Inspection·October 18, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a fall prevention intervention was in place and failed to safely transfer a resident by not using a gait belt for 2 of 20 residents (R92 and R3) reviewed for safety in the sample of 20. The findings include: 1. R92's Care Plan indicated R92 was at risk for falls due to confusion, general weakness, and a history of repeated falls. Listed under approach was, Equip resident with a device that monitors rising. On 10/16/23 at 01:35 PM, R92 was in his room sitting in his reclining chair sleeping. There were no staff present in the room or visible in the hallway. There was a gray cord coming out of the seat portion of the reclining chair. The cord was resting on the floor and was not plugged into anything. On 10/16/23 at 02:22 PM, V5 (Certified Nursing Assistant/CNA) confirmed the cord was unplugged and the cord was for R92's chair/position alarm. V5 said the cord needed to be plugged into the alarm box for the chair/position alarm to work. R92's Progress Notes indicated R92 had falls on 9/6/23, 9/26/23, and 10/11/23. The 9/6/23 and 9/26/23 Progress Notes indicated R92 fell in his room and was found on the floor in front of the recliner. 2. R3's face sheet printed on 10/16/23 showed diagnoses to include but not limited to muscle wasting and atrophy, presence of artificial knee joint bilateral, low back pain, and type two diabetes mellitus without complications. R3's care plan dated 9/19/23 showed activity of daily living decline related to muscle weakness, extensive assist for coming from a supine to a sitting position and boosting up in bed, (R3) is able to come from a sit to a stand with the use of a gait belt and her rolling walker or side rails and extensive one assist. (R3) is able to ambulate .with a gait belt her four wheeled walker (FWW) and limited one assist. Provide (R3) with safety device/appliance FWW, gait belt, wheelchair, side rails. Apply gait belt around (R3's) waist. If contraindicated, apply gait belt around chest/under arm pits. R3's minimum data set (MDS) dated [DATE] showed R3 is cognitively intact, R3 is extensive assist with bed mobility and toileting, and limited assist with transfers with assist of one. On 10/16/23 at 09:04 AM, R3 was sitting in her wheelchair inside the entry way of the bathroom V6 (CNA) positioned the wheelchair (w/c) next to the toilet and transferred R3 from her w/c to toilet without a gait belt. She scooped R3 up by locking her inner elbows and grabbing the back of R3's pants. V6 then assisted R3 to a seated position onto the toilet. On 10/16/23 03:29 PM, R3 said, I have to have help going to the bathroom. They help me get into my wheelchair and from the wheelchair to the toilet. No, they don't use a gait belt. I don't have any strength in my legs, I don't walk or stand. When I get out of bed, they have to help me also. They do under the arms when they transfer me. Only one CNA helps me. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145440 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 145440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Neighbors Health Center 811 West 2nd Byron, IL 61010 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 On 10/17/23 03:56 PM, V7 (License Practical Nurse) said I am familiar with [R3]. She uses a wheelchair, and she is a one assist to get in and out of her bed or to the toilet. They are supposed to use a gait belt. If she would start to go down, she could fall easier. V7 said they wouldn't have a way to slowly lower her to the floor if needed. If she were to go down/fall she could end up with an injury because she has bad arthritis. Residents Affected - Few On 10/17/23 04:02 PM, V2 (Director of Nursing) said, The CNAs are to use a gait belt with transfers. If she is a one assist transfer a gait belt should have been used. She could get injured from a fall. There is potential for an injury to occur, but I can't say exactly what type of injury. On 10/18/23 08:26 AM, V10 (CNA) said we are to use a gait belt because they could fall if we don't use a gait belt. The facility's gait belt policy revised 5/17 showed 1. Nursing assistants will routinely have a gait belt immediately available to them during resident transfers .7. Apply gait belt ensuring two fingers are able to get beneath belt. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145440 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 145440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Neighbors Health Center 811 West 2nd Byron, IL 61010 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide incontinence care for dependent residents in a manner to prevent cross contamination for 2 of 20 residents (R43 and R58) reviewed for infection control in the sample of 20. Residents Affected - Few The findings include: 1. R43's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include hypertensive, heart and chronic kidney disease, atherosclerotic heart disease of native coronary artery without angina pectoris, retention of urine, and diastolic heart failure. R43's facility assessment dated [DATE] showed she requires extensive assistance of one staff member for toileting needs and is always incontinent of urine and frequently incontinent of bowel. R43's care plan initiated 7/26/23 and revised 10/5/23 showed, [R43] is on contact isolation related to MDRO (multidrug resistant organism) . Use appropriate PPE (personal protective equipment) when providing care . R43's 7/28/23 Nurse Practitioner note showed, HPI (History of Present Illness): Patient returns from [acute care hospital] related to acute metabolic encephalopathy related to UTI (urinary tract infection) . On 10/16/23 at 9:50 AM, V8 (Certified Nursing Assistant/CNA) was assisting R43 to the bathroom. V8 removed R43's incontinence brief and stool were noted on R43's buttocks. R43 sat on the toilet. V8 wiped stool from R43's buttocks and front perineal area. V8 then pulled R43's clean incontinence brief and pants up. V8 did not change gloves at any time during R43's incontinence care. Once all care was completed V8 removed her gloves. 2. R58's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include late onset Alzheimer's Disease, dysphagia, hypertension, polycystic kidney disease, benign neoplasm of colon, hypothyroidism, and type 2 diabetes mellitus. R58's facility assessment dated [DATE] showed he requires extensive assistance of 2 staff for toileting and is incontinent of bowel and bladder. On 10/16/23 at 10:25 AM, V6 and V8 (CNAs) assisted R58 to the toilet. V6 removed R58's incontinence brief and sat him onto the toilet. R58 urinated in the toilet. V6 then wiped R58's perineal area and buttocks. V6 and V8 then assisted R58 with a clean incontinence brief and pulled up his pants. V6 and V8 did not change gloves at any time during R58's cares. Once all care was completed V6 and V8 removed their gloves. On 10/18/23 at 10:10 AM, V9 (Assistant Director of Nursing) said gloves should be changed when going from dirty to clean. When entering the resident room they should wash their hands, don gloves, remove the old incontinence brief, provide pericare, once patient is clean, they should remove their gloves, perform hand hygiene, put new gloves on and then the clean incontinence brief should be put on. Once care is provided those gloves are dirty and we don't want to use dirty gloves to put on clean incontinence briefs and clothing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145440 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 145440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Neighbors Health Center 811 West 2nd Byron, IL 61010 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The facility's policy and procedure with revision date of 5/17 showed, Perineal Care; Objective: 1. To cleanse the perineum. 2. To prevent infection . Procedure: . 3. Wash hands and put on disposable gloves. 4. Wash perineal area with soap and water or perineal cleanser . 6. Remove gloves and wash your hands . The facility's policy and procedure with revision date of 05/17 showed, Gloves; Objective: 1. Gloves must be worn when handling blood, body fluids, secretions, excretions, mucous membranes and/or non-intact skin . Event ID: Facility ID: 145440 If continuation sheet Page 5 of 5