Health inspection·May 18, 2023

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 observation, interview and record review the facility failed to develop a comprehensive care plan for four of 12 residents (R15, R16, R21, R33) reviewed for care plans in the sample list of 22. Residents Affected - Some Findings include: The facility's Comprehensive Care Planning policy with a revised date of 11/1/17 documents, It is the policy of (the facility) to comprehensively assess and periodically reassess each Resident admitted to this facility. The results of this Resident assessment shall serve as the basis for determining each Resident's strengths, needs, goals, life history and preferences to develop a person centered comprehensive plan of care for each Resident that will describe the services that are to be furnished to attain or maintaining the resident's highest practicable physical, mental, and psychosocial well-being. Components of the CPC (Comprehensive Care Plan) may include: e. Care Plan - Plan of care describing a need/problem and indicating approaches/interventions to be instituted to assist the Resident in maintaining/receiving care in relation to the need/problem. 1.) R15's Medication Administration Record (MAR) dated 5/1/23 through 5/31/23 documents diagnoses including Rhabdomyolysis, Cellulitis of Unspecified Part of Limb, Localized Edema, Hypokalemia, Other Specified Infestations, Type 2 Diabetes Mellitus, Essential Hypertension and Hyperlipidemia. This MAR documents an admission date of 4/20/23 (28 days ago) and documents orders for blood glucose monitoring four times a day, oral Diabetic medications (Metformin and Onglyza), Insulin (Basaglar), oral Hyperlipidemia medications (Fenofibrate and Rosuvastatin), BPH (Benign Prostatic Hypertrophy) medication (Tamsulosin), diuretic (Furosemide) and Potassium Chloride. R15's Care Plan with a revision date of 4/27/23 only documents R15 is a high fall risk and R15 had an actual fall. On 5/17/23 at 12:13 PM, V16 Care Plan Coordinator confirmed R15 does not have a comprehensive care plan in place and stated R15 should have a comprehensive care plan in place at this time. 2.) R21's MAR dated 5/1/23 through 5/31/23 documents diagnoses including Dehydration, Muscle Weakness, Need for Assistance with Personal Care and Dysphagia. R21's Registered Dietician Notes dated 3/6/23 by V21 Dietician document a noted significant weight gain of 11% (16 pounds) in three months. This note documents R21 is on a regular, mechanical soft diet. R21's Nurse's Notes dated 5/17/23 document V2 Director of Nursing had a conversation with the family regarding R21's decline in condition. This note documents V2 discussed with R21's family that R21 is now having some swallowing difficulties at times. On 5/17/23 at 2:27 PM, V2 Director of Nursing stated that R21 has had a steady decline lately and hasn't wanted to get out of bed for meals. R21's Care Plan with a revision date of 5/1/23 does not address R21's diet orders or significant weight gain or R21's increased need for assistance during meals. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145466 If continuation sheet Page 2 of 9 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 05/18/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3.) R16's Physician Progress Note dated 5/3/23 documents Chief complaint/Reason for visit: Wound on Left Knee. Diagnosis: Pressure Ulcer. Assessment and Plan: Recommend bordered foam to area to avoid further pressure. Replace every three days or as needed if soiled. On 05/17/23 at 10:13 AM Observed R16's Left Inner Knee Pressure Ulcer. V13 Licensed Practical Nurse (LPN) completed the dressing change. R16's Left Inner Knee Pressure Ulcer was dark red with three dark yellow dry areas in the center. R16's Left Inner Knee Pressure Ulcer did not have a bandage covering the area. On 5/17/23 at 10:20 AM V13 Licensed Practical Nurse (LPN) stated (R16's) Left inner Knee wound appeared to be a bug bite at first but now they (facility) called it a pressure ulcer. V13 stated I hadn't seen it for about a week because I was off work, but it looks like it has gotten worse. R16's Care Plan does not include a focus area, goal nor interventions for R16's Left Inner Knee Pressure Ulcer. On 05/17/23 at 11:30 AM V16 stated (R16) does have a pressure ulcer on (R16's) Left Inner Knee. (R16's) pressure ulcer should have been included on (R16's) comprehensive careplan and was not. 4.) R33's Nurse Progress Note dated 4/26/23 at 10:41 AM documents Skin Evaluation: Skin Issue: Pressure Ulcer / Injury. Skin issue location: Right Ankle Pressure Ulcer / Injury Stage: Stage II - Partial thickness skin loss. Length: 3.0 centimeters (cm) Width: 2.0 cm Depth: 0.1 cm. R33's Skin Only Evaluation dated 5/4/23 documents a Right Ankle Stage 2 Pressure Ulcer as having partial thickness skin loss with painful with purulent tan and yellow drainage. This same evaluation did not document measurements. R33's Care Plan does not include a focus area, goal nor interventions for R33's Right Ankle Pressure Ulcer. On 5/15/23 at 7:35 AM Observed R33's Right Inner Ankle with a quarter sized dry intact dark brown/black scab. Another smaller dime sized area was just lateral to the larger area still on R33's Right Inner Ankle. No dressing was noted on R33's Right Ankle or in the bed linen. On 05/15/23 at 7:30 AM R33 stated I fell at home and broke my Right Ankle in two areas. After I had my surgery, I came here. R33 stated I have a pressure ulcer on my Right Ankle from where the cast rubbed. I think it has gotten worse since they (staff) first noticed it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145466 If continuation sheet Page 3 of 9 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 05/18/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete wound treatments for one of four residents (R5) reviewed for wound care in the sample list of 22 residents. Residents Affected - Few Findings include: R5's Medication Administration Record dated 5/1/23 through 5/31/23 documents diagnoses including Age Related Physical Debility, Cerebral Palsy, Functional Urinary Incontinence and Mental Disorder. R5's Nurse's Note dated 4/25/23 at 9:40 AM by V16 Wound Nurse documents R5 has MASD (Moisture Associated Skin Damage) to the buttocks and R5 was seen by the Wound Physician. R5's Minimum Data Set (MDS) dated [DATE] documents R5 had MASD. R5's Wound Assessment and Plan dated 4/4/23 by V22 Wound Nurse Practitioner, documents Wound Type as MASD and a treatment order to cleanse area, pat dry well, Zinc Barrier Cream 20% or greater, apply every shift and as needed and every half day cleanse wound with normal saline or sterile water, apply to wound bed, cover with dry clean dressing and as instructed, (disinfectant/antiseptic). R5's Treatment Administration Record (TAR) dated 4/1/23 through 4/30/23 documents an order with a start date of 4/5/23 at 6:00 PM and a discontinue date of 4/8/23 for the Sacrum: Cleanse wound with normal saline or sterile water- Apply to wound bed, cover with dry clean dressing, every shift. This TAR then documents an order with a start date of 4/9/23 for the Sacrum: Cleanse wound with normal saline or sterile water- Apply to wound bed, cover with dry clean dressing. everyday shift -Start Date- 4/08/2023 and a D/C (discontinue) Date- 4/12/2023. This treatment was not signed off as completed on 4/8/23 or 4/12/23. R5's Wound Assessment and Plan dated 4/11/23 by V22 documents the Wound Type as MASD and documents a treatment order to cleanse area, pat dry well, zinc barrier cream 20% or greater, apply every shift and as needed and twice a day cleanse wound with normal saline or sterile water, apply to wound bed, cover with dry clean dressing and as instructed. R5's TAR dated 4/1/23 through 4/30/23 does not document the 4/11/23 order. There is no treatment documented after 4/11/23. R5's Wound Assessment and Plan dated 4/18/23 by V22 documents the wound type as MASD to the Sacrum and documents a treatment order to cleanse area, pat dry well, zinc barrier cream 20% or greater, apply every shift and as needed and every twice a day cleanse wound with normal saline or sterile water, apply to wound bed, cover with dry clean dressing and as instructed, (gel forming moisture-retentive dressing), change as indicated and as needed. R5's TAR dated 4/1/23 through 4/30/23 does not document this order as being written or completed. R5's Wound Assessment and Plan dated 4/25/23 by V22 documents the Wound Type as MASD and documents a treatment order to cleanse area, pat dry well, zinc barrier cream 20% or greater, apply every shift and as needed and twice a day cleanse with normal saline or sterile water, apply to wound bed and cover with dry clean dressing and as instructed. R5's TAR does not document this order as being written or completed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145466 If continuation sheet Page 4 of 9 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 05/18/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R5's Wound Assessment and Plan dated 5/16/23 by V22 documents the Wound Type as MASD and documents a treatment order to cleanse area, pat dry well, skin barrier cream/ointment, apply every shift and as needed and twice a day cleanse wound with normal saline or sterile water, apply to wound bed, cover with dry clean dressing and as instructed. R5's TAR dated 5/1/23 through 5/31/23 documents an order with a start date of 5/16/23 to cleanse area. Pat dry well. Skin barrier cream/ointment-apply every shift and as needed for MASD. R5's TAR does not document that this has been completed. There are no signatures on the dates to indicate the treatments were completed. On 5/18/23 at 12:20 PM, V2 Director of Nursing confirmed the orders are not entered correctly according to V22's orders. V16 Wound Nurse confirmed that V22's orders are documenting things that are not getting completed. The facility policy titled 'Skin Conditioning Monitoring' revised 3/16/23 documents it is facility policy to provide proper monitoring, treatment and documentation of any resident with skin abnormalities. Upon notification of a skin lesion, wound, or any other skin abnormality, the nurse will assess and document the findings in the nurses notes and complete a skin evaluation. The treatment order will include type of treatment, location of area to be treated, frequency of how often treatment is to be performed, how area is to be cleansed and stop date if necessary. Any skin abnormality will have a specific treatment order until area is resolved. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145466 If continuation sheet Page 5 of 9 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 05/18/2023 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 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 transcribe physician orders and complete wound treatments and pressure risk assessments for one of four residents (R33) reviewed for wound care in a sample list of 22 residents. Residents Affected - Few Findings include: R33's undated Face Sheet documents an admission date of 3/17/23 with medical diagnoses of Displaced Bimalleolar Fracture of Right Lower Leg, Atrial Fibrillation and Congestive Heart Failure. R33's Pressure Ulcer Risk assessment dated [DATE] documents R33 as high risk for skin breakdown. R33's Medical Record does not document any further Pressure Ulcer Risk Assessments after R33's Stage 2 Right Inner Ankle Pressure Ulcer was identified on 4/25/23. R33's Skin Only Evaluation dated 4/26/23 documents a Right Inner Ankle Stage 2 Pressure Ulcer measuring 3.0 centimeters (cm) long by 2.0 cm wide by 0.1 cm deep. This same evaluation documents R33's Stage 2 Right Inner Ankle Pressure Ulcer was first noted at the Physician office after cast removal. R33's Skin Only Evaluation dated 5/4/23 documents a Right Ankle Stage 2 Pressure Ulcer as having partial thickness skin loss with painful purulent tan and yellow drainage. This same evaluation did not have measurements. R33's Nurse Progress Note dated 5/4/23 at 9:26 AM documents (R33) seen by (V17) Wound Physician. New orders to Inner Ankle on Right R33's Nurse Progress Note dated 5/8/23 at 5:18 PM documents (R33) seen by (V18) Family Nurse Practitioner (FNP). FNP would like the dressing to pressure wound on Right Ankle changed daily instead of every other day. R33's Skin Only Evaluation dated 5/11/23 documents a Right Ankle Stage 3 Pressure Ulcer as measuring 2.5 cm long by 1.5 cm wide by no depth documented with full thickness skin loss. R33's Physician Order Sheet (POS) dated April 1-30, 2023, and May 1-31, 2023, does not document physician orders for treatment of R33's Right Inner Ankle Pressure Ulcer. R33's Treatment Administration Records (TAR) dated April 1-30, 2023, and May 1-31, 2023, do not document any treatment orders for R33's Right Ankle Pressure Ulcer. R33's Care Plan does not include a focus area, goal nor interventions for R33's Right Ankle Pressure Ulcer. On 05/15/23 at 7:30 AM R33 stated I fell at home and broke my Right Ankle in two areas. After I had my surgery, I came here (facility). R33 stated I have a pressure ulcer on my Right Ankle from where the cast rubbed. I think it has gotten worse since they (staff) first noticed it. On 5/15/23 at 7:35 AM Observed R33's Right Inner Ankle with a quarter sized dry intact dark brown/black scab. Another smaller dime sized area was just lateral to the larger area still on R33's Right (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145466 If continuation sheet Page 6 of 9 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 05/18/2023 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 0686 Inner Ankle. No dressing was noted on R33's Right Ankle or in the bed linen. Level of Harm - Minimal harm or potential for actual harm On 05/17/23 at 1:45 PM V2 Director of Nurses (DON) stated any newly admitted resident or established resident that has pressure ulcers documented should have those wounds measured, documented, care planned, and Physician should be notified to obtain wound orders. We (facility) documented that (R33) had a Stage 2 Pressure Ulcer that worsened to a Stage 3 and we (facility) had no orders on the POS or TAR. That is terrible. I have no way to say if the treatments were even getting done. By the documentation, (R33's) Right Inner Ankle Pressure Ulcer was being measured but there was no other follow up. I have been trying to educate all the nurses on how to document a pressure wound. I can't say why the nurses didn't have treatment orders on the POS or TAR, but I do know that they (staff) have been educated on this many times before. It looks like I will have to re-educate again. Residents Affected - Few The undated facility policy titled 'Preventative Skin Care' documents all residents will be assessed using the pressure ulcer risk assessment at the time of admission and weekly for four weeks. Then will be reassessed at least quarterly and/or as needed. The facility policy titled 'Skin Conditioning Monitoring' revised 3/16/23 documents it is facility policy to provide proper monitoring, treatment and documentation of any resident with skin abnormalities. Upon notification of a skin lesion, wound, or any other skin abnormality, the nurse will assess and document the findings in the nurses notes and complete a skin evaluation. The treatment order will include type of treatment, location of area to be treated, frequency of how often treatment is to be performed, how area is to be cleansed and stop date if necessary. Any skin abnormality will have a specific treatment order until area is resolved. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145466 If continuation sheet Page 7 of 9 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 05/18/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm 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 maintain proper sanitation of serving utensils. This failure has the potential to affect all 36 residents residing in facility. Residents Affected - Many Findings include: Daily Census Report dated 5/15/23 documents 36 residents residing in facility. On 5/15/23 at 7:30 AM Observed the commercial coffee pot dripping brown liquid from the front of the spigot. The Coffee pot was sitting on the kitchen counter directly above an open utensil drawer. Coffee was dripping from the coffee pot directly into the utensil drawer onto the serving utensils. Multiple serving spoons in the drawer of various sizes were covered with small brown dry spots. The bottom of the drawer was splattered with dried brown spots. On 5/15/23 at 7:35 AM V6 Certified Dietary Manager (CDM) stated That coffee pot has been dripping into the utensil drawer ever since they (supplier) moved it to the counter. It used to sit somewhere else so we (staff) could put something under it to catch the drips. Now it just drips all day into the utensil drawers. We (staff) use those utensils all day long. I have seen staff using those utensils to dish out resident's food. I have to come up with a better plan. The facility policy titled 'Kitchen Sanitation' issued October 2014 documents the Food Service Manager will monitor sanitation of the Dietary Department on a daily basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145466 If continuation sheet Page 8 of 9 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 05/18/2023 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 0912 Level of Harm - Minimal harm or potential for actual harm Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation, interview and record review, the facility failed to provide bedrooms that measure at least 80 square feet per resident bed for 28 resident rooms 2,4-11, and 14-32. Residents Affected - Many Findings include: Historical room documentation and actual onsite measurements on 5/16/23 at 11:10 AM with V14 Maintenance Director, determine rooms 2, 4 through 11, and 14 through 32 are undersized, providing only 77.3 square feet per resident bed. The most recent Centers for Medicare and Medicaid Services Certification and Transmittal undated, documents 56 of the facility's 62 beds are certified Title 18 (Medicare) and/or Title 19 (Medicaid). Rooms 2, and 4 through 11 are double occupancy and dually certified for Medicare and Medicaid, while rooms 14 through 32 are double occupancy and certified for Medicaid. The facility's Daily Roster dated 5/14/23, documents 36 of these 56 certified beds are occupied by residents residing in the facility. On 5/16/23 at 11:20 AM, V1 (Administrator) stated, the rooms that we have waivers for not being the correct size are in the Annual Long Term Care Survey Information book. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145466 If continuation sheet Page 9 of 9