Health inspection·July 20, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify a resident's responsible party after a significant weight loss was identified for one of four residents (R1) reviewed for notifications of change in a sample of 30.Findings include:The facility's Weight Assessment and Intervention Policy, dated 1/2025, documents The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month- Five percent weight loss is significant; greater than 5% is severe. b. 3 months- 7.5 percent weight loss is significant; greater than 7.5% is severe. c. 6 months- 10 percent weight loss is significant; greater than 10 percent is severe.The facility's Notification of Consumer Change in Condition Policy, dated 1/2025, documents Policy: It is the policy of this facility to promptly notify the consumer, their legal representative(s) and attending physicians of changes in the consumer's health condition. Policy Specifications: To establish guidelines for assuring consumers, their legal representative and attending physicians are informed of changes in the consumer's condition. As per the Guidelines for Reporting to Physicians as per INTERACT Change in Condition Guidelines. Responsibility: Director of Nursing and Licensed Nurses. Standards: 3. Clinical change in condition is determined by consumer visualization, medical record review, clinical assessment findings and care plan review. Review of high-risk clinical issue such as skin breakdown, falls, weight loss, dehydration and others are conducted on a daily basis. 12. Consumer representative(s) notifications and attempts will be made promptly and documented in the nurses' notes. In the event the licensed nurse is unable to contact the consumer's representative, after a reasonable time period, the director of Nursing will be notified.The facility's Notification of Change Guidelines, dated 1/2025, documents Purpose: It is the practice of this facility that changes in a resident condition or treatment are immediately shared with the resident and/or resident representative, according to their authority, and are reported to and consulted with the attending physician. The resident and/or the resident representative will be educated about treatment options and supported to make an informed decision. Responsible Party: Clinical. Physician Notification and Consultation- Notification is provide to residents and/or the resident representative(S) to promote the right to make informed decisions regarding choices for care and treatment while keeping them informed about their current health status.1. R1's Face Sheet, dated 7/16/25, documents R1 is a [AGE] year-old male that admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Cerebral Palsy, Epilepsy, Unspecified Intellectual Disabilities, Hypothyroidism, Bradycardia, and Dysphagia, and Gastrostomy Status Placed 4/30/25.R1's MDS (Minimum Data Set) Assessment, dated 7/1/25, documents R1 had a significant weight loss of five or more percent in one month and/or ten percent or more in six months and is not on a physician-prescribed weight loss regimen.The facility's Weight Variance Report, dated 1/1/25 through 7/9/25, documents R1 weighed 126.2 pounds on 6/3/25 and 109.60 pounds on 7/1/25 indicating R1 had a severe weight loss of 13.2 percent weight loss in one month.R1's Electronic Medical Record does not include notification to V22/R1's Guardian of R1's severe weight loss of 13.2 percent identified on 7/1/25.On 7/15/25 at 9:35 AM V22/R1's Guardian stated she was never notified of R1's significant weight loss identified on 7/1/25 or any weight loss prior to that date. V22 stated, I would have liked to have known about (R1's) severe weight loss. I am very involved in (R1's) care and want him to be able to return to where (R1) lived prior to admitting to (this facility).On 7/15/25 at 10:12 AM V18/Regional Director stated it is the responsibility of the Director of Nursing to notify the family after a significant weight loss is identified. V18 stated, I cannot find any documentation of anyone notifying V22/R1's guardian of R1's significant weight loss (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145719 If continuation sheet Page 2 of 25 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 07/20/2025 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 0580 identified on 7/1/25. 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: 145719 If continuation sheet Page 3 of 25 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 07/20/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to protect a resident from staff-to-resident verbal abuse for one of three residents (R13) reviewed for staff-to-resident abuse in the sample of 30. Findings include:The facility's Abuse Prevention Policy, undated, documents The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of the individual's age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never to be able to see his/her family again.R13's MDS (Minimum Data Set) assessment dated [DATE] documents R13 is cognitively intact.On 7/16/25 at 2:45 PM R13 stated, One night about a month ago a CNA (Certified Nursing Assistant/unknown name) picked up a trash can and wanted to throw it at me and cussed me out. I reported this to (V3/Prior Director of Nursing). (V3) told me she fired the CNA because of abusing me. I felt threatened.On 7/17/25 at 11:00 AM V1 (Administrator-In-Training) stated, I was on maternity leave around a month ago, so (V18/Regional Director) was covering for me. A CNA should not cuss or threaten to throw a trashcan at (R13). (R13) would know if this happened and would know if the CNA still works here. I have not been able to figure out who the CNA was, as (R13) said she no longer works here. Event ID: Facility ID: 145719 If continuation sheet Page 4 of 25 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 07/20/2025 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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to obtain consent prior to administering psychotropic medications for one of three residents (R1) reviewed for psychotropic medications in a sample of 30.Findings include:The facility's Psychotropic Medication Policy, dated 2/2014, documents Policy: To establish the process for monitoring the use of and the Reduction of doses of psychotropic medications without compromising the resident's health and safety, ability to function appropriately, or the safety of others. Policy Specifications: Psychotropic medication shall not be prescribed without the informed consent of the resident, the resident guardian, or other authorized representative.R1's Face Sheet, dated 7/16/25, documents R1 admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Unspecified Intellectual Disabilities and Epilepsy.R1's current Physician Order Sheet documents R1 receives Risperidone (psychotropic medication) 0.5 mg (milligram) tablet twice a day and Clobazam (psychotropic medication) 5mg twice a day.On 7/15/25 at 9:35 AM V22/R1's Guardian stated she never verbally gave consent or signed an informed consent for R1's psychotropic medications.On 7/15/25 at 2:24 PM V1/Administrator in Training stated, We (the facility) could not locate an informed psychotropic consent for (R1). We should have obtained one prior to administering (R1's) psychotropic medication.On 7/17/25 at 10:07 AM V19/Regional Nurse Consultant verified an informed psychotropic consent could not be produced for the use of R1's Psychotropic medication. Event ID: Facility ID: 145719 If continuation sheet Page 5 of 25 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 07/20/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to implement their Abuse Policy to immediately report an allegation of resident abuse to the State Agency and Administrator for one of seven residents (R13) reviewed for Abuse in the sample of 30.Findings include:The facility's Abuse Prevention Policy, undated, documents The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. V. Internal Reporting Requirements and Identification of Allegation: Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer. In the absence of the administrator, reporting can be made to an individual who has been designated to act in the administrator's absence. Reports will be documented, and a record kept of the documentation. Supervisors shall immediately inform the administrator or person designated to act in the administrator's absence of all reports of incidents, allegations or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property. Any allegation of abuse or any incident that results in a serious bodily injury will be reported to the Illinois Department of Public Health immediately, but not more than two hours of allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported withing 24 hours. External Reporting- 1. Initial Reporting of Allegations: When an allegation of abuse, exploitation, neglect, mistreatment or misappropriation of resident property has been made, the administrator or designee, shall notify Department of Public Health's regional office immediately by telephone of fax. Public health shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property has been reported to the administrator and is being investigated. 2. Five-day Final Investigation Report: Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health.R13's MDS (Minimum Data Set) assessment dated [DATE] documents R13 is cognitively intact.On 7/16/25 at 2:45 PM R13 was lying in bed. R13 stated, One night about a month ago a CNA (Certified Nursing Assistant/unknown name) picked up a trash can and wanted to throw it at me and cussed me out. I reported this to (V3/Prior Director of Nursing). (V3) told me she fired the CNA because of abusing me. I felt threatened.R13's Electronic Health Record and the facility's Abuse Investigations do not include evidence of the administrator or the State Agency being notified of R13 alleging a CNA cursed at R13 and threatened to pick up a trash can and throw the trash can at R13.On 7/17/25 at 11:00 AM V1 (Administrator-In-Training) stated, I was on maternity leave around a month ago, so (V18/Regional Director) was covering for me.On 7/17/24 at 11:25 AM V18 (Regional Director) verified V3 did not report R13's allegation that a CNA cursed at R13 and threatened to throw a trash can at R13. V18 stated V3 should have reported the allegation to V18 immediately. Event ID: Facility ID: 145719 If continuation sheet Page 6 of 25 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 07/20/2025 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to immediately investigate an allegation of resident abuse for one of seven residents (R13) reviewed for Abuse in the sample of 30.Findings include:The facility's Abuse Prevention Policy, undated, documents The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. VII. Internal Investigation- 2. Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation. 8. Final Investigation Report: The investigator will report the conclusions of the investigation in writing to the administrator or designee within five working days of the reported incident.R13's MDS (Minimum Data Set) assessment dated [DATE] documents R13 is cognitively intact.On 7/16/25 at 2:45 PM R13 was lying in bed. R13 stated, One night about a month ago a CNA (Certified Nursing Assistant/unknown name) picked up a trash can and wanted to throw it at me and cussed me out. I reported this to (V3/Prior Director of Nursing). (V3) told me she fired the CNA because of abusing me. I felt threatened.R13's Electronic Health Record and the facility's Abuse Investigations do not include evidence of an investigation being conducted regarding R13 alleging a CNA cursed at R13 and threatened to pick up a trash can and throw the trash can at R13.On 7/17/25 at 11:00 AM V1 (Administrator-In-Training) stated, I was on maternity leave around a month ago, so (V18/Regional Director) was covering for me.On 7/17/24 at 11:25 AM V18 (Regional Director) verified V3 did not report R13's allegation that a CNA cursed at R13 and threatened to throw a trash can at R13, therefore an investigation has never been done. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145719 If continuation sheet Page 7 of 25 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 07/20/2025 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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Based on interview and record review the facility failed to provide residents with a bed hold and written notice of transfer when transferring to the hospital for three of three residents (R3, R13, and R14) reviewed for hospital transfers in a sample of 30. Findings include: The facility's Transfer and Discharge Policy, un-dated, documents Policy: To assure resident transfers and discharges will be conducted in accordance with residents' rights, physician orders, and in such a manner as to maintain continuity of care for the resident. Policy Specifications: 2. When the facility transfers or discharges a resident under any circumstances, the resident/authorized legal representative must be notified verbally and in writing at least 30 days prior to the intended discharge unless the resident waives the notification period or in an emergency. (including situations where the safety of other residents may be compromised). The facility must also: b. Include a written notice to the resident/authorized legal representative the following. i. reason for transfer/discharge; ii. Effective date of transfer, iii. Location to which the resident will be transferred/discharged ; iv. A statement that the resident has the write to appeal the action to the State; v. the name, address, and telephone number of the State long term care ombudsman; and vi. Any other appropriate advocacy or protective services agency as required by the state. The facility's Bed Hold Policy Notification, undated, documents This Bed Hold Policy will be given to you at the time of admission and a copy will be given to you each time you are transferred from the facility. 1. R3's current Census Sheet, documents R3 was sent to the hospital on 1/13/25 and 7/5/25. R3's medical record did not contain documentation of a written notice of the facility's bed hold policy or notice of discharge was given to R3 or R3's representative for 1/13/25 and 7/5/25. 2. R13's current Census Sheet, documents R13 was sent to the hospital on 6/26/25. R13's medical record did not contain documentation of a written notice of the facility's bed hold policy or notice of discharge was given to R13 or R13's representative for 6/26/25. 3. R14's current Census Sheet, documents R14 was sent to the hospital on 2/9/25. R14's medical record did not contain documentation of a written notice of the facility's bed hold policy or notice of discharge was given to R14 or R14's representative for 2/9/25. On 7/16/25 at 10:30 AM V1/Administrator in Training verified R3 or R3's representative was not given a bed hold or notice of transfer on 1/13/25 and 7/5/25 when transferred to the hospital, R13 or R13's representative was not given a bed hold or notice of transfer on 6/26/26 when transferred to the hospital, and R14 or R14's representative was not given a bed hold or notice of transfer on 2/9/25 when transferred to the hospital. V1 stated When any resident goes out to the hospital, they should receive a bed hold and a written notice of transfer. Event ID: Facility ID: 145719 If continuation sheet Page 8 of 25 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 07/20/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 ensure a resident received a consultation with a lymphedema specialist and a nephrologist, as ordered by the physician, for one of four residents (R26) reviewed for physician orders in the sample of 30. Findings include:The facility's Physician Orders Policy, dated 1/23/25, documents Procedures: 6. Nursing staff will follow physician orders. In an event where a resident refuses medication or treatment, or medication is not available, Physician or Nurse Practitioner will be notified.The facility's Transportation Policy, dated 6/21/2021, documents Policy: It is the policy of this facility to assist residents in obtaining transportation when necessary for services outside the facility. Standards: 3. Nursing or Social Service personnel or designee shall assist residents in obtaining transportation when it is necessary to obtain medical, dental, diagnostic, or other services outside the facility. Staff shall be familiar with requirements for prior approval from the State Department of Public Aid, as appropriate. 10. If the facility is unable to provide in-house transportation, an outside transport will be sough within a reasonable travel distance.R26's Face Sheet documents R26 was admitted on [DATE] with the following, but not limited to, diagnosis: Lymphedema, Type Two Diabetes Mellitus, Stage Two Chronic Kidney Disease, and Hyponatremia.R26's Physician Order Sheet, dated 4/8/25, documents Start Date 4/8/25: Follow up with nephrologist in one to two weeks for hyponatremia. Start Date 4/8/25: Follow up with outpatient lymphedema clinic.R26's Progress Note dated 5/21/25 at 9:54 AM documents, Reviewed for significant weight gain of 50 pounds past month per fluid status/lymphedema. Good appetite per regular diet with 1500 cc (cubic centimeters) fluid restriction. Nursing to review with physician as need for diuretic. Per staff, not following 1500 cc fluid restriction.R26's Physician's Order dated 5-22-25 documents, Lymphedema clinic consult for evaluation and treatment.R26's Electronic Medical Record does not include evidence of R26 receiving a physician ordered consult with an outpatient lymphedema clinic or a physician ordered follow up with a nephrologist.On 7/17/25 at 9:40 AM R27 was lying in her bed in her room. R27's bilateral lower extremities were swollen, dry, and had multiple dry scabs. R27 stated, I admitted to this facility to get treatment for my lymphedema so I can return home. I have never received my appointment to see a lymphedema specialist or to see my nephrologist and would like to receive them so I can work towards going home.On 7/15/25 at 1:15PM V25/Receptionist stated, I had called a Lymphedema Specialty Clinic to get an appointment for (R27) at some point and the Lymphedema Specialty Clinic stated they needed a referral from a Lymphedema Specialist to be able to see (R27). I let V3/Prior Director of Nursing know what the Lymphedema Specialty Clinic said. I did not hear anymore after that and did not schedule any other appointment for (R27) to go to a Lymphedema Specialty Clinic. I am unaware of (R27) needing a follow up appointment for nephrology.On 7/17/25 at 11:20AM V7/Transportation/Scheduling stated, I am responsible for scheduling appointments and taking residents to their appointments. (V3/Prior Director of Nursing) never let me know that (R27) needed a follow up appointment with a Nephrologist after (R27's) admission to (our facility). That appointment never got scheduled. (V3) did ask me to set up an appointment for (R27) to see a Lymphedema Specialist. I reached out to a few Lymphedema clinics. I got an appointment set up at a clinic, but then they called back and said there is no lymphedema doctor at that clinic and that I would need a referral sent to them by a Lymphedema Specialist for them to see (R27). I let (V3) know this. (V3) told me to search for a Lymphedema Specialist in the area. We (the facility) cannot transport residents over a 50-mile radius due to the transportation van liability. I could not find a Lymphedema Specialist within that radius, so I again let (V3) know. (V3) never let me know anything after that, so (V3) never seen a Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145719 If continuation sheet Page 9 of 25 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 07/20/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Lymphedema Specialist.On 7/17/25 at 11:25 AM V1/Administrator in Training verified R27 had never received an appointment to see a Lymphedema Specialist or to see a Nephrologist as physician ordered. V1 stated We (the facility) are getting (R27) set up today to see a Lymphedema Specialist and a Neurologist. (V3/Prior Director of Nursing) did not let me know there was an issue getting (R27) in for her appointments. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145719 If continuation sheet Page 10 of 25 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 07/20/2025 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 update a pressure ulcer care plan and implement pressure relieving interventions for one of three residents (R1) reviewed for pressure ulcers in the sample of 30.Findings include:The facility's Prevention of Pressure Wounds Policy, dated 1/2025, documents Purpose: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. General Guidelines: 1. Pressure injuries are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue. 2. The Most common site of a pressure injury is where the bone is near the surface of the body including the back of the head around th4 ears, elbows, should blades, backbone, hips, knees, heels, ankles, and toes. 5. Once a pressure injury develops, it can be extremely difficult to heal. Pressure injuries are a serious skin condition for the resident. Interventions and Preventative Measures: 1. Identify risk factors for pressure injury development. Additional Factors that Indicate Residents at Risk: The following are additional clinical conditions, treatments, and abnormal lab values that indicate that a resident is at risk for pressure injuries. 1. Impaired/decreased mobility and decreased functional ability; 2. Co-morbid conditions, such as end stage renal disease, thyroid disease, or diabetes mellitus; 6. Cognitive Impairment; 7. And Malnutrition, and hydration deficits. Equipment and Supplies: The following equipment and supplies will be necessary when providing preventive skin care. 1. Tools for assessing skin and pressure injury risk: a. Braden Risk Assessment Form. b. Intervention Preventive Measures.The facility's Skin and Wound Care Management, dated 11/28/2017, documents Guidelines: 8. Preventative measures, such as barrier creams, can be employed to help maintain skin integrity as well as utilization of pressure relieving surfaces, floating heels, protective boots, and use of positioning devices.R1's Face Sheet, dated 7/16/25, documents R1 is a [AGE] year-old male that admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Cerebral Palsy, Epilepsy, Unspecified Intellectual Disabilities, and Hypothyroidism.R1's MDS (Minimum Data Set) Assessment, dated 7/1/25, documents R1 is dependent with all Activities of Daily Living, is at risk for developing pressure ulcers, and has one stage 2 unhealed pressure ulcer.R1's Full Clinical/Body Observation, dated 5/15/25, documents R1 had no skin alterations/pressure ulcers.R1's Braden Scale Pressure Risk Assessment, dated 5/19/25, documents R1 was a very high risk for pressure ulcer development.R1's Initial Wound Evaluation and Management Summary, dated 6/30/25 and signed by V14/Wound Physician, documents Chief Complaint: (R1) presents with a wound on his right posterior heal. Stage two Pressure Wound of the Right, Posterior Heel Partial Thickness: Etiology: Pressure. Stage: 2. Duration: Less than one day. Wound Size: 4.5cm (Centimeters) x 5.0cm x Not Measurable. Exudate: None. Dermis: Open areas with exposed dermis. Blister: Fluid Filled. Additional Care Plan Items. Pressure Off-Loading Boot.R1's Wound Management Detail Report, dated 7/14/25 and signed by V4/Wound Nurse, documents an in house acquired stage two pressure ulcer was identified on 7/1/25 to R1's right heel. This same report documents, Date Observed: 7/14/25. Length 4.5cm (Centimeters) x Width 5.0cm x Depth 0.0cm. Exudate Amount: None. Tissue Type: Closed/Resurfaced.R1's current Care Plan does not document an intervention to apply a pressure relieving off-loading boot to R1's right heel.On 7/14/25 from 1:05 PM through 1:15 PM R1 was sitting in his wheelchair in the dining room. R1's right foot was observed to have a sock on and R1's right heel was resting on his right foot pedal of his wheelchair.On 7/15/25 at 11:32 AM R1 was sitting in the dining room in his wheelchair. R1's right heel observed to have a tennis shoe on and was resting on his right wheelchair foot pedal.On 7/16/25 at Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145719 If continuation sheet Page 11 of 25 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 07/20/2025 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 10:12 AM V4/Wound Nurse prepared treatment to R1's right heel. R1's right heel area observed to be approximately a quarter in size. No drainage observed.On 7/16/25 at 12:05 PM V4/Wound Nurse stated, (R1) has a facility acquired pressure ulcer stage 2 to his right heel. (R1's) right heel area was caused by pressure. (R1) should be wearing a pressure relieving boot to his right heel but it sometimes would make his heel slide off his foot pedal. I did not let (V14/Wound Physician) know that we were not following her recommendation to apply a pressure relieving boot to (R1's) right heel. We (the facility) should still be offloading (R1's) heel or applying his pressure relieving boot and haven't been. I am responsible for updating (R1's) skin care plan. I did not update (R1's) skin care plan with new interventions to offload (R1's) heels while in bed or to apply a pressure relieving boot to (R1's) right heel while out of bed to prevent deterioration of the right heel pressure wound and should have. Event ID: Facility ID: 145719 If continuation sheet Page 12 of 25 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 07/20/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 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** Based on observation, interview, and record review the facility failed to monitor an indwelling urinary catheter for urine output, urine color, and urine consistency, perform a voiding trial as ordered by a physician, follow-up with urology as ordered by a physician, and provide catheter care every shift for one of four residents (R4) reviewed for indwelling urinary catheters in the sample of 30.Findings include:The facility's Urinary Catheter Care Policy, dated 9/2005, documents Purpose: The purpose of this procedure is to prevent infection of the resident's urinary tract. Preparation: 1. Review the residents plan to assess for any special needs of the resident. 7. Maintain an accurate record of the resident's daily output, per facility policy and procedure. Documentation: The following information should be recorded in the resident's medical record- 1. The date and tie that catheter care was given. 2. The name and title of the individual(s) giving the catheter care. 3. All assessment data obtained when giving catheter care. 4. Character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), and odor. 5. Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain. 5. Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting or pain. 6. Any problems or complaints made by the resident related to the procedure. 7. How the resident tolerated the procedure. 8. If the resident refused the procedure, the reason(s) why and the intervention taken. 9. The signature and title of the person recording the data.R4's Hospital Pre-admission Progress Note dated 6/26/25 documents R4 had an indwelling urinary catheter placed on 6/18/25 for the diagnoses of Urinary Retention. ‘R4's Hospital Discharge Orders dated 6/25/25 document Transfer to (facility). Voiding trial in next three to five days. Follow-up with the urology for recurrent urinary retention.R4's current Physician Order Report documents R4 was admitted to the facility on [DATE] with the diagnoses of Urinary Retention.R4's current Care Plan documents, Start Date 6/25/25: (R4) requires an indwelling urinary catheter related to urinary retention. Goal: (R4) will have catheter care managed appropriately as evidenced by not exhibiting signs of urinary tract infection or urethral trauma. Approach: Assess the drainage each shift. Measure and record intake and output. Provide catheter care each shift and as needed.R4's Electronic Health Record dated 6/25/25 (date of admission) through 7/15/25 does not include evidence of R4's intake and output being monitored, R4's urinary catheter drainage being monitored each shift, or R4's urinary catheter care being performed every shift. This same record also does not include evidence of a voiding trial being completed as ordered or a follow-up with urology.On 7/15/25 at 12:20 PM R4 was lying in bed with an indwelling urinary catheter bag hanging on the left side bed frame. R4's urinary catheter tubing had brown dried debris located at the insertion site. R4 stated staff do not clean his catheter tubing daily.On 7/16/25 at 1:00 PM V19 (Regional Nurse Consultant) verified R4's voiding trial and follow-up with urology did not get completed as ordered, and the facility did not monitor R4's intakes and outputs, urinary drainage, or provide urinary catheter care every shift. Event ID: Facility ID: 145719 If continuation sheet Page 13 of 25 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 07/20/2025 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to update weight loss care plans with weight loss interventions for two of four residents (R1 and R16) reviewed for significant weight loss in the sample of 30.Findings include:The facility's Weight Assessment and Intervention Policy, dated 1/2025, documents The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month- Five percent weight loss is significant; greater than 5% is severe. b. 3 months- 7.5 percent weight loss is significant; greater than 7.5% is severe. c. 6 months- 10 percent weight loss is significant; greater than 10 percent is severe. Care Planning: 2. Individualized care plans shall address to the extent possible: a. The identified causes of weight loss; b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment.1. R1's Face Sheet, dated 7/16/25, documents R1 is a [AGE] year-old male that admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Cerebral Palsy, Epilepsy, Unspecified Intellectual Disabilities, Hypothyroidism, Bradycardia, and Dysphagia, and Gastrostomy Status Placed 4/30/25.R1's MDS (Minimum Data Set) Assessment, dated 7/1/25, documents R1 had a significant weight loss of 5 or more percent in one month and/or 10 percent or more in 6 months and is not on a physician-prescribed weight loss regimen.The facility's Weight Variance Report, dated 1/1/25 through 7/9/25, documents R1 weighed 126.2 pounds on 6/3/25 and 109.60 pounds on 7/1/25 indicating R1 had a significant weight loss of 13.2 percent weight loss in one month.R1's current Physician Orders documents R1 has a physician order to receive a magic cup (Nutritional Supplement) daily and Prostat (Nutritional Supplement) 30 milliliters twice a day to promote weight/protein status.R1's current Care Plan does not include updated weight loss interventions to prevent further weight loss of a magic cup and Prostat after a significant weight loss was identified on 7/1/25.2. R16's Face Sheet, dated 7/16/25, documents R16 is a [AGE] year-old male that admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Quadriplegia, Cerebral Infarction, Alzheimer's, Type Two Diabetes Mellitus, and Major Depressive Disorder.The facility's Weight Variance Report, dated 1/1/25 through 7/9/25, documents R16 weighed 156.40 on 1/6/25 and 130.40 on 7.3.25 indicating a significant weight loss of 16.6 percent in 6 months and weight 137.60 on 6/2/25 and 130.40 indicating a significant weight loss of 5.2 percent in one month.R16's current Physician Orders documents R16 has a physician order to receive Prostat 45 milliliters (Nutritional Supplements) twice a day and double portions at all meals to promote weight/protein status.R16's current Care Plan documents R16 is at risk for malnutrition. This same plan of care does not document updated weight loss interventions to prevent further weight loss of Prostat 45 milliliters twice a day and double portions at all meals after a significant weight loss was identified on 7/3/25 of 5.2 percent in one month and 16.6 percent in 6 months.On 7/16/25 at 1:19 PM V10/Dietary Manager stated she is responsible for updating dietary care plans for residents who are identified for significant weight losses and have new physician ordered nutritional interventions. V10 verified she did not update R1's nutritional care plan with new nutritional interventions after a significant weight loss was identified on 7/1/25 or R16's nutritional care plan with new nutritional interventions after a significant weight loss was identified on 7.3.25. V10 stated, I should have updated both (R1) and (R16's) nutritional care plan with new physician ordered weight loss interventions when the significant weight losses were identified to prevent further weight loss. I just haven't got that far yet. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145719 If continuation sheet Page 14 of 25 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 07/20/2025 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to administer prescribed opioid medications to keep residents' pain controlled, failed to perform pain assessments and implement pain relieving interventions while the residents were not receiving their prescribed pain relieving opioid medications, and failed to notify the physician of the need for a opioid medication refill order and complaints of increased pain for three of three residents (R2, R14, and R22) reviewed for pain in the sample of 30. These findings resulted in R2 experiencing restlessness and unrelieved pain after seven days of going without his prescribed opioid medication, R14 experiencing excruciating and stabbing unrelieved pain to the lower back, and R22 experiencing unrelieved severe pain to the lower back and legs.Findings include:The facility's Pain Management Policy, dated 1/2025, documents Purpose: To establish a program with a multi-level approach to pain management to assist the facility in delivering safe, individualized pain care. Policy: It is the policy of the facility to facilitate resident safety, independence, promote resident comfort, preserve and enhance resident dignity and facilitate life involvement. The purpose of this policy is to accomplish the goals through an effective pain management program. Definition: The facility will utilize a consistent pain assessment. The resident's descriptive words regarding the quality, duration, and location of pain will be used to evaluate the pain and to identify changes in pain. When the resident is unable to describe pain, physical signs such as grimacing, body posturing/protecting, vital sign changes, and changes in behavior and mood will be used to determine the presence of pain. Standards: 1. Pain assessment protocol may be initiated under any of the following situations: Any indication of pain based on the Pain Assessment performed for each resident at the time of admission, quarterly and with any condition change associated with the potential of pain, when the Minimum Data Set triggers an indication of pain (section J2, J3), Resident received routine pain medication and/or pain is not controlled, a change in a resident condition occurs to require pain control, A significant increase in the need for use of as needed use of pain medication, and a change in pain identification related to behavior, cognition or mood. 5. An interdisciplinary process and care plan will be developed and implemented based on the assessed findings, pain rating scale, and pain relieve strategies (interventions). 7. Care plans will be reviewed and updated each time the resident's pain management plan is found not to be effective and at least each quarterly care conference. 11. Documentation of assessments and the resident's response to the pain management plan will be made with each assessment. 12. The resident's physician will be notified of the resident's complaints of pain which are not relieved by comfort measures, including pain medications.The facility's Physician Orders policy dated 1/23/25 documents, Nursing staff will follow physician orders. In an event where a resident refused medication, or mediation is not available physician or nurse practitioner will be notified.1. R2's admission Care Plan dated 7/3/25 documents, (R2) is at risk of complaints of chronic pain related to infection/inflammatory reaction due to internal fixation with removal of hardware and pressure ulcers. (R2) has narcotic and non-narcotic pain medications orders prn (as needed). Approach: Administer medications as per orders. Evaluate/record/report effectiveness and any adverse side effects.R2's current Physician Order Report documents R2 was admitted on [DATE] with the diagnoses of a Pressure Ulcer of the right hip, Osteomyelitis, Pressure ulcer of the left hip, Pressure Ulcer of the right buttock, Contracture of Right Hip, Contracture of the right knee, Contracture of right lower leg muscle, Infection and inflammation reaction due to internal fixation device, and Anxiety Disorder. This same Physician Order Report documents, Start Date 6/30/25 (Admission) Hydrocodone-Acetaminophen (Norco) 10-325 mg (milligrams) one tablet every eight hours as Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145719 If continuation sheet Page 15 of 25 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 07/20/2025 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 0697 Level of Harm - Actual harm Residents Affected - Few needed.R2's Pharmacy Packing Slip dated 7/7/25 documents R2's Hydrocodone/Acetaminophen 10-325 mg 30 tablets was not delivered until 7/7/25 (seven days after R2 was admitted to the facility).R2's Medication Administration Records (MARs) dated 6/30/25 through 7/7/25 document R2 did not receive any Norco as ordered during this timeframe. R2's Electronic Health Record does not include documentation of R2's Physician (V30) being notified of the need for a prescription to fill R2's Norco, or documentation of pain relieving interventions utilized while R2 was not receiving his Norco as ordered from 6/30/25 through 7/7/25.R2's Progress Notes dated 7/5/25 at 3:45 PM and signed by V28 (Agency RN/Registered Nurse) documents, (R2) alert with confusion. Very confused on (R2's) whereabouts and day to day things. (R2) very restless at times. (R2) throws his legs and upper half of body out of the bed. Staff repositioned (R2) very frequently. (R2) is however contracted. (R2) has legs drawn up in a fetal position. (R2) frequently yells out for someone to get the people out of there while he points at his window. Will continue to monitor and follow current plan of care.On 7/15/25 at 1:35 PM R2 was lying in a low bed with the head of the bed up 90 degrees. R2 had multiple bruises to the right lower arm and a four by four bandage to the right lower arm. R2 had pressure ulcers to the right and left hip and right buttock. R2's legs were drawn up into a fetal position. R2 had facial grimacing and when asked if R2 was in pain R2 replied, Yes.On 7/16/25 at 9:50 AM V27 (CNA/Certified Nursing Assistant Manager) stated, On 7/5/25 around 2:25 PM (V28/Agency RN/Registered Nurse) was working and told me (R2) seemed to be in pain and had no medication. I called (V3/Prior Director of Nursing) and (V3) said she would take care of getting (R2's) pain medication.On 7/16/25 at 1:00 PM V28 (Agency RN) stated, I was working on 7/5/25 and it seemed throughout the shift that (R2) could not get comfortable. I looked at (R2s) MAR and noticed (R2) did not have Norco. (V27) called (V3) and (V3) was supposed to take care of getting (R2's) Norco. (R2's) Norco never did come in that day.On 7/16/25 at 1:30 PM V24 (Director of Rehabilitation) stated, I have worked with (R2) in therapy since (R2's) admission. It seems like (R2) is in a lot of pain most often when (R2) is being moved. (R2) is very contracted and has a lot of wounds. (R2) does not talk much but does say ouch whenever I roll (R2) or move (R2's) legs. I think moving (R2's) legs agitates (R2's) hip pain.On 7/18/25 at 11:10 AM V30 (R2's Physician) stated, (R2) absolutely should not go without his Norco. With all (R2's) illnesses and wounds, going without Norco would cause (R2) severe pain. There is no reason for any of my residents to be without their pain medications. The facility should have gotten ahold of me immediately to get (R2's) Norco ordered. I am always available by phone call and fax.2. R14's MDS (Minimum Data Set) assessment dated [DATE] documents R14 is cognitively intact. R14's Nursing Home Visits dated 319/25 and 4/9/25 and signed by V30 (R14's Physician) document, Chronic Pain: On Norco and Ibuprofen. R14's current Care Plan documents, Problem: Pain (R14) is at risk for chronic pain related to spinal stenosis. (R14) is no routine narcotic pain medication and PRN (as needed) non-narcotic medication for pain. 2/9/25 history of fracture o lumbar vertebrae. Goals: (R14) will verbalize reduction of pain. Approach: Administer medications as ordered. Monitor and record effectiveness. Report adverse side effects. Assess past effective and ineffective pain relief measures. Problem: (R14) has been asking for more pain medications, asking other nurses for pain \medications and telling other staff that (R14) did not get his pain medications. Approach: Nursing staff will give (R14) a sticky note of times he takes his schedules pain medications at the beginning of each shift.R14's Physician's Order Report dated 6/15/25 through 7/15/25 document R14 has the diagnoses of Spinal Stenosis of the Lumbosacral Region and Low Back Pain. This same Physician's Order Report documents, Start Date 10/16/23: Hydrocodone-Acetaminophen (Norco) 5-325 mg two tablets every six hour for low back pain. Start Date 9/1/23 Pain Scale/Evaluation every shift. Pain Scale 0-10. 0=No pain. 1=Mild Pain of uncomfortable/annoying. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145719 If continuation sheet Page 16 of 25 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 07/20/2025 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 0697 Level of Harm - Actual harm Residents Affected - Few 4=Moderate Pain that is distressing/miserable. 10=Excruciating Pain that is the worst possible and interferes with the ability to carry on with daily routine, socialization, or sleep.R14's MARs dated 5/1/25 through 7/15/25 documents R14 did not receive his schedule Norco 5-325 mg as ordered on 13 occasions due to the Norco being unavailable.R14's MARs dated 5/1/25 through 7/15/25 document on 5/23/25 during the R14 was rating his back pain at a level 7 on a 0-10 pain scale. According to R14's MARs R14 did not receive his Norco 5-325 mg as ordered on 5/23/25 at 8:00 AM, 2:00 PM, or 8:00 PM and on 5/23/25 R14 was rating his back pain at a level 7 on a 0-10 scale.R14's MARs dated 5/1/25 through 7/15/25 document on 6/15/25 during the entire day R14 was rating his back pain at a level 7 on a 0-10 pain scale and on 6/16/25 during the night R14 was rating his back pain at a level 10 on a 0-10 pain scale. According to R14's MARs R14 did not receive his Norco 5-325 mg as ordered on 6/15/25 at 8:00 PM or 6/16/25 at 2:00 AM.R14's Electronic Medical Record does not include any pain relieving interventions, physician's notification, or comprehensive pain assessments after the 13 occasions between 5/1/25 through 7/15/25 when R14 did not receive his Norco as prescribed.On 7/15/25 at 10:05 AM R14 was walking with a walker in the dining room. R14 stated, The facility runs out of my Norco every month. I was an iron worker and hurt my back years ago. I have been on Norco for the pain in my lower back and was seeing a specialist for the pain. When I don't get my scheduled Norco I have excruciating, stabbing pain to my lower back. The pain keeps me awake. I really wish the facility would get this fixed, so I do not have to go without the Norco.On 7/16 /25 at 10:30 AM V2 (Director of Nursing) stated, (R14) did not get his Norco as ordered on 13 occasions between 5/1/25 through 7/15/25. (R14) has a lot of back pain and should not go without his scheduled Norco.On 7/16/25 at 1:20 PM V1 (Administrator-In-Training) stated, I was made aware that (R14) was running out of his Norco frequently. I know (R14) needs his Norco for lower back pain and should not ever run out of Norco.On 7/16/25 at 2:00 PM V19 (Regional Nurse Consultant) stated, (R14) has not had a comprehensive pain assessment completed since 5/13/25. V19 verified (R14) should have had a comprehensive pain assessment completed anytime (R14) went without his ordered Norco and was experiencing pain.On 7/18/25 at 11:00 AM V20 (R14's Family Member) stated, I know agency nurses do not get (R14's) medication refills done on time. (R14) has always had chronic pain and was a construction worker and hurt his back by following out of a third floor window of a building. (R14) has had multiple back surgeries. (R14) is usually out of his pain medications on the weekends and calls me when (R14) does not get his pain medication because he is having pain. If (R14) misses even one dose of Norco (R14) is in pain.On 7/18/25 at 11:10 AM V30 (R14's Physician) stated, (R14) should never have to go without his Norco. (R14) is dependent on the Norco and needs the Norco routinely to control his back pain. The facility should get ahold of me before (R14's) Norco runs out.3. R22's current Pain Care Plan documents R22 has complaints of chronic pain due related to osteomyelitis, pressure ulcer to the right ischium, tear of the hamstring tendon, and peripheral vascular disease, and is receiving hospice services for pain control management. This same care plan documents R22's pain medications should be administered as ordered and R22 will verbalize reduction of pain and/or show no signs of non-verbal pain.R22's current Physician Order Report documents R22 has the diagnoses of strain of muscle of the fascia and tendon of the posterior muscle group at right thigh level and malignant neoplasm of the large intestine and receives hospice services. This same Physician Order Report documents the following orders, Start Date 6/10/25 pain scale/evaluation every shift. Start Date: 7/7/25 MS Contin (Morphine) tablet extended release 15 mg twice daily at 8:00 AM and 8:00 PM.R22's Physician's Order dated 6/26/25 documents an order to increase R22's Hydrocodone/Acetaminophen from 5-325 mg every four hours to 10-325 mg every four hours and then discontinue on 7/7/25.R22's Medication Administration Record dated 6/10/25 through (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145719 If continuation sheet Page 17 of 25 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 07/20/2025 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 0697 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 7/15/25 documents R22's MS Contin 15 mg was not received on 7/7/25 at 8:00 AM or 8:00 PM due to the medication being unavailable.R22's Medication Administration Record dated 6/10/25 through 7/7/25 documents R22's Hydrocodone/Acetaminophen from 10-325 mg was not received as ordered on 15 occasions due to the Hydrocodone/Acetaminophen being unavailable.R22's Electronic Medical Record documents R22's last Comprehensive Pain Assessment was completed 6/26/25.On 7/16/25 at 11:00 AM R22 was lying in bed. R22 stated, I have cancer, and I hurt all over. I do not like to complaint. I have had pain all over and especially in my lower back and legs. I had no idea I was out of my pain medication. That would explain why I was hurting so bad.On 7/18/25 at 10:30 AM V12 (Hospice RN/Registered Nurse) I was not aware that (R22) was not getting his Hydrocodone/Acetaminophen 10mg-325 mg as ordered or his MS Contin 15 mg for two doses. I made (R22's) Hydrocodone/Acetaminophen 10mg-325 mg scheduled around the clock due top (R22) having wound pain, back pain, arm pain, and leg pain. It is unacceptable for (R22) to go without pain medication and (V9/Hospice Physician) was not notified. (V9) should have been notified so me or (V9) could have reached out to the pharmacy to make sure (R22) was getting his medication or we would have ordered something else to control (R22's) pain until the Hydrocodone/Acetaminophen and MS Contin was received. Event ID: Facility ID: 145719 If continuation sheet Page 18 of 25 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 07/20/2025 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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement a process for the timely ordering and reordering of medications, failed to notify the physician of the need for opioid analgesic medications and anti-anxiety medication prescription refill orders, failed to notify the physician of the need for an alternative to ordered Ozempic, and failed to obtain physician ordered opioid analgesic medications, anti-antianxiety medication, and weight-loss medication from the pharmacy for four of four residents (R2, R14, R18, and R22) reviewed for pharmacy services in the sample of 30. These findings resulted in R2 experiencing restlessness, increased anxiety, and unrelieved pain after seven days of going without his prescribed opioid medication and anti-anxiety medication, R14 experiencing excruciating and stabbing unrelieved pain to the lower back and withdrawal symptoms, and R22 experiencing unrelieved severe pain to the lower back and legs. Findings include: The facility's Controlled Substance Prescription Pharmacy Policy, dated 10/25/2014, documents Policy: Before a controlled drug can be dispensed, the pharmacy must be in receipt of a clear, complete, and signed written prescription from a person lawfully authorized to prescribe. To facility effective communication, documentation, and aide in prevention of medication errors, medication orders should be clear and concise and free of potentially dangerous abbreviations. Procedures: A. Elements of a controlled substance prescription: 12) Manual signature of prescriber. C. The prescriber and/or nurse are contacted for direction when delivery of a medication will be delayed, or the medication is not or will not be available. E. New Controlled Substance Prescriptions: 1) For emergency-controlled substance orders, the nurse will review the Emergency Kit list for available medications prior to contacting the prescriber. The nurse will communicate to the prescriber the emergency medications available to provide appropriate care to the patient. 4) In order to communicate Controlled II orders orally/verbally between the prescriber and pharmacist, the prescription must meet DEA's (Drug Enforcement Administration) criteria of an emergency situation. Conformance with such criteria must be discussed between the prescriber and pharmacist and documented on the prescription: a. Immediate administration of the controlled substance is necessary for proper treatment of the intended ultimate user. b. No appropriate alternative treatment is available, including administration of a drug which is not a controlled substance under Schedule II; AND c. It Is not reasonably possible for the prescriber practitioner to provide written prescription to be present to the person dispensing the substance prior to dispensing. 4) Only after verifying that the above communication has occurred and the pharmacy and facility receive a complete prescription, the nurse reviews the Emergency Kit List to assess the contents. After finding the medication list, the nurse unlocks the container seal and removes the required medication if it is available in the emergency kit. If the medication is not available in the emergency kit, the nurse contacts the pharmacy using the afterhours emergency number(s) if necessary. (See IC5: Emergency Pharmacy Service and Emergency Kits). The United States Food and Drug Administration Safety Communication Website article dated 4-9-19 documents, Opioid's are a class of powerful prescription medicines that are used to manage pain when other treatments and medicines cannot be taken or are not able to provide enough pain relief. Patients taking opioid pain medicines long-term should not suddenly stop taking your medicines without first discussing with hour health care professional a plan for how to slowly decrease the dose of the opioid and continue to manage your pain. Even when the opioid dose is decreased gradually, you may experience symptoms of withdrawal. Rapid discontinuation can result in uncontrolled pain or withdrawal symptoms. These include serious withdrawal symptoms, uncontrolled pain, psychological distress, and suicide. 1. R2's admission Care Plan (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145719 If continuation sheet Page 19 of 25 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 07/20/2025 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 0755 Level of Harm - Actual harm Residents Affected - Few dated 7/3/25 documents, (R2) is at risk of complaints of chronic pain related to infection/inflammatory reaction due to internal fixation with removal of hardware and pressure ulcers. (R2) has narcotic and non-narcotic pain medications orders prn (as needed). Approach: Administer medications as per orders. Evaluate/record/report effectiveness and any adverse side effects.R2's current Physician Order Report documents R2 was admitted on [DATE] with the diagnoses of a Pressure Ulcer of the right hip, Osteomyelitis, Pressure ulcer of the left hip, Pressure Ulcer of the right buttock, Contracture of Right Hip, Contracture of the right knee, Contracture of right lower leg muscle, Infection and inflammation reaction due to internal fixation device, and Anxiety Disorder. This same Physician Order Report documents, Start Date 6/30/25 (Admission) Hydrocodone-Acetaminophen (Norco) 10-325 mg (milligrams) one tablet every eight hours as needed.R2's admission Physician's Orders dated 6/30/25 document, Lorazepam 0.5 mg twice daily as needed for Anxiety.R2's Pharmacy Packing Slip dated 7/7/25 documents R2's Lorazepam 0.5 mg 28 tablets was not delivered until 7/7/25 (seven days after R2 was admitted to the facility).R2's Pharmacy Packing Slip dated 7/7/25 documents R2's Hydrocodone/Acetaminophen 10-325 mg 30 tablets was not delivered until 7/7/25 (seven days after R2 was admitted to the facility).R2's Medication Administration Records (MARs) dated 6/30/25 through 7/7/25 document R2 did not receive any Norco as ordered during this timeframe. R2's Electronic Health Record does not include documentation of R2's Physician (V30) being notified of the need for a prescription to fill R2's Norco or R2's Lorazepam, or documentation of pain relieving interventions utilized while R2 was not receiving his Norco as ordered from 6/30/25 through 7/7/25.R2's Progress Notes dated 7/5/25 at 3:45 PM and signed by V28 (Agency RN/Registered Nurse) documents, (R2) alert with confusion. Very confused on (R2's) whereabouts and day to day things. (R2) very restless at times. (R2) throws his legs and upper half of body out of the bed. Staff repositioned (R2) very frequently. (R2) is however contracted. (R2) has legs drawn up in a fetal position. (R2) frequently yells out for someone to get the people out of there while he points at his window. Will continue to monitor and follow current plan of care.On 7/15/25 at 1:35 PM R2 was lying in a low bed with the head of the bed up 90 degrees. R2 had multiple bruises to the right lower arm and a four by four bandage to the right lower arm. R2 had pressure ulcers to the right and left hip and right buttock. R2's legs were drawn up into a fetal position. R2 had facial grimacing and when asked if R2 was in pain, R2 replied, Yes.On 7/16/25 at 9:50 AM V27 (CNA/Certified Nursing Assistant Manager) stated, On 7/5/25 around 2:25 PM (V28/Agency RN/Registered Nurse) was working and told me (R2) seemed to be in pain and anxiety and had no medication. I called (V3/Prior Director of Nursing) and (V3) said she would take care of getting (R2's) pain medication.On 7/16/25 at 1:00 PM V28 (Agency RN) stated, I was working on 7/5/25 and it seemed throughout the shift that (R2) could not get comfortable. (R2) was seeing things and very fidgety and anxious. I looked at (R2s) MAR and noticed (R2) did not have Norco. I also did not have (R2's) Lorazepam to give (R2) to help with his restlessness. (V27) called (V3) and (V3) was supposed to take care of getting (R2's) Norco. (R2's) Norco never did come in that day.On 7/18/25 at 11:10 AM V30 (R2's Physician) stated, (R2) absolutely should not go without his Norco or Lorazepam. With all (R2's) illnesses and wounds, going without Norco would cause (R2) severe pain. There is no reason for any of my residents to be without their pain medications. The facility should have gotten ahold of me immediately to get (R2's) Norco ordered. I am always available by phone call and fax to get the prescription to pharmacy.2. R14's MDS (Minimum Data Set) assessment dated [DATE] documents R14 is cognitively intact. R14's Nursing Home Visits dated 319/25 and 4/9/25 and signed by V30 (R14's Physician) document, Chronic Pain: On Norco and Ibuprofen. R14's current Care Plan documents, Problem: Pain (R14) is at risk for chronic pain related to spinal stenosis. (R14) is no routine narcotic pain medication and PRN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145719 If continuation sheet Page 20 of 25 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 07/20/2025 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 0755 Level of Harm - Actual harm Residents Affected - Few (as needed) non-narcotic medication for pain. 2/9/25 history of fracture o lumbar vertebrae. Goals: (R14) will verbalize reduction of pain. Approach: Administer medications as ordered. Monitor and record effectiveness. Report adverse side effects. Assess past effective and ineffective pain relief measures. Problem: (R14) has been asking for more pain medications, asking other nurses for pain \medications and telling other staff that (R14) did not get his pain medications. Approach: Nursing staff will give (R14) a sticky note of times he takes his schedules pain medications at the beginning of each shift.R14's Physician's Order Report dated 6/15/25 through 7/15/25 document R14 has the diagnoses of Spinal Stenosis of the Lumbosacral Region and Low Back Pain. This same Physician's Order Report documents, Start Date 10/16/23: Hydrocodone-Acetaminophen (Norco) 5-325 mg two tablets every six hour for low back pain. Start Date 9/1/23 Pain Scale/Evaluation every shift. Pain Scale 0-10. 0=No pain. 1=Mild Pain of uncomfortable/annoying. 4=Moderate Pain that is distressing/miserable. 10=Excruciating Pain that is the worst possible and interferes with the ability to carry on with daily routine, socialization, or sleep.R14's MARs dated 5/1/25 through 7/15/25 documents R14 did not receive his schedule Norco 5-325 mg as ordered on 13 occasions due to the Norco being unavailable.R14's MARs dated 5/1/25 through 7/15/25 document on 5/23/25 during the R14 was rating his back pain at a level 7 on a 0-10 pain scale. According to R14's MARs R14 did not receive his Norco 5-325 mg as ordered on 5/23/25 at 8:00 AM, 2:00 PM, or 8:00 PM and on 5/23/25 R14 was rating his back pain at a level 7 on a 0-10 scale.R14's MARs dated 5/1/25 through 7/15/25 document on 6/15/25 during the entire day R14 was rating his back pain at a level 7 on a 0-10 pain scale and on 6/16/25 during the night R14 was rating his back pain at a level 10 on a 0-10 pain scale. According to R14's MARs R14 did not receive his Norco 5-325 mg as ordered on 6/15/25 at 8:00 PM or 6/16/25 at 2:00 AM.R14's Electronic Medical Record does not include any pain relieving interventions, physician's notification, or comprehensive pain assessments after the 13 occasions between 5/1/25 through 7/15/25 when R14 did not receive his Norco as prescribed.On 7/15/25 at 10:05 AM R14 was walking with a walker in the dining room. R14 stated, The facility runs out of my Norco every month. I was an iron worker and hurt my back years ago. I have been on Norco for the pain in my lower back and was seeing a specialist for the pain. When I don't get my scheduled Norco I have excruciating, stabbing pain to my lower back. I know when I don't get the Norco because I start to have withdrawals and start feeling sick and jittery. The pain keeps me awake. I really wish the facility would get this fixed, so I do not have to go without the Norco.On 7/16 /25 at 10:30 AM V2 (Director of Nursing) stated, (R14) did not get his Norco as ordered on 13 occasions between 5/1/25 through 7/15/25. (R14) has a lot of back pain and should not go without his scheduled Norco.On 7/16/25 at 1:20 PM V1 (Administrator-In-Training) stated, I was made aware that (R14) was running out of his Norco frequently. I asked (V3/Prior Director of Nursing) sometime around April 10th to start doing narcotic medication audits on every Monday and Friday each week after I was made aware that narcotics were running out and residents were not getting their pain medications as ordered due to not getting renewal prescriptions in time. I wanted (V3) to make sure all residents were getting their narcotic medications as ordered. (V3) did not complete those audits as I instructed. I know (R14) needs his Norco for lower back pain and should not ever run out of Norco. If a resident does not have their narcotic the nurses should know the process and should call the physician immediately to get the prescription and call pharmacy to get a code to get the narcotic out of the facility's back-up supply.On 7/16/25 at 2:00 PM V19 (Regional Nurse Consultant) stated, (R14) has not had a comprehensive pain assessment completed since 5/13/25. V19 verified (R14) should have had a comprehensive pain assessment completed anytime (R14) went without his ordered Norco and was experiencing pain.On 7/18/25 at 11:00 AM V20 (R14's Family Member) stated, I know agency nurses do (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145719 If continuation sheet Page 21 of 25 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 07/20/2025 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 0755 Level of Harm - Actual harm Residents Affected - Few not get (R14's) medication refills done on time. (R14) has always had chronic pain and was a construction worker and hurt his back by following out of a third floor window of a building. (R14) has had multiple back surgeries. (R14) is usually out of his pain medications on the weekends and calls me when (R14) does not get his pain medication because he is having pain. If (R14) misses even one dose of Norco (R14) is in pain.On 7/18/25 at 11:10 AM V30 (R14's Physician) stated, (R14) should never have to go without his Norco. (R14) is dependent on the Norco and needs the Norco routinely to control his back pain. The facility should get ahold of me before (R14's) Norco runs out.3. R18's MDS assessment dated [DATE] documents R18 is cognitively intact.R18's Physician's Progress Note dated 5/3/25 and signed by V5 (R18's Primary Physician) documents, Chief complaint: (R18) is a [AGE] year-old who is trying to lose weight. (R18) wants to get stronger and hopefully go home. Hopefully will get (R18) started on an agent that will help (R18) lose some weight. Obesity.R18's current Physician Order Report documents R18 has the diagnoses of Severe Morbid Obesity and Type II Diabetes Mellitus. This same Physician Order Report documents, Start Date 6/16/25: Ozempic pen injector 0.25 mg subcutaneous once a day on Wednesdays.R18's Medication Administration Record dated 6/16/25 through 716/25 documents R18 did not receive Ozempic 0.25 mg as ordered on Wednesdays dated 6/18/25, 6/25/25, 7/2/25, 7/9/25, and 7/16/25.R18's Pharmacy Notice of Rejection dated 6/26/25 documents, Ozempic 2mg/3 ml quantity 3 not covered. Reason for denial: (Insurance Plan) requires additional information from medical doctor. Alternative: Trulicity 0.74 m/0.5 ml subcutaneous once a week.R18's Electronic Medical Record does not include notification or follow-up with the physician or pharmacy once insurance rejected to fill R18's Ozempic.On 7/15/25 at 11:00 AM R18 was sitting outside in a wheelchair. R18 stated, (V5/Physician) order me Ozempic so I can get my weight off and get my hip surgery. My insurance will not cover it. I really need it.On 7/16/25 at 9:00 AM V2 (Director of Nursing) stated, I was not aware that (R18) was not getting her ordered Ozempic.On 7/16/25 at 11:12 AM V31 (V5's Registered Nurse) stated, The nursing home has not called or followed up with (V5) to let us know (R18) was not getting Ozempic to get an alternative to (R18's) Ozempic or more information to get (R18's) Ozempic covered by insurance.4. R22's current Pain Care Plan documents R22 has complaints of chronic pain due related to osteomyelitis, pressure ulcer to the right ischium, tear of the hamstring tendon, and peripheral vascular disease, and is receiving hospice services for pain control management. This same care plan documents R22's pain medications should be administered as ordered and R22 will verbalize reduction of pain and/or show no signs of non-verbal pain.R22's current Physician Order Report documents R22 has the diagnoses of strain of muscle of the fascia and tendon of the posterior muscle group at right thigh level and malignant neoplasm of the large intestine and receives hospice services. This same Physician Order Report documents the following orders, Start Date 6/10/25 pain scale/evaluation every shift. Start Date: 7/7/25 MS Contin (Morphine) tablet extended release 15 mg twice daily at 8:00 AM and 8:00 PM.R22's Physician's Order dated 6/26/25 documents an order to increase R22's Hydrocodone/Acetaminophen from 5-325 mg every four hours to 10-325 mg every four hours and then discontinue on 7/7/25.R22's Medication Administration Record dated 6/10/25 through 7/15/25 documents R22's MS Contin 15 mg was not received on 7/7/25 at 8:00 AM or 8:00 PM due to the medication being unavailable.R22's Medication Administration Record dated 6/10/25 through 7/7/25 documents R22's Hydrocodone/Acetaminophen from 10-325 mg was not received as ordered on 15 occasions due to the Hydrocodone/Acetaminophen being unavailable.R22's Electronic Medical Record documents R22's last Comprehensive Pain Assessment was completed 6/26/25.On 7/17/25 at 1:00 PM V1 (Administrator-In-Training) verified R22 never received the Hydrocodone/Acetaminophen 10-325 mg as ordered due to the mediation not being delivered from the pharmacy. V1 also verified she was not aware of R22 not receiving the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145719 If continuation sheet Page 22 of 25 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 07/20/2025 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 0755 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Hydrocodone/Acetaminophen 10-325 mg and should have been informed and the nurses should have notified the physician immediately to get a signed prescription and ensure the medication was received. V1 verified R22 did not receive the first two doses of MS Contin 15 mg due to the medication being unavailable.On 7/18/25 at 10:30 AM V12 (Hospice RN/Registered Nurse) I was not aware that (R22) was not getting his Hydrocodone/Acetaminophen 10mg-325 mg as ordered or his MS Contin 15 mg for two doses. I made (R22's) Hydrocodone/Acetaminophen 10mg-325 mg scheduled around the clock due top (R22) having wound pain, back pain, arm pain, and leg pain. It is unacceptable for (R22) to go without pain medication and (V9/Hospice Physician) was not notified. (V9) should have been notified so me or (V9) could have reached out to the pharmacy to make sure (R22) was getting his medication or we would have ordered something else to control (R22's) pain until the Hydrocodone/Acetaminophen and MS Contin was received. Event ID: Facility ID: 145719 If continuation sheet Page 23 of 25 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 07/20/2025 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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Based on record review and interview the facility failed to obtain a physician ordered Basic Metabolic Panel for one of five residents (R19) reviewed for laboratories in the sample of 30.Findings include:The facility's Physician Orders policy dated 1/23/25 documents, Nursing staff will follow physician orders.R19's current Physician Order Report documents, Start Date 1/15/25: Basic Metabolic Panel every Wednesday every two weeks.R19's Medical Record dated 1/15/25 documents R19 has only had a Basic Metabolic Panel laboratory obtained on 6/25/25, 7/2/25, 7/4/25, and 7/9/25. On 7/16/25 at 11:00 AM V19 (Regional Nurse Consultant) verified R19 did not have a Basic Metabolic obtained every two weeks as ordered on 1/25/25. Event ID: Facility ID: 145719 If continuation sheet Page 24 of 25 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 07/20/2025 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 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 implement Enhanced Barrier Precautions during direct cares for one of five residents (R22) reviewed for infection control in the sample of 30.Findings include:The facility's Enhanced Barrier Precautions policy dated 01/2025 documents, Guideline: It is the practice of this facility to implement enhanced barrier precautions for the prevention of transmission of multi-drug-resistant organisms. Enhanced Barrier Precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents know to be colonized or infected with a MDRO (Multi-Drug-Resistant Organism) as well as those at increased risk of MDR acquisition. Implement Enhanced Barrier Precautions for residents with any of the following: Wounds and/or indwelling devices. High-contact resident case activities include dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care.R22's current Physician Order Report documents R22 has the diagnoses of a Colostomy, a Pressure Ulcer of right buttock, and an Indwelling Urinary Catheter.R22's current Care Plan documents, Problem start date 6/10/25: (R22) requires Enhanced Barrier Precautions related to indwelling urinary catheter, colostomy, and open wound on right ischium. Goal: Enhanced Barrier Precautions will reduce the spread of the infectious agent, minimize the transmission of the infection, and reduce the risk of colonization through next review. Approach: Gown and glove use when performing high-contact resident contact activity.On 7/16/25 at 11:00 AM R22 was lying in bed and had an Enhanced Barrier Precautions sign posted on his doorway to his room. V29 (CNA/Certified Nursing Assistant) had gloves on and was emptying stool out of R22's colostomy into a urinal. V29 was not wearing a gown while emptying R22's colostomy bag stool.On 7/16/25 at 12:10 PM V29 stated, I should have worn a gown when emptying the stool out of (R22's) colostomy bag. I guess I just forgot.On 7/16/25 at 12:15 Pm V11 (Infection Preventionist) stated V29 should have worn a gown when emptying R22's colostomy bag. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145719 If continuation sheet Page 25 of 25