Inspection·March 27, 2025

F 0677 Level of Harm - Minimal harm or potential for actual harm 3. R3's current Continuity of Care Document/CCD documents that R3 admitted to the facility on [DATE]. R3's Census History (1/1/25 through 3/26/25) does not documents any leaves of absence/discharges from the Facility. R3's Skin Monitoring/Comprehensive Shower Review document R3 was showered on 1/23/25, 1/27/25, 2/24/25, 2/27/25, 3/3/25 and 3/24/25. The Facility could not provide weekly Shower Review documents for R3 for the entirety of the dates requested 1/1/25 through 3/26/25. Residents Affected - Some 4. R4's current Continuity of Care Document/CCD documents that R4 admitted to the facility on [DATE]. R4's Census History (1/1/25 through 3/26/25) does not document any leaves of absence/discharges from the Facility. R4's Skin Monitoring/Comprehensive Shower Review document R4 was showered on 1/9/25, 1/13/25, 1/20/25, 1/28/25, 1/31/25, 2/11/25, 2/14/25, 3/4/25, 3/7/25 and 3/14/25. The Facility could not provide weekly Shower Review documents for R4 for the entirety of the dates requested 1/1/25 through 3/26/25. 5. R5's current Continuity of Care Document/CCD documents that R5 admitted to the facility on [DATE]. R5's Skin Monitoring/Comprehensive Shower Review document R5 was showered on 1/21/25, 1/24/25, 1/28/25, 2/7/25, 2/18/25, 2/25/25, 3/1/25 and 3/21/25. The Facility could not provide weekly Shower Review documents for R5 for the entirety of the dates requested 1/1/25 through 3/26/25. 6. R7's current Continuity of Care Document/CCD documents that R7 admitted to the facility on [DATE]. R7's Census History (1/1/25 through 3/26/25) does not document any leaves of absence/discharges from the Facility. R7's Skin Monitoring/Comprehensive Shower Review document R7 was showered on 1/2/25, 1/4/25, 1/6/25, 1/16/25, 1/20/25, 1/21/25, 1/30/25, 2/14/25, 2/20/25, 2/22/25, 2/25/25, 2/27/25, 3/3/25, 3/6/25, 3/10/25, 3/17/25 and 3/24/25. The Facility could not provide weekly Shower Review documents for R4 for the entirety of the dates requested 1/1/25 through 3/26/25. 7. R8's current Continuity of Care Document/CCD documents that R8 admitted to the facility on [DATE]. R8's Census History (1/1/25 through 3/26/25) documents a hospital leave on 1/1/25 through 1/6/25. R8's Skin Monitoring/Comprehensive Shower Review document R8 was showered on 1/1/25, 1/13/25, 1/27/25, 2/24/25, 2/27/25, 3/3/25, 3/10/25, 3/17/25, 3/20/25 and 3/24/25. The Facility could not provide weekly Shower Review documents for R4 for the entirety of the dates requested 1/1/25 through 3/26/25. On 3/25/25 at 12:05 pm, R2 (Resident Council President) stated, I am not getting my showers on my scheduled shower days which are Monday and Friday. They tell me that they do not have time, or that they will come back to get me for one, but they never come back. When I first came here and needed more assistance, they would say that I refused my showers, when I really did not. On 3/26/25 at 9:15 am, R3 stated, I am on hospice care, and I do not like the way the hospice people give me a shower because they squirt me in the head with the water head and no one here checks on my showers or gives me one, so I just wash myself up in my room most times. I really need my hair washed. On 3/26/25 at 9:08 am, R4 stated, I do not always get my showers when I should. On 3/26/25 at 9:32 am, R5 stated, Sometimes, I get showers and sometimes I do not, it just depends. On 3/26/25 at 9:41 am, R8 stated, I do not always get a shower. On 3/27/25 at 9:32 am, V2 (Director of Nursing) stated, I have not been here that long. We are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145719 If continuation sheet Page 2 of 4 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 145719 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Village Healthcare 2202 North Kickapoo Street Lincoln, IL 62656 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 slowly working on getting better with the shower schedules, they have had some problems. I cannot provide anymore documentation for the Residents showers. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145719 If continuation sheet Page 3 of 4 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 145719 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Village Healthcare 2202 North Kickapoo Street Lincoln, IL 62656 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on observation, interview, and record review the Facility failed to follow their Dietary Menu and provide condiments for six of nine Residents (R1, R2, R4, R5, R6, R7) reviewed for dietary preferences in a sample of nine. Findings include: The Facility Week at a Glance Dietary Menu documents condiments be served with the Breakfast, Lunch, and Supper meals. The Facility Dietary Purchase Orders, dated 3/3/25, 3/6/25, 3/10/25, 3/13/25, 3/17/25, 3/20/25 and 3/24/25, document one box of sugar substitute/sweetener was received on 3/10/25. No other substitute sugar/sweetener was purchased. R1's, R2's, R4's, R5's, R6's and R7's Continuity of Care Documents/CCD, document a diagnoses of Diabetes Mellitus. On 3/25/25 at 12:09 pm, 3/26/25 at 8:35 am, 3/26/25 at 12:20 pm and 3/27/25 at 8:25 am, no substitute sugar/sweetener was available/stocked on the dining room tables, individual serving trays or in the Main Dining Room condiment cart/bar. On 3/26/25 at 8:35 am and 12:20 pm, no substitute sugar/sweetener packets were observed on the room tray carts. On 3/27/25 at 9:48 am, no sugar substitute sugar/sweetener packets were in the dry storage room storage container. The Facility's dietary supply shipment had just been received and was stacked in the Facility kitchen unpacked. One box of sugar substitute/sweetener was in the shipment. On 3/25/25 at 12:05 pm, R2 (Resident Council President) stated, There is usually sweetener on the condiment bar in the dining room, but sometimes they run out. On 3/26/25 at 9:08 am, R4 stated, I use a lot of sweetener and we usually buy extra to keep in my room. On 3/26/25 at 9:32 am, R5 stated, I buy my own sweetener because they run out. On 3/27/25 at 9:48 am, V8 (Dietary Manager) stated, I have to order a box of sweetener every week, because we use so much and the Residents hoard the sweetener packets in their rooms. If I run out of product, they will allow me to go to a local store and purchase it, but I did not realize that we were out of the sweetener. V8 verified that no sugar packets were in the storage bin in the dry storage room and that no substitute sugar/sweetener had been received since 3/10/25. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145719 If continuation sheet Page 4 of 4