Health inspection·October 12, 2023

F 0600 R2's Progress Note, dated 10/5/2023 at 10:18 AM R2 did exhibit facial expression as if was going to cry no tears, noted stopped as quickly as started only lasting few seconds. Level of Harm - Actual harm Residents Affected - Few R1's Progress Note dated 9/22/2023 documents Social Service Director was notified of R1's inappropriate contact with a female peer and 1:1's are being provided. Facility provided voluntary statement written by V1 (Administrator) documenting V12 witnessed R1 inappropriately touching R2's breast; R1 stated he was teasing R2, and R2 was trying to cover herself; seemed upset. R2 is non-verbal but seemed upset. On 10/5/2023 at 3:00 PM V1 stated V12 witnessed R1 touching R2's breast at the nurse's station on 9/21/2023. V1 states she investigated this and found it have occurred, and R1 is on 1:1 supervision. Facility Abuse Prevention Policy, dated 11/28/2016, documents this facility prohibits abuse of its residents and to ensure that the facility is preventing abuse of its residents. The Policy documents Sexual Abuse is non-consensual sexual contact of any type with a resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145478 If continuation sheet Page 2 of 7 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 10/12/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on record review and interviews, the facility failed to report allegation of abuse delaying the investigation for two of three residents (R1 and R2) reviewed for reporting of abuse allegations in the sample of 8. Findings include: The Illinois Department Notification from, dated 9/21/23, documented, Resident (R1) was found touching Resident (R2) inappropriately. There were immediately separated. Both residents have DX (diagnosis) of dementia. Addendum to Incident, written by V1, Administrator, regarding her phone interview with V12, Licensed Practical Nurse, documented, Passing meds went to nurse's desk. (R1) was groping her (R2) breast. He was squeezing and massaging her. When asked, he said he was teasing her. I told him he couldn't do that. Immediately separated them. She looked very uncomfortable. Knees to her chest and looked upset. I kept her with me until CNA (Certified Nursing Assistant) could lay her back down. Addendum to Incident, dated 9/26/23, written by V1 while she conducted a telephone interview with V11, Certified Nursing Assistant (CNA), documented, I caught (R2) and (R1) in the dining room in the dark. (R2) was starting to undo (R1's) pants. I gave report to the nurse. This document did not include a date when this incident occurred. Statement written by V10, CNA, dated 9/20/23, documented, Last time this happened, (R1) inappropriately touching (R2), (V8, LPN/Licensed Practical Nurse) told me he's not alert x 3 and because (R2) is known to also touch res (residents), she's just as much at fault, and that (R1) doesn't know it's wrong, but he VERY MUCH does. Last time he asked me if I was gonna get him in trouble for putting 'his hands in the cookie jar'. He said he knows he shouldn't. Tonight, we caught him again and he stated, he knows she wants it. She didn't look happy and wasn't touching or looking @ (at) him. Addendum to Incident, dated 9/26/23, written by V1 during phone interview with V10, CNA, documented, I've caught (R1) three times touching (R2). I was told nothing can be done about it because he is not alert and oriented times three by (V8). On 10/10/2023 at 11:45 AM, V10 states she didn't report the previous incidents regarding R1 and R2 to administration. On 10/10/2023 at 11:45 AM, V11 states she didn't report the previous incidents to administration. On 10/5/2023 at 3:00 PM, V1 (Administrator) stated V12 witnessed R1 touching R2's breast at the nurse's station on 9/21/2023. V1 stated she investigated this and found it had occurred. V1 stated V9, LPN, called her and reported the inappropriate touching as V12 informed V9 during report on 9/21/23. V1 stated V12 did not report the occurrence between R1 and R2 at the time it occurred. V1 stated she did report it, notify the police, and start her investigation when she was notified. V1 stated during the investigation of the 9/21/2023 incident between R1 and R2, V10 made a written statement of R1 touching R2 three times, and that R1 made comments after the last episode of inappropriate touching that he knew he shouldn't do it. V1 stated she was not notified of these previous occurrences, did not report these, and did not investigate these statements. V1 also stated V11's written statements (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145478 If continuation sheet Page 3 of 7 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 10/12/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete stated R2 was caught undoing R1's pants on a previous occasion. V1 stated that she did not report this, nor did she investigate this. The Facility's Abuse Prevention Program, dated 11/28/2016, documents employees are required to immediately report any alleged abuse to administrator. The Program documents Supervisors shall immediately inform the administrator or his/her designated representative (specified by the administrator in the case of a planned absence) of all reports or potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property. Event ID: Facility ID: 145478 If continuation sheet Page 4 of 7 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 10/12/2023 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on record review and interviews, the facility failed to investigate allegations of abuse to protect residents from potential future abuse for two of three residents (R1 and R2) reviewed for investigation of abuse allegations in the sample of 8. Residents Affected - Few Findings include: Addendum to Incident, written by V1, Administrator regarding her phone interview with V12, Licensed Practical Nurse/LPN, documented, Passing meds went to nurse's desk. (R1) was groping her (R2's) breast. He was squeezing and massaging her. When asked he said he was teasing her. I told him he couldn't do that. Immediately separated them. She looked very uncomfortable. Knees to her chest and looked upset. I kept her with me until CNA (Certified Nurse's Aide) could lay her back down. Addendum to Incident, dated 9/26/23, written by V1 while she conducted a telephone interview with V11, Certified Nursing Assistant (CNA), documented, I caught (R2) and (R1) in the dining room in the dark. (R2) was starting to undo (R1's) pants. I gave report to the nurse. This document did not include a date when this incident occurred. The facility had no documentation that this incident was investigated. Statement written by V10, CNA, dated 9/20/23, documented, Last time this happened, (R1) inappropriately touching (R2), (V8, LPN) told me he's not alert x 3, and because (R2) is known to also touch res (residents), she's just as much at fault, and that (R1) doesn't know it's wrong, but he VERY MUCH does. Last time he asked me if I was gonna get him in trouble for putting 'his hands in the cookie jar'. He said he knows he shouldn't. Tonight, we caught him again and he stated, he knows she wants it. She didn't look happy and wasn't touching or looking @ (at) him. Addendum to Incident, dated 9/26/23, written by V1 during phone interview with V10, CNA, documented, I've caught (R1) three times touching (R2). I was told nothing can be done about it because he is not alert and oriented times three by (V8). The facility had no documentation regarding V10's allegation of R1 touching R2 inappropriately three times. On 10/10/2023 at 11:45 AM, V10 stated she didn't report the previous incidents regarding R1 and R2 to administration. On 10/5/2023 at 3:00 PM, V1 (Administrator) stated V12, LPN, witnessed R1 touching R2's breast at the nurse's station on 9/21/2023. V1 stated she investigated this, and found it had occurred. V1 stated V9, LPN, called her and reported the inappropriate touching, as V12 informed V9 during report on 9/21/23. V1 stated V12 did not report the occurrence between R1 and R2 at the time it occurred. V1 stated she did report it, notify the police, and start her investigation when she was notified. V1 stated during the investigation of the 9/21/2023 incident between R1 and R2, V10 made a written statement of R1 touching R2 three times, and R1 made comments after the last episode of inappropriate touching that he knew he shouldn't do it. V1 stated she was not notified of these previous occurrences, did not report these, and did not investigate these statements. V1 also stated V11's written statements stated R2 was caught undoing R1's pants on a previous occasion. V1 stated she did not report this, nor did she investigate this. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145478 If continuation sheet Page 5 of 7 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 10/12/2023 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The Facility's Abuse Prevention Program, dated 11/28/2016, documents employees are required to immediately report any alleged abuse to administrator. The Policy documented Upon learning of the report, the administrator or designed shall initiate an investigation. The Program documents Residents who allegedly mistreat or abuse another resident or misappropriate resident property will be removed from contact with that resident during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches and placement considering his or her safety, as well as the safety of other residents and employees of the facility. Event ID: Facility ID: 145478 If continuation sheet Page 6 of 7 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 10/12/2023 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 Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to provide the services of a Director of Nursing on a full time basis. This failure has the potential to affect all 26 residents in the facility. Residents Affected - Many Findings include: On 10/3/2023 at 3:00 PM, V1, Administrator, stated V2, Director of Nursing (DON), is the fulltime DON and works full time hours as of 10/1/202,3 but prior to 10/1/2023, there was no fulltime DON. On 10/3/2023 at 9:45AM, V8, Licensed Practical Nurse, LPN, stated V2 is not in building every day, but they can get a hold of her. 10/3/2023 at 11:00 AM, V6, Certified Nursing Assistant, CNA, stated V2 is reachable by phone, but not sure what hours she works at the facility. The facility's Nursing staffing was reviewed, with no noted DON for the month of September until 10/1/2023. On 10/2/2023 at 3:00 PM, V1 stated the current census of facility was 26. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145478 If continuation sheet Page 7 of 7