Inspection·April 29, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R3's medication (Polyethylene Glycol Powder/Metamucil) in a cup at R3's bedside. R3 stated, Just leave my medicine here and I will take it when I am done eating. V7 then left the medicine and walked out of R3's room. On 4/27/24 at 10:40 am, V7 (Licensed Practical Nurse) stated, I am just going to leave that with him (R3), he is just going to drink that after he finishes his breakfast. 3. R4's Physician Order Sheet/POS, dated 4/27/24, document R4's diagnoses including: Chronic Obstructive Pulmonary Disease, Hypertensive Heart Disease with Heart Failure, Heart failure, Protein-Calorie Malnutrition, Anorexia, Emphysema, Severe Hypertension, Palpitations, Major Depressive Disorder, Osteoarthritis, Anemia, Hypothyroidism, Hyperlipidemia, Urgency of Urination; Hypokalemia, Macular Degeneration and Dry Eye Syndrome. R4's POS also documents medication orders for Symbicort 160 mcg-4.5 mcg/actuation aerosol inhaler inhale two puffs by inhalation route two times per day at 8:00 am, Complete Multivitamin-Multimineral 18 milligram/mg-400 microgram/mcg tablet, give 1 tablet by oral route once daily with food every day at 8:00 am, Spiriva with HandiHaler 18 mcg and inhalation capsules inhale the contents of one capsule (18 mcg) using two inhalations by inhalation route once daily via handihaler every day at 8:00 am, Ascorbic Acid (Vitamin C) 500 mg tablet give 1 tablet by oral route once daily at 8:00 am, Ferrous Sulfate 325 mg (65 mg iron) tablet give one tablet (325 mg) by oral route once daily with breakfast at 8:00 am, Docusate Sodium 100 mg capsule give one capsule (100 mg) by oral route two times per day as needed, PreserVision one mg capsule give by oral route at 8:00 am, Cholecalciferol (Vitamin D3) 50 mcg (2,000 unit) tablet give one tablet by oral route at 8:00 am, Metoprolol Succinate Extended Release 25 mg 24 hour give one tablet (25 mg) by oral route once daily at 8:00 am, Citalopram 40 mg tablet give one tablet (40 mg) by oral route once daily at 8:00 am. On 4/27/24 at 9:10 am, 10:01 am and 11:50 am, a plastic medication cup that contained tablets/capsules and three inhalation medications (Spiriva, Albuterol and Symbicort) were on R4's bedside table. On 4/27/24 at 11:50 am, R4 stated, I was going to take those medications after I ate my breakfast. R4 stated, I think that cup has some iron, potassium, eye medicine and my anti-depressant, I am not really sure what else is in there. They usually just leave them sitting there (on the bedside table) for me to take when I am done eating. On 4/27/24 at 11:50 am, V3 (Licensed Practical Nurse) stated, I cannot believe that (R4) did not take her pills or inhalers yet. She usually takes them with her breakfast. I know it is probably not a good idea to leave them in (R4's) room. That medicine cup had Metoprolol, Eye Vitar, Vitamin C, Ducosate Sodium, Mutlivitamin and Citalopram in it and those inhalers are Symbicort and Spiriva. (R4) also likes to keep her rescue inhaler by her at all times also because she gets anxious. On 4/27/24 at 12:00 pm, V2 (Director of Nursing) stated, The nurses should not be leaving medicine in the rooms without watching the Residents take them, they should be staying with the Residents until they take them. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145457 If continuation sheet Page 2 of 4 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 145457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quincy Healthcare & Sr Living 1440 North 10th Street Quincy, IL 62301 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the Facility failed to timely administer medications as ordered by the Physician for one (R3) of four Residents reviewed for Medication Administration in a sample of four. Residents Affected - Few Findings include: Facility Administering Oral Medications (Version 1.2), undated, documents: purpose is to provide guidelines for the safe administration of oral medications; verify that there is physician's medication order for this procedure; follow the medication guidelines in the policy; use Medication Administration Record; check the label on the medication and confirm name and dose with the Medication Administration Record; make sure all documentation is completed in a timely manner; responsible for administering all medications following the policies and standards of practice; monitor and assist in developing safety measures to provide a safe environment at all times; and promote safe practices at all times. R3's Physician Order Sheet/POS, dated 4/27/24, document R2's diagnoses including: Sepsis, Cellulitis of Lower Limb, Pressure Ulcer Left Heel, Osteoarthritis, Diabetes Mellitus, Hypertension, Atrial Fibrillation, Transient Cerebral Ischemic Attack, Morbid Obesity, Bronchitis and Chronic Kidney Disease. R3's POS documents Physician Orders for Humalog KwikPen sliding scale at 7:00 am. The POS also documents Physician Orders for 8:00 am medications (Allopurinol 100 milligram/mg two times a day, Carvedilol 25 mg tablet daily, Farxiga 5 mg tablet daily, Hydrocodone 5mg/Acetaminophen 325 mg two times a day, Losartan 50 mg daily, Pregabalin 150 mg two times a day, Ranexa 500 mg every twelve hours, Vitamin D3 25 micrograms/mcg daily, Acidophilus capsule daily, Psyllium Husk 2.6 mg moral powder daily, Lidocain Pain Relief Patch on at 8:00 am and off at 8:00 pm, Multivitamin daily, Lantus Solostart Insulin 40 units once daily, Humalog KwikPen 15 units daily, Levaquin 500 mg daily and Polyethlene Glycol 17 gram powder daily. Facility Medication Administration Times, undated, documents medication pass times at 5:00 am, 8:00 am, 12:00 pm, 5:00 pm and 8:00 pm. On 4/27/24 at 9:13 am, R3's breakfast tray was delivered and at 9:35 am, R3 had completed the breakfast meal. R3 stated I am almost done, I just cannot eat as much as I used to before I went to the hospital. On 4/27/24 at 9:35 am, V7 (Licensed Practical Nurse) prepared and administered R3's scheduled 7:00 am medications (Humalog KwikPen sliding scale) and 8:00 am medications (Allopurinol 100 milligram/mg two times a day, Carvedilol 25 mg tablet daily, Farxiga 5 mg tablet daily, Hydrocodone 5mg/Acetaminophen 325 mg two times a day, Losartan 50 mg daily, Pregabalin 150 mg two times a day, Ranexa 500 mg every twelve hours, Vitamin D3 25 micrograms/mcg daily, Acidophilus capsule daily, Psyllium Husk 2.6 mg moral powder daily, Lidocain Pain Relief Patch on at 8:00 am and off at 8:00 pm, Multivitamin daily, Lantus Solostart Insulin 40 units once daily, Humalog KwikPen 15 units daily, Levaquin 500 mg daily and Polyethlene Glycol 17 gram powder daily). On 4/27/24 at 9:35 am, V7 (Licensed Practical Nurse) stated, (R3) just got back from the Hospital a day or so ago and is still on an antibiotic (Levaquin) for an infection and (R3) also takes a lot of insulin, (R3) will be getting four extra units of Humalog for his blood sugar (Accucheck) for his sliding scale. V7 verified that R3 received medication, including insulin, after the scheduled (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145457 If continuation sheet Page 3 of 4 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 145457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quincy Healthcare & Sr Living 1440 North 10th Street Quincy, IL 62301 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 0760 Physician ordered times and received insulin after R3 had finished the breakfast meal. Level of Harm - Minimal harm or potential for actual harm On 4/27/24 at 12:00 pm, V2 (Director of Nursing) stated, They should be getting their medicine at their scheduled times, especially insulin, that should not normally be given after a meal. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145457 If continuation sheet Page 4 of 4