Health inspection·August 24, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure an end of life care plan includes Hospice services that identify specific resident needs and individualized interventions and ensure Hospice plans of care were kept updated in the resident's record for three of three residents (R1, R6, R8) reviewed for Hospice in the sample of 24. Residents Affected - Few Findings include: The facility's Interdisciplinary Plan of Care policy (undated) documents, All Long Term Care residents will have a comprehensive interdisciplinary care plan developed with quantifiable objectives for the highest level of functioning the resident may be expected to attain, based on the comprehensive assessment. This policy also documents, All staff will be familiar with each resident's plan of care and are responsible for implementation of plan of care. Care plans will be continuously evaluated by each discipline and modified as indicated. The facility's Hospice Programs (undated) policy documents, Policy: Staff members will follow the policies/procedures of Hospice agency depending upon the admitting. Procedure: Communicate with hospice staff members regarding admissions of hospice patient. Follow the plan of treatment which has been initiated. The facility's (undated) Hospice Nursing Facility Hospice Service Agreement documents, C. Hospice will furnish a copy of each Hospice patient's Plan of Care to the facility at the times of the resident's admission into the Hospice program. The Plan of Care will be furnished to the facility in the form of Physician orders. K. Facility acknowledges and agrees that when facility personnel are responsible for the administration of prescribed therapies, including those therapies determined appropriate by Hospice and delineated in the Hospice patient's Plan of Care. Facility personnel may administer the therapies where permitted by State law and as specified by the Facility. 1. R1's current Hospice Plan of Care, dated 6/21/23, documents that R1 was admitted to hospice services on 2/2/23 with the diagnosis of senile degeneration of brain. The Plan of care also documents that R1's current benefit period is 5/3-7/31/23. R1's Physician's orders, dated 8/1-8/31/23, have no documentation of an order for R1 to receive hospice services. R1's facility care plan, dated 2/6/23, documents, R1 was recently admitted to hospice services. R1's care plan is not revised to include person centered interventions to address end of life care. On 08/24/23 at 10:54 AM, V3 (Minimum Data Set Coordinator/Infection Preventionist) confirmed that R1 is receiving hospice care, however R1's care plan does not document her hospice diagnosis nor interventions to address end of life care. 2. R6's Hospice Plan of Care, dated 6/19/23, documents that R6 is a hospice patient with the diagnosis of Coronary Artery disease. The Plan of care also documents that R6's benefit period is 3/31/23-6/28/23. R6's facility care plan, dated 1/31/23, documents, (R6) has a terminal prognosis related to failing health. R6's care plan is not specific to Hospice services or what Hospice cares R6 is receiving. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145464 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 145464 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hammond-Henry District Hsp 600 North College Avenue Geneseo, IL 61254 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 - Minimal harm or potential for actual harm 3. R8's Hospice Plan of Care, dated 6/20/23, documents that R8 is a hospice patient with the diagnosis of Parkinson's disease. The Plan of care also documents that R8's benefit period is 5/26/23-7/24/23. R8's facility care plan, dated 5/25/22, documents, (R6) has a terminal prognosis related to end stage disease. R8's care plan is not specific to Hospice services or what Hospice cares R8 should receive. Residents Affected - Few On 8/23/23 at 12:35 PM V2 (Registered Nurse) stated We didn't have the updated Care Plan from Hospice in the building until today. They (Hospice services) said they have volunteers who bring them and the last delivery there was an (unknown) issue. Hospice just came in today and brought the updated Hospice care plans for (R1, R6 and R8). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145464 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 145464 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hammond-Henry District Hsp 600 North College Avenue Geneseo, IL 61254 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, record review and interview, the facility failed to ensure a controlled substance medication was reconciled at the time of medication administration for one of ten residents (R21) reviewed for controlled medication in the sample of 24. Findings include: The facility's Medication Administration policy (undated) documents Objective/ Purpose: To provide safe, consistent method to administer medications. Controlled Substances: Controlled substances are to be signed out on controlled substance sign out sheet and charted as they are given. On 8/22/23 at 2:00 PM V6 (Registered Nurse) completed a controlled substance count. During this count, R21's Controlled Substances Proof of Use form for Lorazepam 1 milligram (controlled substance medication) documented the count of remaining pills should be 28. At this time the actual count that V6 had of R21's Lorazepam was 27. V6 then stated I gave (R21) a dose at 12:15 PM today. I usually sign them out as given, right when I administer the medication. That's what we are supposed to do. I am not sure why I didn't with this one. The sign-out sheet should say 27. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145464 If continuation sheet Page 4 of 4