Inspection·September 15, 2022

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that have Unspecified Dementia with Behavioral Disturbances, Atrial Premature Depolarization, Hyperlipidemia and Hypercholesterolemia and instructs extreme caution to be taken, as the resident's condition is to be monitored. R81's current Plan of Care, dated 8/25/22, fails to identify the use of Anti-psychotic medications and what specific conditions are to be monitored with their use. 3. The Electronic Medical Record documents R135 was admitted to the facility for Therapy Services following the surgical amputation of the right lower extremity on 8/31/22. The Electronic Medical Record documents R135 has the current diagnoses of Unsteadiness on Feet, Muscle Weakness, Abnormal Gait, and Lack of Coordination. On 9/12/22 at 1:30 PM, V7 (Certified Nursing Assistant) assisted R135 to transfer from her wheelchair to her bed using a stand aid (transfer-assist unit which actively engages the patient in the standing process). V7 did not have a gait belt, and provided stand by assistance to R135 as she transferred her with the stand aid. At that time, V7 stated she was unsure if a gait belt was to be utilized during R135's transfer. R135's current Plan of Care, dated 9/02/22, fails to identify what level or method of transfer assistance R135 requires, and what safety measures are to be implemented by staff when transferring. On 9/14/22 at 2:59 PM, V2 (Director of Nursing) stated the facility should have a plan of care developed that is resident specific, and includes focus areas such as, the use of psychotropic medications, nutritional concerns and specifics related to Activities of Daily Living. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145597 If continuation sheet Page 2 of 13 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 145597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pekin Manor 1520 El Camino Drive Pekin, IL 61554 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 Based on observation, interview, and record review, the facility failed to ensure a pressure ulcer dressing/packing was not soiled with feces prior to covering it with a dressing for one of two residents (R12) reviewed for pressure ulcers in the sample of 32. Residents Affected - Few Findings include: The facility's Wound Care policy, dated 3/2004, documents, Objective: To prevent the wound from contamination and control bleeding. All wound treatments should be done in an aseptic manner, employing standard precautions throughout. R12's Wound Evaluation & Management Summary, dated 9/13/22, documents R12 has a full thickness stage 4 pressure ulcer to her coccyx measuring 1.8 cm (centimeters) x 1.3 cm x 1 cm. R12's Physician's Orders, dated 9/14/22, documents R12 has an order to cleanse R12's coccyx, apply skin prep to peri-wound, apply collagen to wound bed, lightly pack with calcium alginate, and cover with a border dressing two times a day. On 9/14/22 at 11:04 AM, R12 had open area to her coccyx with significant depth. The edges of the wound were macerated. V9 (Licensed Practical Nurse) cleansed the wound with wound cleanser, and using her finger, packed the wound with collagen. Then, V9 packed the wound with calcium alginate using her finger again. During this process, R12 was incontinent of her bowels. While the wound was uncovered but packed, V11 (Certified Nursing Assistant) provided incontinent care using disposable wipes. While providing the care, bm (bowel movement) was wiped onto the calcium alginate packing. Once V11 was finished, V9 covered the wound with a border gauze. V11 rolled R12 to her back to redress R12, when the surveyor stopped staff due to the resident having a bm contaminated dressing on. On 09/14/22 at 11:24 AM, V9 removed the dressing and confirmed the calcium alginate did have bm on it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145597 If continuation sheet Page 3 of 13 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 145597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pekin Manor 1520 El Camino Drive Pekin, IL 61554 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 - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to ensure a gait belt was used during a transfer with a stand aid, for one of six residents (R135) reviewed for transfer assistance in a sample of 32. Findings include: The facility policy, titled Safe Resident Handling (revised 11/12) documents, the Facility is dedicated to providing quality care to residents who have entrusted their lives to us, and to provide a work environment that is safe and enjoyable to our staff. Our Safe Resident Handling Program is designed to meet the following goals: Improve working conditions by reducing the incident of back fatigue and musculoskeletal injuries; Maintain a high level of resident dignity and quality of care; Standardize all lifting procedures and provide the tools to life safely; Protect staff and residents from injury. The policy later documents, 9. When physically transferring residents, gait belts will be used to maintain appropriate transfer technique. The Electronic Medical Record documents R135 was admitted to the facility for Therapy Services following surgical amputation of the right lower extremity on 8/31/22. The Electronic Medical Record documents R135 has the current diagnoses of Unsteadiness on Feet, Muscle Weakness, Abnormal Gait, and Lack of Coordination. On 9/12/22 at 1:30 PM, V7 (Certified Nursing Assistant) assisted R135 to transfer from her wheelchair to her bed using a stand aid (transfer-assist unit which actively engages the patient in the standing process). V7 did not have a gait belt, and provided stand by assistance to R135, as she gripped the handles of the stand aid and pulled herself to an upright position. V7 wheeled the stand aid as R135 stood in an upright position, from the wheelchair to the bed. Before V7 started to lower R135 to the bed, R135 verbally reminded V7 to lock the stand aid, so it would not roll away from the bed. V7 locked the stand aid, and lowered R135 to a sitting position on the side of the bed. At that time, V7 was questioned if she had a gait belt, and if it was facility protocol to utilize a gait belt when transferring a resident. V7 stated it was her first day working at the facility and she was not given a gait belt to use during transfers. V7 stated she was unaware of the facility protocol for transferring residents with a stand aid. On 9/14/22 at 10:54 AM, V1 (Administrator) stated staff should be utilizing a gait belt when using a stand aid to ensure resident safety. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145597 If continuation sheet Page 4 of 13 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 145597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pekin Manor 1520 El Camino Drive Pekin, IL 61554 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to follow the Registered Dietitian's dietary recommendations in a timely manner for a resident that experienced a significant weight loss, for one of two residents (R67) reviewed for nutrition, in a sample of 32. Residents Affected - Few Findings include: The facility policy, titled Weight Monitoring (revised 6/21) documents, Objective: 1. To consistently assess residents for significant weight loss or gain. The policy documents that Licensed staff will notify the physician of the following: A. 5% or more gain or loss in 30-day period. B. 7 1/2 % or more gain or loss in a 90 day period. C. 10% or more gain or loss in a 180 day period. Notification to the physician must be documented, and also whether or not new orders were received. Lastly, the policy advises, 6. The RD (Registered Dietitian) will review significant weight losses and any other residents referred by the weight committee on a monthly basis, and make recommendations to physicians as necessary. The Electronic Medical Record documents R67 has the current diagnoses of Vascular Dementia with Behavioral Disturbance, Cognitive Communication Deficit and Dysphagia. Minimum Data Set assessment, dated 8/10/22, documents R67 requires set up assistance and supervision for dining. The Electronic Medical Record documents R67 weighed 144 pounds on 5/03/22. The next documented weight in the Electronic Medical Record is on 7/06/22, with R67 weighing 131 pounds, which is a decrease of 9.03% in two months. On 7/12/2022, Progress Notes by the Registered Dietitian document, July (weight 7/6/22) 131.6 (pounds); (significant loss of) 8.7% (13 pound weight loss in two months), (significant) 11.7% (~17#) (weight) loss in (3 months), & (significant) 5.9% (~25#) (weight loss in 6 months). BMI (Body Mass Index) = 25.7; (overweight). (Oral) intakes are poor. Receiving Ensure or Boost Breeze (twice per day) between meals. (Recommend): 1) High Calorie High Protein Supplementation 2) One (multivitamin with) minerals (orally) daily 3) Weekly (weights) x 4 (weeks). Encourage (oral) intakes. On 8/17/2022, Progress Notes by the Registered Dietitian document, (August weight 8/10/22) 132 (pounds); (significant) 8.5% (~12 pound weight) loss in 3 (months and significant) 10.8% (16 pound weight) loss in 6 (months). (Weight) is down ~17 (pounds from) from previous annual assessment. BMI = 25.78; (Overweight). (Oral) intakes at mealtime appear to be poor but supplement & snack intakes appear to be good. (R67) has an Advance Directive for no feeding tubes. (Multi-vitamin with) minerals was added on (8/09/22) per previous (recommendations on 7/12/22) & (high calorie high protein supplement) was also approved on (8/9/22) but not yet in orders; requesting follow-up. R67's Physician's Orders in the Electronic Medical Record documents R67's Multi-Vitamin with Minerals was started 8/09/22 (four weeks after the recommendation), and the High Calorie/High Protein Supplement was not started until 8/17/22 (five weeks after the recommendation). Additionally, there are no documented weekly weights beginning 7/12/22. On 9/14/22 at 1:39 PM, V2 (Director of Nursing) stated staff are expected to promptly act upon all of the Registered Dietitian's recommendations, and a physician's order is not needed to start a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145597 If continuation sheet Page 5 of 13 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 145597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pekin Manor 1520 El Camino Drive Pekin, IL 61554 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 0692 resident on a high calorie/high protein supplement. Level of Harm - Minimal harm or potential for actual harm On 9/14/22 at 1:46 PM, V10 (Registered Dietitian) stated she would expect all resident dietary changes to be followed through within a couple of days. V10 stated there are issues with the Physician taking long periods of time, sometimes a couple of weeks, to authorize her dietary orders. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145597 If continuation sheet Page 6 of 13 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 145597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pekin Manor 1520 El Camino Drive Pekin, IL 61554 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R18's current diagnoses include: Metabolic encephalopathy, Cognitive communication deficit, Vascular Dementia with behavioral disturbance, Depression and Anxiety. R18's Prescription Order documents the following: Start date 5/7/2022, Seroquel 25 mg (milligram) twice a day; Start date 5/9/2022, Risperdal tablet, 1 mg (milligram) twice a day for a diagnosis of Vascular Dementia. R18's current MAR (Medication Administration Record), dated 9/2022, documents R18 receives the following medications: Fentanyl Patch,25 mcg/hr (microgram/hour) every 72 hours, started on 8/29/2022; Lorazepam 0.5 mg (milligram) three times a day (started 9/7/2022) and at bedtime (started 5/13/2022) for anxiety; Seroquel 25 mg twice a day for Vascular Dementia with behavioral disturbance, started 5/7/2022; Tramadol 50 mg, 1 tablet BID (twice a day) started 8/8/2022 and Morphine 100 mg/5 ml (milliliter) (20 mg/ml) 0.5-1 ml every two hours PRN (as needed) started 8/25/2022. This same MAR documents the Morphine has been given 2-4 times a day from 9/1/2022-9/13/2022. R18's Behavior Analysis records were reviewed, dated 4/25/2022-9/13/2022. These forms document the following behaviors are being monitored for R18: wandering, physical symptoms directed towards others, verbal behavioral symptoms directed towards others, and rejection of care. R18's current care plan documents the following problem with goals and interventions: (R18) has a diagnosis of depression. (R18) has had some recent traumatic family events that have lead to an increase in symptoms including statements of self harm. Symptoms of depressions fluctuate day to day and seem to be increased after family visits. (R18) has been displaying verbal behaviors directed towards staff and family. (R18) displays rejection of care and at times can be physical during cares. R18's psychotropic medictions, including Seroquel are documented as interventions for falls on R18's current fall care plan. On 9/12/2022 at 11:30 AM, R18 was lying in her bed, sleeping. On 9/13/2022 and 9/14/2022 at 11:45 AM- 12:10 PM, R18 was sitting in a high back wheelchair, slumped over on her side sleeping. On 9/14/2022 at 1:30 PM, R18 was in her high back wheelchair in the dining room. Staff woke her up and told her to eat, she took a bite and rested her head on her right hand and said she was tired. On this same date and time, R18 was continuing to take a bite of food and then lean over on a hand between bites. On this date at 1:35 PM, R18 took off her clothing protector, slumped to the right and closed her eyes. On 9/14/2022 at 12:20 PM V8, LPN (Licensed Practical Nurse) stated R18 sleeps all day, and is up all night. V8 stated R18 crawls out of her bed and wheelchair and puts herself on the floor. V8, Licensed Practical Nurse/LPN stated, Since this new medication regimen she is doing much better. V8 stated R18's Ativan used to be PRN, and now it is scheduled. On this same date and time, R18 was sitting in her high back wheelchair, slumped to her right side sleeping. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145597 If continuation sheet Page 7 of 13 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 145597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pekin Manor 1520 El Camino Drive Pekin, IL 61554 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 9/14/2022 at 12:00 PM, V9, LPN (Licensed Practical Nurse), stated R18 is sleeping more since they started her on new meds. V9 stated she is not her nurse, so she is unsure what the medications are. On this same date and time, R18 was sitting in her high back wheelchair, slumped to her right side sleeping. On 9/14/2022 at 12:45 PM V2, DON (Director of Nursing) stated R18's behaviors are putting herself on the floor, crying, yelling, resisting care, cussing, and spitting, and has a history of a family member getting murdered. Based on observation, interview, and record review, the facility failed to document clinically indicated diagnoses and behaviors to justify the use of an antipsychotic, failed to initiate an antipsychotic at the lowest dose, failed to implement non-pharmacological interventions, failed to perform a GDR (Gradual Dose Reduction), and failed to complete an AIMs (Abnormal Involuntary Movements) assessment for three of six residents (R18, R46, R49) reviewed for antipsycotic medication use, in the sample of 32. Findings include: The facility's Psychopharmacologic Drug Usage Procedure, dated 10/18/17, documents, AIMS testing must be done on all residents receiving anti-psychotic (neuroleptic) drugs at initiation of the therapy and at least every six months thereafter. Documentation of behaviors and conditions requiring the use of these medications must be done on a routine basis, as well as medication response and adverse consequences. Gradual Dose Reductions must be attempted. Psychopharmacologic drugs must have a reduction attempt at least in two separate quarters during the first year (with at least one month between attempts) and then annually, unless clinically contraindicated. Reduction of medication must be done per physician's order. The ultimate goal of successful gradual dose reduction is to discontinue the medication, or to utilize the lowest possible dose of medication necessary for the benefit of the resident and to minimize adverse consequences. 1. On 9/12/22 at 1:18 PM, R46 was alert sitting up in her wheelchair. R46 was pleasant and smiling not displaying any behaviors. On 9/14/22 at 12:50 PM, R46 was alert sitting up in her wheelchair in her room eating lunch. R46 was pleasant and laughing in conversation. R46 did not display any behaviors. R46's Physician's orders, dated 9/14/22, document R46 has an order to receive Seroquel (antipsychotic) 25 mg (milligrams) by mouth twice a day, dated 2/23/22. R46's Medication consent, dated 12/8/21, documents R46 is receiving Seroquel to decrease episodes of behaviors. R46's Prescription order, dated 2/23/22, documents R46 is receiving Seroquel for the diagnosis of vascular dementia with behavioral disturbance. R46's Minimum Data Set (MDS), dated [DATE], documents that R46 has not displayed any behaviors, and receives seven days of antipsychotic medications. R46's care plan, dated 9/13/22, documents, Problem: (R46) is at risk for adverse consequences related to receiving antipsychotic, anti-depressant and anti-anxiety medication for treatment of vascular (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145597 If continuation sheet Page 8 of 13 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 145597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pekin Manor 1520 El Camino Drive Pekin, IL 61554 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 0758 dementia with behavioral disturbances. Level of Harm - Minimal harm or potential for actual harm R46's Pharmacy Note to Attending Physician/Prescriber, dated 5/18/22, documents, (R46) receives the following medication used for BPSD (Behavioral and Psychological Symptoms in Dementia): Seroquel 25 mg BID (twice a day). The Centers for Medicare and Medicaid Services (CMS) requires attempts at dosage reductions on medications used for BPSD twice a year in two separate quarters (with at least one month between attempts), within the first year of admission or initiation unless clinically contraindicated. After the first year, dosage reduction attempts are required annually unless clinically contraindicated. (R46) is due for an evaluation. The Pharmacy note also documents the physician signed the note on 7/20/22, agreeing to reduce the Seroquel to 12.5 mg in the morning and 25 mg in the evening. Residents Affected - Few R46's Pharmacy Note to Attending Physician/Prescriber, dated 6/23/22, documents, 2nd Request. The Pharmacy note is recommending again that R46's Seroquel have a GDR. The Pharmacy note also documents that the physician signed the note on 7/20/22 agreeing to reduce the Seroquel to 12.5 mg in the morning and 25 mg in the evening. On 9/14/22 at 1:56 PM, V3 stated R46's diagnosis for the use of Seroquel is Vascular Dementia. On 9/14/22 at 3 PM, V2 stated, (R46's) pharmacy recommendation on 5/18/22 and 6/23/22 were both to reduce (R46's) Seroquel. They are both signed and dated 7/20/22, but I did not receive them back until last Friday (9/9/22). The physician agreed on both of them to reduce the Seroquel. I should have followed up earlier. 2. On 9/12/22 at 1:53 PM, R49 was lying in bed pleasant in conversation, and not displaying any behaviors. On 9/14/22 at 12:03 PM, R49 was alert sitting up in her bed reading, pleasant, and no behaviors were observed. R49's Physician's orders, dated 9/14/22, documents R49 has an order to receive Zyprexa (antipsychotic) 20 mg (milligrams) by mouth once a day dated 4/29/21. R49's Mood and Behavior Assessment, dated 4/22/22, documents R49 does not have any behaviors. R49's Pharmacy Note to Attending Physician/Prescriber, dated 1/20/22, documents, 2nd Request. (R49) receives the following medication used for psychiatric condition: Zyprexa 20 mg every day. The Centers for Medicare and Medicaid Services (CMS) requires attempts at dosage reductions on medications used for psychiatric symptoms twice a year in two separate quarters (with at least one month between attempts), within the first year of admission or initiation unless clinically contraindicated. After the first year, dosage reduction attempts are required annually unless clinically contraindicated. (R49) is due for an evaluation. The Pharmacy note also documents that the physician signed the note on 2/15/22, agreeing to reduce the Zyprexa to 15 mg every day. However, there is a hand written statement of, Declined due to family request. R49's Pharmacy Note to Attending Physician/Prescriber, dated 6/23/22, documents, 2nd Request. (R49) currently receiving Zyprexa 20 mg every day. in excess of the CMS-recommended daily maximum. The recommended maximum for this medication in elderly patients, per CMS, is 5 mg a day. Noted from recommendation in February that family is against any dose reduction and has a listed diagnosis of bipolar (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145597 If continuation sheet Page 9 of 13 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 145597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pekin Manor 1520 El Camino Drive Pekin, IL 61554 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 0758 Level of Harm - Minimal harm or potential for actual harm disorder. Some of the potential warnings: Orthostatic hypotension: may lead to subsequent falls and increased risk of fractures. High anticholinergic burden: Increased risk for new onset delirium, cognitive dysfunction and falling. If the medication is continued as written, please write a brief statement explaining the rationale, and that the risk vs benefit has been considered. The Pharmacy note has no documentation of a response to this recommendation, nor a signature. Residents Affected - Few R49's Pharmacy Note to Attending Physician/Prescriber, dated 6/23/22, documents, 4th Request. (R49) currently receiving Zyprexa 20 mg every day. in excess of the CMS-recommended daily maximum. The recommended maximum for this medication in elderly patients, per CMS, is 5 mg a day. Noted from recommendation in February that family is against any dose reduction and has a listed diagnosis of bipolar disorder. Some of the potential warnings: Orthostatic hypotension: may lead to subsequent falls and increased risk of fractures. High anticholinergic burden: Increased risk for new onset delirium, cognitive dysfunction and falling. If the medication is continued as written, please write a brief statement explaining the rationale, and that the risk vs benefit has been considered. The Pharmacy note has no documentation of a response to this recommendation, nor a signature. R49's MDS, dated [DATE], documents R49 receives antipsychotic medication 7 days a week, and no GDR has been attempted since the last assessment. R49's Care plan, dated 9/12/22, documents, (R49) was admitted to the facility on a routine antipsychotic Zyprexa related to the diagnosis of Bipolar. R49's care plan has no documentation of the target behaviors that R49 is receiving an antipsychotic for. The most recent AIMS on R49's current medical record is dated 1/27/22. R49's medical record has no documentation of monitoring for R49's behaviors. On 9/14/22 at 12:38 PM, V3 stated, I'm in charge of tracking all psychotropics. I'm not sure of what (R14's) target behaviors are for the Zyprexa. That's a good question. On 9/14/22 at 12:46 PM, V2 (Director of Nursing) stated, (R49) hasn't had any behaviors since she was admitted in April 2021. We haven't reduced it because the family won't allow it. V2 also confirmed R49's most recent AIMs was completed on 1/27/22, and R49 has not had a GDR done. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145597 If continuation sheet Page 10 of 13 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 145597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pekin Manor 1520 El Camino Drive Pekin, IL 61554 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to maintain a clean kitchen including can openers, refrigerators, ovens and fans; failed to label and or discard food items as needed, and failed to keep scoops out of food bins. This has the potential to affect all 90 residents living in the facility. Findings: The Food Storage and Labeling Policy, dated 10/21, states Keep all food covered in a resealable bag or container or the original container if applicable. Discard any food item past it's use by date or expiration date. Do not store any utensil in a container of food. The label should include: Product Name; Date; Discard Date; Staff Initials. Items left in their original containers should say Opened with the date. Gallons of milk should be labeled by the Open Date. The discard date is within seven days of the open date. If the expiration date is less than seven days, the milk should be discarded on the expiration date. All staff are responsible for monitoring and discarding outdated items. The Sanitation and Safety Policy, dated 9/10, stated, Can openers shall be cleaned daily. Stove tops will be cleaned daily as well as monthly. Refrigerators and Freezers will be cleaned on an assigned schedule. Foods under refrigerators and in freezers shall be inspected daily. Foods shall be labeled and dated. Once a week food will be removed from shelves which are cleaned with detergent. A cleaning schedule will be developed and posted by the (Dietary Manager) and posted. The schedule will include all items to be cleaned as used, on a daily, weekly or monthly basis. It will include the staffs name and will be checked when cleaned. On 9/12/22 at 10:05 AM, the outside and inside of the coolers, ovens, and storage drawers, had splashes, crumbs, and a build up of unknown food debris. The door handles were sticky. The grease pans under the range had not been emptied, one of the drawers would not open because of a build up of grease. Both large manual can openers had a black sticky, gooey substance, including on the table base. The wall fan that blows over a food preparation area had grime and dust hanging on the blades. The window air conditioner, located by the three compartment sink, has dust on the area where air blows out of the appliance. The air conditioner did not fit flush with the window frame, and there is one and a half inch by one half inch area open directly to the outside. Large scoops were in the large storage bins containing flour, sugar and oats. A gallon of skim milk that was in the milk cooler had a use by date of 9/03/22. The walk in cooler had two opened five pound bags of lettuce with 50 % used. The appearance of the lettuce was a darker green, watery and slimy. One bag of lettuce had no open date, and the other was dated 9/05/22. An opened 16 ounce bag of whipped topping, with 50 % used was not labeled. Four boxes containing two, 10 pounds each of hamburger, and, four, eight to ten pound raw turkey breasts thawing, were stored on a shelf above a 20 pound smoked, ready to eat ham, three 15 pound cases of bacon and two 10.7 pound boxes of peeled boiled eggs. The reach in cooler at the door by the dining room contained an opened 46 ounce container of undated or labeled tomato juice; one pound remaining of a five pound bag of shredded cheddar cheese; one pound remaining of a five pound bag of shredded blended cheese, both bags not sealed; Three pounds remaining in a five pound shredded cheddar cheese bag, no label; ten pounds of sliced bulk American Cheese, in a container without any wrapping or lid; six ounces remaining in a 32 ounce package of deli smoked ham, no open date; one half full pan of chicken noodle soup, uncovered and no label; two half pans, one full containing sliced onions and one with one cup of sliced pickles, uncovered, unlabeled;. In the stock room, an opened five pound bag, 50 % remaining of cornbread mix, dated 5/05/22; an opened five pound bag, 50 % (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145597 If continuation sheet Page 11 of 13 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 145597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pekin Manor 1520 El Camino Drive Pekin, IL 61554 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many remaining of a bag of basic muffin mix, dated 6/07/22, with a brown sticky substance on the outside of the package; and an opened five pound bag white cake mix, no label. On 9/12/22 at 11:10 AM, V1, Administrator, acknowledged the above items which were shown to her. V1 stated, This kitchen will be cleaned up. We have a new Certified Dietary Manager starting who will make sure the kitchen stays that way. The Centers for Medicare and Medicaid (CMS) Resident's Census and Condition of Residents' Report, form 672, dated 9/12/22 and signed by V2, Director of Nursing, documents at the time of the survey 90 residents live in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145597 If continuation sheet Page 12 of 13 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 145597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pekin Manor 1520 El Camino Drive Pekin, IL 61554 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 Based on observation, interview, and record review, the facility failed to ensure all staff was wearing required Personal Protective Equipment (PPE) according to Centers for Disease Control (CDC)guidelines. This failure has the potential to affect all 90 residents in the building. Residents Affected - Many Findings include: The facility's COVID-19 policy, dated 1/19/2022, documents the following: The Infection Control Program (ICP) at this facility recognizes Novel Coronavirus (COVID-19) as a highly contagious virus and has a focus to reduce the risk of unnecessary exposures among residents, staff and visitors. Measures are based on guidance from the Centers for Disease Control (CDC), Center for Medicare and Medicaid Services (CMS) and state and local authorities. Interventions focus on prevention of exposure, early detection of symptoms, effective triage and isolation of potentially infectious residents. Prevention: 6. All employees must wear a well-fitted face mask while present in resident care areas. Other PPE (personal protective equipment) may be required. The facility's electronic records document R339 and R340 were diagnosed COVID-19 positive on 9/12/2022. On 9/13/2022 from 7:58 AM-8:20 AM and on 9/14/2022 from 9:25 AM-9:35 AM, V6, RN (Registered Nurse) had a face mask on that sat below her nose. On 9/14/2022 at 9:40 AM, V6, RN verified her mask was under her nose, and should be covering her nose. On 9/14/2022 from 9:25 AM- 9:35 AM, V5, LPN, (Licensed Practical Nurse) was sitting in the COVID-19 hallway with her facemask under her nose. On 9/14/22 at 9:35 AM, V4, ICP (Infection Control Preventionist) observed, and verified V5, LPN, was wearing her facemask under her nose while working in the COVID Unit. V5 verified there are two COVID Positive residents on the hall, and R339 and R340 tested positive for COVID-19 on 9/12/2022. V4, ICP stated, (V5, LPN) should have her mask covering her nose, as well as have a gown on. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145597 If continuation sheet Page 13 of 13