Inspection·July 20, 2023

F 0677 Level of Harm - Minimal harm or potential for actual harm On 7/17/23 at 12:52 PM, R89 was sitting in her wheelchair, eating lunch independently inside her room. R89 was alert, oriented and verbally responsive. R89 had a left-hand splint in place and was using her right hand fingers to eat chicken nuggets. R89's fingernails were long and with black substances underneath. R89 wanted the staff to trim and clean her fingernails. V9 (CNA) was informed of R89's request to have her fingernails trimmed and cleaned. Residents Affected - Some On 7/18/23 at 2:44 PM, R89 was in bed, alert, oriented and verbally responsive. R89 stated the staff did not trim and/or clean her fingernails. R89's fingernails remained long with black substances underneath. V2 and V3 were both present during the observation. R89's active care plan initiated on 9/22/22 showed the resident had ADL deficit due to hemiparesis and extensive assistance is needed to complete most task. On 7/19/23 at 8:51 AM, V2 stated for residents needing assistance with fingernails trimming and cleaning and shaving of unwanted facial hair, the staff should assist those residents to ensure good personal hygiene and grooming. 5. Face sheet shows that R57 is 83 years-old who has multiple medical diagnoses which include hemiplegia and hemiparesis affecting left non-dominant side, lack of coordination and weakness. Minimum Data Set (MDS) dated [DATE] shows that R57 requires extensive assistance for personal hygiene. On 7/17/23 at 12:27 PM (in the dining room) and on 7/18/23 at 4:44 PM (in the bedroom), R57 was observed with long dirty fingernails (with black/brown substance underneath nails) and hair on the chin curled up. On 7/18/23 at 4:45 PM, R57 stated she would love to have her face shaven, and her nails cleaned and polished. V30 (Certified Nursing Assistant/CNA) was at bedside when R57 verbalized it. On 7/19/23 at 12:13 PM, V2 (Director of Nursing/DON) stated when staff provides personal hygiene and grooming this includes ensuring that a resident is clean and dry, wearing clean clothes, face is washed, teeth are brushed, facial shaving/hair removal for the ladies, and nails are clean and trimmed. 6. R3's face sheet included diagnoses of unspecified intellectual disabilities (mental retardation) and other idiopathic scoliosis, site unspecified. R3's quarterly MDS dated [DATE] showed that R3 was severely impaired with cognition and required extensive one person assistance for personal hygiene. On 7/17/23 at 11:01 AM, R3 was lying in bed with arms under blanket. R3 was alert and able to convey needs and stated she is unable to move her arms and is fed by staff. R3 was noted to have multiple long facial hairs and stated would like it removed. On 7/18/23 at 01:38 PM, R3 was seen fed by V18 CNA (Certified Nursing Assistant). R3 still had long facial hair on her upper lip area. V18 was made aware that R3 would like her facial hair removed. V18 stated she worked for Agency and remarked, Today is my first day coming here. 7. R110's face sheet included diagnosis of other displaced fracture of upper end of left humerus, subsequent encounter for fracture with routine healing. R110's admission MDS dated [DATE] showed R110 is intact with cognition and required extensive two person assistance for personal hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145538 If continuation sheet Page 2 of 18 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 145538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beecher Manor Nrsg & Rehab Ctr 1201 Dixie Highway Beecher, IL 60401 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 7/17/23 at 11:08 AM, R110 was lying in bed and had multiple upper lip long facial hairs. R110 remarked, I know its long. I used to do it but now I can't do it myself with my arm hurting. I fell at my house 2-3 weeks ago and left arm hurts and I am hardly able to use it. On 7/17/23 at 11:33 AM, R110 was seen in therapy and facial hairs on upper lip were still present and V17 (Licensed Practical Nurse) was notified of the same. Based on observation, interview and record review, the facility failed to assist residents identified as needing assistance with personal hygiene. This applies to 7 of 7 residents (R3, R23, R40, R50, R57, R89, R110) reviewed for ADL (activities of daily living) in the sample of 24. The findings include: 1. R50 had multiple diagnoses which included dementia, functional quadriplegia, acquired absence of right hand, cognitive communication deficit, and weakness, based on the face sheet. R50's quarterly MDS (minimum data set) dated 5/8/23 showed that R50 was severely impaired with cognition. The same MDS showed that R50 required extensive assistance from staff with personal hygiene. On 7/17/23 at 11:41 AM, R50 was sitting in his wheelchair across the unit nursing station. R50 had right below elbow amputation. R50's left hand fingernails were long, jagged, with black substances underneath. R50 had an accumulation of facial hair. R50 stated that he wanted to be shaven, and his fingernail trimmed and cleaned. V7 (nurse) was informed of R50's request to be shaven and nails trimmed and cleaned. R50's active care plan initiated on 2/4/22 showed that R50 had an ADL deficit due to functional quadriplegia and dementia. The care plan showed that R50 required extensive to total assistance from staff for most tasks. The same care plan showed multiple approaches which included provision of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145538 If continuation sheet Page 3 of 18 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 145538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beecher Manor Nrsg & Rehab Ctr 1201 Dixie Highway Beecher, IL 60401 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, interview and record review, the facility failed to apply a splint and provide treatment plan as recommended and ordered to prevent contractures. This applies to 1 of 3 residents (R24) reviewed for range of motion in the sample of 24. The findings include: R24's diagnoses on the face sheet included Multiple sclerosis, Weakness, Dysarthria and Anarthria, Aphasia. R24's POS (Physician Order Sheet) included Restorative Programming PROM (Passive Range of Motion) to bilateral upper/lower extremities 10 reps [repetition] times one set, daily 6 to 7 days a week start date 5/17/23. The POS also included for R24 to get up in the [mechanical] chair on Monday, Wednesday and Friday from 1:00 PM-4:00 PM. R24's Annual MDS (Minimum Data Set) dated 5/17/23 showed R24 requires total dependence of two-person physical assistance for transfer and has impairment on both sides for functional range of motion. On 7/17/23 at 10:53 AM, on 7/18/23 at 11:14 AM and 1:38 PM, and on 7/19/23 at 11:25 AM, R24 was seen lying in bed and noted to have no hand splint on. R24 was nonverbal and was unable to move her extremities. A hand splint was seen on the side table with signage posted on wall, Please remove hand splints on PM. They are placed on AM. R24 was also not seen up in mechanical chair on 7/17/23 Monday from 1:00 PM-4:00 PM. On 7/18/23 at 1:52 PM, R24 was not wearing a hand splint, this was verified by V18 CNA (Certified Nursing Assistant). V18 stated she works for agency and it was her first day at the facility and does not know specifics about R24's care. On 7/19/23 at around 9:45 AM, V25 (CNA) stated she was not aware R24 wears splints. On 7/18/23 at 2:42 PM, V5 (MDS Nurse) stated R24 has orders for PROM and the restorative staff should be doing them. V5 stated R24 has orders to get up 3 times a week on [mechanical] chair. V5 added V24 (Restorative Nurse) currently oversees the program. On 7/19/23 at 10:36 AM, V24 stated she works part time for 20 hours a week. V24 stated she worked on 7/17/23 but she did not see R24 for PROM or apply any splints on R24. V24 stated the facility has 2 restorative staff who do the PROM exercises and apply the splints but are unable to get to all the residents they need to see in the facility and do what they can. V24 stated ideally the CNA's should do these tasks but the facility has multiple agency staff who are not familiar with the resident needs. V24 stated the PROM when done, is recorded in Restorative Nursing under POC (Point of Care). V24 stated a splint treatment was added to R24's right hand to prevent contracture and is to be on 6-7 days per week. V24 stated she overlooked to add the orders for splints on R24's POS but had it documented in the care plans. V24 added the order for the same was added on 7/19/23. Review of POC Nursing Restorative Time log for number of minutes for PROM from 7/01/23-7/19/23 showed PROM was only done on 7/11/23 and 7/16/23 for 15 minutes on each of these days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145538 If continuation sheet Page 4 of 18 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 145538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beecher Manor Nrsg & Rehab Ctr 1201 Dixie Highway Beecher, IL 60401 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 0688 R24's care plan last revised 5/29/23 included as follows: Level of Harm - Minimal harm or potential for actual harm -R24 requires passive range of motion related to weakness and requires a restorative PROM program. Goal for this problem included R24 will receive 1 set of 10 reps of PROM to upper extremities 6-7 days/week through next review 8/29/23. Residents Affected - Few -R24 has a splint to right hand related to preventing contracture and requires a restorative splint/brace program. Goal for this problem included staff will monitor splint to be on all times 6-7 days per week through next review 8/29/23. -R24 does not have the capacity to transfer self without use of [mechanical] lift due to diagnoses of Multiple Sclerosis, impaired mobility and decreased strength. Goal for this problem included R24 will transfer safely with use of [mechanical] lift and 2 staff assist through next review 8/29/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145538 If continuation sheet Page 5 of 18 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 145538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beecher Manor Nrsg & Rehab Ctr 1201 Dixie Highway Beecher, IL 60401 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R40 had multiple diagnoses which included right femur-right hip hardware acute osteomyelitis, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type 2 diabetes mellitus and neuromuscular dysfunction of the bladder, based on the face sheet. R40's admission MDS dated [DATE] showed the resident was moderately impaired with cognition and required extensive assistance from the staff with toilet use and personal hygiene. The same MDS showed R40 had an indwelling urinary catheter and was always incontinent of bowel function. On 7/18/23 at 2:22 PM, while V2 (Director of Nursing) and V3 (Assistant Director of Nursing) were turning and repositioning R40 during bowel incontinence care. R40's indwelling urinary catheter was getting tugged. A foam anchor pad was observed on R40's right inner leg area, however, the lock portion was left open, and the urinary catheter tubing was not secured/anchored to prevent tension on the catheter which can cause urethral tears or dislodgement of the catheter. R40's active care plan initiated on 5/15/23 showed the resident required the use of an indwelling urinary catheter due to diagnosis of neurogenic bladder. The same care plan showed multiple approaches which included securing the urinary catheter for resident's safety. On 7/19/23 at 8:54 AM, V2 (Director of Nursing) stated all residents with indwelling urinary catheter should have their catheter secured on their leg to prevent pulling/tugging and/or dislodgment. Review of the facility's policy and procedure regarding urinary catheter care revised on September 2005 showed in-part under general guidelines, 15. Ensure the catheter remains secured with a leg strap to reduce friction and movement at the insertion site and 16. Report unsecured catheters to the supervisor. Review of the facility's policy and procedure regarding perineal care revised on 8/2008 showed in-part, 10. For a male resident: b. Wash perineal area starting with urethra and working outward. (1) Retract foreskin of the uncircumcised male. Based on observation, interview, and record review, the facility failed to provide incontinence and catheter care in a manner that would prevent potential urinary tract infection and reduce friction at the catheter insertion site. This applies to 4 of 7 residents (R40, R57, R60, R67) reviewed for incontinence and catheter care in the sample of 24. The findings include: 1. Face sheet shows that R57 is 83 years-old who has multiple medical diagnoses which include hemiplegia and hemiparesis affecting left non-dominant side, lack of coordination and weakness. Minimum Data Set (MDS) dated [DATE] shows that R57 requires extensive assistance for personal hygiene. On 7/18/23 at 4:39 PM, V30 (Certified Nursing Assistant/CNA) rendered incontinence care to R57 who was wet with urine. V30 used wet wipes to clean R57 from front to back of her peri-area. V30 wiped R57 in a downward stroke from the pubic area down to the groin, and from pubic area down to outer labia. However, V30 did not separate the labia to clean inner area of the perineum. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145538 If continuation sheet Page 6 of 18 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 145538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beecher Manor Nrsg & Rehab Ctr 1201 Dixie Highway Beecher, IL 60401 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Face sheet shows that R67 is 70 years-old who has multiple medical diagnoses which include hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right non-dominant side, and weakness. Minimum Data Set (MDS) dated [DATE] showed that R67 requires extensive assistance for toileting and hygiene. On 7/19/23 at 11:16 AM, V20 and V32 (Both CNAs) rendered incontinence care to R67 who was wet with urine and had a bowel movement. V20 used wet wipes to clean R67's frontal perineum up and down, back, and forth (from the pubic area to the phallus, down to the groins and back) with the same wet wipes. In addition, R67 was not circumcised and V20 did not retract foreskin of the phallus to clean the inner area. On 7/19/23 at 12:07 PM, V2 (Director of Nursing/DON) stated when providing incontinence care for uncircumcised male the staff needs to retract foreskin. Wipe frontal perineum from top to bottom in downward stroke and use different wet wipes on each area. For female resident, the staff must wipe from front to back. Use different wipes from clean to dirty. Separate labia and clean the inner area of the perineum to prevent potential infection. 3. R60 had multiple diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic urinary tract infection, history of ESBL (extended spectrum beta-lactamase), neuromuscular dysfunction of the bladder, based on the face sheet. R60's quarterly MDS (minimum data set) dated 6/19/23 showed the resident was severely impaired with cognition and required extensive assistance from the staff for personal hygiene and toileting. The same MDS showed the resident had an indwelling urinary catheter and was always incontinent of bowel function. On 7/18/23 at 1:34 PM, with the assistance of V16 (CNA/Certified Nursing Assistant), V15 (CNA) provided incontinence care to R60. V15 used disposable cloths to wipe R60's left outer groin area, folded the same disposable cloth to wipe the right outer groin area and then using the same side of the used disposable cloths (without folding) proceeded to wipe R60's middle outer groin area. V15 did not clean R60's front perineal area and did not clean and separate the resident's labial folds. V15 also did not clean R60's urinary catheter insertion site and tubing. R60's active care plan initiated on 9/22/22 showed R60 required an indwelling urinary catheter due to neurogenic bladder. The same care plan showed multiple approaches which included provision of catheter care every shift, and as needed, and routine incontinence care. On 7/19/23 at 2:11 PM, V2 (Director of Nursing) stated for female resident's incontinence care, it is expected the nursing staff separate the labial folds for cleaning to prevent urinary tract infection and maintain hygiene. During the same interview V2 stated cleaning the urinary catheter insertion site and the catheter tubing should be performed during incontinence care to prevent infection as well as to maintain hygiene. The facility's policy and procedure regarding perineal care revised on 8/2008 showed the purpose of the procedure is to provide cleanliness and comfort to the resident to prevent infections and skin irritations and to observe the resident's skin condition. The same policy under procedures showed in-part, 9. For a female resident (1) Separate labia and wash area downward from front to back. (Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area. (2) Continue to wash the perineum (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145538 If continuation sheet Page 7 of 18 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 145538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beecher Manor Nrsg & Rehab Ctr 1201 Dixie Highway Beecher, IL 60401 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 0690 moving from inside outward to and including thighs, alternating from side to side, and using downward strokes. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145538 If continuation sheet Page 8 of 18 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 145538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beecher Manor Nrsg & Rehab Ctr 1201 Dixie Highway Beecher, IL 60401 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review the facility failed to ensure that accurate documentation of controlled drugs was maintained. This applies 6 of 6 residents (R2, R5, R12, R29, R66, R99) reviewed for controlled medications. The findings include: On 7/19/23 9:30 AM, the zone 2 medication cart was reviewed with the nurse on duty, V12 (Licensed Practical Nurse). V2 (Director of Nursing/DON) was present. During the review of controlled substances on the medication cart it was noted that quantities of resident medication on hand did not match the quantity documented for 4 residents as follows: R99's prescribed Lacosamide 100 MG (milligrams) tablet, was to be administered one tablet by mouth every 12 hours. The actual quantity on hand in the blister-pack medication package showed there were 20 tablets remaining, and R99's-controlled drug receipt documented there were 21 tablets remaining. R5's prescribed Phenobarbital 64.8 MG tablet, was to be administered one tablet by mouth every morning and two tablets by mouth at bedtime. The actual quantity on hand in R5's blister-pack medication package showed there were 6 tablets remaining, and R5's controlled drug receipt documented there were 7 tablets remaining. R2's prescribed Hydrocodone/APAP tab 5-325 MG, was to be administered by mouth twice daily as needed. The actual quantity on hand in R2's blister-pack medication package showed there were 8 tablets remaining, and R2's-controlled drug receipt documented there were 9 tablets remaining. R29's prescribed Clonazepam 0.5 MG tab, was to be administered one tablet by mouth twice daily. The actual quantity on hand in R29's blister-pack medication package showed there were 10 tablets, and R29's controlled drug receipt documented there were 11 doses remaining. Regarding the discrepancies, V12 stated, I gave it this morning and didn't sign it out yet. V12 added she administered the medications with the 8:00 AM medication pass, and she was supposed to document the medication right after administering to the resident. V2 who was present confirmed the expectation was the medication should be signed out when administered. On 7/19/23 at 10:16 AM, the Zone 4 medication cart was reviewed with the assigned nurse, V33 (LPN, Agency). V2 (DON) was also present. During the review of the controlled substances on the medication cart, it was noted that the quantities of resident medication on hand did not match the quantity documented for 2 residents as follows: R12's prescribed Hydrocodone/APAP 10-325 MG Tabs, was to be administered one tablet by mouth twice daily. The actual quantity on hand in R12's blister-pack medication package showed there was one tablet remaining, and R12's controlled drug receipt documented there were 2 tablets remaining. R66's prescribed Hydrocodone/APAP 10-325 MG tab, was to be administered one tablet by mouth every four hours as needed. The actual quantity on hand in R66's blister-pack medication package showed there were 23 tablets remaining, and R66's controlled drug receipt documented there were 24 tablets (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145538 If continuation sheet Page 9 of 18 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 145538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beecher Manor Nrsg & Rehab Ctr 1201 Dixie Highway Beecher, IL 60401 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 0755 remaining. Level of Harm - Minimal harm or potential for actual harm V33 reported she administered R12's and R66's medications earlier in the morning with morning medication pass, but didn't sign it out. V33 added, You're supposed to sign it out right after giving it .I didn't sign it out. V2, who was present confirmed the medications are to be signed out right after it is administered. Residents Affected - Few The facility's policy IIA7: Controlled Substances (dated 10/25/14) stated in part, Procedures, D. Accurate accountability of the inventory of all controlled drugs is maintained at all times. When a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record: 1) Date and Time of administration. 2) Amount administered. 3) Remaining quantity. 4) Initials of the nurse administering the dose, completed after the dose is administered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145538 If continuation sheet Page 10 of 18 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 145538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beecher Manor Nrsg & Rehab Ctr 1201 Dixie Highway Beecher, IL 60401 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review, the facility failed to serve sauce over mechanically ground chicken as shown on menu spreadsheet. This applies to 5 of 5 residents (R67, R88, R92, R99, R110) observed for dining in the sample of 24. The findings include: On 7/17/23 starting at 12:25 PM, during lunch meal service, R67 and R99 received very dry ground chicken without any sauce over it or ranch dressing on the side. R88 also received a room tray without any sauces on the dry ground meat or ranch dressing on the side. R92 and R110 received the dry ground chicken and received one packet of ranch sauce on the side. R92 took only a few bites and stated she does not want the rest. R92 stated she cannot open the ranch dressing packet. R110 was attempting to pick up the dry flaky ground chicken with her fork with some spillage and stated she is unable to open the ranch dressing packet. V1 (Administrator) who was in the vicinity, was notified about R92 and R110. On 7/17/23 at 12:31 PM, when V19 (Cook), who was at the tray line, was asked why the residents on mechanical soft did not receive any sauce as shown on the menu spreadsheet. V19 stated, The ladies who pass the tray are supposed to open the packet and put it on (the ground chicken nuggets) when thy pass the trays. On 7/19/23 at 10:55 AM, V22 (Dietitian) stated the facility should be following the menu spreadsheet. Menu spread sheet for Spring Summer 2023 (Week 3 Monday) showed ground chicken nuggets (#8 scoop=4 oz/ounce plus 1 oz sauce) for mechanical soft diets. The same menu also included Ranch dressing 2 tablespoons for all diet consistencies. Recipe (undated) for ground chicken nuggets included as follows: Place prepared chicken nuggets in food processor and grind to appropriate consistency. Portion with #8 scoop plus 1 oz ranch sauce to keep moist. Facility (undated) Policy and Procedure for Mechanical soft (Dysphagia Level 3) included meat items are designated to be ground and served with a sauce, gravy or both. Facility diet order report printed on 7/17/23 included R67, R88, R92, R99 and R110 were on mechanical soft diets. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145538 If continuation sheet Page 11 of 18 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 145538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beecher Manor Nrsg & Rehab Ctr 1201 Dixie Highway Beecher, IL 60401 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** 4. R40 had multiple diagnoses which included right femur-right hip hardware acute osteomyelitis, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type 2 diabetes mellitus and neuromuscular dysfunction of the bladder, based on the face sheet. Residents Affected - Some R40's admission MDS dated [DATE] showed R40 was moderately impaired with cognition and required extensive assistance from the staff with toilet use and personal hygiene. The same MDS showed R40 had an indwelling urinary catheter and was always incontinent of bowel function. On 7/18/23 at 2:22 PM, with the assistance of V3 (Assistant Director of Nursing), V2 (Director of Nursing) provided bowel incontinence care to R40. V2 with her gloved hands used disposable cloths to clean R40's rectal area, handled and placed the clean disposable brief on the resident and then proceeded to clean R40's front perineal area. During the entire procedure, V2 did not remove her gloves and perform hand hygiene in between dirty and clean procedure. On 7/19/23 at 8:54 AM, V2 stated when providing care to residents from dirty to clean procedure, gloves should be removed, hand hygiene should be performed either handwashing or use of alcohol-based sanitizer and then re-gloved, especially after providing bowel incontinence care to a resident. The facility's handwashing/hand hygiene policy dated 3/2020 showed, It is the policy of the facility to assure staff practice recognized handwashing/hand hygiene procedures as a primary means to prevent the spread of infections among residents, personnel and visitors. Alcohol based hand rubs (ABHR) can be used for hand hygiene when hands are not visibly soiled or contaminated with blood or bodily fluids. The policy under specifications showed that handwashing/hand hygiene should be performed before moving from a contaminated body site to a clean body site during resident care, before and after putting on and upon removal of PPE (personal protective equipment), including gloves, after contact with a resident's intact skin and after removing gloves. The same policy showed in-part, 6. The use of gloves does not replace compliance with handwashing/hand hygiene procedures. Based on observation, interview and record review, the facility failed to follow standard infection control practices with regards to hand hygiene and gloving during provisions of care, and use of PPE (Personal Protective Equipment) when entering an isolation room. The facility also failed to ensure a resident had a physician's order for isolation, and the indwelling urinary catheter bag was not touching the floor. This applies to 6 of the 24 residents (R24, R40, R48, R57, R60, R67) reviewed for infection control in the sample of 24. The findings include: Face sheet shows that R57 is 83 years-old who has multiple medical diagnoses which include hemiplegia and hemiparesis affecting left non-dominant side, lack of coordination and weakness. Minimum Data Set (MDS) dated [DATE] shows R57 requires extensive assistance for personal hygiene. 1. On 7/18/23 at 4:39 PM, V30 (Certified Nursing Assistant/CNA) rendered incontinence care to R57 who was wet with urine. V30 cleaned R57 from front to back of the perineum, applied barrier cream and new incontinence brief while wearing same soiled gloves. After completing the peri-care, V30 changed her gloves without hand hygiene, and proceeded to reposition and straightened R57's clothes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145538 If continuation sheet Page 12 of 18 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 145538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beecher Manor Nrsg & Rehab Ctr 1201 Dixie Highway Beecher, IL 60401 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. R67 is 70 years-old who has multiple medical diagnoses which include hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right non-dominant side, and weakness. Minimum Data Set (MDS) dated [DATE] showed he requires extensive assistance for toileting and hygiene. On 7/19/23 at 11:16 AM, V20 and V32 (Both CNAs) rendered incontinence care to R67 who was wet with urine and had a bowel movement. V20 cleaned R67's frontal perineum then she changed her gloves without hand hygiene. V20 proceeded to clean the back peri-area, she changed gloves without hand hygiene and proceeded to clean the rectal and buttocks area and applied incontinence brief while wearing the same soiled gloves. On 7/19/23 at 12:05 PM, V2 (Director of Nursing/DON) stated staff must perform hand hygiene, before they apply their gloves and before they provide care. The staff must also change gloves and perform hand hygiene in between dirty to clean task. 6. R24's POS (Physician Order Sheet) included indwelling [urinary] catheter related to Neurogenic bladder. On 07/18/23 at 01:42 PM, R24's urinary catheter bag and tubing with urine was lying on the floor near the foot of the bed. R24 was immobile and depended on staff for all activities of daily living. V18 (Certified Nursing Assistant) who was in the room feeding R24's roommate stated, It shouldn't be on the floor. I don't know who put it on the floor. R24's care plan start date 04/11/2023 included: Do not allow tubing or any part of the drainage system to touch the floor. 5. On 7/17/23 at 1:01 PM, V20 (CNA/Certified Nursing Assistant) entered R48's contact isolation room without donning a gown or gloves. V20 placed R48's lunch meal tray on R48's bedside table and adjusted the bedside table over R48 who was sitting up in a chair so that R48 could reach the tray. V20 then took the lid off the plate and placed it on R48's bed. On 7/17/23 at 1:04 PM, V20 stated when entering a contact isolation room, a gown and gloves should be worn. When the surveyor asked if V20 donned appropriate PPE when entering R48's room, V20 turned around, noticed the contact isolation sign on R48's door and replied, I sure didn't. On 7/18/23 at approximately 12:49 PM, V6 (Infection Preventionist) stated she (V6) expects staff to don full PPE when entering a contact isolation room even if it is just dropping off a meal tray. V6 added that contact isolation PPE includes wearing a gown and gloves. Upon review of R48's EMR (Electronic Medical Record), there was no physician's order for isolation. On 7/19/23 at 2:21 PM, V2 (DON/Director of Nursing) acknowledged that residents on isolation should have a physician order for the type of isolation. V2 also affirmed that proper PPE should be worn when delivering a meal tray to an isolation room. V2 stated that wearing PPE, Maintains consistency and maintains that barrier. V2 added that more than likely, when bringing in a meal tray, something will need to be moved around on the bedside table to put the tray down so wearing proper PPE as well as performing hand hygiene is important to prevent transmission of disease. R48's Resident face sheet documents diagnoses including but not limited to pressure ulcer of sacral (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145538 If continuation sheet Page 13 of 18 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 145538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beecher Manor Nrsg & Rehab Ctr 1201 Dixie Highway Beecher, IL 60401 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 region stage 4. Level of Harm - Minimal harm or potential for actual harm R48's 3/8/23 Wound Culture Laboratory Report documented that the following organisms were cultured in R48's wound: 1. Proteus mirabilis-heavy growth 2. Klebsiella pneumoniae - CRE, light growth: Carbapenemase detected. All carbapenems should be considered resistant. Isolation precautions may be required. Please refer to your Infection Control Policy. Positive for ESBL (Extended Spectrum Beta-lactamase). This organism is an extended-spectrum beta-lactamase producer .Isolation precautions may be required .3. Enterococcus species-heavy growth. Residents Affected - Some The 8/2008 Isolation-Categories of Transmission-Based Precautions facility policy documents, in part, 1. Transmission-Based Precautions will be used whenever more stringent than Standard Precautions are needed to prevent the spread of infection .Contact Precautions: In addition to Standard Precautions, implement Contact Precautions for resident known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. a. Examples of infections requiring Contact Precautions include, but are not limited to: (1) Gastrointestinal, respiratory, skin, or wound infections with multi-drug resistant organisms (e.g. VISA, VRSA, VRE, ESBL, MRSA) .c. Gloves and Handwashing (1) In addition to wearing gloves as outlined under Standard Precautions, wear gloves (clean, non-sterile) when entering the room .d. Gown (1) In addition to wearing a gown as outlined under Standard Precautions, wear a gown (clean, nonsterile) when entering the room if you anticipate that your clothing will have substantial contact with an actively infected resident, with environmental surfaces, items in the residents room . The 8/2008 Isolation-Initiating Transmission-Based Precautions facility policy documents, in part, 2. The Charge Nurse shall obtain and document a physician's order for appropriate isolation precautions. 3. R60 had multiple diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic urinary tract infection, history of ESBL (extended spectrum beta-lactamase), neuromuscular dysfunction of the bladder, based on the face sheet. R60's quarterly MDS (minimum data set) dated 6/19/23 showed R60 was severely impaired with cognition and required extensive assistance from the staff for personal hygiene and toileting. The same MDS showed R60 had an indwelling urinary catheter and was always incontinent of bowel function. On 7/18/23 at 1:34 PM, with the assistance of V16 (CNA/Certified Nursing Assistant), V15 (CNA) with her gloved hands provided incontinence care to R60. After the provision of incontinence care, V15 used the same gloves to apply barrier cream to R60's buttocks. After applying the barrier cream, V15 removed her used gloves then put on a new pair of gloves without performing hand hygiene, then proceeded to transfer R60 from bed to the high back reclining chair using a full body mechanical lift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145538 If continuation sheet Page 14 of 18 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 145538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beecher Manor Nrsg & Rehab Ctr 1201 Dixie Highway Beecher, IL 60401 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 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on interview and record review, the facility failed to ensure the Infection Preventionist (IP) has the required professional training to perform the role. This failure has the potential to affect all 114 residents residing in the facility. Findings include: Resident Census and Condition of Residents report dated 7/17/23 documents a total of 114 residents residing in the facility. On 7/18/23 at 12:41 PM, V6 (Infection Preventionist) stated, I do not have a degree. I took the class through the CDC (Centers for Disease Control and Prevention). On 7/18/23 at 2:16 PM, V1 (Administrator) stated corporate told her (V1) the IP did not need a degree as long as the training was completed. V1 affirmed V6 does not have any training in nursing or any health-related fields. V1 also added V6 did have a degree. On 7/19/23 at 10:17 AM, V6's personnel file showed V6 does not have any professional training and/or degrees other than a certificate from a Nursing Home Infection Preventionist Training Course dated 7/18/22 among other basic training certificates. The file showed V6 was previously employed as a secretary (2009-1/2017) and was hired by the facility as a resident assistant on 9/1/17. V6 then transferred to the position of admissions assistant on 4/26/21. At 10:30 AM, V6 stated she (V6) transitioned into the IP role in July of 2022 and trained with the IP of a sister facility in March of 2023. On 7/19/23 at 10:35 AM, during review of the facility's influenza (flu) and pneumonia vaccinations with V6, a concern was found with tracking of the vaccinations. V6 stated she (V6) is definitely still learning. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145538 If continuation sheet Page 15 of 18 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 145538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beecher Manor Nrsg & Rehab Ctr 1201 Dixie Highway Beecher, IL 60401 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to adequately monitor and track the status of influenza (flu) and pneumococcal (pneumonia) vaccinations to ensure eligible residents were offered a vaccine or residents who consented to receive a vaccine actually received it. This failure affected 5 out of 5 (R2, R48, R60, R66, R90) residents reviewed for influenza and pneumococcal vaccinations in the total sample of 24 residents. Residents Affected - Some Findings include: On 7/19/23 at approximately 10:30 AM, the influenza and pneumococcal vaccine consents were compared to the spreadsheet V6 (Infection Preventionist) provided for tracking of the flu and pneumonia vaccines. The following concerns were identified: 1. For R2, the tracking sheet was noted blank for both the flu and pneumonia. R2's Informed Consent for Vaccinations shows a verbal consent for the Influenza Vaccine was obtained on 10/16/20 from R2's POA. The pneumococcal immunization section was left blank. A second Informed Consent for Vaccinations was provided for R2. On the second form, under the influenza section, is written Given 10/22/20, however V6 was unable to provide documentation of this. Under the pneumococcal section, a box was checked off, I decline the Pneumococcal Immunization with the reason, Not administered/unknown 3/14/20 and in parenthesis Refused 7/15/19. This was missing the signature of the resident/authorized representative. No documentation was provided R2 was offered or received an influenza vaccine after 2020 and R2 or R2's representative was provided education regarding the vaccine. R2's Resident Face Sheet documents a current admission date of 6/25/2018. R2's age is documented as [AGE] years old, and R2's diagnoses include but are not limited to multiple sclerosis, essential hypertension (high blood pressure) and adult failure to thrive. 2. For R48, the tracking sheet was noted blank for the pneumonia vaccine. R48's Authorization and Release for Pneumococcal Vaccine consent shows R48 consented to receive the Pneumococcal Vaccine on 4/18/22. When enquired why the pneumococcal vaccine was not administered, V6 answered she believes R48 received her Covid booster and influenza vaccine the same day so the vaccine clinic did not want to administer three vaccines on the same day or R48 may have had the pneumonia vaccine in the past. V6 added, A lot of times family will say they got it (vaccine) but I don't have proof of that. R48's Informed Consent for Immunization with Inactivated and Live Viruses, dated 10/13/22, which was completed during the facility's vaccine clinic provided by an outside vendor shows for the question, Have you ever received a pneumonia vaccine the box is checked Yes,. However, the next line asking, If yes, when and what kind(s), was left blank. R48's Resident face sheet documents a current admission date of 4/15/22. R48's age is documented as [AGE] years old, and R48's diagnoses include but are not limited to essential hypertension, history of blood clot in the left lower extremity and stage 4 sacral pressure ulcer. 3. For R60, the tracking sheet was noted blank for the pneumonia vaccine. R60 was noted to have declined the pneumococcal vaccine on 1/31/22, however the Authorization and Release for Pneumococcal Vaccine was noted to be signed by R60's POA (Power of Attorney) on 2/4/22. R60's Informed Consent for Immunization with Inactivated and Live Viruses, dated 10/12/22 which was completed during the facility's vaccine clinic provided by an outside vendor shows for the question, Have you ever received a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145538 If continuation sheet Page 16 of 18 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 145538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beecher Manor Nrsg & Rehab Ctr 1201 Dixie Highway Beecher, IL 60401 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 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some pneumonia vaccine, the box is checked Yes,. However, the next line asking, If yes, when and what kind(s) documents, Yes, but unsure when. R60's Resident Face Sheet documents an initial admission date of 1/27/22. R60's age is documented as [AGE] years old and R60's diagnoses include but are not limited to cerebral infarction (stroke), type 2 diabetes mellitus, atrial fibrillation, and obesity. 4. For R66, the tracking sheet was noted blank for the pneumonia vaccine. R66's Informed Consent for Vaccinations shows, on 2/25/22, R66 declined the pneumococcal vaccine with the reason listed as already had,. However, R66 also has an Authorization and Release for Pneumococcal Vaccine which shows R66 consented to receive the pneumococcal vaccine on 4/1/22. R66's Informed Consent for Immunization with Inactivated and Live Viruses, dated 10/20/22, which was completed during the facility's vaccine clinic provided by an outside vendor shows for the question, Have you ever received a pneumonia vaccine?, there is no answer selected. R66's Resident Face Sheet documents a current admission date of 2/25/22. R66's age is documented as [AGE] years old, and R66's diagnoses include but are not limited to type 2 diabetes mellitus, asthma, essential hypertension, and reduced mobility. 5. For R90, the tracking sheet was blank for both the flu and pneumonia vaccines. R90's Informed Consent for Immunization with Inactivated and Live Viruses, dated 10/19/22, which was completed during the facility's vaccine clinic provided by an outside vendor shows box for flu was marked under, Vaccine(s) requested,. However, there is no documentation of any vaccine administered on the form. R90's Authorization and Release for Influenza Vaccine was noted to be signed and dated 2/8/23. The form for the pneumonia vaccine was checked Refused to sign. When the surveyor inquired why R90 did not receive the flu vaccine, V6 stated at the time, R90 had just returned from the hospital and her (V6) husband declined the vaccine because he didn't want R90 poked anymore. Regarding the pneumonia vaccine, V6 added, I guess I could put they declined in here (on spreadsheet). Definitely still learning. R90's Resident Face Sheet documents a current admission date of 4/21/23. R90's age is documented as [AGE] years old, and R90's diagnoses include but are not limited to asthma, multiple sclerosis, and adult failure to thrive. During the same interview, when enquired why there were three different consents forms for flu and pneumonia vaccinations. V6 stated, the Authorization and Release for Influenza/Pneumococcal Vaccine forms are part of the resident's admission packet while the Informed Consent for Vaccinations form is provided by the nurses. Lastly, the Informed Consent for Immunization with Inactivated and Live Viruses form was provided by the outside vendor during the vaccine clinics. On 7/19/23 at 2:21 PM, enquired why it's important to accurately track the status of vaccinations. V2 (DON/Director of Nursing) answered, if people are vaccinated at a great enough rate, then the facility is less likely to have an outbreak. V2 added, she would expect the flu vaccine to be offered every flu season and the pneumonia vaccine to be offered at any time if the resident hasn't had it. V2 acknowledged, We may need to review the process again and start from scratch. The 11/2016 Influenza and Pneumococcal Immunizations facility policy documents, in part, .3. The facility will document both the education provided and the resident's decision, or when appropriate of the resident representative, to accept or refuse the offered immunizations will be maintained in the resident's clinical record. 4. The facility will maintain additional documentation for those (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145538 If continuation sheet Page 17 of 18 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 145538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beecher Manor Nrsg & Rehab Ctr 1201 Dixie Highway Beecher, IL 60401 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 0883 Level of Harm - Minimal harm or potential for actual harm residents offered immunizations including: date(s) the immunizations were provided; vaccine agent type(s); vial lot numbers; injection sites(s); post-vaccination monitoring of adverse effects. 5. The facility will assure an on-going process exists to educate and provide new residents or their representatives with the opportunity to accept or refuse both the pneumococcal and influenza immunizations, the latter of which will be offered during the annual influenza season. Residents Affected - Some The 2/13/23 CDC (Centers for Disease Control and Prevention) online article titled Pneumococcal Vaccination: Summary of Who and When to Vaccinate documents, in part, CDC recommends pneumococcal vaccination for adults 19 through [AGE] years old who have certain chronic medical conditions or other risk factors. This includes but is not limited to chronic lung disease, including chronic obstructive pulmonary disease, emphysema, and asthma; diabetes mellitus; and chronic heart disease. Also, CDC recommends pneumococcal vaccination for all adults 65 years or older. (www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145538 If continuation sheet Page 18 of 18