Health inspection·January 19, 2024

F 0550 to all requests for assistance. Level of Harm - Minimal harm or potential for actual harm On 1/16/24 at 10:00 AM R11 stated when he pushes his call light it takes forever for someone to respond. Residents Affected - Few The Call Light Alarm report documents R11 had a call light response time of ten minutes thirty-two seconds on 01/14/2024 at 4:03 PM. On 1/16/24 at 1:30 PM V2 (Director of Nurses) stated the facility does not have a call light policy but the expectation is that staff will answer call lights within the first five minutes. On 1/18/24 at 3:45 PM V2 confirmed it is important for staff to answer call lights as quickly as possible. This is especially important for those residents who require staff assistance for toileting, activities of daily living, and those who are at risk for falls. V2 confirmed the goal is to provide resident centered care and meet the residents needs and expectations quickly and efficiently. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145381 If continuation sheet Page 2 of 5 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 145381 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clark-Lindsey Village 101 West Windsor Road Urbana, IL 61801 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Potential for minimal harm Based on interview and record review, the facility failed to develop their abuse prevention policy to include the prohibition against the use of technology to facilitate or enable abuse or mental abuse. This failure has the potential to affect all 12 residents residing in certified beds in the facility on the sample list of 16. Residents Affected - Many Findings Include: The facility's Bed Change Request Approval letter dated 1/16/24 documents the facility houses 29 resident beds certified under Title 18, Medicare, which are rooms 101, 103 through 118, and 201 through 212. The facility's Resident Roster dated 1/16/24 documents twelve residents currently reside in the facility's certified beds. The facility's Abuse Prevention and Prohibition policy dated 12/22/16 documents this policy is applicable to all departments and nursing units of the facility including the Meadowbrook Skilled Care, which includes the certified beds. This same policy does not include a prohibition regarding the use of technology to facilitate or enable resident abuse or mental abuse. On 1/16/24 at 2:16 PM V1 (Assistant Administrator) stated, That is the most recent up-to-date abuse prevention policy. The State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care facilities, revised 2/3/23, documents the definition of abuse (reference F600), It (abuse) includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. This same Operations Manual documents the definition of mental abuse, Mental abuse includes abuse that is facilitated or enabled through the use of technology, such as smartphones and other personal electronic devices. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145381 If continuation sheet Page 3 of 5 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 145381 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clark-Lindsey Village 101 West Windsor Road Urbana, IL 61801 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to prevent the potential for cross-contamination and foodborne illness, by failing to maintain the facility commercial food mixers in a sanitary manner, free of food-like debris and rust. The facility also failed to wear hair restraints during meal preparation. These failure affects all 12 residents in certified beds. Findings include: 1. On 1/16/24 at 9:20 am, a commercial, four feet tall, stand-up mixer, had a clear plastic garbage can liner covering an 80-quart capacity mixing bowl. The mixing bowl sat directly under an eight-inch circular mixer attachment plate and protruding armature. V6 (Chief Operation Officer/Certified Dietary Manager) and V8 (Cook) both stated the plastic bag covering the mixing bowl indicated the mixer was considered clean and ready for use. The stand -up mixer attachment plate and protruding armature were visibly and completely corroded with rust. The same stand-up mixer had copious amounts of crusted brown and beige food-like build- up adhering to the rusted attachment plate and armature that was positioned above the mixing bowl. 2. During the same kitchen tour, adjacent to the above commercial stand-up mixer was a table- top commercial type mixer. The table-top commercial mixer had an 18-quart capacity bowl positioned under the mixer attachment plate and protruding armature. The mixer attachment plate and protruding armature were corroded with rust. The same table-top mixer had copious amounts of crusted brown and beige food-like build-up that adhered to the rusted attachment plate and protruding armature, positioned above the mixing bowl. The under plate also was rust covered and had food debris build up. V6 stated that it too was considered clean. V6 stated These mixers (stand-up and table -top) obviously need a deep cleaning. V6 then stated We are going to take care of this right away. The rust on the mixers, is unacceptable. That (rust), I will have to consult on, (unidentified person) to find out how best to address this problem. 3. On 1/17/24 at 10:50 am, V5 (Chef) was working on the cook's line preparing food for the lunch meal. V5's hair was thick, braided-like dreadlocks strands that reached the middle of V5's back, and over V5's shoulders. V5 had a cloth head band on that covered V5's forehead. The headband was tied under V5's braid-like dreadlocks at the back of V5's neck, leaving V5's braid-like dreadlocks to dangle free. V5 stated he did not realize that all his hair needed to be covered during meal preparation. V14 (Cook) was also preparing food for lunch. V14 had a thick black beard that extended down four inches from V14's chin. V14 was not wearing a hair restraint covering over V14's beard. On 1/17/24 at 10:55 am V6 (Chief Operations Officer/ Certified Dietary Manager) stated all kitchen staff must have their hair and beards covered with a hair restraint. The facility Dining Services Food Sanitation Policy for Equipment dated 10/01/2023 documents the following: Sanitation policies for kitchen equipment are essential to ensure food safety and maintain a hygienic environment. Here are some general guidelines for sanitation in kitchen equipment: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145381 If continuation sheet Page 4 of 5 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 145381 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clark-Lindsey Village 101 West Windsor Road Urbana, IL 61801 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Regular Cleaning: Level of Harm - Minimal harm or potential for actual harm Clean kitchen equipment regularly, following the manufacturer's recommendations. Establish a cleaning schedule for different equipment based on frequency of use. Residents Affected - Many Food Contact Surfaces: Pay special attention to food contact surfaces such as cutting boards, countertops, and utensils. Use appropriate cleaning agents and sanitizers approved for foodservice establishments. Dishwashing: Ensure that dishwashing equipment (dishwashers or manual washing stations) reaches adequate temperatures for effective sanitization. Train staff on proper dishwashing procedures, including pre-rinsing and loading. Storage and Handling: Store kitchen equipment in a clean and dry environment to prevent the growth of bacteria. Properly handle and store utensils and equipment to avoid cross-contamination. Deep Cleaning: Schedule deep cleaning sessions for kitchen equipment on a regular basis. Disassemble equipment when necessary for thorough cleaning. Staff Training: Provide training to kitchen staff on proper sanitation practices, including handwashing and the use of gloves. Ensure that staff members are aware of the importance of maintaining a clean kitchen environment. The Resident Roster dated 01/16/24 documents 12 residents reside in the facility's certified beds. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145381 If continuation sheet Page 5 of 5