Inspection·March 7, 2024

F 0550 of R46 was compromised by V14's actions. Level of Harm - Minimal harm or potential for actual harm The facility policy titled 'Resident Privacy and Dignity' dated 8/2/2017 documents it is the responsibility of all staff to ensure that all residents have privacy and dignity. Medically necessary procedures will be conducted in the resident's room or private setting. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145449 If continuation sheet Page 2 of 13 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 145449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Paxton Senior Living 450 Fulton Street Paxton, IL 60957 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete a Baseline Care Plan timely for one (R266) resident out of one resident reviewed for Baseline Care Plans in a sample list of 33 residents. Findings include: The facility policy titled '24 Hour Interim Care Plan' revised 2/2021 documents the purpose is to provide guidelines for completion of a 24 hour (Interim) Plan of Care for newly admitted residents. The policy states a 24 Hour Care Plan guides provision of care from the time of the resident transfer/admission until the Interdisciplinary Care Plan is completed and to provide a [NAME] with the Electronic Medical Record (EMR) for resident care direction. R266's undated Face Sheet documents R266 admitted to facility on 3/1/24. R266's undated medical diagnosis list documents R266's medical diagnoses of Local Infection of the Skin and Subcutaneous Tissue, Cellulitis Unspecified, Diabetes Mellitus Type II, Chronic Venous Hypertension with Ulcer and Inflammation of Bilateral Lower Extremities, Atrial Fibrillation, Chronic Congestive Heart Failure, Acute Kidney Failure, Peripheral Venous Insufficiency and Hypertension. R266's Electronic Medical Record (EMR) documents R266's Baseline Care Plan was initiated on 3/5/24. On 3/6/24 at 2:00 PM V17 Care Plan Coordinator (CPC) stated every resident should have a baseline care plan completed within 48 hours of admission. V17 CPC stated the admission nurse is supposed to start a baseline admission care plan when the resident admits. V17 CPC stated (R266) was admitted on [DATE] and his baseline care plan was not initiated until 3/5/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145449 If continuation sheet Page 3 of 13 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 145449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Paxton Senior Living 450 Fulton Street Paxton, IL 60957 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 prevent cross contamination of pressure ulcers during pressure ulcer wound care and failed to complete wound treatments for two (R45, R266) residents out of four residents reviewed for Pressure Ulcers in a sample list of 33 residents. Residents Affected - Few Findings include: 1.) R45's undated Face Sheet documents R45 admitted to the facility on [DATE]. This same Face Sheet documents R45's medical diagnoses of Right Hip Pressure Ulcer Stage IV, Morbid Obesity, Acute Respiratory Failure with Hypoxia, Sepsis, Diabetes Mellitus Type II, Cognitive Communication Deficit, and Embolism and Thrombosis of Deep Veins of Right Lower Extremity. R45's Physician Order Sheet (POS) dated March 2024 documents a physician order to cleanse Right Lateral Hip wound with gauze and 1/4 strength bleach solution, apply Gentamicin Sulfate 0.1% topical ointment to periwound and in wound tunnel. Soak roll gauze in 1/4 strength bleach solution and pack into wound after Gentamicin placed into wound. DO NOT USE GAUZE-IT MUST BE CONTINUOUS ROLL GAUZE. Once hole is packed, cut roll gauze leaving tail on the outside to cover the peri wound. Apply two absorbent pads and retention tape to secure. change twice daily and every two hours as needed for wound management. R45's Minimum Data Set (MDS) dated [DATE] documents R45 as cognitively intact. This same MDS documents R45 requires maximum assistance for bed mobility and is dependent on staff for assistance with bathing and dressing. R45's Treatment Administration Record (TAR) dated March 2024 documents R45's Right Hip Stage IV Pressure Ulcer dressing change was not completed as ordered by the Physician on 3/1/24 night shift and 3/5/24 night shift. On 3/6/24 at 3:00 PM V12 Licensed Practical Nurse (LPN) completed wound care for R45's Stage IV Right Hip Pressure Ulcer. As R45 turned to his Left side, the fitted sheet underneath where R45's dressing was touching was smeared in multiple areas with a brown substance, food particles and unknown debris. V12 LPN removed the undated bandage from R45's Right Hip. The bandage was overly saturated with brown, foul smelling drainage that was dripping from the bandage onto R45's open wound, Right Hip area and flat sheet. R45's Right Hip Stage IV Pressure Ulcer was a half dollar sized hole with reddened edges. V12 LPN inserted a long cotton tipped applicator into R45's Right Hip wound to approximately half the length of the cotton tipped applicator. V12 stated Wow. This wound is really tunneled at the 5-6 o'clock area. I can stick half this stick in there. R45 moved the contaminated sheet back over R45's Stage IV Pressure Ulcer after V12 LPN had cleansed the wound causing the contaminated sheet to directly touch the open area of the wound. V12 LPN did not re-cleanse R45's open wound after the contaminated sheet touched it. V12 LPN used her contaminated Right hand to push R45's flat sheet off of the open wound and did not perform hand hygiene after moving contaminated sheet before continuing wound care. On 3/6/24 at 3:40 PM V12 Licensed Practical Nurse (LPN) stated R45's Stage IV Pressure Ulcer to Right Hip should not be laying on soiled sheets. V12 LPN stated R45's wound had a copious amount of drainage. V12 LPN stated I can't be sure when (R45's) Right Hip Pressure Ulcer dressing was changed because there was no date, time or initials on the old bandage. (R45's) bed is a mess. That brown (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145449 If continuation sheet Page 4 of 13 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 145449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Paxton Senior Living 450 Fulton Street Paxton, IL 60957 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 0686 Level of Harm - Minimal harm or potential for actual harm substance was probably the chocolate ice cream (R45) had for lunch and I am not sure what the rest of that debris was. V12 LPN stated V12 cross contaminated R45's Pressure Ulcer by not cleansing his wound again after R45 put the sheet directly on it and by not performing hand hygiene after V12 used her Right hand to move the sheets. V12 LPN stated Cross contaminating an open wound could cause bacteria to get into wound and cause an infection or make an infection worse. Residents Affected - Few On 3/6/24 at 4:00 PM R45 stated They (facility) change my dressing to my Right Hip sometimes. They have missed a few times too. They did not change it last night. I don't know why. 2.) R266's undated Face Sheet documents R266 admitted to facility on 3/1/24. R266's undated medical diagnosis list documents R266's medical diagnoses of Local Infection of the Skin and Subcutaneous Tissue, Cellulitis Unspecified, Diabetes Mellitus Type II, Chronic Venous Hypertension with Ulcer and Inflammation of Bilateral Lower Extremities, Atrial Fibrillation, Chronic Congestive Heart Failure, Acute Kidney Failure, Peripheral Venous Insufficiency and Hypertension. R266's Physician Order Sheet (POS) dated March 2024 documents a physician order to cleanse Left Leg (Knees to Toes) with (antiseptic soap) 4.0 % and gauze, then allow to dry. Paint with (povidone-iodine), cover with abdominal pads, wrap with roll gauze, wrap with elastic gauze wrap from toes up. DO NOT PULL ELASTIC GAUZE WRAP OR ROLL GAUZE TIGHT change daily and as needed (PRN) for soilage. This same POS does not document a specific order for R266's Stage II Left Heel Pressure Ulcer. R266's Pressure Ulcer Risk assessment dated [DATE] documents R266 is at risk for Pressure Areas. R266's Facility Wound Rounds report dated 3/4/24 documents R266's Left Heel wound as a Stage II Pressure Ulcer. R266's Care Plan intervention dated 3/5/24 documents R266 requires assistance with bathing, dressing, bed mobility and full mechanical lift for transfers and to follow facility protocols for treatment of injury. This same careplan does not include any pressure relief interventions prior to 3/5/24. On 3/6/24 at 3:55 PM V12 Licensed Practical Nurse (LPN) and V13 Registered Nurse (RN)/Wound Care Certified (WCC) completed wound care for R266's Stage II Left Heel Pressure Ulcer. V12 LPN removed a partially filled urinal from R266's bedside table. R266's bedside table had several areas where unknown liquid had been spilled. V13 RN/WCC observed V12 remove the urinal, then V13 placed bottles of wound supplies (wound cleanser, (antiseptic soap) and (providone-iodine)) directly on the contaminated bedside table. V12 LPN and V13 RN/WCC positioned R266 with a pillow under R266's knees for the dressing change. On R266's Left Heel was a nickel sized open area with red drainage. R266 rested the Left Heel Pressure Ulcer directly on the contaminated fitted sheet three separate times during wound care after V12 cleansed wound. A dime sized red area of drainage was observed on fitted sheet directly under where R266's Left Heel was laying. V12 LPN continued to dress R266's Left Heel contaminated Pressure Ulcer without re-cleansing the wound. On 3/6/24 at 5:45 PM V12 Licensed Practical Nurse (LPN) stated V12 cross contaminated R266's Stage II Left Heel Pressure Ulcer by not cleansing it after R266 had laid his Left Heel directly on the contaminated sheet. V12 LPN stated a clean field should have been provided prior to starting wound care for R266. V12 LPN stated I usually make sure I have a clean area to start with but (R266) just didn't have any room for all the supplies. I saw (R266) lay his Left Heel on the sheet but didn't think to reclean it. I should have. I have never met (R266) before this wound change so I didn't know (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145449 If continuation sheet Page 5 of 13 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 145449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Paxton Senior Living 450 Fulton Street Paxton, IL 60957 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 0686 what to expect. Level of Harm - Minimal harm or potential for actual harm On 3/7/24 at 11:00 AM V10 Infection Preventionist (IP)/Registered Nurse (RN) stated cross contaminating a wound during wound care could introduce bacteria to the resident's wound and possibly cause an infection. V10 IP stated We (facility) have a few policies on Pressure Ulcers but I don't think we (facility) have a policy on this but it should be considered a standard of care to not cross contaminate open wounds. Residents Affected - Few The facility policy titled 'Preventative Skin Care' revised April 2023 documents the facility should maintain wrinkle free, clean, dry bed linen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145449 If continuation sheet Page 6 of 13 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 145449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Paxton Senior Living 450 Fulton Street Paxton, IL 60957 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 provide a safe environment for use of oxygen in the presence of electrical heating devices and flammable materials in the facility beauty shop. This failure affects two residents (R11 and R48) out of nine reviewed for accidents and safety on a sample list of 33. Findings include: On 3/5/24 at 10:40 AM, R11 was in the beauty shop wearing oxygen tubing on her face and nose and actively receiving oxygen therapy from a portable liquid oxygen tank flowing at 2 liters per minute through a nasal cannula (tube connecting the oxygen tank to the resident's nose). V7, Beauty Shop Operator, was in the process of drying R11's hair with a hand-held electric blow dryer (glowing orange electrical coils and an electric fan motor which produces sparks, ignition source) approximately one foot from R11's head. R48 was seated in a wheelchair inside the beauty shop approximately 6 feet away from R11 and the hair dryer being used by V7. R48 was also wearing oxygen tubing on her face and nose and actively receiving oxygen therapy from a portable liquid oxygen tank through a nasal cannula flowing at 2 liters per minute. In the beauty shop there were flammable products present such as aerosol hair spray. On 3/5/24 at 10:41 AM, V1, Administrator, removed R48 from the beauty shop, and instructed V7 to remove the oxygen tubing from R11's face and turn R11's portable liquid oxygen tank to the off position. V7 stated, I have only been told not to use the large commercial hair dryers that the residents sit under when a resident is wearing oxygen. V7 stated, I have not been told about not using hand-held hair dryers when residents are wearing oxygen. On 3/5/24 at 11:05 AM, the door of the beauty shop was closed and R11 remained inside the beauty shop. R11 was then again wearing oxygen tubing on her face and nose and actively receiving oxygen therapy from the portable liquid oxygen tank flowing at 2 liters per minute through the nasal cannula. V7 again stated, I have not been informed about not using a curling iron (internal glowing orange electrical coils, ignition source) when a resident is wearing oxygen, only not to use the large hair dryers. On 3/5/24 at 11:10 AM, V1 stated, I would need to look up the facility policy and go over that policy with (V7). The current (3/5/24) American Lung Association guidelines for safe use of oxygen document, Do not use any electrical appliances such as hair dryers, curling irons, heating pads, and electric razors while wearing oxygen. The facility policy Oxygen Safety dated 2/2000 documents, spark producing devices shall be prohibited in oxygen storage. Refer to manufacturer recommendations as needed. The facility provided a piece of copy paper (untitled and undated) which was a manipulated copy of pages labeled 2, 3, 14, and 15. The provided page 2 was a picture of liquid oxygen portable tanks. Page 3 was a list of hazards and safety measures related to the use of oxygen concentrators (room air concentrators) and not related to the liquid oxygen portable tanks. Page 14 was related to care of the tubing associated with oxygen administration (cannulas). Page 15 was blank except for a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145449 If continuation sheet Page 7 of 13 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 145449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Paxton Senior Living 450 Fulton Street Paxton, IL 60957 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 handwritten manufacture (sic, manufacturer) reccommendations (sic, recommendations) for safety. The safety measures for room air concentrators listed on the page 3 did include statements such as, Keep all flammable materials away from your oxygen. Do not use your oxygen around space heaters (glowing orange electrical coils). It takes 15 minutes for oxygen to leave your clothing, hair, and skin once you take off your oxygen. Be careful around anything that produces a spark such as a hair dryer or electric razor. Residents Affected - Few On 3/6/24 at 11:05 AM, V11, Life Safety Architect, confirmed, Oxygen in a beauty shop is a no-no. First you have pure oxygen along with flammable materials like hair spray, then a blow dryer is an ignition source. Upon request, V1, Administrator, provided the (Oxygen Supply Company) complete manufacturer education pamphlet dated 2/2021. This education pamphlet included additional cautionary statements such as, Keep the liquid oxygen tank at least 5 feet away from electrical appliances. Keep the liquid oxygen away from any flammable material. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145449 If continuation sheet Page 8 of 13 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 145449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Paxton Senior Living 450 Fulton Street Paxton, IL 60957 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 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 complete perineal care for one resident (R8) of one resident reviewed for perineal care in the sample list of 33. Residents Affected - Few Findings include: R8's undated Face Sheet documents R8's diagnosis as: Chronic Kidney Disease, Stage 2. R8's Care Plan dated 2/15/24, documents R8 is incontinent of bowel and bladder, clean perineal area with each incontinent episode. On 3/7/24 at 11:00 AM, V18 Certified Nursing Assistant (CNA) provided perineal care to R8. During this care, V18 wiped R8's outer labia and failed to spread the labia to wipe the inner labia. At this same time, V18 cleansed R8 buttocks but failed to clean R8's anal area. On 3/7/24 at 11:20 AM, V2 Director of Nursing (DON) stated V18 should be following the perineal care policy. The facility's Perineal Care policy dated Revised 12/22, documents cleanse the outer skin folds, open all skin folds, cleanse from front to back, cleanse the anal area. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145449 If continuation sheet Page 9 of 13 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 145449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Paxton Senior Living 450 Fulton Street Paxton, IL 60957 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain and implement physician orders for Continuous Positive Airway Pressure (CPAP) machine settings and cleaning schedules and failed to properly store Nebulizer tubing. These failures have the potential to affect three residents (R12, R17, R21) out of three reviewed for respiratory care on a sample list of 33. Residents Affected - Few Findings include: 1. On 3/5/24 at 10:06 AM, there was a CPAP machine in R12's room next to R12's bed. On 3/5/24 at 10:20 AM, R12's Care plan focus area initiated 7/15/22 documents (R12) has OSA (Obstructive Sleep Apnea) and utilizes a CPAP machine. This Care Plan focus area documents nursing interventions for the CPAP machine include, Clean CPAP per orders. R12's medical record including R12's Physician Order Sheet, Treatment Administration Record, and Care Plan, did not contain any specific orders for pressure settings to be utilized for the CPAP machine during use, nor a cleaning schedule for R12's CPAP. On 3/5/24 at 12:54 PM, R12's Physician Order Sheet was revised to include a physician order for CPAPuse during sleep hours, place CPAP at HS (hour of sleep), remove in the morning. There was not a physician order for CPAP cleaning schedule, nor for pressure settings to be utilized during the CPAP operation. On 3/5/24 at 1:14 PM, R12's Physician Order Sheet was revised to include a physician order for CPAP- use during sleep hours, place CPAP at HS, remove in the morning and in the morning for remove. There was not a physician order for CPAP cleaning schedule, nor for pressure settings to be utilized during CPAP operation. On 3/6/24 at 11:58 AM, R12's Physician Orders were revised to include a physician order for Dream Station CPAP set to a pressure of 14- use during sleep hours, place CPAP at HS, remove in the morning and in the morning for remove. There was not a physician order for CPAP cleaning schedule, nor for the low end of the pressure settings to be utilized for CPAP operation. On 3/6/24 at 12:03 PM, R12's Physician Order Sheet was revised to include a physician order for Dream Station CPAP set to a pressure of 8 - 14- use during sleep hours, place CPAP at HS, remove in the morning and in the morning for remove. There was not a physician order for CPAP cleaning schedule. On 3/6/24 at 1:29 PM, R12's Physician Order Sheet was revised to include a physician order for CPAP cleaning to be conducted every Sunday night and as needed. On 3/7/24 at 1:09 PM, R12's CPAP tubing was stretched out across the floor beside R12's bed. The tubing on the floor was the portion of tubing that was designed to connect to R12's face mask. At that time, R12's face mask was stored in a plastic bag on the window sill. V20, Registered Nurse, stated, The tubing should not be on the floor. V20 further stated, (R12) can not take care of her own CPAP and tubing. 2. R17's undated Face Sheet, documents R17's diagnoses as Shortness of Breath, Insomnia due to medical condition, Chronic Obstructive Pulmonary Disease (COPD), moderate, persistent Asthma, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145449 If continuation sheet Page 10 of 13 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 145449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Paxton Senior Living 450 Fulton Street Paxton, IL 60957 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 Snoring. Level of Harm - Minimal harm or potential for actual harm R17's Medication Administration Record (MAR) dated 3-1-24 - 3-31-24, documents Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) milligrams (mg)/3 Milliliters (ml) (Ipratropium-Albuterol) 3 ml inhale orally every 6 hours related to COPD. R17's Treatment Administration Record (TAR) dated 3-1-24 - 3-31-24, documents Continuous Positive Airway Pressure (CPAP) Pressure: 4-20 pressure centimeters (cm) water autosense 11 or 10 pap with oxygen bled into CPAP if needed in the evening related to COPD, place CPAP at night, remove in the morning. Residents Affected - Few R17's Care Plan dated 1/11/24, documents utilize a CPAP machine secondary to COPD, Asthma, Alveolar / Parieto-Alveolar Conditions. On 03/05/24 at 10:06 AM, R17's nebulizer tubing was observed on the floor. R17's Continuous Positive Airway Pressure (CPAP) was observed on the dresser by the bed, not in plastic bag. On 3/5/24 at 3:45 PM, R17 stated R17 has used a nebulizer and CPAP for about a year and a half. On 03/06/24 at 10:29 AM, R17's nebulizer face mask and tubing observed not in a bag, out in the open on the nebulizer machine. 3. R21's undated Face Sheet documents an admission date of 6/20/2022. R21's undated medical diagnoses list documents medical diagnoses of Alveolar and Parieto-Alveolar Conditions, Morbid Obesity, Portal Hypertension, Cardiomegaly, Obstructive Sleep Apnea, Lack of Coordination, Carpal Tunnel Syndrome, Essential Tremor and Weakness. R21's Minimum Data Set (MDS) dated [DATE] documents R21 as cognitively intact. R21's Physician Order Sheet (POS) dated March 2024 documents a physician order starting 3/5/24 for R21 to wear Continuous Positive Airway Pressure (CPAP) every night and remove every morning. This same POS does not document any orders for R21's use of the CPAP prior to 3/5/24. This same POS does not document Physician orders to clean R21's CPAP machine as per manufacturer guidelines. On 3/5/24 at 11:20 AM R21's CPAP machine was setting on top of the bedside dresser with tubing extending down the front of the dresser and CPAP mask attached to end of the tubing was placed in the top drawer of R21's bedside dresser with other personal items. R21's CPAP machine water reservoir contained water and had visible debris on the inside wall of the water reservoir. R21's CPAP tubing was not contained in a plastic bag. On 3/5/24 at 11:22 AM R21 stated I admitted here (facility) over a year and a half ago with the CPAP. I have used it every night since I admitted . The mask has been cleaned two times since I admitted . The machine has never been cleaned. The staff here do a pretty good job. I don't want to complain but that air from the CPAP goes directly into my lungs. On 3/6/24 at 8:35 AM V10 Infection Preventionist (IP) stated all of the devices that residents use should be cleaned regularly. V10 IP stated R21's Continuous Positive Airway Pressure (CPAP) machine should be cleaned by the manufacturer guidelines. V10 stated R21's orders for administering the CPAP were entered on 3/5/24. V10 IP stated (R21) admitted to the facility with his own CPAP machine a year or so ago. (R21) should have had orders entered as soon as he admitted . The CPAP machines have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145449 If continuation sheet Page 11 of 13 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 145449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Paxton Senior Living 450 Fulton Street Paxton, IL 60957 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reservoirs that hold the water and that can be a source for bacterial growth. If (R21's) CPAP machine has not been cleaned that that could definitely present a health risk for (R21). On 3/6/24 at 10:00 AM V2 Director of Nurses (DON) stated every resident that utilizes Oxygen or Continuous Positive Airway Pressure (CPAP) should have orders in place to instruct nursing staff on the resident usage. V2 DON stated the orders should include the specific settings for each resident and the cleaning of the mask and the CPAP machines. V2 DON stated resident orders for their CPAP's were not entered for the use of the CPAP nor for the cleaning of the machine. V2 DON stated I am working on cleaning up all the Oxygen and CPAP orders today. All residents receiving Oxygen or use a CPAP will have their orders reviewed and adjusted for accuracy today. The facility provided Continuous Positive Airway Pressure (CPAP) machine undated manufacturer guidelines documents Cleaning: Daily-Empty the humidifier tub and wipe it thoroughly with a clean disposable cloth. Allow it to dry out of direct sunlight. Refill the standard humidifier with distilled water only or the cleanable water tub with potable drinking quality water. Weekly-Wash the components as described: air tubing-in warm water using a mild dishwashing liquid. humidifier tub-in warm water using a mild dishwashing liquid OR in a solution with a ration of one part vinegar and nine parts water at room temperature. Outlet connector-in warm water using a mild dishwashing liquid OR in a solution with a ration of one part vinegar and nine parts water at room temperature. Components should not be washed in temperatures higher than 131 degrees Fahrenheit (F). Rinse each component thoroughly in water. Allow to dry out of direct sunlight or heat. Wipe the exterior of the device with a dry cloth. The facility policy titled 'Oxygen Administration Continuous Positive Airway Pressure (CPAP)/Bilevel Positive Airway Pressure (BIPAP)' revised 8/2018 documents all orders for CPAP and/or BIPAP must be ordered by the Physician. All orders include the following: Type of unit (CPAP or BIPAP), Pressure settings, Oxygen order (if applicable), deliver device and size (mask, nasal prongs), frequency of therapy (continuous, at bedtime) and need for humidifier. When using a mask, advice resident not to eat two to three hours prior to using unit. The facility's Nebulizer Therapy policy dated Revised 9/2018, documents store in plastic bag when not in use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145449 If continuation sheet Page 12 of 13 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 145449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Paxton Senior Living 450 Fulton Street Paxton, IL 60957 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 monitor the dishwasher rinse temperatures to ensure sanitation of service wares and utensils utilized to serve meals to the residents. This failure affects nearly all (62 of 63) residents residing in the facility. Findings include: On 3/5/24 at 8:57 AM, V3, Dietary Manager, stated the commercial dishwasher utilized to wash the resident dishes, wares, and utensils, was a hot water sanitizing dishwasher. At this time, while the facility commercial dishwasher was in operation, the final rinse temperature was not displaying as designed on the digital display on the front of the dishwasher. When asked how the kitchen staff are monitoring the final rinse temperature to ensure the wares are being properly sanitized, V3 replied, I will have to look for test strips. V3 could not locate the temperature sensitive test strips. V3 questioned a Dietary Aid (V4) who likewise could not identify the location of the test strips. V4 also stated, I don't know how long the display has not been showing the final rinse temperature. V3 then stated, I will get maintenance in here to look at it. On 3/5/24 at 09:25 AM, V9, Maintenance Assistant, stated, I'm not sure but I think something like a knife or spoon may be stuck in the drain outlet because the drain is releasing water while the wash cycle is going. On 3/5/24 at 9:35 AM, V5, Dietary Aid, stated, The final rinse temperature display has not been working since they came and repaired the dishwasher about 2 weeks ago. V3 confirmed (the dishwasher repair company) had worked on the dishwasher about 2 weeks prior. On 3/6/24 at 8:25 AM, V9, Maintenance Assistant, stated, I think it may be the rinse thermostat not working but I will need to get with my boss because I don't want to start tearing this dishwasher apart. On 3/6/24 at 8:32 AM, V3, Dietary Manager, provided the dishwasher temperature recording log for January 2024, which was the log in place on the clipboard in the dishwashing room. This temperature log documented 3 columns for recording the final dishwashing rinse temperature once for each of the three daily mealtimes, breakfast, noon, and evening. This temperature log documented the final dishwashing rinse temperature had not been recorded for 1/25/24 all three meals, 1/26/24 for breakfast and noon, 1/27/24 through 1/30/24 all three meals each day, and 1/31/24 breakfast and evening. On 3/6/24 at 10:12 AM, V3 provided the dishwasher temperature recording log for February 2024. This log documented the dishwasher final temperature was not being monitored from 2/24/24 though 2/29/24 all three meals each day. V3 confirmed, The temperature has not been monitored for about the past 2 weeks since the repair company worked on the dishwasher. The facility's Form 671 Long Term Care Facility Application for Medicare and Medicaid dated 3/5/24 documents 63 residents reside in the facility, all of whom, with one exception (R31 who receives nothing by mouth), consume food prepared by the facility kitchen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145449 If continuation sheet Page 13 of 13