Inspection·January 4, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm R21's Fall Care Plan, initiated on 9/16/21, documents, Resident has risk factors that require monitoring and interventions to reduce potential for self-injury. This care plan has not been revised since 12/23/21 with the new interventions put into place for R21 for the falls that R21 has had since 7/2/22 - 11/29/22. On 1/3/22 at 3:55 PM, V1, Administrator, stated the Care Plans are not updated as they should be. Residents Affected - Some The Comprehensive Care Planning policy, dated 7/20/22, documents, 9. The Resident Care Plan may be kept electronically or in hard copy printed format. a. Problems, Goals and Interventions should include the date initiated for ease of reference. b. All intervention entries should include the date the care interventions was initiated by the staff as well as the date the intervention was added to the care plan if added after the original CP (Care Plan) date. 3. R23's MDS, dated [DATE], documents R23 is cognitively impaired and requires extensive assistance from staff for transfers. R23's Fall Risk Assessment, dated 12/7/21, documents R23 is at a high risk for falls. R23's Care Plan undated documents, Resident has risk factors that require monitoring and intervention to reduce potential for self injury. Resident has low cognitive score and does not understand safety needs. Risk factors include resident attempting to transfer self, as evidenced by past falls. It continues to document a low bed and tab alarm (an alarm to alert staff of resident attempting to self-transfer) was added as a fall prevention on 12/9/2022. The Facility's Fall Log, dated November 2022, documents R23 fell on [DATE] and 11/27/2022. It continues to document on 11/27/2022, R23 sustained an injury to her left forehead, elbow, and knee. R23's Progress Notes, dated 11/27/2022 at 2 AM, documents, (R23) on floor in room lying on back. Noted to have area to left forehead bleeding. 911 called at this time. R23's Progress Notes, dated 11/27/2022, further document R23 returned to the facility with a noticeable hematoma/laceration to her left orbital area and left elbow both of which had to be glued at the Emergency Room. R23's Care Plan does not include interventions for the falls on 11/16/2022 or 11/27/2022. Based on interview and record review, the Facility failed to revise resident's care plans to address resident's current needs for 5 of 12 residents (R1, R4, R11, R21, R23) reviewed for Care Plan revision in the sample of 21. Findings include: 1. R1's Face Sheet, undated, documents R1 was admitted to the facility on [DATE]. R1's Care Plan, dated 1/24/19, documents (R1) Mobility, impaired physical related to: diagnosis Osteoarthritis, history of multiple fractures to BLE (Bilateral Lower Extremities). Resident ambulates in wheelchair propelled by self. The Care Plan Interventions document Assist to transfer with (full body mechanical lift device), dependent, use gait belt for all transfers. The Care Plan documents (R1) has risk factors that require monitoring and interventions to reduce potential for self-injury. Risk factors include developmental delay, early onset dementia. Resident is non-weight bearing at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145478 If continuation sheet Page 2 of 19 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 145478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nokomis Hc & Senior Living 505 Stevens Street Nokomis, IL 62075 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some this time. Other resident specific information, resident is non-weight bearing, (full body mechanical lift device) for transfers, uses an immobilizer for left leg. Interventions: Review quarterly and PRN (as needed) resident's ADL (Activities of Daily Living), mobility, cognitive, behavior and overall medical status. IDT review of changes and needs with resident and/or responsible party (when choose to attend) during care plan. Discuss fall related information to review and revise plan as needed. Fall Risk Assessment quarterly and as needed with change in condition or fall status. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact (BIMS/Brief Interview for Mental Status is 15), and requires extensive assistance from one staff member for bed mobility, transfer, dressing, and bathing. R1's MDS documents R1 requires extensive assistance from two staff members for toilet use. On 12/27/22 at 10:25 AM, R1 stated, It takes two staff members to assist me in using the sit-to-stand device. On 1/3/23 at 2:00 PM, R1 stated, When I first came back from the hospital a long time ago, they were using the (full body mechanical lift device). I didn't really like it because it felt like I was just swinging, and it scared me. Now they are using the sit-to-stand device to get me up. They do have problems with it sometimes because I can't really put any weight on my legs, so I just sit in the sling. There have been times when it doesn't get me up enough, so they have to use the emergency button to put me back down. On 1/3/23 at 2:45 PM, V8, CNA (Certified Nursing Assistant), stated, We always use the Sit-To-Stand with (R1). I have only been here about a month, and we have used that since I have been here. I have noticed that she has been deteriorating lately while trying to use the sit-to-stand. She hasn't been as strong with it as she has before. I'm not sure why the Care Plan says to use the (full body mechanical lift). On 12/28/22 at 10:42 AM, R1 was assisted by V5, CNA, and V10, CNA, with a transfer from her bed to her wheelchair using a sit-to-stand device. V5 and V10 put the device's sling around R1, attached the straps to the lift device, and lifted R1 off her bed as R1 held the handles of the device. R1 appeared to be sitting in the sling as her legs were bent and not supporting her during the transfer. V10 operated the lift device as V5 held R1 as they moved her to her wheelchair. R1 was then lowered to her wheelchair. There was no gait belt used on R1 as documented as required in the Care Plan. R1 confirmed they do not use a gait belt on her, just the sling with belt around her. R1's Care Plan, dated 1/24/19, documents a full body mechanical lift device and a gait belt should be used for transfers. The Care Plan has not been updated since 2019. 2. R4's Face Sheet, undated, documents R4 was admitted to the facility on [DATE]. R4's Care Plan, dated 5/10/22, documents (R4) has risk factors that require monitoring and intervention to reduce potential for self-injury. (R4) has periods of weakness, does not understand need for safety and will attempt to transfer self. As evidenced by attempts to transfer self from chair to bed and bed to chair. Interventions: Review quarterly and PRN (as needed). Resident's ADL, mobility, cognitive, behavior and overall medical status. IDT review of changes and needs with resident and/or responsible party (when choose to attend) during care plan. Discuss fall related information to review and revise plan as needed (5/10/22). IDT review of function and referral to PT (Physical Therapy) as needed for change in function (5/10/22). IDT review and referral to OT (Occupational Therapy) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145478 If continuation sheet Page 3 of 19 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 145478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nokomis Hc & Senior Living 505 Stevens Street Nokomis, IL 62075 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some as needed for change in function (5/10/22). Remind resident to lock wheelchair brakes (5/10/22). Attempt to anticipate needs-toileting, hydration, hunger and provide cares before resident attempts to fulfill on own (5/10/22). Fall Risk Assessment quarterly and as needed with change in condition or fall status (5/10/22). It continues (R4) has mobility, impaired physical related to history of TIA (Trans Ischemic Attack). As evidenced by need for extensive assist with most ADL's and use of wheelchair for locomotion (5/10/22). Self-Care deficit: needs supervision and/or assist to complete ADL's. History of TIA (5/10/22). It continues (R4) has alteration in transfer ability. Unable to transfer independently related to diagnosis of TIAs, weakness. as evidenced by inability to stand independently (12/20/22). Interventions: Assess ability and need of adaptive/assistance equipment in safe and efficient manner, assist with transfer as necessary with staff assist of one, pivot with gait belt. Use gait belt with every hands-on transfer (12/20/22). R4's MDS, dated [DATE], documents R4 is cognitively intact (BIMS 15) and requires extensive assistance from one staff member for bed mobility, transfers, dressing, and personal hygiene and bathing. R4's MDS documents R4 requires extensive assistance from two staff members for toileting. R4 is always incontinent of both bowel and bladder. R4's admission Fall Risk Assessment, dated 4/26/22, documents R4 is a high fall risk (score of 12 with greater than 10 indicating a high fall risk). This is the only fall risk documented in R4's medical record. R4's Nurse's Note, dated 10/12/22 at 2:45 AM, documents, Resident observed on floor next to low bed at 2:00 AM. Resident obtained hematoma to right forehead. Ice pack applied for ten minutes, ROM (Range of Motion) WNL (Within Normal Limits) for resident. PERRLA (Pupils Equal Round Reactive Light Accommodation), grips equal. Vital Signs Temperature 97.9, Blood Pressure 132/80, Pulse 108, Respirations 18, SpO2 (Oxygen Saturation) 95% on 2 liters via NC (nasal cannula). The Facility's Fall Log, dated September 2022 and October 2022, documents R4 had falls on: 9/29/22, 10/6/22, 10/12/22, 10/16/22. The Facility's Quality Improvement Review, dated 10/7/22 at 10:00 AM, documents, QA (Quality Assurance) team met and reviewed previous fall. Root Cause: Attempting to ambulate, weakness. Intervention: Call don't fall sign. The Facility's Quality Improvement Review, dated 10/17/22 at 10:05 AM, documents, QA team met and reviewed previous fall. Root Cause: Attempting to self-transfer from wheelchair, slid off edge of wheelchair. Intervention: (Non-slip pad) under wheelchair cushion. On 12/27/22 at 10:15 AM, R4 stated, I have fallen a couple of times here. On 12/27/22 at 10:20 AM, a Call Don't Fall sign was seen posted on a wall in R4's room, R4 was sitting in his recliner, with his walker and wheelchair sitting next to his bed. R4's Care Plan was updated on 5/20/22. Since then, R4 has had four falls (as documented on the Fall Log) without any updates to the care plan or fall interventions until 12/20/22. There are no other nurse's notes regarding R4's falls seen in his medical record. The Facility's Comprehensive Care Planning Policy, dated 7/20/22, documents, It is the policy of (this Facility) to comprehensively assess and periodically reassess each resident admitted to this (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145478 If continuation sheet Page 4 of 19 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 145478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nokomis Hc & Senior Living 505 Stevens Street Nokomis, IL 62075 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. The Resident Assessment Instrument (RAI) shall be the guide utilized for all comprehensive assessments, care area assessments and care planning. It continues 9. The resident Care Plan may be kept electronically or in hard copy printed format. a. Problems, Goals, and Interventions should include the date initiated for ease of reference. b. All intervention entries should include the date the care intervention was initiated by the staff as well as the date the interventions was added to the care plan if added after the original Care Plan date. The Facility's Fall Prevention Policy, dated 10/2007, documents, Policy: To provide for resident safety and to minimize injuries related to falls, decrease falls and continue to honor each resident's wishes/desires for maximum independence and mobility. Procedure: 1. Conduct fall assessment upon admission, quarterly, with a significant change and after a fall. 2. Identify, on admission, the resident's risk for falls. Initiate appropriate individual intervention to prevent falls (e.g., 15 min visuals, body alarm, education, call light within reach, education, etc ), in accordance with why the resident may be at risk for falls. It continues 6. Documentation of any new interventions will be placed on the CNA assignment worksheet by the charge nurse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145478 If continuation sheet Page 5 of 19 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 145478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nokomis Hc & Senior Living 505 Stevens Street Nokomis, IL 62075 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 provide pressure relief and follow physician's orders to treat pressure ulcers for 1 of 1 resident (R14) reviewed for pressure ulcers in the sample of 21. Residents Affected - Few Findings include: The Facility's Weekly Wound Tracking, dated October 2022, documents on 10/4/2022, R14 acquired a Deep Tissue Injury (DTI) measuring 2 centimeters (cm) by (x) 1.1 cm to her left medial foot. R14's Minimum Data Set (MDS), dated [DATE], documents R14's cognitive skills are moderately impaired, requires extensive assistance for bed mobility, and has one stage 3 pressure ulcer. R14's Treatment Administration Record (TAR), dated December 2022, documents, 11/23/2022-Heel protectors on at all times. The initials are circled for the whole month of December 2022. On 1/03/23 at 1:55 PM, V4, Licensed Practical Nurse (LPN), was asked the meaning of circling initials on the TAR. V4 stated, I think they (heel protectors) would get dirty and sent to laundry. I just circled them on the TAR if they weren't on her. R14's Physician's Order Sheet (POS), dated 12/13/2022, documents, Apply Medi-Honey to left foot/heel and cover with dry dressing every day. On 12/28/2022 at 2:45 PM, V1, Administrator, stated R14 was admitted to the facility in July 2020, with no open areas/impaired skin. V1 stated R14 acquired the open area to R14's left heel while at the facility. On 12/29/2022 at 11:15 AM, R14 was not wearing heel protectors. There was no dressing on R14's left foot pressure ulcer. V6, Certified Nursing Assistant (CNA), verified there was no dressing to R14's left medial foot. V6 stated, There's nothing on it, just a hole. V6 did not know how long R14's dressing had been off. On 12/29/2022 at 1:15 PM, V9,LPN, stated, I have not done treatments yet today. I have had order upon order, and now I'm getting an admit. R14's left heel treatment had not been completed. On 1/4/2023 at 9:09 AM, V1 stated she would expect staff to follow doctor's orders regarding the heel protectors and treatment orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145478 If continuation sheet Page 6 of 19 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 145478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nokomis Hc & Senior Living 505 Stevens Street Nokomis, IL 62075 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to investigate to determine a root cause of the falls, failed to implement progressive interventions based upon root cause to prevent future falls, failed to provide supervision to prevent elopement, and failed to provide safe transfer techniques to prevent injury for 5 of 13 residents (R1, R20, R21, R23, R30) reviewed for accidents/supervision in the sample of 21. Findings include: 1. R20's admission Sheet, undated, documents R20 was admitted on [DATE]. R20's Physician Orders, dated December 2022, documents R20 has diagnoses of Dementia, falls, aggressive behaviors, diabetes, and seizures. R20's Minimum Data Set (MDS), dated [DATE], documents R20 is severely impaired cognitively, requires supervision of 1 staff member for transfer and bed mobility. R20's Care Plan, dated 9/13/22, documents, Resident has risk factors that require monitoring and intervention to reduce potential for self-injury. Risk factors include unsteady gait and inability to understand safety limitations, will transfer self and walk independently. Interventions, dated 9/13/22, Observe for unsteady / unsafe transfer or ambulation and provide stand by or balance support as needed. Intervention, dated 12/16/22, Resident will have a Call don't Fall Sign in room. Intervention, dated 12/20/22, (non-slip pad) in wheelchair. Intervention, dated 12/28/22, Resident in low bed with side rails. The Facility Fall log documents R20 fell on [DATE] at 10:10 AM in the hallway, resulting in a bruise to the scalp and she was sent to the hospital. R20's Initial Report with Final Investigation, dated 10/3/22, documents R20 pinched R28, R28 shoved R20, and R20 fell backwards and hit her head. The root cause was confusion and unaware of resident's boundaries. The Facility Fall log documents R20 fell on [DATE] at 10:42 AM in her room. R20's Nurse's Note, dated 12/16/22 at 5:36 PM, documents, Res (resident) fell at 10:42 AM in bedroom (room #). Res was found sitting on buttocks on the floor with back facing the legs of reclining chair. It continues, As an intervention, (nonslick pad) will be put in reclining chair seat to help res. from sliding off seat. R20's Quality Assurance (QA) notes, dated 12/19/22, documents, QA (Quality Assurance) team met and reviewed previous fall. Root cause: Attempting to self-transfer; weakness; unaware of physical limitations. Intervention: Call don't fall sign. The Facility Fall log documents R20 fell on [DATE] at 3:18 PM in her room. R20's Nurse's Note, dated 12/20/22, documents, Res. fell at 3:18 PM in room (room number). Res on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145478 If continuation sheet Page 7 of 19 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 145478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nokomis Hc & Senior Living 505 Stevens Street Nokomis, IL 62075 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 0689 buttocks on ground in middle of floor. Level of Harm - Minimal harm or potential for actual harm R20's QA notes, dated 12/22/22, documents, QA team met and reviewed previous fall. Root cause: Slid from wc (wheelchair). Intervention: (Non-slip pad) in wc. This had been a previous intervention which was implemented on 12/16/22 to address the fall she had on that date. Residents Affected - Some On 12/28/22 at 11:05 AM, V8, Certified Nurse's Aide (CNA), and V10, CNA, attempted to transfer R20 with a full mechanical lift from her recliner to her wheelchair. R20 would not cooperate, and V8 and V10 decided transferring her with a partial mechanical lift would be safer. V10 placed the transfer belt around R20's waist. The belt was attached to the machine. R20 placed her hand on the transfer arms to hang on. V10 raised the machine. R20 was not supporting her own weight. The transfer belt raised up into R20's underarms. R20 was hanging from the transfer belt. On 12/28/22 at 2:00 PM, R20's room was entered. R20 is lying on the floor next to the bed. V18, Social Service Director, was notified. V18 got V13, MDS nurse, and V5, Certified Nurse's Aide (CNA), entered the room and assessed her. R20 was lifted with a mechanical lift and put in bed. On 12/28/22 at 2:10 PM, V5, CNA stated, I just put (R20) to bed not long ago. R20's QA notes, dated 12/29/22, documents, QA team met and reviewed previous fall. Root cause: Attempting to self-transfer; weakness; unaware of physical limitations. Intervention: Low Bed. R20's Nurse's Note, dated 1/2/23, documents, Res found in hallway on floor sitting up on bottom in front of wheelchair. No injuries noted. R20's QA notes, dated 1/3/23, documents, QA team met and reviewed previous fall. Root cause: Attempting to ambulate in wheelchair; slid out of wheelchair. Intervention: Offer to lay down between meals. On 1/3/23 at 9:46 AM, V4, Licensed Practical Nurse (LPN), stated R20 has had a decline recently. V4 stated R20 had a fall, and she has not been the same since then. V4 stated R20 does need help with transfers and eating. On 1/3/23 at 12:38 PM, V13, MDS/Care Plan Coordinator, was questioned about why she had not done a significant change MDS for R20. V13, stated R20 has had a significant decline recently. V13 stated, Well, I guess I could but, she was just up walking on Christmas. It was the Christmas miracle. On 1/4/22 at 9:11 AM, V1, Administrator, stated the partial mechanical lift transfer should be done only when the resident can bear at least partial weight on their legs. V1 further stated if staff feel a mechanical transfer is unsafe, it should be stopped. On 1/3/22 at 4:00 PM, V3, Resident Care Coordinator, (RCC), stated she agrees the fall investigations do not look at last time resident seen and when care when was provided last. V3 also stated she understands why the root cause should not be poor safety awareness or physical limitations. 2. R21's admission Profile, undated, documents R21 was admitted on [DATE]. R21's Physician Orders, dated December 2022, documents R21 has diagnoses of Alzheimer's Dementia and Anxiety. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145478 If continuation sheet Page 8 of 19 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 145478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nokomis Hc & Senior Living 505 Stevens Street Nokomis, IL 62075 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R21's Minimum Data Set, (MDS), dated [DATE], documents R21 is moderately cognitively impaired and is totally dependent on 2 staff members for bed mobility and transfers. R21's Fall Care Plan, initiated on 9/16/21, documents Resident has risk factors that require monitoring and interventions to reduce potential for self-injury. R21's Care Plan Goal, dated 12/15/21, documented (R21) will follow safety suggestions and limitation with supervision and verbal reminders for better control of risk factors thru next 90 days. The following Care Plan Interventions were initiated on R21's Care Plan as of 9/16/21: Discuss fall related information to review and revise plan as needed; Review quarterly and as needed during daily care and services of Resident's plan for safety , giving verbal cues as needed to gain resident participation in minimizing risk factors and injury, IDT (Interdisciplinary Team) review of function and referral to physical therapy as needed for change inf unction; IDT review of function and referral to Occupational therapy as needed for changes in function; Keep call light within reach at all times. Answer promptly and notify that help is coming; remind of safety precautions and limitation as necessary; Observe for non-verbal sings of restlessness that may precipitate movement and attempt to stand/walk unattended. The following Care Plan interventions were implemented on the following dates: 11/06/21 Slipper socks at HS (time of sleep); 11/22/21 Keep in high traffic area when up; 11/22/21 Place dycem in wheelchair (w/c); 11/26/21 Anti rollback place on w/c; and 12/23/21 Keep in visual while in dining room. There have been no further revisions to this care plan since 12/23/21. The Facility Fall log documents R21 fell on 7/2/22 at 9:40 AM in the common area. R21's Nurse's Note, dated 7/2/22 at 1:32 PM, documents, Res. (resident) found on buttocks in front of w/c (wheelchair) in TV (television) room at 9:47 AM. Res opened scab on L (left) elbow. R21's Quality Assurance (QA) Progress Notes, dated 7/5/22, documents, QA team met and reviewed previous fall. Root cause: Restless, unaware of physical limitations, reaching forward. Intervention: Encourage activities while up. There was no documentation available regarding if R21 was in an area of high traffic during the incident on 7/5/22. There was no documentation regarding if this was a witnessed event. The Facility's Fall Log documented R21 fell on 8/6/22 at 1600 in the hallway and sustained a laceration to her left eyebrow, and she was sent to the hospital. R21's Abnormal Skin Report, dated 8/6/22, at 4:00 PM, documents, Post Fall ER (Emergency Room). Findings: 9 sutures L (left) eyebrow line (above), bruising L eye, bruising L elbow, bruising Left inner upper arm. There was no documentation in R21's Nurse's Notes R21 was sent to the hospital. There was no documentation if R21's fall was witnessed, what occurred, and if she was in an area of high traffic where she was being observed by staff. R21's QA Progress Notes, dated 8/9/22, documents, QA team met and reviewed previous fall. Root cause: Restless, reaching to floor nothing observed on floor during assessment. Intervention: Resident to remain at nurses' station or in view of staff while up in wheelchair. The Facility's Fall log documented R21 fell on 8/28/22 at 12:15 in her room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145478 If continuation sheet Page 9 of 19 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 145478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nokomis Hc & Senior Living 505 Stevens Street Nokomis, IL 62075 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R21's Nurse's Note, dated 8/28/22 at 12:15 PM, documents, Resident in DR (dining room) in chair awaits staff to assist feed. Resident then 'falls to floor' per a witness. Resident falls forward, does not hit head. R21's QA Progress Notes, dated 8/29/22, documents, QA team met and reviewed previous fall. Root cause: Reaching for drinks across table, impulsiveness. Intervention: Nothing placed on table until meal tray is ready. The Facility's Fall Log documented R21 fell on 8/30/22 at 3:35 PM in the hallway. R21's Medical Record fails to document a Nurse's note for R21's fall on 8/30/22, what occurred, was staff present, and was she in within view of staff when this incident occurred. R21's QA Progress Notes, dated 8/31/22, documents, QA team met and reviewed previous fall. Root cause: leaning forward in wheelchair. Intervention: Therapy to eval (evaluate) for positioning. The Facility's Fall Log documented R21 fell on [DATE] at 8:30 PM in her room. R21's Nurse's Note, dated 11/3/22 at 8:30 PM, documents, On floor sitting upright on buttocks beside bed. R21's QA Progress Notes, dated 11/4/22, documents, QA team met and reviewed previous fall. Root cause: Attempting to self transfer from bed. Intervention: therapy to screen for positioning. The Facility's Fall Log documented R21 fell on [DATE] at 4:00PM in the dining room and sustained an injury to her left knee and forehead and she was not sent to the hospital. R21's medical record had no documentation how the fall occurred and if staff were present at the time R21 fell on [DATE]. R21's QA Progress Notes, dated 11/30/22, documents, QA team met and reviewed previous fall. Root cause: Unaware of physical limitations; leaning forward in wheelchair. Intervention Dycem pad placed in w/c under cushion; (click) alarm placed. R21's Care Plan documented the Dycem should have been an intervention implement as of 11/22/21. The Facility's Fall Prevention Policy, dated 10/2007, documents Policy: To provide for resident safety and to minimize injuries related to falls, decrease falls and continue to honor each resident's wishes/desires for maximum independence and mobility. Procedure: 1. Conduct fall assessment upon admission, quarterly, with a significant change and after a fall. 2. Identify, on admission, the resident's risk for falls. Initiate appropriate individual intervention s to prevent falls (e.g., 15 min visuals, body alarm, education, call light within reach, education, etc ), in accordance with why the resident may be at risk for falls. It continues 6. Documentation of any new interventions will be placed on the CNA assignment worksheet by the charge nurse. 3. R23's MDS, dated [DATE], documents R23 is cognitively impaired and requires extensive assistance from staff for transfers. R23's Fall Risk Assessment, dated 12/7/21, documents R23 is at a high risk for falls. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145478 If continuation sheet Page 10 of 19 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 145478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nokomis Hc & Senior Living 505 Stevens Street Nokomis, IL 62075 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R23's Care Plan undated documents, Resident has risk factors that require monitoring and intervention to reduce potential for self-injury. Resident has low cognitive score and does not understand safety needs. Risk factors include resident attempting to transfer self, as evidenced by past falls. Start Date: 11/11/22. The Care Plan Intervention, with start date of 11/11/22, documents Review quarterly and PRN (as needed) Resident's ADL, mobility, cognitive, behavior and overall medial status. IDT review of changes and needs with resident and/or responsible party (when choose to attend) during car plan. Discuss fall related information to revie and revise plan as needed. R23's Care Plan continues to document a low bed and tab alarm (an alarm to alert staff of resident attempting to self-transfer) was added as a fall prevention on 12/9/2022. The Facility's Fall Log, dated November 2022, documents R23 fell on [DATE]. R23's Care Plan was not revised after R23 fell on [DATE] The Facility's Fall Log documented R23 fell on [DATE]. It continues to document on 11/27/2022, R23 sustained an injury to her left forehead, elbow, and knee. R23's Progress Notes dated 11/27/2022 at 2 AM documents, (R23) on floor in room lying on back. Noted to have area to left forehead bleeding. 911 called at this time. R23's Progress Notes, dated 11/27/2022, further document R23 returned to the facility with a noticeable hematoma/laceration to her left orbital area and left elbow both of which had to be glued at the Emergency Room. R23's Care Plan was not revised after R23 fell on [DATE] with progressive interventions to prevent her from future potential falls/injury. The Facility's Fall Log, dated December 2022, documents R23 fell on [DATE], once at 3:45 AM, and again at 6:30 PM. On 12/27/2022 at 10:15 AM, R23 was observed in her wheelchair. R23 did not have a tab alarm attached to her person. On 12/27/2022 at 12:00 PM, V5, CNA, stated R23 has had a lot of falls. On 12/28/2022 at 12:00 PM, R23 was observed in the dining room in her wheelchair and did not have a tab alarm attached. On 12/28/2022 at 2:31 PM, R23 was observed in her room in her recliner and did not have a pull tab alarm attached. On 12/28/2022 at 2:45 PM, V5 verified R23 did not have a pull tab alarm attached or a low bed. At this time, V5 stated, I'll find her one. I think the battery stopped working. I think the pressure pad alarms are better because they alert you to their movement. These pull tabs just let you know when they fall. V5 then located a pull tab alarm attached to R23's bed and when tested, it alarmed, but very faintly. V5 also verified R23's bed was not a low bed. On 12/28/22 at 3:08 PM V5 stated, Just so you know, she (R23) now has a low bed in her room and a pressure pad alarm. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145478 If continuation sheet Page 11 of 19 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 145478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nokomis Hc & Senior Living 505 Stevens Street Nokomis, IL 62075 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 0689 4. R30's New admission Information, dated 12/1/22, documents R30 was admitted to the facility on [DATE]. Level of Harm - Minimal harm or potential for actual harm R30's Care Plan, dated 12/13/22, documents (R30) is known to wander, may seek to leave the home. Related to diagnosis include Dementia. Resident specific information: resident attempts to leave facility several times daily. Interventions: IDT (Inter-Disciplinary Team) review behavior plan quarterly and PRN (as needed) for changes in exit seeking/wandering. Share plan and risks factors with responsible party. IDT to assign risk level after assessment and resident will wear a (Security Anklet/Bracelet). Seek alternative/diversional activities for exit seeking behaviors. 1:1 close and constant or continuous visual monitoring when resident is agitated and not easily redirected from exits or wandering. Provide towels/washcloths to fold to allow feeling of usefulness and participation. It continues (R30) has impaired cognition results in wandering behavior. Related diagnosis Dementia. Behavior exhibited: walking through facility with no set destination, going into other rooms and elopement attempts. Interventions: Provide supervision, approach calmly, offer assistance and attempt to redirect. Assess level of elopement risk by identifying reason for leaving the unit, destination, and ability to return unassisted. Resident attempts to leave facility several times daily. Provide regular opportunities to go outdoors with supervision, assist as needed. Redirect when enters room of another resident. Intervene as needed with other residents to prevent altercation. Ask all staff to notify nursing if resident is found in other areas of the building and requires assistance to return. [NAME] the room with name, familiar object or picture. It continues (R30) has risk factors that require monitoring and interventions to reduce potential for self-injury. Risk factors include resident being unaware of safety limitations related to diagnosis/condition/history includes Dementia. Residents Affected - Some R30's MDS, dated [DATE], documents R30 has severe cognitive impairment and requires supervision for walking. R30's admission Fall Risk Assessment, dated 12/1/22, is not fully complete, however, the scores that are completed, documents R30 is a high fall risk. R30's admission Elopement Evaluation, dated 12/1/22, documents R30 is a high elopement risk. Interventions: visual checks every fifteen minutes, door alarm/bracelet/anklet, redirect common areas. Haldol 5 MG (milligram) IM (Intramuscular) and Ativan 2 MG IM ordered on 12/26/22 for agitation. R30's Nurse's Note, dated 12/2/22 at 2:00 PM, documents, At 5:30 AM, Resident pushed staff member who was attempting to escort her out of another resident's room. R30's Nurse's Note, dated 12/4/22 at 12:09 PM, documents, Resident refused AM (morning) medications, resident spit medications out at writer. Resident continues to be exit seeking, (Security Anklet/Bracelet) working. No s/s (signs/symptoms) of pain voiced/noted. R30's Nurse's Note, dated 12/10/22 at 1:58 PM, documents, Resident pulled fire alarm on Center Hall at approximately 9:50 AM. All protocols performed. Resident pulled fire alarm again at 1:43 PM, all protocols performed. Administrator and RCC (Resident Care Coordinator/V3) aware. Resident educated on importance of not using/pulling fire alarm. R30's Nurse's Note, dated 12/13/22 at 3:20 AM, documents, Resident pulled fire alarm around 11:40 PM. Resident exit seeking/anxious/agitated this shift. Resident complaint of back pain, at 2:35 AM writer administered PRN (as needed) Tylenol and was effective. Resident resting in room at this time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145478 If continuation sheet Page 12 of 19 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 145478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nokomis Hc & Senior Living 505 Stevens Street Nokomis, IL 62075 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R30's Nurse's Note, dated 12/14/22 at 1:00 PM, documents, Resident attempts to leave facility several times and redirected. R30's Nurse's Note, dated 12/17/22 at 9:00 AM, documents, Resident up and about. She has gone out the doors numerous times, redirected. Resident takes items (cups) off of med cart, tears papers off doors (Christmas decorations), continuous redirection. R30's Nurse's Note, dated 12/20/22 at 10:20 AM, documents, Resident continues to be exit seeking and aggression continues towards staff when redirected. Resident spit out AM medications at writer. No s/s of pain noted. R30's Nurse's Note, dated 12/23/22 at 5:20 AM, documents, Resident noted to be combative with care (toileting) this shift. Resident noted to be exit seeking times four this AM and combative when staff redirects. Staff tried redirecting, re-approaching, and changing staff members multiple times. Resident appears very anxious/wandering and pacing hallways. Resident currently resting in resident's room. R30's Nurse's Note, dated 12/24/22 at 12:13 PM, documents, Resident continues to be exit seeking and combative towards staff when being redirected. Resident with family member at this time and resident continues exit seeking behaviors. Resident c/o pain, PRN offered, and writer educated resident on med and what it was for and resident spit it out at writer. Resident took AM medications without difficulty but refused to use Flonase per order, writer re-approached multiple times in AM and refusal remains. On 12/27/22 at 11:35 AM, V6, CNA (Certified Nursing Assistant), stated, (R30's) ankle bracelet only goes off with the front door. Most of the time (R30) only gets to the sidewalk outside before we get her back in. We try to do one-on-one with her and then redirect her. I remember there was one Saturday where (R30) got out about eight or nine times, but usually it is only a couple times a day. On 12/28/22 at 1:25 PM, V1, Administrator, stated, The only thing we can do for (R30) is one-on-one with her. We are lucky and have an abundance of CNAs so we can assign one person to be with her each shift. She is still getting out a door, she is a handful. We have an anklet on her, but it does not work for all of the doors. I plan on calling one of our sister facilities to see if they would be willing to take her in a locked unit. I also plan on having a care plan meeting with (R30's) daughter and see if she is willing to transfer her. At this point, it is becoming a safety issue. I have nightmares about her disappearing and every time my phone rings I worry that it is the facility calling me about her. On 12/29/22 at 10:45 AM, V15, CNA, stated, I have been with (R30) all morning. At about 10:30 AM, (R30) was walking towards the front door, I was trying to stand in her way, but she pushed her way through me and opened the front door, setting off the alarm and other staff came to help me get (R30) back into the building. On 12/27/22 at 10:12 AM, Facility's North Hall door alarm went off, and R30 was seen walking quickly out the door to the outside with multiple staff running towards the door and was able to get to R30 and bring her back inside within a minute or two. On 12/27/22 at 11:30 AM, R30 was wandering around the facility, entering other resident's rooms and back out, has a (exit alarm anklet) around her left ankle. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145478 If continuation sheet Page 13 of 19 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 145478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nokomis Hc & Senior Living 505 Stevens Street Nokomis, IL 62075 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 12/27/22 at 12:45 PM, R30 was wandering around the facility, walking in/out other resident rooms, up and down the halls. No staff member was walking with or supervising R30. On 12/28/22 at 10:40 AM, R30 was wandering the halls and went into her room to sit down. V11, CNA, was assigned to be a one-on-one with R30; however, V11 came from the opposite hall and entered R30's room to check on her. On 12/28/22 at 12:18 PM, R30 pushed the Facility's front door open, and alarm went off. Staff quickly stopped R30 from exiting. On 12/29/22 at 1:49 PM, R30 was seen walking through a door at the end of her hallway which goes to another section of the building. There was no staff with R30. The alarm went off, but that alarm shuts itself off as soon as the door is closed. R30 walked around the back area, which is located by the Therapy Department, and then went straight to the outer door which exits to the outside and was next to the conference room the IDPH (Illinois Department of Public Health) Surveyors were in. R30 pressed open the outside exit door and the alarm sounded. There were no staff seen in the area at the time, so for resident safety reasons, the Surveyors stopped R30 from exiting out of the building. V16, PTA (Physical Therapist Assistant), arrived and came over to assist with R30. Once R30 pressed open the outside exit door and the alarm sounded. V6, CNA, came running into the area in a panic, and escorted R30 back to her hallway. On 12/29/22 at 2:20 PM, V1, Administrator, stated, Well, (R30) is supposed to have one-on-one and I'm not sure where that person is right now. I have already called (R30's) daughter and we have a Care Plan meeting with her tomorrow (12/30/22) at 11:00 AM, with regards to all of this, so hopefully we can do something for her. On 1/3/23 at 9:30 AM, V1, Administrator, stated, We had the Care Plan meeting last Friday (12/30/22) with (R30's Daughter) and we are all in agreement that (R30) needs to be transferred to a more secure facility. I sent three referrals to local area facilities and the first one said no, that (R30) would not be a good fit for them. I am still waiting for the other two to get back with me. I will follow-up today on these. For now, we are just doing one-on-one with (R30). On 1/3/23 at 9:40 AM, R30 sitting in her room by herself. There was no staff present supervising R30. The Facility's Elopement Prevention Policy, dated 10/2006, documents It is the policy of (Facility) to provide a safe and secure environment for all residents. To ensure this process, the staff will assess all residents for the potential for elopement. Determination of risk will be assigned for each individual resident and interventions for prevention be established in the plan of care to minimize the risk for elopement. It continues 8. Revision of the Elopement Risk Assessment will be completed quarterly, after an isolated elopement attempt, monthly for residents who attempt elopement more than five times per week, upon a resident's significant change in condition and as needed, determined by the IDT (Inter Disciplinary Team). 9. The plan of care for minimizing elopement risks will be reviewed each time the risk Assessment is completed with initials and dating of the care plan by any member of the IDT present for review. The Facility's Missing Resident Policy, dated 10/2006, documents It is the policy of (Facility) that reasonable precautions are taken to minimize the risks of resident elopement attempts. Reasonable precautions include, but are not limited to: door alarms, personal door alarm activation devices, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145478 If continuation sheet Page 14 of 19 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 145478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nokomis Hc & Senior Living 505 Stevens Street Nokomis, IL 62075 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 0689 Level of Harm - Minimal harm or potential for actual harm staff interventions, staff education regarding response to door alarms, and individual resident intervention. It is the policy of (Facility) to demand immediate response to elopement attempts, door alarm activation and participation in search attempts in the event that a resident is deemed missing. 5. R1's Face sheet, undated, documents R1 was admitted to the facility on [DATE]. Residents Affected - Some R1's Care Plan, dated 1/24/19, documents, (R1) Mobility, impaired physical related to: diagnosis Osteoarthritis, history of multiple fractures to BLE (Bilateral Lower Extremities). Resident ambulates in wheelchair propelled by self. Interventions: Assist to transfer with (full body mechanical lift device), dependent, use gait belt for all transfers. IDT (Inter-Disciplinary Team) to review for need for Physical Therapy, allow resident to actively participate in turning, repositioning, and transfers. Non-Ambulatory. Wheelchair for mobility, self-propels wheelchair. It continues (R1) has risk factors that require monitoring and interventions to reduce potential for self-injury. Risk factors include developmental delay, early onset dementia. Resident is non-weight bearing at this time. Other resident specific information, resident is non-weight bearing, (full body mechanical lift device) for transfers, uses an immobilizer for left leg. Interventions: Review quarterly and PRN (as needed) resident's ADL (Activities of Daily Living), mobility, cognitive, behavior and overall medical status. IDT review of changes and needs with resident and/or responsible party (when choose to attend) during care plan. Discuss fall related information to review and revise plan as needed. Fall Risk Assessment quarterly and as needed with change in condition or fall status. R1's MDS, dated [DATE], documents R1 is cognitively intact (BIMS/Brief Interview for Mental Status is 15) and requires extensive assistance from one staff member for bed mobility, transfer, dressing, and bathing. R1 requires extensive assistance from two staff members for toilet use. On 12/27/22 at 10:25 AM, R1 stated, It takes two staff members to assist me in using the sit-to-stand device. On 1/3/23 at 2:00 PM, R1 stated, When I first came back from the hospital a long time ago, they were using the (full body mechanical lift device). I didn't really like it because it felt like I was just swinging, and it scared me. Now they are using the sit-to-stand device to get me up. They do have problems with it sometimes because I can't really put any weight on my legs, so I just sit in the sling. There have been times when it doesn't get me up enough, so they have to use the emergency button to put me back down. On 1/3/23 at 2:45 PM, V8, CNA, stated, We always use the Sit-To-Stand with (R1). I have only been here about a month, and we have used that since I have been here. I have noticed that she has been deteriorating lately while trying to use the sit-to-stand. She hasn't been as strong with it as she has before. I'm not sure why the Care Plan says to use the (full body mechanical lift). On 12/28/22 at 10:42 AM, R1 was assisted by V5, CNA, and V10, CNA, with a transfer from her bed to her wheelchair using a sit-to-stand device instead of a full body mechanical lift as documented in R1's Care Plan. V5 and V10 put the device's sling around R1, attached the straps to the lift device, and lifted R1 off her bed as R1 held the handles of the device. R1 was sitting in the sling as her legs were bent and not supporting her during the transfer. V10 operated the lift device as V5 held R1 as they moved her to her wheelchair. R1 was then lowered to her wheelchair. There was no gait belt used on R1 as indicated in the Care Plan. R1 confirmed they do not use a gait belt on her, just the sling with belt around her. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145478 If continuation sheet Page 15 of 19 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 145478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nokomis Hc & Senior Living 505 Stevens Street Nokomis, IL 62075 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete The Facility's Specific Best Practice Transfer Guidelines, undated, documents Transfer Status: The transfer status will be noted on the Care Plan. A caregiver has the ability to increase the level of assistance at anytime if that caregiver feels that the resident is not safe to perform the noted transfer method on the Care Plan. It continues Combative and Mentally Impaired Residents: It is expected that in most situations, a combative or mentally impaired resident requiring a lift based on dependency needs can be lifted using the appropriate mechanical lifting aid device. Combative or uncooperative residents may require a particular resident due to their mental condition or behavior, that determination should be made by a member of the facilities professional staff and noted in the accessible records for that resident. Under such circumstances a specific plan for lifting and transferring that resident should be developed in advance, specifying the number and type of caregivers needed to assist. Event ID: Facility ID: 145478 If continuation sheet Page 16 of 19 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 145478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nokomis Hc & Senior Living 505 Stevens Street Nokomis, IL 62075 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 observation, interview, and record review, the Facility failed to provide a full time Director of Nursing (DON) and failed to provide a Registered Nurse (RN) 8 hours a day 7 days a week. This has the potential to affect all 29 residents in the facility. Findings include: During the survey, there was no Director of Nursing (DON) and no RN coverage. The Facility's Nursing Schedule for November and December 2022 were reviewed and documents there was no RN on duty the entire month of December. On 12/28/22 at 1:15 PM, V1, Administrator, stated, Our staffing matrix right now is one LPN (Licensed Practical Nurse) for Days and one LPN for Nights. We usually run with four to five CNAs (Certified Nursing Assistant) on each shift. On 12/28/22 at 1:20 PM, V1 stated, On the November Nurses Schedule, from the first through the fifteenth, the DON was the only RN working Monday through Friday. Our DON quit on us around 12/5/22. Since then, we have not had an RN working here, and we are having a hard time finding RNs. All of our current nurses are LPN's. We do have a Regional Nurse who will come in every now and then to help out, but as of now, we only have an LPN schedule because we only have LPN's. On 1/4/23 at 9:12 AM, V1 stated, I have tried to use Social Media, texts, emails and other means to ask nurses if they wanted to work here, and as of today, I still can't find anyone. We do use an agency to provide nurses when needed. I feel like if we had a strong DON, things will turn around here. The Facility's Nurse Staffing Policy, undated, documents, It is the policy of (Facility) to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental and psychosocial well-being of each resident. Nurse staffing shall be based upon resident evaluation by the Administrator and Director of Nursing as specified by the Illinois Department of Public Health. Each skilled care resident shall receive at least 3.8 hours of nursing and personal care each day and 2.5 hours of nursing and personal care each day for a resident needing intermediate care. A minimum of 25% of nursing and personal care time shall be provided by licensed nurses, with at least 10% of nursing and personal care time provided by Registered Nurses. Registered Nurses and Licensed Practical Nurses employed by a facility in excess of these requirements may be used to satisfy the remaining 75% of the nursing and personal care time requirements. The Resident's Census and Conditions of Residents, CMS 672, dated 12/27/22, documents the facility has 29 residents living in the facility. The CMS 672 documented 4 residents receive Hospice Care, 1 resident has an ostomy, 2 residents have catheters, one resident has tube feeding, one resident has a pressure ulcer, and 20 residents are receiving psychoactive medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145478 If continuation sheet Page 17 of 19 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 145478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nokomis Hc & Senior Living 505 Stevens Street Nokomis, IL 62075 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. On 12/27/22 at 1:15 PM, V5 and V12 entered R11's room to provide incontinent care and to take him to the shower room for a shower. R11 had been incontinent for urine and stool. R11's bed pad was saturated in urine and R11's top sheet was wet with urine.V5 and V12 both washed their hands and donned gloves. V5 cleansed R11's penis and scrotum with a wet cloth that had peri-wash on it. V5 cleansed R11's rectal area, V5 flipped the cloth and wiped again. The cloth had a moderate amount of stool on it. V5 dried R11's rectal area. V5 then sat R11 up and placed her gait belt around his waist. V5 and V12 both assisted R11 up to a standing position and pivoted him into his wheelchair. V5 then removed her gloves and gown and washed her hands with soap and water. V12 removed her gloves and gown and washed her hands. R11 was then taken to the shower room. Residents Affected - Some On 1/3/22 at 4:00 PM, V1, Administrator, stated she expects staff to change gloves when the gloves are soiled. V1 further stated staff should wash hands before donning gloves and after removal of gloves and between residents. The Facility's Hand Hygiene Policy, dated 12/7/18, documents Policy: All staff will wash hands, as washing hands as promptly and thoroughly as possible after resident contact and after contact with blood, body fluids, secretions, excretions, and equipment or articles contaminated by them is an important component of the infection control and isolation precautions. The Facility's Perineal Cleansing Policy, dated 12/2017, documents Note: The basic infection control concept for peri-care is to wash from the cleanest to the dirtiest area and remember to change or remove gloves and wash hands when going from working with contaminated items to clean items. Based on observation, interview, and record review, the Facility failed to perform hand hygiene before and after donning gloves and during medication administration, and failed to perform glove changes when gloves were visibly soiled for 6 of 14 residents (R1, R4, R5, R10, R11, and R18) reviewed for infection control in the sample of 21. Findings include: 1. On 12/28/2022 at 8:00 AM, V9, Licensed Practical Nurse (LPN), administered R10's pills, nasal spray, and insulin injection. V9 did not perform hand hygiene or use alcohol-based hand rub (ABHR) prior to or after the procedure. 2. On 12/28/2022 at 8:15 AM, V9 administered R5's medications. V9 did not perform hand hygiene or use ABHR prior to or after assisting/administering R5's medications, including an injection as well as a nasal spray. 3. On 12/28/2022 at 8:30 AM, V9 administered R4's medications, without the benefit of hand hygiene or using ABHR prior to or after administering R4's medications. The Facility's Medication Administration,, dated 11/18/2017, documents, 12. Appropriate hand washing is to be completed and or alcohol-based gel rub or (brand name hand sanitizer) must be used, throughout the medication pass. This should occur: Before and after medication pass, after any contact with mucous membranes, blood or bodily fluids, secretions or excretions. It continues to document, Handwashing between every resident is not required according to CDC (Centers for Disease Control) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145478 If continuation sheet Page 18 of 19 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 145478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nokomis Hc & Senior Living 505 Stevens Street Nokomis, IL 62075 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 0880 guidelines. It is acceptable to use an antiseptic gel type solution between residents. Level of Harm - Minimal harm or potential for actual harm 4. R1's MDS, dated [DATE], documents R1 is cognitively intact (BIMS/Brief Interview for Mental Status of 15) and requires extensive assistance from one staff member for bed mobility, transfer, dressing, and bathing. R1's MDS documents R1 requires extensive assistance from two staff members for toilet use. Residents Affected - Some On 12/28/22 at 10:42 AM, V10, Certified Nursing Assistant (CNA), and V5 (CNA) assisted R1 with a transfer from her bed to her wheelchair using a sit-to-stand device. V10 donned clean gloves, while V5 had no gloves on. V5 and V10 put the device's sling around R1, attached the straps to the lift device, and lifted R1 off her bed as R1 held the handles of the device. V10 operated the lift device as V5 held R1 as they moved her to her wheelchair. R1 was then lowered to her wheelchair. V10 and V5 did not perform hand hygiene before or after transferring R1. 5. R18's Care Plan, dated 12/2/21, documents, (R18) has an alteration in bladder elimination as skin will remain intact X 90 days, related to incontinence. Interventions: Pad appropriately for dignity and comfort, toilet and/or change padding and give proper hygiene before/after meals, upon rising, upon request, before retiring for the evening, after napping, and PRN for incontinence. It continues (2/3/20) (R18) new environment and routine may affect resident ability to complete ADLs and/or maintain continence effectively. Interventions: Observe and assess toileting routine and pattern of incontinence using monitoring log if necessary. Refer to Restorative Nursing for scheduled toileting program or bladder/bowel retraining. Brief while up, pad on bed when sleeping. Provide assist as needed for changing brief, accomplishing peri-care, use of barrier cream as needed and appropriate. Keep call light in reach and answer promptly. Encourage to ask for help until safe toileting ability is established. R18's MDS, dated [DATE], documents R18 has a severe cognitive impairment (BIMS 6) and requires extensive assistance from two staff members for most of her ADL's. R18's MDS documents R18 is frequently incontinent of both bowel and bladder. On 12/28/22 at 11:35 AM, V5 and V12, CNAs, went into R18's to perform perineal care on R18. V5 and V12 donned gloves. R18's dirty linen was removed and put into a bag. V5 and V12 both doffed gloves and donned clean gloves, with no hand hygiene done. V12 wiped once to R18's left groin, once down middle of R18's vagina, and once to R18's right groin. V12 wiped once from front to back including anal area, changed the glove on the hand that was performing the wiping, then wiped R18's buttocks off. R18 rolled and the other side of her buttocks wiped off. V12 doffed her soiled gloves and donned clean gloves, clean linen was put on the bed, and a clean incontinent brief was applied to R18 and R18 was then dressed. V5 and V12 did not perform hand hygiene in between any glove changes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145478 If continuation sheet Page 19 of 19