnosis Bipolar disorder and GAD (Generalized Anxiety Disorder). R43 is known to have false accusation against care givers and derogatory name calling to staff. Goal documents initiate Behavior Monitoring program to attempt to identify patterns, precursors, and causes of behavior and to attempt to understand the meaning of the behavior. The current Psychotropic Drug Care Plan for R43 documents R43 requires use of psychotropic medications to manage mood and/or behavior issues. This Care Plan does not include any resident specific behaviors for R43's use of Antidepressant, Antianxiety and Antipsychotic medications. This same Care Plan documents an intervention to Obtain informed consent prior to administration of medication. On 8/3/23 at 3:45 pm, V6 LPN (Licensed Practical Nurse) stated R43 has had a decline in her condition and has been on hospice for about a month and half, used to be in a regular wheelchair, would propel herself but stopped doing that quite a while ago. V6 stated R43 hasn't been able to walk or transfer, is total assist for her cares and transfers with a mechanical lift. V6 stated R43 gets anxious at times but is unaware of any other behaviors. The Physician's Order Sheet for R43, dated August 2023, lists a Physician Order dated 6/14/23 for Antianxiety medication Lorazepam (Ativan) 1 mg at bedtime and 7/19/23 Lorazepam 0.5 mg twice daily. The Psychotropic Medication Consent, dated 4/3/22, documents R43's Representative signed consent on 4/16/22 for R43 to receive Lorazepam 0.5 mg every am for anxiety. There was no consent obtained after the increase of this medication. The Psychotropic Medication Quarterly Evaluation for R43, dated 5/7/23, documents a medication assessment for Ativan was completed with targeted behaviors documented as anxious and delusions. The Behavior Tracking Forms, dated May, July and August 2023, do not include resident centered identified targeted behaviors for the use of Ativan. There is no Behavior Tracking completed for June 2023. The Physician's Order Sheet for R43, dated August 2023, lists a Physician Order dated 5/3/23 for Antipsychotic medication Risperidone (Risperdal) 1 mg three times a day. The Psychotropic Medication Consent for R43, dated 4/3/22, documents R43's Representative signed consent on 4/16/22 for R43 to receive Risperidone 1 mg with 0.5 mg at every bedtime and 1 mg every (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 If continuation sheet Page 22 of 34 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 08/04/2023 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 0758 morning for Bipolar behavior. There was no consent obtained after the increase of this medication. Level of Harm - Minimal harm or potential for actual harm The Psychotropic Medication Quarterly Evaluation for R43, dated 5/7/23, documents a medication assessment for Risperdal was completed with targeted behaviors documented as anxious and delusions. Residents Affected - Some The Behavior Tracking Forms, dated May, July, and August 2023, do not include resident centered identified targeted behaviors for the use of Risperidone. There is no Behavior Tracking completed for June 2023. The Physician's Order Sheet for R43, dated August 2023, lists a Physician Order dated 3/10/23 for Antidepressant medication Sertraline (Zoloft) HCL (hydrochloride) 100 mg nightly. The Psychotropic Medication Consent for R43, dated 4/3/22, documents R43's Representative signed consent on 4/16/22 for R43 to receive Sertraline 100 mg every evening for depression. The Psychotropic Medication Quarterly Evaluation for R43, dated 5/7/23 documents a medication assessment for Zoloft was completed with targeted behaviors of anxious and delusions. This evaluation does not include behaviors of depression as the consent was signed for. The Behavior Tracking Forms, dated May, July, and August 2023, do not include behavior tracking was completed for the use of Sertraline (Zoloft). There is no Behavior Tracking completed for June 2023. The Physician's Order Sheet for R43, dated August 2023, lists a Physician Order dated 2/6/23 for Divalproex Sodium (Depakote) ER (Extended Release) 500 mg (milligrams) to twice daily. The Psychotropic Medication Consent for R43, dated 4/3/22, documents R43's Representative signed consent on 4/16/22 for R43 to receive Divalproex Sodium ER 250 mg at bedtime for manic behavior and Bipolar behavior. There was no consent obtained after the increase of this medication. The Psychotropic Medication Quarterly Evaluation for R43, dated 5/7/23, documents a medication assessment for Depakote was completed with targeted behaviors of anxious and delusions. The Behavior Tracking Forms for R43, dated May, July and August 2023, do not include behavior tracking being completed for the use of Divalproex Sodium ER. There is no Behavior Tracking completed for June 2023. On 8/4/23 at 8:00 AM V2 DON (Director of Nursing) provided Behavior Tracking Records for R43, dated May, July, and August. V2 DON stated that is all she was able to find. 5. On 8/2/23 at 10:05 AM, R23 was lying in bed on her right side with eyes closed. On 8/2/23 at 2:44 PM, R23 was sitting in a stationary chair in the activity area participating in activity. On 8/3/23 from 8:00 AM through 8:30 AM, R23 was sitting in a stationary chair in the dining room eating breakfast independently. On 8/3/23 at 10:22 AM and 3:45 PM, R23 was ambulating the facility hallways. There were no identified behaviors for R23 between 8/2/23 and 8/3/23. The Quarterly MDS (minimum data set) assessment for R23, dated 6/7/23, documents R23 is cognitively intact with no depression or identified behaviors and receives Antidepressant medication daily for Depression. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 If continuation sheet Page 23 of 34 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 08/04/2023 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 0758 There is no Behavioral Care Plan for R23. Level of Harm - Minimal harm or potential for actual harm The current Psychotropic medication Care Plan for R23, documents R23 requires use of psychotropic medication to manage mood and/or behavior issues. resident specific behaviors for R23's use of Antidepressant medication. This same Care Plan documents intervention to: Obtain informed consent prior to administration of medication. Residents Affected - Some The current Lifestyle Preferences Care Plan for R23, documents start dated 7/20/23 as Recent onset of cognitive behavior changes r/t (related to) Dementia progression. (R23) unaware of social limits as well as safety. There are no resident centered identified documented behaviors for R23. On 8/3/23 at 8:37 AM V4 LPN (Licensed Practical Nurse) stated R23 had a mental episode a few months ago but no others since. V4 LPN stated R23 walks around the facility all day and will sometimes go into other resident rooms but that is about it. The Physician Order Sheet for R23, dated August 2023, documents a Physician Order dated 5/30/23 for Trazodone 50 mg at bedtime. The facility was unable to provide a signed Consent for R23's use of the Trazodone medication for R23. The Psychotropic Medication Evaluation for R23 is blank and has not been completed. Behavior Tracking Forms for R23, dated August 2023, documents R23 with a Diagnosis of Depression and Dementia with target behavior documented as: Monitor for s/s (signs and symptoms) of depression and (R23) unaware of social limits and do not include resident centered identified targeted behaviors for the use of Trazodone. There is no Behavior Tracking completed prior to August 2023. On 8/4/23 at 8:00 AM V2 DON (Director of Nursing) provided Behavior Tracking Records for R23, dated August 2023. V2 DON stated that is all she was able to find. Based on observation, interview and record review, the facility failed to obtain consents for residents on psychotropic medications, failed to provide clinical justification for the use of dual therapy, failed to identify and track behaviors that warranted the use of psychotropic medications, failed to ensure behavior tracking logs and resident care plans identified specific target behaviors, failed to document non-pharmacological interventions prior to the use of psychotropic medications, and failed to complete psychotropic medication assessments for five of six residents (R23, R37, R38, R43, R65) reviewed for unnecessary medications in the sample of 26. Findings include: The facility's Psychotropic Medication Policy revised 11/28/17, states, It is the policy of this facility that residents shall not be given unnecessary drugs. Unnecessary drugs is any drug used: 1. In an excessive dose, including in duplicative therapy. 2. For excessive duration. 3. Without adequate monitoring. 4. Without adequate indications for its use. 5. In the presence of adverse consequences that indicate the drugs should be reduced or discontinued. Procedure: 1. Attempt to rule out social and environmental factors as causative agents of the maladapted behavior. 2. Psychotropic medications shall not be prescribed prior to attempted non-Pharmalogical interventions to decrease behavior. 3. Initiate a Pre-Psychotropic Medication Assessment prior to administration of a newly prescribed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 If continuation sheet Page 24 of 34 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 08/04/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some psychotropic medication. 4. Initiate a Psychotropic Medication Quarterly Evaluation within 14 days of admission for those residents currently receiving psychotropic medication. 5. Psychotropic medication shall not be prescribed or administered without the informed consent of the resident, the resident's guardian, or other authorized representative. Side effects of the medicine shall be described. 8. The Behavioral Tracking Sheet of the facility will be implemented to ensure behaviors are being monitored. 18. Any resident receiving psychotropic medications will have the Psychotropic Medication Assessment done at a minimum of every quarter. 19. Any resident receiving any psychotropic medication will have certain aspects of their use and potential side effects addressed in the resident's care plan at least quarterly. The care plan will identify target behaviors causing the use of psychotropic medications. The care plan will address the problem, approaches and goals to address these behaviors. 1. R37's Face sheet documents R37 was admitted to the facility on [DATE]. R37's Cumulative Diagnosis Log documents R37 with a diagnosis of Depression with Anxiety. R37's Minimum Data Set (MDS) assessment dated [DATE] documents the following: R37 is cognitively intact, took Antidepressant Medications for seven out of seven days reviewed, Diagnoses of Depression and Anxiety, feeling down, depressed or hopeless for two to six days out of 14 reviewed; and documents no behavioral symptoms present. R37's Physician Order Sheet for the months of July and August 2023 document orders with a start date of 7/3/23 for the following medications: Cymbalta 60 milligrams (mg) by mouth daily and Trazodone 50 mg by mouth nightly. On 7/13/23, a new medication order for Elavil 25 mg daily was received. R37's Medication Administration Record (MAR) for August 2023 documents R37 received R37's Cymbalta, Trazadone and Elavil (Amitriptyline) medications as prescribed. The class of these three medications is labeled as Antidepressants. R37's current Care Plan documents R37 requires the use of psychotropic medication to manage mood and/or behavior issues and documents an intervention of obtain informed consent prior to administration of medication. This same Care Plan does not document specific target behaviors for R37's use of psychotropic medications. The facility's Behavior Tracking Logs were noted in white binders at the nurses' station. These binders did not contain any behavior tracking logs for R37. On 8/3/23 at 12:17 PM, V5 (Care Plan Coordinator) verified that no behavior tracking logs for July or August 2023 were completed for R37. V5 stated, Due to (R37's) diagnoses and medications, there should be. At this same time, V5 verified R37's psychotropic medication assessments were blank, had not been completed and should have been. V5 denied being aware of R37 exhibiting any behaviors. V5 stated, (R37) has pain and will sometimes cry because of it but that's not a reason for psych (psychotropic) meds (medications). On 8/3/23 at 12:15 PM, V1 (Administrator) denied being aware of R37 exhibiting any behaviors. On 8/03/23 at 12:10 PM, in a joint interview, V7 (Certified Nursing Assistant/CNA) and V12 (CNA) stated R37 has pain but denied witnessing any behaviors from R37. V7 stated R37 is compliant with cares, gets along with others, is mostly independent and seems happy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 If continuation sheet Page 25 of 34 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 08/04/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 8/4/23 at 2:30 PM, V2 (Director of Nursing) denied being aware of R37 displaying any type of mood or behavioral issues. V2 stated R37 is quiet and cooperative with cares. V2 verified R37 is R37's own person and is able to sign her own consents. During the days of 8/2/23-8/4/23, R37 was observed at various times. No mood or behavior issues of any kind was noted from R37. R37 appeared well-groomed and dressed. R37 was observed out of R37's room, socializing with tablemates for the lunch meals. On 8/4/23 at 2:55 PM, the facility stated they were unable to provide the following regarding R37's psychotropic medications: Consent Forms; Psychotropic Medication Assessments, Attempted Non-Pharmalogical Interventions prior to the initiation of a new psychotropic medication; Behavior Tracking Logs; or documentation to support R37's duplicative drug therapy. 2. R38's current physician order sheet, dated 8/1-8/31/23, documents Fluoxetine 40mg/milligrams by mouth daily as an antidepressant; and Olanzapine 10mg by mouth at bedtime as an antipsychotic. R38's consent form, dated 7/19/23, for Fluoxetine has no behavior identified for the medication use. R38's medical record has no documentation the facility is monitoring R38 for any behaviors, was unable to provide daily behavior documentation for May, June, July, or August 2023, and has no documentation of any identified behaviors to warrant the use of the medications on the consent form. On 8/4/23 at 11:30 AM, V2 DON/Director of Nursing verified there was no behavior tracking or identified behaviors in R38's chart and should be. 3. R65's current physician order sheet, dated 8/1-8/31/23, documents Haloperidol 0.5mg by mouth daily at noon and Haloperidol 10mg by mouth twice a day for mood disorder; Zoloft 25mg by mouth daily for depression; and Benztropine 2mg by mouth twice a day for mood disorder. R65's medical record has no documentation the facility is monitoring R65 for any behaviors, was unable to provide daily behavior documentation for May, June, July, or August 2023, and has no documentation of any identified behaviors to warrant the use of the medications. On 8/4/23 at 11:30 AM, V2 DON/Director of Nursing verified there was no behavior tracking or identified behaviors in R65's chart and should be. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 If continuation sheet Page 26 of 34 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 08/04/2023 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on interview and record review, the facility failed to offer residents snacks outside of the scheduled meal service times. This has the potential to affect all 62 residents residing in the facility. Findings include: Facility Diet Listing, undated, documents 62 residents eat at the facility. Facility posted mealtimes documents Breakfast: 7:30am; Lunch: 12:00pm; and Dinner 5:30pm. Facility Evening Snacks, revised 10/15, documents It is the policy to offer each resident an evening snack and document whether the resident accepted or declined the evening snack. All residents will be offered a bedtime snack. On 8/03/23 at 10:05 AM, a resident council meeting was conducted in the sunroom. During the resident council meeting, R39, R42, R33, and R11 were asked if they were offered snacks throughout the day. R39, R41, R33, and R11 all stated they were not offered snacks and R41, R11, and R33 stated they were all diabetics and not offered a bedtime snack. On 8/03/23 11:40 AM, V7 Certified Nurse Aid/CNA stated There are no resident snacks passed by us, I just came to day shift off of PM shift and we did not pass snacks at night or bedtime to anyone or the diabetics. Dietary doesn't send snacks on a tray or have available for the residents, we pass ice water but no nourishment cart, and I have never seen any prepared snacks from dietary. R39, R41, R33, and R11's medical records document they are moderately impaired and cognitively intact for cognition. Resident Census and Conditions form, dated 8/2/23, documents 62 resident live in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 If continuation sheet Page 27 of 34 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 08/04/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 8/4/23 at 11:30 AM, V5 LPN (Licensed Practical Nurse) MDS/CPC (Care Plan Coordinator) stated she is responsible for the residents MDS and Care Plans. V5 also stated she is the facility's Restorative Nurse, among other titles, works as a floor Nurse at times, and has not been able to get everything done. V5 stated all the Care Plans in the residents' charts are working Care Plans and she tries to keep them updated. V5 LPN provided the MDS Transmission Report for R23. The MDS (minimum data set) Assessment Transmission Report for R23, documents: Quarterly MDS was submitted on 7/3/23; Significant change MDS was submitted on 6/7/23; Quarterly MDS was submitted on 3/20/23; Annual MDS was submitted on 12/13/22; and Quarterly MDS was submitted on 9/6/22. None of these MDS's are located in R23's Medical Record. R23's Medical Record does not include any MDS assessment for 2022 or 2023. The last MDS Assessment included in R23's medical record is an Annual MDS dated [DATE]. R23's Medical Record documents the last IDT (Interdisciplinary Team) Progress Note was made on 3/2/20 and does not contain hospital transfer orders for R23's 5/14/23 and 5/21/23 hospitalizations. The working Care Plan is not resident centered and has not been updated. On 8/3/23 at 11:06 AM, V1 Administrator confirmed the resident's charts do not contain all the required documents they should, and the Care Plans are generic, sloppy, and have not been updated like they should. V1 stated there are stacks of papers everywhere that need to go into the charts and doesn't know why they aren't. 5. On 8/4/23 at 11:30 AM, V5 LPN (Licensed Practical Nurse) MDS/CPC (Care Plan Coordinator) stated she is responsible for the residents MDS and Care Plans. V5 also stated she is the facility's Restorative Nurse, among other titles, works as a floor Nurse at times, and has not been able to get everything done. V5 stated all the Care Plans in the resident's charts are working Care Plans and she tries to keep them updated. V5 LPN provided the MDS Transmission Report for R43. The MDS (minimum data set) Assessment Transmission Report for R43, documents: Quarterly MDS was submitted on 7/14/23; Significant Change MDS was submitted on 5/3/23; Quarterly MDS was submitted on 4/26/23; Quarterly MDS was submitted on 2/23/23; Annual MDS was submitted on 4/26/23; Annual MDS was submitted on 11/11/22; Quarterly MDS was submitted on 11/10/22; and Quarterly MDS was submitted on 8/18/22. None of these MDS's are located in R43's Medical Record. R43's Medical Record does not include any MDS Assessments for 2022 or 2023. The last MDS Assessment included in R43's medical record is an Annual MDS dated [DATE]. R43's Medical Record includes a working Care Plan which is not resident centered and has not been updated. On 8/3/23 at 11:06 AM, V1 Administrator confirmed the resident's charts do not contain all the required documents they should and the Care Plans are generic, sloppy, and have not been updated like they should. V1 stated there are stacks of papers everywhere that need to go into the charts and doesn't know why they aren't. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 If continuation sheet Page 28 of 34 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 08/04/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the Facility failed to accurately complete, document, systematically organize and have readily accessible medical records for all 62 Residents residing in the Facility. This failure has the potential to affect all 62 Residents residing in the Facility. Findings include: Residents Affected - Many Resident Census and Condition Report, dated 8/2/23, document 62 residing in the Facility. Facility Administrator Job Summary, undated, documents: the Administrator is responsible for managing, planning, organizing, staffing, directing, coordinating, reporting, budgeting and the physical management of the Facility, Residents and equipment in a way that the purpose of the Facility shall be maintained in accordance with all established practices, policies, laws and applicable State Regulations; the Administrator will manage and conduct the business of the Facility in a manner that protects the Facility license and certification at all times; and the major goal of the Administrator is to provide an atmosphere in which residents may achieve their highest physical, mental and social wellbeing. Facility Medical Records Personnel Job Summary, undated, documents maintain Resident files and statistics by ensuring that all the proper forms are present and signed and make certain that the medical information is correct and accessible to doctors, nurses, government agencies, etc.; and responds to requests for medical records; and performs clerical duties. 1. R219's Physician Order Sheet/POS, dated 7/19/23, documents that R219 admitted to the facility on [DATE]. The POS also documents an order for daily weights for three days, then every week for four weeks. R219's Treatment Administration Record/TAR, dated 7/19/23 through 7/31/23, documents an order on 7/19/23 for Daily Weights for three days, then every week for four weeks. The TAR does not document R219's daily weight on 7/19/23, 7/20/23 or 7/21/23. The TAR does not document R219's weekly weight on 7/26/23. Facility Monthly Weight Grid, dated 8/2022 through 7/2023 (provided on 8/2/23 by V2/Director of Nursing), does not document an entry with R219's name or weights. On 8/2/23 (during the hours of 9:00 AM and 3:00 PM) and 8/3/23 (during the hours of 7:30 and 3:00 PM), R219's Assessments (Braden Scale for Predicting Pressure Ulcer Risk, Respiratory/Orthopnea Assessment, Pain Assessment, Elopement Evaluation, Range of Motion Assessment, Hydration Assessment, Bed Rail/Transfer Bar Evaluation and Bed Rail Algorithm) were all undated and not completed. 2. R36's Physician Order Sheet, dated 6/26/23, documents that R36 admitted to the facility on [DATE]. R36's Minimum Data Set/MDS Transmission Schedule, undated, documents R36's last MDS was scheduled and completed on 6/8/23. On 8/2/23 (during the hours of 9:00 AM and 3:00 PM), 8/3/23 (during the hours of 7:30 AM and 3:00 PM, and 8/4/23 (7:45 AM to 11:40 AM, R36's current Medical Chart, Tab MDS (Minimum Data Set), documents R36's most recent MDS, dated [DATE], Sections B through Section S was accessible and documented (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 If continuation sheet Page 29 of 34 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 08/04/2023 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 0842 in R36's Medical Record. R36's MDS, dated [DATE], was not accessible or documented in R36's Medical Chart. Level of Harm - Minimal harm or potential for actual harm R36's current updated Care Plan was not documented or available in R36's Medical Chart. Residents Affected - Many 3. R48's Physician Order Sheet, dated 8/1/23, documents that R48 admitted to the facility on [DATE]. R48's Minimum Data Set/MDS Transmission Schedule, undated, documents R48's last MDS was scheduled and completed on 7/4/23. On 8/2/23 (during the hours of 9:00 AM and 3:00 PM), 8/3/23 (during the hours of 7:30 am and 3:00 pm, and 8/4/23 (7:45 AM to 11:40 PM), R48's current Medical Chart, Tab MDS (Minimum Data Set), documents R48's most recent MDS, dated [DATE], Sections A through Section Z was accessible and documented in R48's Medical Record. R48's MDS, dated [DATE], was not accessible or documented in R48's Medical Chart. R48's current updated Care Plan was not documented or available in R48's Medical Chart. On 8/3/23, at 11:26 AM, V2 (Director of Nursing/DON) stated, We are not electronic charting yet, it is coming soon. Hopefully that will solve a lot of our problems with all of our medical records and charts not updated. We do not keep everything in the Resident's charts like I know we probably should, it is kind of scattered all over the place, so it makes it hard to find stuff. Plus, I have had problems with keeping Medical Records staffed, so we are playing catch up. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 If continuation sheet Page 30 of 34 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 08/04/2023 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility's Medication Administration policy and procedure, Revised 11/18/17, documents 11. Avoid touching medication. If contact with medication is likely, prepare medication using gloves. 12. Appropriate hand washing is to be completed and/or alcohol based get rub or (cleansing agent) must be used, throughout the medication pass. This should occur: Before and after medication pass. After touching an oral medication during administration. It is acceptable to use an antiseptic gel type solution between residents. Residents Affected - Many On 8/2/23 at 8:18 am V4 LPN (Licensed Practical Nurse) stepped up to the medication cart and did not perform hand hygiene prior to preparing medications for R15. V4 LPN noted to have a soiled protective adhesive bandage to her right thumb. V4 LPN reached into her uniform pocket, pulled out set of keys, unlocked the medication cart, and using keys unlocked the narcotic lock box. V4 LPN pulled out R15's Phenobarbital 64.8 mg bubble packed medication card and using her ungloved soiled right thumb pushed the Phenobarbital pill from the bubble pack into the palm of her soiled left hand. V4 LPN placed the medication card back into the narcotic box, picked up the Phenobarbital pill from her ungloved soiled left hand with her ungloved soiled right first finger and right soiled bandaged thumb and placed the pill into a plastic medication cup. After preparing and administering the medications to R23 V4 LPN returned to the medication cart. Without performing hand hygiene V4 LPN began preparing medications for R3. On 8/2/23 at 8:25 am, V4 LPN stated I probably shouldn't have touched her pill with my hands. Based on observation, interview and record review the facility failed to perform hand hygiene and maintain glove use for two residents (R3 and R15) observed during medication pass and failed to ensure physician ordered contact isolation precautions were initiated for one of 16 residents (R37) reviewed for infection control in the sample of 26. This failure has the potential to affect all 62 residents who currently reside in the facility. Findings include: 1. The facility's Contact Precautions Policy reviewed 12/17/18 states, In addition to Standard Precautions, use Contact Precautions, or the equivalent for specified residents known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact with the resident (hand or skin to skin contact that occurs when performing resident care activities that require touching the residents dry skin) or indirect contact (touching with environmental surfaces or resident care items in the residents environment). This same policy documents gown and gloves will be worn when entering the resident's room. R37's Cumulative Diagnosis Log documents R37 with diagnoses to include but not limited to: Sepsis; Left Fibula Osteomyelitis; Type I Diabetes Mellitus and bilateral lower extremity amputations. R37's Nurses Notes documents the following: R37 admitted to the facility on [DATE]; R37 was transferred and admitted to the local area hospital on 5/14/23 with a diagnosis of sepsis; R37 did not return to the facility again until 7/3/23; and R37 was re-admitted to the hospital on [DATE] with R37 returning to the facility on 7/19/23. R37's Nursing admission assessment dated [DATE] documents R37 with a left stump incision measuring 17 centimeters (cm) by 2 cm and a left stump wound measuring 9 cm by 2 cm by 0.3 cm. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 If continuation sheet Page 31 of 34 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 08/04/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many R37's Weekly Wound Tracking for the month of July 2023 documents R37's left below the knee surgical incision/wound was being monitored. R37's Physician Order Sheet/POS dated 7/3/23-7/31/23 documents an order for contact isolation for MRSA (Methicillin-resistant Staphylococcus aureus) wound and ESBL (Extended Spectrum Beta-Lactamase) VRE (Vancomycin-resistant Enterococci) urine. R37's Physician Order Sheet/POS dated 7/19/23-7/31/23 documents an order for contact isolation precautions. This same POS documents on 7/19/23, V3 (Licensed Practical Nurse/Infection Preventionist) received a telephone order from V11 (R37's Physician); this order states, Readmit to (name of skilled nursing facility) with transfer orders, admit labs and Contact Isolation Precautions. R37's Hospital Records documents the following laboratory results: Urine Culture on 5/14/23 states, Culture Results: Greater than 100,000 CFU/ML (colony-forming unit per millilitre) Klebsiella pneumoniae. Comment: Multidrug resistant organism (CRE/Carbapenem-Resistant Enterobateriaceae) found.; Aerobic Culture of bone specimen on 5/20/23 states, Few Klebsiella pneumoniae. Comment: ESBL (Extended Spectrum Beta-Lactamase) positive status; and Urine Culture dated 7/14/23, states, Vancomycin Screen is positive. This is VRE. Please follow appropriate patient isolation protocols. R37's Post Acute Care Transition Document dated 7/19/23 documents discharge orders for R37's return to the skilled nursing facility. This same document states, Infection: Carbapenem-Resistant Enterobateriaceae (CRE) Wound 1/25/23 (CRE Klebsiella pneumonia) CP-CRE (Carbapenemase-producing Carbapenem-Resistant Enterobateriaceae) confirmed from urine 5/14/23. This infection does not expire. (R37) will need to be in contact isolation for every future stay. This same discharge document notes R37 with infection types of ESBL (Extended Spectrum Beta-Lactamase), MRSA (Methicillin-resistant Staphylococcus aureus) and VRE (Vancomycin-resistant Enterococci). Isolation type is ordered as contact. Throughout the days of 8/2/23-8/4/23, no contact isolation precaution sign was noted on the outside of R37's bedroom door and no personal protective equipment was noted outside R37's bedroom ready for use. On 8/2/23 at 12:15 PM, R37 was observed in the main dining room eating the lunch meal. On 8/03/23 at 12:04 PM, in a joint interview, V7 (Certified Nursing Assistant/CNA) and V12 (CNA) stated R37 has not been placed in contact isolation precautions after either of R37's July admission dates and stated they were not aware R37 needed to be. V7 and V12 stated they work in all areas of the facility, including R37's room. On 8/04/23 at 8:15 AM, R37 was sitting in R37's room in a wheelchair. Two white garbage bins labeled trash were on the right side of R37's room. The trash bins were both empty. At this time, R37 denied being placed in contact isolation while at the skilled nursing facility. R37 stated, They brought those bins in here but never did anything with them. On 8/04/23 at 11:45 AM V3 (Infection Preventionist/Licensed Practical Nurse) stated V3 admitted R37 back from hospital on 7/3/23 and 7/19/23. V3 stated on both dates, R37 came with documentation that stated R37 needed to be in contact isolation for several different type of infections. V3 stated V3 ordered R37's contact isolation precautions as it was on R37's discharge paperwork. V3 stated V3 asked housekeeping to place isolation barrels in R37's room. V3 denied calling V11 to clarify R37's isolation precaution orders. V3 verified that R37 being in contact isolation precautions was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 If continuation sheet Page 32 of 34 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 08/04/2023 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 appropriate until R37 could be seen by a physician. Level of Harm - Minimal harm or potential for actual harm On 8/04/23 at 9:48 AM, V11 (R37's Physician) stated V11 would have expected the facility to place R37 in contact isolation precautions according to the hospital's discharge paperwork until calling V11 to clarify. V11 stated depending on the conversation V11 had with the facility regarding R37's status, V11 would have determined R37's contact isolation precautions. At this time, V11 denied recalling anyone from the facility calling to clarify R37's isolation status. Residents Affected - Many The Resident Census and Conditions of Residents Form dated 8/2/23 documents 62 residents currently reside in the facility. 2. (b) On 8/2/23, at 12:19 AM, V4 (Licensed Practical Nurse/LPN), with a soiled protectant adhesive (band aid) on V4's right thumb, was dispensing medication (Calcium) to R15. With V4's bare hands, V4 touched each end of the medication tablet and broke the medication tablet in half and placed in a medicine cup, then administered the tablet to R15. No hand sanitizing was performed before the preparation or administration of R15's medication. On 8/2/23, at 12:22 PM, V4 stated, Whoops, I have been making mistakes all day. I have formed bad habits over the years and I should know better than to break that apart with my bare hands. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 If continuation sheet Page 33 of 34 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 08/04/2023 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 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 interview and record review, the facility failed to ensure the facility's designated Infection Control Preventionist (ICP) was scheduled to work at the facility in a manner that allowed the Infection Control Preventionist role to be fulfilled and failed to ensure the DON (Director of Nursing) who assists in the ICP role completed an approved ICP Certification. This failure has the potential to affect all 62 residents who currently reside in the facility. Findings Include: The facility's Infection Control Surveillance and Monitoring Policy, revised 4/11/22, states, It is the policy of the facility to do routine surveillance and monitoring of the facility to determine if compliance with infection control practices is maintained. The facility shall employ, at a minimum, a part time Infection Control Preventionist (ICP). These duties may be performed by the Director of Nursing (DON) with an approved Infection Control Certification. This same policy documents that the DON/ICP will: Investigate and implement controls to prevent infections in the facility; Direct the correct procedures to prevent the spread of infections; Follows up on documentation and reporting of infections to the physicians; Maintains programs that prohibits employees with communicable diseases from direct resident contact; Maintains and enforces hand washing by all staff; Updates the Infection Control Log on a daily basis; and Prepares quarterly Infection Control reports for presentation to the Quality Assurance Committee. On 8/4/23 at 10:29 AM, V3 (Infection Preventionist/Licensed Practical Nurse) stated V3 has received an Infection Control Certification but that V3 has not been able to work in the ICP role due to staffing issues in the facility. V3 stated, I have only worked as the ICP nurse for maybe ten days this entire year. V2 (Director of Nursing) does most of it. We are so short staffed; I have only been working the floor. V3 stated V3 never has time to work on ICP requirements. On 8/3/23 at 11:40 AM, V2 (Director of Nursing) stated that V3 has been having to work the floor as a bedside nurse on second shift and that V3 has not been able to complete ICP tasks. V2 stated that V2 has been assisting V3 with maintaining Infection Control Logs and Antibiotic Tracking. At this time, V2 verified that V2 has not completed the required training to receive an Infection Control Certification. The Resident Census and Conditions of Residents (Centers for Medicare and Medicaid Services/CMS 672) Form, dated 8/2/23, documents 62 residents currently reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145266 If continuation sheet Page 34 of 34