Inspection·July 25, 2025

F 0684 Level of Harm - Actual harm Residents Affected - Few r/t (related to) PNA (pneumonia.) 2. R103's Undated Face Sheet, documents initially admitted to the facility on [DATE] diagnosis including acute respiratory disease and bacterial pneumonia. R103's Significant Change MDS, dated [DATE] documents cognitively impaired. R103's POS (physician order sheet) dated, 3/1/2025 new physician's order: STAT chest x ray. R103's Medical Record, including progress notes no documentation R103's STAT chest x ray was done on 3/1/2025. R103's Progress Note, dated 3/2/2025 at 12:15 PM documents called radiology company as STAT CXR was still not completed that was due yesterday. Received fax from radiology company stating they will be here today between 4pm-6pm to obtain CXR. POA (power of attorney) here and aware. Res continues with NP (nonproductive) cough and congestion. Per POA res was able to spit it up. PRN Robitussin given and effective. VSS. VS: 97.4-69-16138/70- 92%RA. No s/s pain or discomfort at this time. R103's Progress Note, dated 3/2/2025 at 4:45 PM, documents radiology company here for STAT CXR. R103's Progress Notes, dated 3/2/2025 at 5:18 PM, documents physician in facility and labs from 02/28/25 reviewed and NNO (no new orders). Physician aware of cough and congestion and awaiting CXR results. R103's Progress Note, dated 3/2/2025 8:57 PM documents, CXR results right lower lobe airspace disease can be related to pneumonia or atelectasis. Call placed to exchange, awaiting call back. POA here and aware of results, will await orders from MD (physician.) R103's Progress Note, dated 3/2/2025 at 9:16 PM documents received call back from NP (nurse practitioner) and new orders received r/t (related to) CXR results. N.O. (new order) to start Levaquin 500mg QD (every day) x 5 days. POA aware. Orders entered. R103's POS, dated 3/2/2025 documents a physician's order Levaquin 500 mg every day for 5 days. R103's Progress Note, dated 3/3/2025 at 10:14 AM documents resident started Levaquin 500 mg x 5 days for pneumonia. On 7/22/2025 at 11:15 AM R103 was sitting up in his Broda chair, he was not interviewable. No breathing abnormalities assessed. On 7/24/2025 at 9:40 AM, V17, RN (Registered Nurse) stated the facility had an issue getting all regularly ordered and STAT labs and x rays being done in a timely manner. V17 stated both lab and x ray companies told her they were short staffed so they couldn't get to the facility within a timely manner. V17 reported the issues to V2, Director of Nurses (DON) and V3, Assistant Director of Nurses (ADON) and the facility recently switched companies and they no longer have an issue getting the labs and x rays done in a timely manner.On 7/24/2025 at 9:50 AM, V20, LPN (Licensed Practical Nurse) stated early in the year of 2025 regular ordered and STAT labs and x rays were not being done in a timely manner at the facility both previous lab and x ray companies stated they were short staff or had to travel from Missouri to come to get the test done. V20 reported the issue to V2 and V3 and they recently changed companies for both lab and x ray and now it's no longer an issue. On 7/24/2025 at 10:00 AM, V18, LPN stated there were issues with getting labs and x rays done in a timely manner but the facility recently got new companies for both lab and x ray and they now have a lab technician at the facility 5 days a week for 5 hours a day and if they have a STAT lab ordered they call the lab and they send a technician out and it's drawn within the hour or so and reported in a timely manner. On 7/24/2025 at 10:10 AM, V16, LPN stated the previous lab and x ray companies were not coming to the facility in a timely manner and the STAT labs and x rays are supposed to be done immediately and they were not being done for at least a day and she reported the issues to V2 and V3 and they have switched companies and no longer have issues getting the labs and x rays done in a timely manner.On 7/24/2025 at 10:18 AM V3, Assistant Director of Nurses (ADON) stated staff reported to her that the facility had significant issues with the lab and x ray company getting regular and STAT labs and x rays being done in a timely manner, but they recently changed companies for both labs and x rays and now they are being done in a timely manner.On 7/24/2025 at 10:30 AM V2, Director of Nurses (DON) stated earlier this year they had a lot of issues with getting regular and STAT labs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145445 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 145445 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Healthcare of Waterloo 623 Hamacher Street Waterloo, IL 62298 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 0684 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete and x rays being done and reported in a timely manner were affected by this. The facility has switched companies in April 2025 and there is no longer an issue with getting these tests done in a timely manner. V2 stated the previous lab and x ray companies told them they didn't have enough staff and that was why the labs and x rays were not being done in a timely manner. On 7/24/2025 at 2:32 PM V2, DON stated due to the STAT labs and x rays not being done in a timely manner did delay the treatment of pneumonia for R4 and R103.The Facility's Radiology & Diagnostic Services Policy, revised on 4/1/2014, documents x rays and diagnostic services are preformed when ordered, no documentation of a STAT diagnostic order should be done by.The Facility's Laboratory Services & Testing Policy, revised 4/1/2014, documents STAT lab orders take a minimum of a 4-hour turnaround. Event ID: Facility ID: 145445 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 145445 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Healthcare of Waterloo 623 Hamacher Street Waterloo, IL 62298 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 FORM CMS-2567 (02/99) Previous Versions Obsolete 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 interview and record review the Facility failed to ensure progressive interventions were being implemented for 1 of 14 residents (R8) reviewed for falls in the sample of 49.Findings include: R8's POS dated July 2025 documents a diagnosis of cellulitis of right lower limb, major depression disorder, acute respiratory disease, cystostomy infection, depression. neuromuscular dysfunction of bladder, stress fracture, unspecified tibia and fibula; methicillin resistant staphylococcus aureus infection, urethral discharge, colostomy status; paraplegia, pressure ulcer of left heel, stage 4. RR MDS dated [DATE] documents BIMS 15/15: Uses a wheelchair. Impairment on both sides for lower extremities. Needs substantial/ maximal assistance for most ADL's (Activities of daily living).R8's Progress Notes dated 5/18/2025 at 1:15 PM, Called to front lobby per receptionist. Maple and cottonwood nurse responded to emergency. Pt (patient) said he was coming inside as a guest opened the door for him his w/c (wheelchair) flipped backwards and pt hit back of head. Noted small hematoma to back of head. Ice applied. Pt denies headache or dizziness. Pt able to move arms without difficulty. No cuts scrapes or bruises noted. Pts back appears free of injury. Dressing in place to back. No s/sx (signs or symptoms) of acute distress noted. Ortho/Neuros started.R8's Incident Report dated 5/18/2025 at 1:15 PM, Patient coming in from outside. Guest holding 2nd door into building as patient flipped wheelchair backwards. Hit back of head. Intervention: Continue current POC (Plan of Care); Isolated Incident. (No other interventions were documented).R8's Progress Notes dated 5/29/2025 at 9:44 AM, IDT (Intradisciplinary Team) met to discuss fall on 5/18/25 at 1:15 pm in front lobby doorway, hematoma to back of head. IDT: Cont. POC (Plan of Care).R8's Care Plan: Resident has a fall risk score 10 placing them at high risk for falls. Care Plan does not document any intervention for fall on 5/18/2025.On 7/23/2025 at 9:28 AM, V2, Director of Nursing stated the Intervention for R8's Fall was continued current POC (Plan of Care); isolated incident. The corrective actions were those two because it was an isolated incident. There were no other interventions.The Fall Prevention Policy with a revision date of 5/14/2024 documents, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Provide interventions that address unique risk factors measured by the risk assessment tool; medications, psychological, cognitive status, or recent changes in functional status. Event ID: Facility ID: 145445 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 145445 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Healthcare of Waterloo 623 Hamacher Street Waterloo, IL 62298 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on interview, observation and record review the facility failed to document the date a multi dose vial of Tuberculin Purified Protein Derivative (Mantoux) Tubersol was opened for 4 of 4 residents (R45,R80,R118,R130) reviewed for medication storage and labeling in the sample of 49. Findings include:R45's, R80's, R118's and R130's face sheets document they were admitted within the last 30 days.On 07/23/2025 at 2:05 PM during review of memory care medication storage room, V10, Registered Nurse (RN) showed Tuberculin Purified Protein Derivative (Mantoux) Tubersol box had been opened, and the vial was not dated. V10 stated she was not sure when the vial was opened and would discard it immediately since it is not dated. V10 states the vial is used for residents on memory care unit for TB tests that are given upon admission and annually. On 7/23/2025 at 2:21 PM during review of long-term care unit medication storage room V4, RN showed Tuberculin Purified Protein Derivative (Mantoux) Tubersol box had been opened, and vial was not dated. V4 stated she was not sure when the vial was opened and will discard it immediately. V4 states the vial is used for the residents on the long-term care unit. V4 states TB tests are given upon admission and annually.On 7/25/2025 at 9:23 AM V2, Director of Nursing, (DON) states she expects staff to date and time Tuberculin Purified Protein Derivative (Mantoux) Tubersol vial when opened. V2 states Tuberculin tests are given upon admission and yearly. V2 states she would expect staff to discard vial immediately if not dated. The instructions on the Mantoux box documents Discard opened product after 30 days.The facility's policy Labeling of Medications and Biologicals dated 9/15/22 documents All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. Policy Explanation and Compliance Guidelines: 8. Labels for multi-use vials must include: a. the date the vial was initially opened or accessed (needle-punctured); b. all opened or accessed vials should be discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. Event ID: Facility ID: 145445 If continuation sheet Page 5 of 5