Health inspection·December 14, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R1 and R2 and observed R1 with his hand down the front of R2's pants and V3 reported the incident to V5 LPN. On 12/11/23 at 3:00PM V20 (R1's POA) stated the facility did not call him when they changed R1's medication on 9/11/23. V20 stated he did not know about the behaviors R1 displayed until he was called about the 11/18/23 incident. V20 stated he would have told the facility not to decrease R1's medication because this is why R1 was at the behavior facility before coming to this facility - to control (R1's) behaviors. V1, Administrator stated on 12/12/23 at 9:40 am Yes, V20 is correct we failed to call (V20) about the change in medication or the additional behaviors. The facility policy titled Notification for Change in Resident Condition or Status with the revision date of 12/7/17 states The facility and/or facility staff shall promptly notify appropriate individuals (i.e., Administrator, DON, Physician, Guardian, HCPOA, etc.) of changes in the resident's medical/mental condition and/or status. 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 12/14/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect the resident's right to be free from sexual abuse by another resident by failing to supervise a resident (R1) with known sexual behaviors from making non-consensual sexual contact with another resident (R2) and failed to protect other vulnerable residents (R4, R5), from inappropriate sexual behaviors by another resident (R1). These failures affect four (R1, R2, R4, R5) of eight residents reviewed for abuse in the sample list of eight residents. These failures resulted in (R1) having unrestricted access to (R2) resulting in (R2) being sexually abused by (R1). Based on V17's (R2's Power of Attorney) statement that R2 would have been angry, upset, sad and would have fought back if R2 did not have Dementia it can be determined that R2 would have experienced psychosocial harm (e.g., embarrassment, humiliation, anxiety) because of the sexual abuse. These failures also resulted in R4 experiencing psychosocial harm as evidenced by V18 (R4's Power of Attorney) stating R4 was withdrawn, feared R1, and had increased anxiety after being harassed by R1. The Immediate Jeopardy began on 9/9/23 when R1 began to display sexually inappropriate behaviors and no interventions or increase in supervision were implemented by the facility. V1 Administrator was notified of the Immediate Jeopardy on 12/12/23 at 2:02 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 12/12/23, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the Abuse in-service training. Findings include: The Facility Reported incident dated 11/27/23 at 2:30 PM documents on 11/18/23 at 10:00 AM that, (V3 Housekeeper) noticed that (R1) and (R2) were sitting together very closely in the TV (television) Lounge. (V3) observed (R1's) hand down the front of (R2's) pants. R1's admission assessment dated [DATE] at 2:40 PM, documents R1 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Seizures, Tremors, Hypertension, Heart Failure, and Psychosis. This assessment documents R1 is alert to person and place. This assessment did not document any behaviors for R1. R1's Behavior Notes document the following: 9/9/2023 at 10:55 AM, written by V5 Licensed Practical Nurse (LPN), (R1) Attempted to grab staff inappropriately when being taken down to the dining room for lunch time. 9/9/2023 at 10:59 AM, written by V5 LPN, Staff alerted me resident (R1) had pulled his private parts out et (and) stated, 'come play with this baby.' 9/10/2023 at 9:04 AM, written by V5 LPN, (R1) Inappropriateness towards staff before et after breakfast. 9/12/2023 at 3:02 AM, written by V10 LPN, (R1 continues) to be inappropriate with staff during HS (hour of sleep). Tries to grope staff members while they are at desk charting. Constantly being told, 'No, that's inappropriate et. Let's not be doing that.' (R1) cont. (continues) to have smile on face and cont. to advance towards staff. Redirection unsuccessful. (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 12/14/2023 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 0600 R1's Psychiatry note dated 10/2/23 documents R1 also has the diagnosis of Inappropriate Sexual Behavior. Level of Harm - Immediate jeopardy to resident health or safety R1's Care Plan with an initiation date of 9/20/23 does not document interventions for R1's sexual behaviors. Residents Affected - Few 10/5/2023 at 11:10 PM, written by V11 RN (Registered Nurse), (R1) attempted to get in (R4's room) several times. Entered (R4's) room et approached bed 2. (R4) yelled for (R1) to get out. (R1) redirected out of room. R1's Behavior Notes document the following: 10/6/23 at 4:25 PM, written by V5 LPN, (R1) Keeps following (R4) into rooms, dining rooms even after (R4) doesn't want him to follow (R4) or be around (R4). 10/6/2023 at 4:27 PM, written by V5 LPN, (R1) playing with (R4's) hair and (R4) screamed not wanting to be bothered. R1's Alert Note dated 10/7/2023 at 12:24 PM, written by V5 LPN documents, (R1) went into (R4's) room around 10:40 PM, woke (R4) up by trying to touch (R4), (R4) yelled no and for him to get out. CNA (Certified Nursing Assistant) removed him from the room and asked him to stop, that's a lady's room and to go back to his own room. R1's Behavior Note dated 10/7/2023 at 12:25 PM, written by V5 LPN documents, (R1) keeps following (R4) around after meals, scaring (R4) and (R4) is yelling out loud. We have asked him to leave (R4) alone, removed him from the area, removed (R4) from the area, he still wheels himself to where (R4) is located. R1's Care Plan with an initiation date of 9/20/23 does not include any new interventions for R1's behaviors towards R4. R4's Care Plan with an initiation date of 3/22/23 documents R4 has a diagnosis of Dementia and has impaired safety awareness. This care plan also documents that R4 has impaired decision making, and long and short-term memory loss. On 12/11/23 at 6:00 PM (V18) R4's Power of Attorney (POA) stated, The facility did not tell her about R1 coming into R4's room and touching her leg. V18 stated They (facility) called me and asked if they could increase her medication due to 'social anxiety.' That would have been right after (R1) came into her room. (R4) was very withdrawn after that. When I would visit (R4), she would hide behind me whenever (R1) came around her. You could tell (R4) was scared of (R1) and now that explains why. I started visiting more often because I thought something was going on. That explains it. (R4) has advanced Dementia. (R4) was married to my dad. (R4) would never allow any other man to touch her in an intimate way. (R4) would be ashamed of something like that happening. It would devastate her. (R1) would come up to (R4) and say, 'there's my girl' and (R4) would try to back away from (R1). (R1) was on her like a magnet. (R1) just couldn't stop trying to be around her. R1's Behavior Note dated 11/15/2023 at 3:26 PM, written by V5 LPN documents, Trying to touch another (R5's) buttocks as they were walking in front of (R1). (R5) said 'hey stop that,' as he (R1) smiled and rolled away. (continued on next page) 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 12/14/2023 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 0600 R1's Behavior Note dated 11/18/2023 at 9:41 AM written by V5 LPN documents, Trying to follow (R5) and get (R5's) attention, (R5 stated) 'no sir or I will slap you.' (R1) left the area and walked away. Level of Harm - Immediate jeopardy to resident health or safety R1's Care Plan with an initiation date of 9/20/23 does not include any new interventions for R1's behaviors towards R5. Residents Affected - Few R5's Care Plan with initiation date of 11/8/23 documents R5 is alert and oriented. On 12/11/23 at 10:50 AM, R5 stated Oh yes. I remember that clearly. I was standing at the nurse's desk there by the dining room and that man (R1) wheeled up behind me and goosed me right on the bottom. The staff were at the nurse's desk and moved (R1) away. There was another time when (R1) wheeled up to me when I was sitting and eating lunch. I was sitting at my dining room table. The dining room was full of other residents. (R1) came up to me and started grabbing my arm trying to pull me away from the dining room table. R1's Behavior Note dated 11/18/2023 at 10:33 AM written by V5 Licensed Practical Nurse documents, (R1) was witnessed touching another resident (R2) inappropriately in the dining room/activity room. Escorted (R1) away from other (R2). The facility's Incident Investigation Form dated 11/18/23 at 10:19 AM, written by V5 LPN documents, I was alerted by (V3 housekeeper) that (R1) was touching another resident (R2). I went down and saw (R1) with his hand in (R2's) pants and he was rubbing back and forth in her pants. (R2) was just sitting there not doing or saying anything. On 11/30/23 at 11:14 am, V3 Housekeeper stated on the morning of 11/18/23 she was getting ready to clean the activity room and saw R1 standing really close to R2 and she thought that was strange, so she approached R1 and R2 and observed R1 having his hand down R2's pants. V3 stated she left the activity room and went to the nursing station and reported the incident to V5 LPN. V3 stated V5 came and told R1 that was inappropriate and to remove his hand from R2's pants. On 11/30/23 at 1:37 PM, V5 LPN stated on 11/18/23, V3 came to the front desk and stated R1 was doing something inappropriate to R2. V5 stated R1 had his hand down R2's pants. V5 stated R1's hand was inside R2's brief. R2's Care Plan with an initiation date of 3/29/23 documents R2 is cognitively impaired and requires total assistance for all daily living activities. On 12/11/23 at 12:40 AM, V17 (R2's POA) stated the facility called him and told him about the incident between R1 and R2. V1 stated R2 would be p***** (expletive) if she didn't have Dementia. V17 stated R2 would have been upset and sad and ready to get out of the facility. V17 stated R2 would have never consented to R1 doing that to her. V17 stated if R2 knew what was going on R2 would have fought back. On 12/11/23 at 9:10 AM, V1 Administrator in Training stated the facility was aware that R1 had inappropriate sexual behaviors prior to the sexual abuse incident with R2 on 11/18/23. V1 stated R1 had previous incidents with R4 that should have been reported to facility management. V1 stated R1 had attempted to touch R4 and R5 inappropriately prior to the 11/18/23 incident with R2. V1 stated I was shocked when I read the nurse progress notes and saw that (R1) had been harassing these other women (continued on next page) 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 12/14/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few (R4, R5) prior to (R1's) sexual abuse incident with (R2). We (facility) should have put (R1) on continual monitoring on 10/5/23 when (R1) tried to chase after (R4). We (facility) could have made some kind of medication changes or something. We (facility) didn't do anything about (R1's) behaviors towards other female residents. I did not know about them until I read all those progress notes yesterday (12/10/23). I was just shocked. On 12/11/23 at 10:00 AM, V12 Nurse Practitioner stated, The facility was aware of R1's inappropriate sexual behavior prior to 11/18/23 when R1 sexually abused R2. V12 stated This is an unfortunate situation. (R1) has had multiple episodes of inappropriate sexual behavior with other female residents (R2, R4, R5). (R1) should have been put on continual monitoring from the first event on 10/5/23. (R1) has exposed himself to other residents, (R1) has followed other female residents around, touched other female residents inappropriately and nothing was done until 11/18/23 when (R1) put his hands down (R2's) incontinence brief. V12 stated Our female Dementia residents are the most vulnerable in this facility. I was never informed of the previous two female residents (R4, R5) having been in incidents with (R1). (R1) should have been placed on continual monitoring from the first time that happened with (R4) on 10/5/23. You do not need a physician order to place someone on continual monitoring. The facility should have done that immediately when it happened on 10/5/23 when (R1) was found in (R4's) room touching (R4's) leg when (R4) was in bed. The facility really should have protected their vulnerable female residents better so this incident with (R2) may not have happened. The Immediate Jeopardy that began on 9/9/23 was removed on 12/12/23 when the facility took the following actions to remove the immediacy: 1. On 12/29/23, V25 Regional Director in-serviced V1 Administrator on the Abuse Prevention Policy and the importance of doing a thorough investigation on all allegations/incidents and the importance of ensuring that new interventions are being followed and are effective. 2. On 11/18/23 one to one supervision of R1 was implemented and remains in place and will continue until the Interdisciplinary team determines it is no longer necessary based upon review of resident's record, behavior monitoring and potential to abuse others or until R1 discharges from facility. 3. On 12/11/23, V1 Administrator initiated additional in-servicing on the Abuse Prevention Policy including types of abuse, identifying abuse and inappropriate behaviors, reporting abuse, and investigating abuse allegations. In-servicing also included the importance of one to one supervision, and the use of the communication book for new behaviors and interventions. 4. On 12/12/23, V6 Care Plan Coordinator reviewed R1's care plan and behavior tracking to ensure all identified behaviors are addressed and appropriate resident centered intervention are in place to prevent any further sexual behaviors. 5. On 12/12/23, V34 Social Service Director and V2 Director of Nursing identified residents at risk for abuse. Residents were determined to be at risk if BIMs (Brief Interview for Mental status) score was below 13 (moderately or severely cognitively impaired). V6 reviewed and updated the resident's care plans to ensure interventions are in place to prevent abuse. 6. On 12/12/23, V1 Administrator and V25 Regional Director in-serviced the Interdisciplinary team to review residents for changes in behaviors and to investigate and identify potential triggers prior to an incident, and to ensure that person centered interventions are developed and communicated to staff. (continued on next page) 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 12/14/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety 7. V1 Administrator confirmed on 12/12/23 that going forward the facility will discuss in daily morning meetings, residents who display new behaviors or increased behaviors, and a root cause analysis will be completed to determine potential triggers and individualized interventions will be developed. 8. On 12/12/23 V6 Care Plan Coordinator confirmed V6 will communicate new interventions to staff through use of the communication book. Residents Affected - Few 9. On 12/12/23 V1 confirmed the Interdisciplinary Team will review residents with behaviors in morning Quality Assurance meetings, and care plans, progress notes, behavior documentation and effectiveness of current interventions will be reviewed during weekly Behavior Quality Assurance Meetings. The facility presented an abatement plan to remove the immediacy on 12/12/23 at 5:17 PM. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions on 12/13/23 at 10:22 AM and 12/13/23 at 1:10 PM. The facility presented revised abatement plans on 12/13/23 at 11:56 AM and 12/13/23 at 1:36 PM, and the survey team accepted the abatement plan on 12/13/23 at 2:45 PM. 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 12/14/2023 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to follow its Abuse Prohibition Policy by failing to determine the risk of abuse for six of eight residents (R1, R2, R3, R4, R7, and R8) reviewed for abuse on the sample list of eight. Residents Affected - Some Findings include: The facility's Abuse Prevention Program with a Revision date of 11/28/2016 documents, Resident Assessment. As part of the resident social history assessment, staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of mistreatment, neglect, and abuse of these residents. On 12/11/23, R1, R2, R3, R4, R7, and R8's medical records nor care plan contained their risk for abuse. On 12/12/23 at 2:30 PM, V6 Care Plan Coordinator stated prior to 12/12/23 the residents' risk for abuse was not determined and was not added to the care plans. On 12/12/23 at 3:00 PM, V1 Administrator in Training stated the facility's Abuse Prevention policy does direct staff to identify residents' risk for abuse and stated that this has not been being done. 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 12/14/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review the facility failed to report allegations of resident to resident abuse to the Administrator for three (R1, R4, and R5) of eight residents reviewed for abuse in the sample list of eight. Residents Affected - Few Findings include: 1. R1's Behavior Note dated 10/6/2023 on 4:27 PM, written by V5 LPN documents, (R1) playing with (R4's) hair and (R4) screamed not wanting to be bothered. R1's Alert Note dated 10/7/2023 at 12:24 PM, written by V5 LPN documents, (R1) went into (R4's) room around 10:40 PM, woke (R4) up by trying to touch (R4), (R4) yelled no and for him to get out. CNA (Certified Nurse's Aide) removed him from the room and asked him to stop, that's a lady's room and to go back to his own room. R1's Behavior Note dated 10/7/2023 at 12:25 PM, written by V5 LPN documents, (R1) keeps following (R4) around after meals, scaring (R4) and (R4) is yelling out loud. We have asked him to leave (R4) alone, removed him from the area, removed (R4) from the area, he still wheels himself to where (R4) is located. On 12/11/23 at 3:00 PM, V1 Administrator stated the staff should have reported the incidents between R1 and R4 so that they could be investigated. V1 stated the staff did not report these incidents to her. 2. R1's Behavior Note dated 11/15/2023 at 3:26 PM, written by V5 LPN documents, Trying to touch another (R5's) buttocks as they were walking in front of (R1). (R5) said hey stop that, as he (R1) smiled and rolled away. On 12/11/23 at 3:00 PM, V1 Administrator stated the staff should have reported the incident between R1 and R5 so that it could be investigated. V1 stated the staff did not report this incident to her. 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 12/14/2023 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 0836 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. Based on observation, interview, and record review the facility failed to employ a full time licensed Administrator. This failure has the potential to affect all 33 residents residing in the facility. Findings include: The facility's census sheet provided by V1 Administrator in Training documents there are 33 residents residing in the facility. On 11/30/23 from 9:45 AM to 3:30 PM and on 12/11/23 from 9:00 AM to 3:00 PM, there was not a licensed Administrator in the facility. On 12/12/23 at 10:05 AM, V25 Corporate Licensed Nursing Home Administrator stated she is the Administrator for the facility since V1 is an Administrator in Training. V25 stated she is present in the facility 16 hours a week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145466 If continuation sheet Page 10 of 10