Inspection·November 2, 2023

F 0690 I thought you wanted to see catheter care. Level of Harm - Minimal harm or potential for actual harm 2. On 10/31/23, at 10:26 am, R7 sat in a wheelchair in his room with an indwelling urinary catheter bag hooked under R7's seat and touching the floor. Residents Affected - Few On 10/31/23, at 10:39 am, V4, Certified Nursing Assistant/CNA, confirmed R7's catheter bag was touching the floor and should not be. On 11/2/23, at 10:09 am, V3, Infection Control Preventionist, stated, They should use hand sanitizer between glove changes and put on a clean pair of gloves. On 11/2/23, at 10:51 am, V2, Director of Nursing/DON, stated during catheter care, the staff should wash the head of the penis, penis, inner thighs and all down the tubing. V2 stated the urinary catheter bag should be always kept below the bladder and up off the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145597 If continuation sheet Page 2 of 5 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 11/02/2023 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to remove Personal Protective Equipment/PPE and perform hand hygiene upon exiting a COVID-19 positive resident room to prevent cross-contamination; failed to follow their COVID-19 policy regarding wearing masks for one resident (R79); and failed to perform hand hygiene during incontinence care for one resident (R7) of 19 residents reviewed for infection control in a sample of 26. Residents Affected - Few Findings include: The facility's Standard Precautions policy, dated 08/09, documents Policy: Standard Precautions will be used in the care of all residents regardless of any suspected or confirmed presence of an infectious agent. Standard Precautions are based on the principle that all, blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents. Objective: To prevent the spread of infectious agents among residents and healthcare personnel in the facility Procedure: 1. Hand hygiene: a. Refers to washing hands with water and either plain soap or soap/detergent containing an antiseptic agent: or thoroughly applying an alcohol-based hand rub (ABHR) .c. Hand hygiene should be performed immediately after gloves are removed, between resident contacts, and when otherwise indicated to avoid transfer of microorganisms to other residents or environment. Utilize hand hygiene between tasks and procedures on the same resident to prevent cross-contamination of different body sites 2. Gloves: c. Change gloves between tasks and procedures on the same resident after contact with material that may contain infectious agents. d. Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another resident. Wash hands immediately to avoid transfer of infectious agents to other residents or environments. The facility's undated Proper Hand Washing Procedure documents When to Wash Hands: Employee must wash their hands: After removing disposable gloves. After engaging in any activity that would contaminate hands. The facility's COVID-19 policy, dated 8/28/23, documents Policy: 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. Purpose: The purpose of this policy is to prevent/minimize the risk of COVID-19 from being introduced into the facility and provide care for resident suspected or confirmed to have COVID-19 .Prevention: Masking: 3. Facility will follow current CDC/CMS recommendations regarding masking while in an outbreak. The CDC's COVID-19 guidelines, provided by the facility and dated 5/25/23, documents The Core Principles of COVID-19 Infection Prevention: 6. Implement Source Control Measures: Source control refers to use of respirators or well-fitting masks to cover a person's mouth and nose to prevent the spread of respiratory secretions when they are breathing, talking, sneezing, or coughing .Source control is always recommended for individuals in health care settings who: Reside or work on a unit or area of the facility experiencing a SARS-CoV-2 (Severe acute respiratory syndrome coronavirus-2) outbreak .If a facility is experiencing an outbreak of COVID-10 or other respiratory illnesses, at a minimum, HCP (Healthcare Personnel) must wear a well-fitted mask while on the unit or floor experiencing an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145597 If continuation sheet Page 3 of 5 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 11/02/2023 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 outbreak. Level of Harm - Minimal harm or potential for actual harm R79's current Physician Order Sheet/POS documents diagnoses including COVID-19 Acute Respiratory Disease (Primary). Residents Affected - Few On 11/2/23, at 10:01 am, V3 Infection Control Preventionist/ICP stated that one or more COVID-19 positive is considered outbreak. V3 stated that staff who are working on that hallway where the COVID Isolation room is, have to wear a surgical mask when caring for the other residents on that hall. 1. On 10/31/23, at 11:34 am, V6, Floor Tech, donned a gown, gloves, N95 face mask, and face shield. V6 stepped inside R79's Isolation room and wiped the isolation garbage lid with a disinfectant spray. When finished, V6 placed the soiled cloth into a clear bag. V6 removed his gown and gloves. Without any hand hygiene and while wearing the same soiled N-95 face mask and face shield, V6 took the clear bag and disinfectant spray bottle, walked up the resident hall, around the corner past a small resident dining area, and down the next resident hall to the end passing by occupied resident rooms. V6 then stepped into the housekeeping office. V6 removed V6's face shield, put a glove on and placed the clear bag with the soiled cloth into another bag then stepped out and carried it to the dirty linen closet to dispose of it. Upon exiting the closet, V6 removed his soiled N-95 face mask. On 10/31/23, at 11:41 am, V6 stated V6 usually wears the mask and face shield clear through (the task). V6 stated, I should not have walked through the hall with it on and should have washed my hands right when I left the room. On 11/2/23, at 10:12 am, V3, Infection Control Preventionist/ICP, stated, It is not correct to be wearing the same face shield or the N95 beyond the COVID isolation room - it should be changed to a surgical mask. 2. On 10/31/23, between 9:30 am and 2:30 pm, R79 was in bed in a COVID-19 Isolation room. Staff noted to be working at various times on this hall were not wearing any face masks, and included V4, V8, and V9, Certified Nursing Assistants/CNAs. On 10/31/23, at 10:10 am, V9, CNA, was in between answering resident call devices on the COVID-19 hall. V9 was not wearing any face mask. On 10/31/23, at 11:27 am, V4, CNA, stood outside R79's Isolation room and handed supplies to V10, Registered Nurse/RN, who had donned PPE and entered R79's room. V4, CNA, was not wearing any face mask. On 11/1/23, at 2:18 pm, V8, CNA, now wearing a surgical face mask on the COVID-19 hall, stated V3, Infection Control Preventionist, told them today they are supposed to wear a surgical mask when working on this (COVID-19) hall. V8 confirmed V8 was not wearing one yesterday (10/31/23). On 11/2/23, at 10:01 am, V3, Infection Control Preventionist/ICP, stated staff who are working on that hallway where the COVID-19 Isolation room is, have to wear a surgical mask when caring for the other residents on that hall. 3. On 10/31/23, at 11:27 am, R79 was lying in bed in an Isolation room. V10, Registered Nurse/RN, donned PPE (Personal Protective Equipment) and entered R79's room to pass medications. After completion and removing V10's PPE at R79's doorway, V10 walked past occupied resident rooms (approximately (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145597 If continuation sheet Page 4 of 5 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 11/02/2023 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 25 feet up the hall) then used hand sanitizer. Level of Harm - Minimal harm or potential for actual harm On 11/02/23, at 10:09 am, V3, ICP, stated, Staff should be either washing their hands or using hand sanitizer as soon as they leave the room. Not to be walking up the hall to sanitize. Residents Affected - Few 4. On 11/01/23, at 10:12 am, R7 sat in a wheelchair in his room. V5, Certified Nursing Assistant/CNA, assisted R7 to the bathroom to put lotion on R7's bottom per his request. As V5 pulled down R7's pants and brief, V5 noticed stool on R7's brief. V5 assisted R7 to sit back down into his wheelchair then gathered supplies for incontinence care. With gloved hands, V5 assisted R7 to stand, lowered and removed R7's soiled brief, and tossed it into the garbage can. V5 wiped stool from R7's bottom with cleansing wipes. With the same soiled gloves, V5 put a clean brief on R7, applied lotion to R7's thighs per his request, then assisted R7 to sit down in his wheelchair. V5 removed her soiled gloves, then with bare hands, adjusted the wheelchair pedals and removed the gait belt from R7. On 11/01/23, at 10:16 am, V5 stated V5 should have changed V5's gloves after cleaning (R7's) butt. On 11/2/23, at 10:09 am, V3, Infection Control Preventionist, stated, They should use hand sanitizer between glove changes. For incontinence care, they should use fresh gloves before start, and [NAME] soiled cloths into the bag, then dropping their gloves into the bag as well, and then sanitizing and putting on a clean pair of gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145597 If continuation sheet Page 5 of 5