Health inspection·May 17, 2022

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review the facility failed to develop a care plan for anticoagulant use for one (R11) of 20 residents reviewed for care plans in the sample list of 20. Residents Affected - Few Findings include: R11's May 2022 Physician's Orders documents an order for Eliquis (anticoagulant) 2.5 milligrams by mouth twice daily. R11's Care Plan with a revision date of 4/19/22 does not document R11's use of an anticoagulant or interventions for monitoring for complications associated with anticoagulant use. On 5/17/22 at 2:48 PM V5 Care Plan coordinator stated R11's care plan does not include a problem area or interventions for anticoagulant use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145466 If continuation sheet Page 2 of 10 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 145466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Twin Lakes Extended Care 310 Eads Avenue Paris, IL 61944 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 0692 Provide enough food/fluids to maintain a resident's health. 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 administer a nutritional supplement and accurately assess for significant weight loss for two (R32, R22) of four residents reviewed for nutrition in the sample list of 20. Residents Affected - Few 1. R22's May 2022 Physician's Orders document R28's diet includes a frozen nutritional supplement with lunch and supper. R22's 2021 Weight Log documents R22 weighed 193.5 lbs (pounds) in August, 188 lbs in November and 193 lbs in December. R22's 2022 Weight Log documents R22 weighed 188 lbs in January, 165.7 lbs in February (an 11.8% loss in 1 month, and 14.37% loss in 6 months), and 166.2 lbs in March (13.89% loss in 3 months). R22's March and May 2022 Medication Administration Records document R22 weighed 163.4 lbs on 3/22, and 169.2 lbs on 5/10. R22's Dietary Notes document the following: On 2/16/22 R22 had an 11.06 % weight loss (21 lbs) in 3 months, and 13.59% loss (26.5 lbs) in 6 months. On 3/10/22 R22 had significant weight loss of 13.89% in 3 months and 13.93% in 6 months. R22 has had decline and weight loss and is dependent on staff for eating. On 4/6/22 R22 had a significant weight loss of 12.77 % in 3 months and 12.95 % in 6 months. On 4/29/22 a frozen nutritional supplement with lunch and supper was added to R22's diet. On 5/11/22, R22 had a significant weight loss of 11.6% in 6 months, and R22's diet includes a frozen nutritional supplement with lunch and supper. R22's Minimum Data Sets (MDS) dated [DATE] documents R22 weighed 164 lbs and does not document R22's significant weight loss (5% or more in 1 month or 10% or more in 6 months). On 5/16/22 at 12:45 PM and on 5/17/22 at 12:01 PM R22's noon meal did not include a frozen nutritional supplement. 2. R32's May 2022 Physician's Orders document R32's diet includes a frozen nutritional supplement with lunch and supper. R32's 2021 Weight Log documents R32 weighed 152.7 lbs in July, 152.6 lbs in August, 154.6 lbs in October, 150 lbs in November, and 137 lbs in December (an 8.67% loss in 1 month.) R32's 2022 Weight Log documents R32 weighed 140 lbs in January (10.28 % loss in 6 months), 151.4 lbs in February, 153 lbs in April, and 147 lbs in May. R32's Dietary Note dated 1/20/22 documents R32 had a significant weight loss of 9.44 % in 3 months. R32's MDS dated [DATE] documents R32's weight as 140 lbs and does not document R32's significant weight loss. On 5/17/22 at 12:35 PM V17 [NAME] stated the dietary aide is responsible for serving the frozen nutritional supplements. V17 confirmed R22's dietary tray card documents R22's and R32's diets include a frozen nutritional supplement at lunch and supper. On 5/16/22 at 12:45 PM and on 5/17/22 at 12:01 PM R32's noon meal did not contain a frozen nutritional supplement. On 5/17/22 at 12:38 PM V14 Certified Nursing Assistant (CNA) stated R32 was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145466 If continuation sheet Page 3 of 10 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 145466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Twin Lakes Extended Care 310 Eads Avenue Paris, IL 61944 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 0692 served a frozen nutritional supplement at lunch. Level of Harm - Minimal harm or potential for actual harm On 5/17/22 at 12:39 PM V15 CNA stated neither R22 or R32 received a frozen nutritional supplement at lunch, R22 and R32 only received the frozen nutritional supplement with supper. V15 stated dietary staff are responsible for serving the frozen nutritional supplements on the meal trays. Residents Affected - Few On 5/17/22 at 3:04 PM V5 Care Plan Coordinator confirmed R22's and R32's MDS do not document significant weight loss. The facility's Supplementation and Nourishments policy revised October 2007 documents: It is the facility's policy to ensure that residents who require additional supplementation receive it in a timely and safe manner. Intake of physician ordered supplements will be monitored and recorded in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145466 If continuation sheet Page 4 of 10 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 145466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Twin Lakes Extended Care 310 Eads Avenue Paris, IL 61944 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record the facility failed to safely install side rails for two residents (R18, R22) of seven residents reviewed for side rails in a sample list of 20 residents. Findings Include: 1. R18's Bed Rail assessment dated [DATE] documents R18 uses side rails to promote independence in turning from side to side. R18's Minimum Data Set (MDS) dated [DATE] documents R18 is moderately cognitively impaired and requires an extensive assist of staff to complete bed mobility and transfer. On 5/16/22 at 10:30AM R18 was in bed. Half side rails were up and in place to both sides of the bed. R18 was lying on her left side. Her mattress had slipped to the left side leaving a six inch gap between the edge of the mattress and the side rail. The springs on the bed were exposed in this gap. On 5/17/22 at 10:45AM V6, Maintenance Director stated I measure the distance from the side rails to the edge of the mattress when the mattress in centered in the bed. I never thought of it slipping and not being safe. I suppose a resident could get caught in that space. 2. R22's Physician's Order Sheet (POS) dated 5/1/22 to 5/31/22 documents a physician's order for 1/2 bilateral side rails to promote independence and encourage participation in bed mobility. On 5/17/22 at 11:00AM R22 was not in her bed, but the half side rails were up and in place to both sides of the bed. The rails were attached loosely to the bed by only the adjustment handle in the center of the rails. The rail could be turned in a complete circle by gentle pressure to either end of the rail. On 5/17/22 at 11:05AM V3 Administrator in training stated that this was unsafe and will be corrected immediately. The facility's policy Determining Need for Use of Bed Rail reviewed September 2019 states Zone assessments for the enablers will be conducted at the time they are placed on the bed and at least annually. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145466 If continuation sheet Page 5 of 10 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 145466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Twin Lakes Extended Care 310 Eads Avenue Paris, IL 61944 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to provide the required eight hours of Registered Nurse staffing coverage per 24-hour period for three of fifteen days reviewed for staffing. This failure has the potential to affect all 33 residents in the facility. Findings include: The facility Nurse Schedule (May 2022) documents the facility did not have any Registered Nurse working anytime on 5/1/2022, 5/8/2022, and 5/15/2022. The same schedule documents no Registered Nurse is scheduled to work in the facility on 5/22/2022 and 5/29/2022. On 5/15/2022 at 10:58AM, V2 (Director of Nursing) reported the facility did not have any Registered Nurse working any hours on the above days. V2 reported the facility only has one part-time Registered Nurse. The facility Resident Census and Conditions of Residents report (5/16/2022) documents 33 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145466 If continuation sheet Page 6 of 10 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 145466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Twin Lakes Extended Care 310 Eads Avenue Paris, IL 61944 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview, and record review, the facility failed to post required nursing staffing information. This failure has the potential to affect all 33 residents in the facility. Residents Affected - Many Findings include: On 5/17/2022 at 11:02AM, V2 (Director of Nursing) reported the required nurse staffing information was posted for view in the North Hall. On 5/17/2022 at 11:02AM, Daily Nursing Staffing sheets (4/27/2022-5/17/2022) were located at standing eye level in a plastic sheet protector hanging from a hook on the wall in North Hall, an area not readily accessible to all residents and visitors. All of the sheets were reversed, with the blank side of the sheets facing outward to the viewer, and no indication anywhere of the reversed sheets containing the required nurse staffing information. None of the staffing sheets contained a resident census number. V2 reported the facility staffing information has always been hung on the wall as above. The facility Resident Census and Conditions of Residents report (5/16/2022) documents 33 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145466 If continuation sheet Page 7 of 10 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 145466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Twin Lakes Extended Care 310 Eads Avenue Paris, IL 61944 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview and record review the facility failed to identify specific behaviors and targeted nonpharmacological interventions to warrant the use of psychotropic medications and failed to complete psychotropic medication assessments for one of five residents (R29) reviewed for unnecessary medications in the sample list of 20. Findings include: R29's Diagnosis List documents R29's diagnosis include Dementia, Depression, Anxiety and Psychotic Disorder. R29's May 2022 Physician's Orders document an order for Trazodone (antidepressant) 50 milligrams (mg) by mouth daily, an order for Lorazepam (antianxiety) 1 mg by mouth three times daily, and an order dated 2/24/22 for Seroquel (antipsychotic) 100 mg by mouth daily. R29's February 2022 Behavior Tracking documents R29 takes Ativan (Lorazepam), Trazodone, and Zoloft (antidepressant), and R29's targeted behavior is episodes of tearfulness. This form does not document behavior tracking for R29's obsessive compulsive behaviors or what nonpharmacological interventions to use in response to the behaviors. R29's Nursing Notes document the following. On 2/9/22 at 12:20 PM R29 had obsessive compulsive of constantly washing R29's hands. New orders implemented to increase Zoloft to 150 mg. On 2/18/22 at 5:08 AM R29 had obsessions over R29's clothing and refused to dress and come out of R29's room. On 2/19/22 at 1:55 AM R29 requested staff dress R29, and R29 was reminded to dress R29's self first as much as possible. On 2/20/22 at 7:00 PM R29 was yelling at staff and throwing R29's hands in the air. R29 was provided one to one, allowed to vent, and R29's mood and behavior improved. On 2/21/22 at 10:45 AM R29 was crying because R29 was out of incontinence briefs, R29 ripped decorations off of R29's wall, and cursed at R29's spouse. R29 was assured that the facility had more incontinence briefs and instructed on deep breathing exercises. R29 seemed calmer and came out for breakfast. On 2/22/22 at 3:00 PM R29 was tearful due to spouse not having someone to help cook at home, and R29 was allowed to vent and provided TLC (Tender Loving Care.) On 2/25/22 at 8:40 AM Seroquel was added due to outbursts, tearfulness, and periods of mania. R29's Pre-Psychoactive Medication Record dated 2/24/22 documents R29's medication changed from Zoloft to Seroquel related to Bipolar. The area to record non-medication approaches or interventions that have proven to be ineffective is left blank, and the reason/targeted behavior for the use of Seroquel is documented as Bipolar with mania and does not identify R29's specific behaviors. There are no documented assessments for the use of Trazodone in R29's medical record in the last 6 months. On 5/17/22 at 2:40 PM V2 Director of Nursing stated psychotropic medication assessments are completed quarterly, and V2 provided all of R29's psychotropic medication assessments that V2 could locate. V2 stated R29 began taking Seroquel for obsessive behaviors that included cleaning, sweeping, and changing clothes. V2 stated behaviors and interventions are documented in behavior tracking and nursing notes. V2 confirmed R29's pre-psychotropic medication assessment for Seroquel and February behavior charting/tracking does not document specific targeted behaviors and nonpharmacological interventions that were ineffective prior to initiating Seroquel. The facility's policy Psychotropic Medication Policy revised 11/28/17 states Residents who receive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145466 If continuation sheet Page 8 of 10 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 145466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Twin Lakes Extended Care 310 Eads Avenue Paris, IL 61944 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 0758 Level of Harm - Minimal harm or potential for actual harm antipsychotic drugs shall receive gradual dose reduction and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Any resident receiving psychotropic medications will be reviewed at minimum of every quarter by the interdisciplinary team. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145466 If continuation sheet Page 9 of 10 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 145466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Twin Lakes Extended Care 310 Eads Avenue Paris, IL 61944 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 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. Based on observation, record review and interview the facility failed to conduct periodic safety inspections of side rails in use for six residents (R20, R11, R184, R19, R22, and R28) of seven residents reviewed for side rails in a sample of 20 residents. Findings Include: Physician's Order Sheets for R20, R11, R184, R19, R22, and R28 dated 5/1/22 through 5/31/22 include physician's orders for half side rails to enable residents to assist with bed mobility. On 5/17/22 at 11:00AM R22 was not in her bed, but the half side rails were up and in place to both sides of the bed. The rails were attached loosely to the bed by only the adjustment handle in the center of the rails. The rail could be turned in a complete circle by gentle pressure to either end of the rail. On 5/17/22 at 10:45AM V6, Maintenance Director stated, do spot checks on the side rails, but I can't find the check list for every bed that has rails. On 5/17/22 at 11:00AM V3, Administrator in training stated, We don't have any documentation to support the periodic audits for side rails. There were no side rail safety audits provided for R20, R11, R184, R19, R22, and R28. The facility's policy Determining Need for Use of Bed Rail reviewed September 2019 states Zone assessments for the enablers will be conducted at the time they are placed on the bed and at least annually. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145466 If continuation sheet Page 10 of 10