Health inspection·July 27, 2022

F 0684 foam dressing was observed to the right coccyx/buttock. At 1:42 PM, R19 was observed lying on her back. Level of Harm - Minimal harm or potential for actual harm On 7/26/22 at 12:18 PM, V11 (LPN) said on 2/21/22 she observed a dark area to her right coccyx with redness surrounding the area. V11 said R19 likes to lay on her back, and she needs assistance with bed mobility and transfers. V11 said the wound was not reported to her prior. Residents Affected - Few On 7/26/22 at 9:44 AM, V4 (RN) said any new skin issues should be reported to nursing and assessed. On 7/26/22 at 10:36 AM, V2 (Director of Nursing) said R19's right buttock wound was infected with MRSA. On 7/26/22 at 12:00 PM, V14 (Director of Clinical Services) said she was not sure how R19 developed her wound on her right buttock. V14 said the wound was infected with MRSA. On 7/26/22 at 12:34 PM, V12 (Wound Physician) said infectious wounds take time to develop. The most recent Wound Physician Progress note dated 6/29/22 documents R19's right buttock is an infectious wound measuring 0.4 cm x 0.3cm x 0.3 cm with undermining at 6:00 and ends at 9:00. The peri wound skin is exhibited with erythema (redness). The same report showed debridement of the wound was performed. (The facility did not provide the wound progress notes from July 2022). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145414 If continuation sheet Page 2 of 11 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 145414 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prairie Crossing Lvg & Rehab 409 West Comanche Road Shabbona, IL 60550 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to apply an arm splint to a resident with a hand contracture for 1 of 5 residents (R15) reviewed for restorative care in the sample of 12. The findings include: R15's care plan dated July 14, 2022 showed R15 had a contracture to her right hand due to her diagnosis of limited physical mobility related to her right sided hemiparesis from a CVA (cerebrovascular accident). The care plan showed facility staff were to apply a palmar (palm of the hand) splint to R15's right hand during the day and remove the splint at night. R15's resident assessment dated [DATE] showed R15 was severely cognitively impaired. On July 25, 2022 at 9:10 AM, V5 Certified Nursing Assistant (CNA) provided cares to R15 in her room. R15's right hand was contracted with the fingers of her right hand contracted/bent at the mid-knuckle area. No spontaneous movement of R15's right arm or leg were noted. No splint was noted to R15's right hand. An arm splint was noted in a storage container located directly across from R15's bed. On July 25, 2022 at 1:34 PM, R15 was asleep in bed. No splint was noted to R15's contracted right hand. On July 26, 2022 at 8:24 AM, R15 was lying in bed. No splint was noted to R15's contracted right hand. An arm splint was noted in a storage container located directly across from R15's bed. On July 26, 2022 at 9:48 AM, V5 CNA stated, I took care of (R15) yesterday. I didn't put a splint on her arm yesterday. I know she used to have a splint for her right hand, but I don't know if she still does. On July 26, 2022 at 9:52 AM, V7 CNA stated, I don't know if (R15) still has a splint for her right hand. I haven't offered it to her today or even looked for it. On July 26, 2022 at 9:57 AM, V3 Restorative Licensed Practical Nurse stated, (R15) has a splint for her contracture to her right hand. It should be in her room. CNA's are responsible for making sure it is applied. She has refused it in the past, but staff should attempt to offer it daily and document if she refuses. Staff should document her refusal under the restorative task charting in the computer. R15's Restorative Task report dated June 27, 2022-July 25, 2022 showed no documentation of R15 refusing to wear her right hand splint. On July 27, 2022 at 9:30 AM, V13 Regional Director of Operations stated the facility did not have a policy on restorative cares or the use of splints. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145414 If continuation sheet Page 3 of 11 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 145414 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prairie Crossing Lvg & Rehab 409 West Comanche Road Shabbona, IL 60550 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 ensure residents were transferred and ambulated in a safe manner for 2 of 12 residents (R35, R36) reviewed for safety and supervision in the sample of 12. The findings include: 1. R35's current care plan showed R35 was at risk for falls due to weakness, a gait balance problem, and her diagnosis of dementia with behaviors. The care plan showed R35 transferred and ambulated with the assistance of staff and a rolling walker. The facility's Incident/Accident Logs printed July 25, 2022 showed R35 had fallen 8 times in the facility from May 2022-July 2022. On July 25, 2022 at 8:50 AM, V5 Certified Nursing Assistant (CNA) transferred R35 out of bed, into a standing position, and began walking with R35, while holding onto the waistband of R35's pants. No gait belt was noted around R35's waist. 2. R36's current care plan showed R36 was at risk for falls related to weakness, deconditioning, pain to her lower extremities, and her history of previous falls. The care plan showed R36 transferred and ambulated with the assistance of one staff member. On July 25, 2022 at 8:54 AM, V5 CNA transferred R36 off of the toilet and ambulated R36 from the toilet to a recliner in her room, while holding onto R36's waist. No gait belt was noted around R36's waist. On July 25, 2022 at 9:02 AM, V5 CNA stated, Gait belts should be placed around the waist of residents and used whenever they are walked, transferred, or toileted. On July 26, 2022 at 9:27 AM, V2 Director of Nursing (DON) stated, Gait belts should be used whenever residents, that need staff assistance, are transferred and ambulated. Staff should be using gait belts with (R35 and R36). (R35) has had a lot of falls lately. The facility's Safe Lifting and Movement of Residents policy dated April 26, 2022 showed, In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents .4. Gait belts shall be used on residents unless residents are independent with ambulation or contraindicated in the resident's care plan . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145414 If continuation sheet Page 4 of 11 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 145414 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prairie Crossing Lvg & Rehab 409 West Comanche Road Shabbona, IL 60550 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview and record review the facility failed to provide incontinence care to a resident and failed to maintain an indwelling urinary catheter bag below the level of the bladder for residents with a history of urinary tract infections (UTI). These failures apply to 2 of 6 residents (R21, R45) reviewed for incontinence care and urinary catheter care in the sample of 12. The findings include: 1. R21's current care plan showed R21 required extensive assistance of one staff for toileting related to her diagnoses of anoxic brain injury and muscle weakness. The care plan showed R21 had a history of recurrent urinary tract infections (UTIs). Staff were to check R21 at least every 2 hours for incontinence. Wash, rinse, and dry soiled areas. On July 25, 2022 at 9:15 AM, V6 Certified Nursing Assistant (CNA) transferred R21 to the toilet and removed R21's soiled incontinence brief. As R21 began urinating into the toilet, R21 stated, Ouch, it hurts to pee. R21 finished urinating and made no attempts to wipe herself. At 9:20 AM, V6 CNA assisted R21 off the toilet, placed a clean incontinence brief on R21, and transferred her to a wheelchair. At no time did V6 CNA wipe or cleanse R21's perineal area upon completion of R21 urinating in the toilet. On July 25, 2022 at 9:24 AM, V6 CNA stated, No, I didn't wipe (R21) after she went to the bathroom. I should have. On July 26, 2022 at 9:27 AM, V2 Director of Nursing (DON) stated, If residents are toileted and unable or unwilling to wipe themselves, staff should cleanse the area, wiping front to back. 2. R45's current care plan showed R45 had an indwelling urinary catheter with a history of UTIs. The care plan showed, Position catheter bag and tubing below the level of the bladder . On July 25, 2022 at 10:20 AM, V5 and V6 CNA's entered R45's room and began providing cares. An indwelling urinary catheter bag hung off of the left side of R45's bed. At 10:21 AM, V6 CNA lifted R45's urinary catheter bag up over R45 and laid the bag in R45's bed (above the level of R45's bladder). A backflow of dark yellow urine, towards R45, was noted in the catheter tubing. At 10:23 AM, R45's urinary catheter bag fell off of R45's bed, landing on the floor. At 10:25 AM, V6 CNA noticed R45's urinary catheter bag lying on the floor, picked the bag up, and laid it next to R45 in bed. A backflow of dark yellow urine, towards R45, was noted in the catheter tubing. At 10:31 AM, V5 and V6 transferred R45 from her bed to a wheelchair using a mechanical lift. V6 CNA placed R45's urinary catheter bag in R45's lap, above the level of her bladder, for the transfer. On July 25, 2022 at 10:31 AM, V4 Registered Nurse stated, (R45) has a history of UTI's. Catheter bags should be kept below the level of the bladder. The facility's Catheter Care, Urinary policy dated July 20, 2022 showed, The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145414 If continuation sheet Page 5 of 11 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 145414 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prairie Crossing Lvg & Rehab 409 West Comanche Road Shabbona, IL 60550 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to identify a resident's significant weight loss. The facility failed to implement weight loss interventions for a resident with significant weight loss. These failures apply to 1 of 5 residents (5) reviewed for weight loss in the sample of 12. Residents Affected - Few The findings include: R5's care plan dated December 6, 2021 showed R5 was at risk for weight loss related to her diagnoses of diabetes, congestive heart failure, and dementia. R5's Weights and Vitals Summary printed July 26, 2022 showed R5 weighed 222 pounds (lbs.) on April 4, 2022 and 202.4 lbs. on July 15, 2022 which showed a significant weight loss of 8.83% (19.6 lbs.) in 3 months. R5's Registered Dietician assessment dated [DATE] showed R5 had sustained an 8.8% weight loss over 3 months using 4/4/22 weight and down 9 pounds over 1 month. The assessment showed R5 also had a worsening wound to her left leg. The assessment showed the registered dietician ordered a liquid protein supplement (Prostat), twice a day, for R5 for wound healing and additional calories . R5's physician order summary report dated July 25, 2022 showed no physician orders for a liquid protein supplement. On July 26, 2022 at 9:08 AM, V4 Registered Nurse stated she was not aware that R5 had lost weight. V4 stated, (R5) does not have an order to get Prostat (liquid protein supplement). She doesn't get it. I would be giving it to her if she did have an order to get it during med (medication) pass. On July 27, 2022 at 8:05 AM, V3 Licensed Practical Nurse (LPN) stated, The CNAs (certified nursing assistants) weigh residents and report the weights to me. I then place the weights in the computer. I monitor the weights for any weight loss. If there is weight loss, I notify the registered dietician and physician and make sure interventions are put into place if ordered. If the registered dietician recommends a supplement or fortified foods on her assessment, I review the dietician's assessment and make sure the orders are placed in the computer. The goal is to try to stop the weight loss before it becomes significant. On July 27, 2022 at 9:08 AM, V3 LPN stated, I was aware (R5) has been losing weight but not aware it had become significant. She is not on a weight loss program. I have not communicated with the registered dietician at all about her weight loss. I did not let her know that (R5) had been losing weight. I know the dietician saw her on July 20, 2022. I have the dietician's assessment she completed on R5 here on my desk, but I haven't read it yet. V3 LPN then retrieved R5's dietician assessment report, dated July 20, 2022, from a pile of papers on her desk and began reading it. V3 LPN stated, I see she ordered Prostat (liquid protein supplement) for (R5). It hasn't been ordered for her yet. I wasn't aware the dietician recommended it for (R5). The dietician never communicated with me verbally after she assessed (R5) on July 20, 2022. The facility's Weight Assessment and Intervention policy dated July 20, 2022 showed, The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents .Negative trends will be evaluated by the treatment team whether or not the criteria for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145414 If continuation sheet Page 6 of 11 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 145414 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prairie Crossing Lvg & Rehab 409 West Comanche Road Shabbona, IL 60550 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 significant weight loss has been met .Interventions will be care planned and implemented where indicated where indicated and re-evaluate with next weighing . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145414 If continuation sheet Page 7 of 11 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 145414 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prairie Crossing Lvg & Rehab 409 West Comanche Road Shabbona, IL 60550 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 3. On 7/26/22 at 8:21 AM, V4 (RN) prepared R9's medications at the medication cart in the hallway. V4 entered the dining room spoon fed R9's medications then left the dining room and did not perform hand hygiene before and after administering the medications. V4 continued to give medications to R4 and R19 and did not perform hand hygiene before and after administering the medications. (hand sanitizer was located on V4's medication cart). Residents Affected - Some On 7/26/22 at 9:43 AM, V2 (DON) said staff should perform hand hygiene in between residents. The facility's Hand Hygiene Policy states, Proper hand hygiene practices reduce the transmission of pathogenic microorganisms to residents, visitors and other staff members .all personal working in long term care facilities are required to wash their hands before and after resident contact 2. On 7/26/22 at 8:21 AM, V8 (Certified Nursing Assistant) was feeding R2 breakfast. V8 had no eye protection on. On 7/26/22 at 8:21 AM, V7 (Certified Nursing Assistant) was feeding R39 breakfast. V7 had glasses on but no eye protection. On 7/25/22 at 2:18 PM, V9 (Environmental Service Supervisor) was sitting within 6 feet of R10 and singing with her. V9 had glasses on but no eye protection. On 7/27/22 at 10:38 AM, V1 (Administrator) said that glasses are not considered eye protection. It has to be a face shield and goggles. V1 said that eye protection needs to be worn at all times. V1 said that the facility is currently in an outbreak and the county community transmission rate is high. The facility's Coronavirus-(COVID-19) Policy reviewed on 3/30/22 shows, PPE (Personal Protective Equipment) .For those residents not suspected to have COVID-19, HCP (Health Care Personnel) should use the community transmission levels to determine the appropriate PPE to wear. When community transmission levels are substantial or high, HCP must wear a well-fitted face mask and eye protection. The facility's Personal Protective Equipment-Using Protective Eyewear Policy reviewed on 6/24/21 shows, Personal eyeglasses should not be considered as adequate protective eyewear. The CDC (Centers for Disease Control) Data Tracker for 7/20/22-7/26/22 shows that the facility's county COVID transmission level is high. Based on observation, interview and record review the facility failed to ensure staff wore PPE (personal protective equipment) when providing cares to a resident on contact isolation precautions. The facility failed to ensure staff wore eye protection during a time of high community COVID-19 transmission rate. The facility failed to perform hand hygiene during medication administration. These failures apply to 7 of 12 residents (R21, R39, R10, R2, R9, R4, R19) reviewed for infection control in the sample of 12. The findings include: 1. A facility list dated July 25, 2022 showed R21 was on contact isolation precautions due to her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145414 If continuation sheet Page 8 of 11 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 145414 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prairie Crossing Lvg & Rehab 409 West Comanche Road Shabbona, IL 60550 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 diagnosis of ESBL (Extended Spectrum Beta Lactamase bacterial infection) of her urine. Level of Harm - Minimal harm or potential for actual harm On July 25, 2022 at 9:15 AM, a contact isolation sign hung on the door of R21's room. The sign showed staff/visitors should don PPE (personal protective equipment) including a mask, gloves, and gown prior to entering the room. An isolation cart with PPE was stationed outside of R21's door. V6 Certified Nursing Assistant (CNA) stood beside R21, in her room, wearing only a mask. V6 CNA wore no gloves or gown. At 9:20 AM, V6 CNA transferred R21 to the toilet and removed R21's incontinence brief that was soiled with urine, without donning gloves or a gown. While R21 sat on the toilet, V6 CNA then exited R21's room to don gloves and a gown and returned to assist R21 off of the toilet. Residents Affected - Some On July 25, 2022 at 9:24 AM, V6 CNA stated, I should have worn a gown and gloves when I was in (R21's) room, especially when I helped her to the bathroom. On July 26, 2022 at 9:27 AM, V2 Director of Nursing stated staff should wear PPE including gloves, mask, and gown when toileting a resident on contact isolation for ESBL of the urine. The facility's Isolation-Categories of Transmission-Based Precautions policy dated July 20, 2022 showed, Implement Contact Precautions for residents with known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. The policy showed staff should don a gown and gloves prior to entering a resident's room on contact isolation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145414 If continuation sheet Page 9 of 11 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 145414 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prairie Crossing Lvg & Rehab 409 West Comanche Road Shabbona, IL 60550 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to administer the pneumococcal vaccine as recommended by the CDC (Centers for Disease Control) for 3 of 5 residents (R13, R24 and R34) reviewed for immunizations in the sample of 12. Residents Affected - Few The findings include: 1. R34's Face Sheet shows that she is [AGE] years old and admitted to the facility on [DATE]. R34's Pneumococcal Consent for Vaccine Administration form dated 6/15/22 shows that she wishes to have the vaccine. R34's Immunization record printed on 7/26/22 shows that she has not received the pneumococcal vaccine. 2. R13's Face Sheet shows that she is [AGE] years old with diagnoses of: chronic obstructive pulmonary disease, dependence on supplemental oxygen, pulmonary fibrosis and a history of COVID-19. R13's Immunization report shows that she received the Pneumococcal PCV 13 vaccine on 5/12/21. 3. R24's Face Sheet shows that she is [AGE] years old. R24's Immunization Report shows that she received the Pneumococcal PCV 13 vaccine on 5/21/21. On 7/26/22 at 12:40 PM, V2 (Director of Nursing) said that R24 and R13 are due for their second pneumonia vaccine. V2 said that R34 did not get her vaccine due to being on new admission isolation and then developed COVID. On 7/26/22 at 9:43 AM, V2 (Director of Nursing) said that all residents should have 2 pneumonia vaccines , the 13 and 23, one year apart. V2 said that the residents vaccine status is obtained on admission. If they are due for the vaccine, a consent form is obtained and the resident is given the vaccine. The facility's Vaccination of Residents Policy dated 7/1/19 shows, Vaccines that are developed for facility population demographic will be provided in the same procedures. Informational materials, consent will be made available to the resident and representatives. New vaccines manufacturer guidelines and CDC recommendations will be adhered to. The CDC Pneumococcal Vaccination document dated 1/24/22 shows, There are two kinds of pneumococcal vaccines available in the United States: Pneumococcal conjugate vaccines (PCV13, PCV15, and PCV20) and Pneumococcal polysaccharide vaccine (PPSV23). CDC recommends PCV13 for all children younger than 2 years old and people 2 through [AGE] years old with certain medical conditions. For those who have never received any pneumococcal conjugate vaccine, CDC recommends PCV15 or PCV20 for adults 65 years or older .If PCV15 is used, this should be followed by a dose of PPSV23. The CDC Pneumococcal Vaccine Recommendations reviewed on 1/24/22 shows, CDC recommends routine administration of pneumococcal conjugate vaccine (PCV15 or PCV20) for all adults 65 years or older who (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145414 If continuation sheet Page 10 of 11 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 145414 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prairie Crossing Lvg & Rehab 409 West Comanche Road Shabbona, IL 60550 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 0883 have never received any pneumococcal conjugate vaccine or whose previous vaccination history is unknown: If PCV15 is used, this should be followed by a dose of PPSV23 one year later. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145414 If continuation sheet Page 11 of 11