Health inspection·March 22, 2024

F 0684 disease. Level of Harm - Minimal harm or potential for actual harm The Face Sheet for R18 documents the following diagnoses: Complete traumatic amputation at level between knee and ankle, right lower leg subsequent encounter 9/25/23; History of right leg amputations with Gangrene, Sepsis and Osteomylitis to right leg. Delayed surgical wound healing; PVD (Peripheral Vascular Disease); Idiopathic Peripheral Autonomic Neuropathy; Long-Term use of antibiotics; Paroxysmal A-fib; Heart-Valve Replacement; CHF (Congestive Heart Failure), A-flutter (Superventricular Arrhythmia fast rate); Ischemic Cardiomyopathy (damaged heart muscle from lack of blood flow); Atherosclerotic Heart Disease (damage to heart's major blood vessels limiting blood flow to the heart); Acquired absence of right leg below knee amputation; Gangrene right leg status post BKA (below the knee amputation); Presence of Aortocoronary Bypass Graft (heart surgery to restore blood flow to the heart) in 12/2001. Residents Affected - Few The current Physician Orders documents the following dated orders: 3/20/24 Doxycycline 100 milligrams twice daily due to suspected soft tissue infection to right leg wound. Culture pending; 3/12/24 Cleanse stump wound. Apply collagen silver to stump. On open areas on lower leg apply collagen powder, cover with oil emulsion gauze. Cover entire lower leg with non-bordered foam dressing and secure with tape to form a sleeve to cover entire lower leg from knee down. Do not tape to skin. Secure in place with (compression dressing), first layer over the knee, apply ring and fold over pulling (compression stocking) up to knee. Change daily. Once a day; 10/31/23 Elevate leg at all times! On 3/19/24 at 4:14 pm, R18 was sitting up in a wheelchair with visible below the knee amputation. R18 raised his right pant leg revealing a bandaged stump. Legs were not elevated at this time. R18 stated he has had multiple surgeries, has had infections, and the doctors just keep cutting more of his leg off which started with his toes. On 3/20/24 at 8:35 am, V2 DON (Director of Nursing) stated We will be culturing (R18's) stump today per doctor order and then he will start the antibiotic for suspected infection to wound. On 3/20/24 at 10:18 am, R18 was sitting on the side of his bed with his pant leg pulled up. Legs were not elevated at this time, On the seat of R18's wheelchair held a white basket that contained treatment supplies, including a package of gauze, wound cleanser, wound treatments, dressings, and tape. V3 LPN (Licensed Practical Nurse) and V2 DON entered R18's room to perform wound measurement and treatment to R18's right stump. V3 LPN pulled a bottle of hand sanitizer from her uniform pocket, applied it to her hands, put the bottle of hand sanitizer back into her uniform pocket, pulled gloves out of the same uniform pocket and applied the gloves to her hands. V3 LPN squatted down in front of R18 with R18's wheelchair to the left and behind her. V3 LPN removed the compression stocking and the soiled dressing which held yellow/tan wet drainage. R18's right stump surgical wound bed was covered with gray sloughing and yellow/tan drainage. With soiled gloves V3 LPN pulled the white basket closer to her, retrieved the wound cleanser, reached into the package of gauze and retrieved gauze pads. V3 LPN sprayed the gauze pads with the wound cleanser, put the wound cleanser back into the white basket and wiped R18's surgical wound bed. V3 LPN repeated this same process three times and a fourth time. V3 LPN retrieved a gauze pad and wiped R18's wound bed dry. With same soiled gloves, V3 LPN reached into the white basket and retrieved a wound culture kit which contained a red cap with two swabs and the vial to hold the swabs. V3 LPN opened the kit by holding the red cap with swabs in her right soiled gloved hand and the vial container with her left soiled gloved hand and pulled them apart. V3 LPN then rubbed the two swabs onto R18's wound bed to obtain wound culture, placed the red cap with the swabs back into the vial, and pushed them together to close the kit. V3 LPN reached back into the white basket, retrieved gauze from the package of gauze, and the wound cleanser, sprayed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145704 If continuation sheet Page 2 of 9 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 145704 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apostolic Christian Home 1102 West Randolph Roanoke, IL 61561 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the cleanser onto the gauze, put the wound cleanser back into the white basket and wiped R18's peri wound area. V3 LPN repeated this same step one more time. V3 LPN then removed her soiled gloves, reached into her right uniform pocket, retrieved the hand sanitizer, squeezed the liquid onto her left hand, and put the hand sanitizer back into her uniform pocket and retrieved another pair of gloves from the same uniform pocket. V3 LPN reached into the white basket, retrieved a bottle of (water-free moisturizer), sprayed R18's peri wound with the (water-free moisturizer) and with gloved hands rubbed the moisturizer over R18's peri wound area. Without performing hand hygiene V3 LPN reached into the white basket and retrieved a package containing collagen silver, opened the package and pulled the collagen silver out, applied the collagen silver to R18's wound bed, and pulled off the excess edges. V3 LPN reached back into the white basket, retrieved a non bordered dressing, placed it around R18's stump wound, reached back into the basket retrieving tape and began securing dressing with the tape and placed the tape back into the basket. After applying the compression dressing to R18's dressing, V3 LPN removed her gloves by retrieving the hand sanitizer from her uniform pocket and after use put the hand sanitizer back into the same uniform pocket. V3 LPN picked up the white basket and the wound culture kit and exited R18's room, walked to the nurse's station, set the basket on the desk, grabbed the culture kit by the red cap, filled out the label, logged into the nurse's station computer using the computer mouse and keyboard. V3 LPN opened the medication room door, picked up the biohazard laboratory bag, handed the bag to V2 DON who held the bag open for V3 LPN to place the culture kit into the bag. V3 LPN walked up to the medication cart, logged into medication cart computer to look up R18's medication orders, opened a medication cart drawer, retrieved R18's card of antibiotic, pushed the medication into a medication cup, closed medication cart drawer, walked out of med room, closed medication room door, walked to R18's room, and administered the antibiotic to R18. V3 LPN exited R18's room, went back to medication room, opened the medication room door, logged back into the computer and signed off R18's antibiotic, exited the medication room, closed the door and walked to the nurse's station desk and picked up the white basket. On 3/20/24 at 10:45 am, V3 LPN stated the white basket contains treatment supplies for R18 only, not for anyone else and after the wound treatment is done the basket goes into the medication room so the next nurse just grabs the basket and will have all R18's supplies together. V3 LPN stated V10 LPN is the wound nurse and recommended trying the (water-free moisturizer) instead of the collagen powder to prevent the dressing from sticking to R18's leg. V3 LPN stated V10 LPN did not get a physician order for the moisturizer but stuck a note in R18's basket and she said she would get the order if it worked. On 3/21/24 at 10:01 am, V3 LPN stated, We are supposed to use hand sanitizer every time our hands get contaminated and before putting on gloves and after taking them off. On 3/21/24 at 11:30 am, V2 DON stated, All employees should be performing hand hygiene before and after glove removal, or when they touch contaminated objects. On 3/21/24 at 2:00 pm, V2 DON confirmed V3 LPN contaminated treatment supplies during R18's surgical wound treatment and should have performed hand hygiene between dirty and clean. V2 DON also confirmed there is no physician order for the use of the (water-free moisturizer) to be used for R18 because the facility wanted to try it first to see if it would work. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145704 If continuation sheet Page 3 of 9 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 145704 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apostolic Christian Home 1102 West Randolph Roanoke, IL 61561 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 perform hand hygiene and maintain adequate infection control during a Pressure Ulcer dressing change for one Resident (R7) of two Residents reviewed for Pressure Ulcers in a sample of 21. Residents Affected - Few Findings include: Facility Procedure for Clean Dressing Change Policy, reviewed 2/1/24, documents: to protect open wound from contamination; prevent infection and spread of infection; provide for optimal healing; wash hands; place plastic bag/waste basket near foot of bed to receive soiled dressing; position the bag to avoid reaching across the sterile field or the wound when disposing of soiled articles; form a cuff by turning down the top of the trash bag to provide a wide opening and to prevent contamination of instruments or gloves by touching the bags edge; slowly remove soiled dressing; discard soiled dressing in the plastic bag; wash hands, put on new gloves; use (brand name) wound cleanser if no solution is specifically ordered; always wipe from clean area toward the less clean area; use each gauze pad for only one stroke; apply prescribed medication if ordered; follow Physicians order for type of dressing; secure dressing edge with tape or method as ordered by Physician; remove gloves and place in plastic bag; wash hands; assist Resident to comfortable position; return equipment to designated area; discard bag containing dressings in infectious waste container; and wash hands. R7's Physician Order Sheet/POS, dated 1/21/24 through 3/21/24, documents R7's Right Heel treatment of cleanse, sure prep (skin protectant) surrounding wound, apply medication (collagen silver) cut to fit open area only, cover with non-bordered dry dressing and wrap with dry dressing (Kerlix) and change daily. R7's POS also documents an order to ensure heels are off loaded with heel boots and pillow, please remove heel boots and put on (don) gripper socks for stand aid transfers. R7's Multi Wound Chart Details, dated 2/28/24, documents: Wound One (Right Heel Pressure Ulcer) acquired on 9/13/23, and measuring 3.2 centimeters/cm by 1.4 cm by 0.2 cm with moderate, serosanguineous drainage. The wound charting documents a right heel treatment order of collagen sheet silver, cover with super absorbent non-bordered four by four, wrap with stretch gauze bandage and reinforce with silk tape. R7's current Care Plan, documents on 2/9/24, a Physician Order for Antibiotic (Cephalexin) for a resolved right heel infection. On 3/19/24 (at 9:35 am, 10:10 am and 12:45 pm) and on 3/20/24 (at 10:04 am and 12:10 pm) and 3/21/24 (at 9:25 am and 10:30 am) R7 was in R7's recliner with legs elevated on the footrest, with no heel boots on. R7's heel boots were on the floor and at the foot of R7's bed. On 3/20/24 at 10:04 am, V3 (Licensed Practical Nurse/LPN) entered R7's room, with R7's wound supply bin/basket, to perform right heel pressure ulcer care. R7 was in recliner with legs elevated on footrest, with no heel boots on. R7's heel boots were on the floor, at the foot of R7's bed. V3 removed R7's soiled dressing and continued to clean R7's right heel pressure ulcer with wound cleanser by spraying the wound cleanser onto R7's heel, then placed the bottle of wound cleanser onto the floor at R7's recliner footrest, then with gauze, cleansed/wiped R7's right heel with approximately five strokes, with the same gauze in a circular motion, red drainage and contaminated wound cleaner dripped onto the floor, at R7's footrest. V3 then picked up the bottle of wound cleanser off of the floor again, sprayed R7's Right Heel and continued to cleanse/wipe R7's right heel and placed the wound (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145704 If continuation sheet Page 4 of 9 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 145704 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apostolic Christian Home 1102 West Randolph Roanoke, IL 61561 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cleanser back onto the floor. V3 then picked up the bottle of wound cleanser off the floor and placed it onto the window ledge, next to R7's wound supply bin/basket. V3 then removed and disposed the contaminated gloves into R7's waste basket across the room (over five feet). V3 hand sanitized and put on clean gloves. When V3 was retrieving new wound supplies from R7's wound care bin/basket, V3 could not locate a non-border dry dressing, so V3 removed V3's gloves and exited R7's room to retrieve a new non-border dry dressing. When V3 re-entered R7's room, V3 placed the new non-border dry dressing package onto R7's recliner footrest and the clean package fell onto the floor. V3 picked up the package off the floor and placed it back onto R7's recliner footrest. V3 then put a new pair of gloves on, without performing hand hygiene, and completed R7's treatment. V3 did not apply sure prep (skin protectant) to R7's peri wound area. V3 was kneeling on the floor at R7's recliner footrest, and as V3 opened the wound supply packages, V3 placed them onto V3's right leg, instead of into the waste basket. V3 then removed the contaminated gloves and tossed them towards the waste basket and the gloves fell onto the floor. V3 then walked over to pick up the soiled gloves off the floor and placed them in the waste basket. V3 then placed R7's right sock back on and re-positioned R7's Right Foot, then covered R7's foot with R7's blanket and placed the bottle of wound cleanser back into the wound supply bin/basket. On 3/21/24 at 10:01 am, V3 (LPN) stated, We are supposed to hand sanitize every time our hands get contaminated and before putting on gloves and after taking them off. I did toss the gloves over to the garbage can, and I probably should have cleaned my hands after picking them up off the floor and not a good idea that I put that wound cleanser bottle onto the floor and should have wiped up the drainage on the floor. I did not even think about it when I was picking up the clean dressing package off of the floor. On 3/21/24 at 11:30 am, V2 (Director of Nursing) verified that V2 entered R7's room after wound care was almost completed and stated, I did see (V3) toss the gloves onto the floor and pick them up and (V3) should have not done that. All employees should be performing hand hygiene before and after glove removal, or when they touch contaminated objects. V2 also verified that V3 (LPN) should not have placed the wound cleanser onto the floor and stated, (V3) should have put down a towel or wound dressing pad before starting the treatment to avoid the drainage and wound cleanser from dripping onto the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145704 If continuation sheet Page 5 of 9 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 145704 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apostolic Christian Home 1102 West Randolph Roanoke, IL 61561 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to obtain a physician order for the use of oxygen, follow the manufacturers guidelines for tubing changes, and store oxygen tubing per facility policy and procedure for one (R20) of two residents reviewed for oxygen in the sample of 21. Residents Affected - Few Findings include: The facility's Oxygen Administration policy and procedure, revised 2/22/2024, documents A physician's order is required to use O2 (oxygen). The standing orders may be used in an emergency situation, but the physician must be notified after oxygen is initiated. Be sure to enter O2 use in the Treatment MAR (Medication Administration Record). The oxygen tubing will be discarded and replaced every 90 days. Please label oxygen tubing with date changed if possible. If a humidifier bottle is being used, this is required to be emptied, cleaned and refilled with distilled water every twice weekly. Replace humidifier bottle per annual recommendations. When resident is not using the O2 cannula, store in cloth bags provided. The (Brand/Company) Oxygen Manufacture Guidelines for nasal cannula, dated 2024, documents Check with your healthcare provider for your prescribed airflow setting when choosing the proper nasal cannula. You'll find (Brand/Company) offers a variety of nasal cannulas to fit most airflow needs. And to ensure the best oxygen delivery possible, remember to replace your nasal cannula at least once every 14 days. The facility's Physicians Order policy and procedure, revised 7/7/23, documents Responsibility: Licensed Nurse, Place new orders into (electronic charting system) as appropriate making sure to discontinue any previous orders no longer being used and All new telephone orders, e-mailed orders, and verbal orders are to be directly entered into matrix and the Dr (doctor) will e-sign them. The current Physicians Orders documents the following dated Physician Orders: 1/9/24 If on oxygen change tubing every 90 days, Special Instructions: Change cannula and tubing every 90 days while on oxygen; and 1/9/24 Check behind ears to monitor skin daily if on continuous oxygen therapy, once a day. As of 3/21/22 at 3:00 pm, there was no physician order for the administration of oxygen for R20. The TAR's (Treatment Administration Record) and the MAR's, dated 1/1/24 through 3/22/24, do not include oxygen orders. The January TAR, documents physician order, dated 1/9/24 Check behind ears to monitor skin daily if on continuous oxygen therapy every shift and Check oxygen saturations q (each) shift on continuous oxygen ever shift prn (as needed). The admission MDS (minimum data set) assessment for R20, dated 1/15/24 documents oxygen therapy was used during the look back period. On 3/19/24 at 4:00 pm, R20 stated she only uses the oxygen when she needs it, and it has been a while. An oxygen sign was noted on the outside of R20's door. R20 was lying in bed on her back with eyes open and without oxygen infusing. An oxygen concentrator was next to R20's nightstand, plugged into a wall electrical outlet with a humidifier bottle and oxygen cannula tubing attached. The undated humidifier bottle was half full of clear liquid and the undated nasal cannula tubing was resting stretched out over the top of the oxygen concentrator. There were no dates on the humidifier bottle or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145704 If continuation sheet Page 6 of 9 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 145704 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apostolic Christian Home 1102 West Randolph Roanoke, IL 61561 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 0695 the oxygen nasal cannula tubing to indicate when they were initiated. Level of Harm - Minimal harm or potential for actual harm On 3/20/24 and 3/21/24 between 8:00 am and 4:00 pm, R20's oxygen concentrator was unchanged, without dates on oxygen tubing and humidifier bottle, and oxygen tubing stretched out over the top of the concentrator and not in a cloth bag. Residents Affected - Few On 3/22/24 at 9:23 am, V9 (Brand/Company) Customer Service Representative stated all oxygen tubing should be changed every two weeks. On 3/22/24 at 3:00 pm, V2 DON confirmed R20 did not have a physician order for oxygen and should have and she called and clarified the order for oxygen administration for R20 the afternoon of 3/22/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145704 If continuation sheet Page 7 of 9 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 145704 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apostolic Christian Home 1102 West Randolph Roanoke, IL 61561 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to conduct quarterly Quality Assurance/QA Performance Improvement meetings and assure the required Committee Members were present for the last calendar year. This failure has the potential to affect all 47 Residents who currently reside in the facility. Residents Affected - Many Findings Include: Facility Census and Condition Report, dated 3/19/24, documents 47 Residents residing in the Facility. The Facility's Quality Assurance Performance Improvement/QAPI Guidance Plan, revised 1/5/24, documents: the purpose of the QAPI is to take proactive approach to continually improve the way we caré for and engage with our Residents, Caregivers and other partners; to do this, all employees will participate in ongoing QAPI efforts which support our mission by meeting the physical, mental and spiritual needs of the residents of this home.; QAPI includes all employees, all departments and all services provided; the Governance and Leadership will be integrated into the responsibilities and accountabilities of top-level management by including them in quarterly QAPI meetings; QAPI leadership team will be comprised of the Administrator, and Director of Nursing who together will provide ongoing leadership to the QAPI team; and the QAPI team will meet quarterly and will be facilitated by the Director of Nursing. Facility Employee Roster, dated 2/27/24, documents V6 (Infection Control Coordinator) as the Facility designated Infection Control Preventionist. The Facility Quality Assurance Meeting Attendance Sheet, dated 4/20/23, documents V1 (Administrator), V2 (Director of Nursing), V4 (Medical Director), V7 (Abuse Coordinator/Social Services) and V8 (Environmental Services) in attendance. The Facility Quality Assurance Meeting Attendance Sheet, dated 7/20/23, documents V1 (Administrator), V2 (Director of Nursing), V4 (Medical Director), V5 (Human Resources) and V6 (Infection Control Nurse) in attendance. The Facility Quality Assurance Meeting Attendance Sheet, dated 10/19/23, documents V1 (Administrator), V2 (Director of Nursing), V4 (Medical Director), V6 (Infection Control Nurse) and V7 (Abuse Coordinator/Social Services) in attendance. The Facility Quality Assurance Meeting Attendance Sheet, dated 1/18/24, documents V1 (Administrator), V2 (Director of Nursing), V4 (Medical Director), V6 (Infection Control Nurse) and V7 (Abuse Coordinator/Social Services) in attendance. On 3/21/24 at 11:35 am, V2 (Director of Nursing) stated, We usually meet quarterly, on the third Thursday of the month, at 7:00 am in the morning. (V1/Administrator), myself (V2) and V4/Medical Director) are all in attendance and I invite all other Department Heads to attend, only if they can make it. It is not mandatory for them. Before COVID, we used to hold the 'QA' meetings and they would take all morning and everyone would attend, but that all changed since COVID. I did not realize that a Medical Director, Administrator, Director of Nursing, Infection Preventionist and two other staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145704 If continuation sheet Page 8 of 9 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 145704 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apostolic Christian Home 1102 West Randolph Roanoke, IL 61561 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 0868 were required to attend the QA meetings. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145704 If continuation sheet Page 9 of 9