Inspection·January 31, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review the facility failed to develop a comprehensive care plan for chronic urinary tract infections, antibiotic and oxygen use for two residents (R21 and R53) of 18 reviewed for comprehensive care plans in a sample of 38. Findings include: The facility's Person-Centered Care Plan (Baseline and Comprehensive) policy, revised 11/28/23, documents the baseline plan of care includes, but not limited to: Identification of resident areas of needs, problems, strengths, goals, life history and preferences. 1. R21's Physician Order Sheet, dated 1/24/24, documents to take Nitrofurantoin Oral Capsule (antibiotic) 100mg (milligrams) by mouth two times a day for a urinary tract infection for 14 days. R21's urinalysis, dated 1/24/24, indicates that R 21 currently has a urinary tract infection. R21's current care plan does not have any goals or interventions to address R21's chronic, UTI's, (Urinary Tract Infections) or antibiotic use. On 1/31/24 at 10:20am, V4, Registered Nurse, Minimum Data Set/Care plan/Wound Care, stated that R21 has had chronic UTI's within the last year. V4 verified that R21 should have a care plan in place for the chronic UTI's and the antibiotic use. V4 verified that R21's Evaluation of progress toward goals. care plan in place does not address the chronic UTI's and antibiotic use. 2. R53's current Physician Order Sheet, dated 1/31/24, documents R53 has an order for Oxygen at four liters per minute, via nasal cannula, continuously to maintain Oxygen saturation of greater than 90 percent for a diagnosis related of Chronic Obstructive Pulmonary Disease with Exacerbation. On 1/30/24 at 10:20 AM, R53 was sitting in his bed watching television. R53 had humidified Oxygen flowing through tubing in his nose. R53 stated he wears oxygen all the time. R53's current care plan, dated 1/31/24, does not document a plan of care for R53's Oxygen use. On 1/31/24 at 11:25 AM, V4 (Care Plan/ Minimum Data Set assessment coordinator) stated Oxygen is not on (R53's) care plan and it should be. He should have one for that. I am not sure why it's not there. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145801 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145801 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant View Luther Home 505 College Avenue Ottawa, IL 61350 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to perform skin risk assessments, implement additional pressure relieving interventions after a change in condition, and identify a pressure ulcer prior to its status worsening to a Stage III for one of three residents (R9) reviewed for pressure ulcers in the sample of 38. This failure resulted in R9's pressure ulcer worseing without new interventions implemented. Residents Affected - Few Findings Include: The facility's Pressure Injury Prevention policy (revised 01/10/24) documents the following: The community must ensure that : A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing. This policy also documents, Each resident is formally assessed for risk of developing pressure injuries using the Braden Scale completed upon admission, quarterly, significant changes, and after developing pressure injury. This same policy documents, Inspect the skin when performing or assisting with personal cares or ADLs (activities of daily living.); Evaluating condition of skin (skin color, moisture, temperature, integrity, and turgor) at least weekly, or more often if indicated, such as when the resident is using a medical device that may cause pressure. This policy also documents, Care Plan documentation: Care Plan will be revised quarterly and as needed. R9's medical record documents R9 was admitted to the facility on [DATE] with a Stage III pressure ulcer present on her sacrum, and physician orders are in place for daily wound care and dressing changes to R9's sacral wound This same medical record documents R9 developed a Stage III pressure ulcer on the right side of her lower thoracic area (middle back) on 08/22/23. R9's current Physician's Orders document the following Physician's Order for R9's lower thoracic pressure ulcer: Lower back - cleanse with wound cleaner, pat dry, cover with bordered gauze every night shift every Tuesday, Thursday, and Saturday. R9's Braden Scale for Predicting Pressure Sore Risk Assessment (dated 06/28/23) documents a score of 17, indicating R9 is at risk for pressure ulcer development. R9's next Braden Scale for Predicting Pressure Sore Risk Assessment was not completed until 12/01/23 and also documents a score of 17, indicating R9 is at risk for pressure ulcer development. R9's monthly Treatment Administration Record (dated 07/2023 - 01/2024) documents R9 has received weekly skin checks during this time frame. R9's Treatment Administration Record (dated August 2023) documents R9 received a skin check on the following days: 08/01/23, 08/08/23, 08/15/23, 08/22/23 and 08/29/23. R9's Wound Evaluation (dated 08/22/23) documents a Stage III pressure ulcer (full-thickness skin loss) measuring 2.5 cm (centimeters) by 2.5 cm by 0.1 cm with the presence of slough tissue was discovered on the right side of R9's lower thoracic area. According to the Pressure Ulcer Prevention & Prevention Treatment Clinical Practice Guideline, Slough tissue: Soft, moist, devitalized (avascular) tissue. It may be white, yellow, tan or green, and it may be loose or firmly adherent. (www.npuap.org). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145801 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145801 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant View Luther Home 505 College Avenue Ottawa, IL 61350 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 - Actual harm Residents Affected - Few R9's care plan documents, (R9) has actual impairment to skin integrity of both ankles and sacrum. All were present on admission. This current care plan has no mention of R9's current right lower thoracic area Stage III pressure ulcer, or R9's risk for skin impairment. On 01/31/24 at 09:55 AM, R9 was lying in bed covered with a blanket watching television. R9 smiled and stated she would be getting her shower soon, I am going to get my hair washed today. V4 (Care Plan/Minimum Data Set Coordinator/Wound Nurse) entered R9's room to provide wound care to R9's pressure ulcers. V4 removed the current dressing in place to R9's right lower thoracic area, and an oval-shaped red, open area approximately 3 cm (centimeters) by 2 cm was present with areas of eschar (brown scabbed) tissue present . V4 cleansed R9's pressure ulcer with wound cleanser and applied a new dressing. On 01/31/24 at 11:00 AM, V4 (Care Plan Coordinator/Wound Nurse) stated that R9's Braden Scale Assessments were not completed quarterly as directed by the facility's Pressure Ulcer Prevention policy. V4 stated R9 had a change in condition around the time her pressure ulcer developed and was admitted under the care of hospice services shortly after. V4 verified no Braden Scale Assessment was completed at that time. V4 also confirmed that no additional pressure relieving interventions were implemented at the time of R9's decline. V4 then stated that R9 should have been considered a high risk for pressure ulcer development, since R9 had a Stage III pressure ulcer on her sacrum upon admission. V4 stated that R9 should have been receiving daily skin checks, and the development of R9's right lower thoracic area pressure ulcer that had progressed to Stage III upon discovery could have been avoided or discovered before progressing to a Stage III if daily skin checks were being completed, Someone should have seen it while (R9) was receiving daily cares. V4 also confirmed that R9's current care plan had no mention of R9's lower thoracic area pressure ulcer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145801 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145801 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant View Luther Home 505 College Avenue Ottawa, IL 61350 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on Observation, Interview and Record Review the facility failed to ensure a range of motion program was in place for a resident with functional limitations in range of motion for two of three residents (R36 and R53) reviewed for range of motion in the sample of 38. Findings include: The facility's Restorative Nursing Services policy (revised 12/19/23) documents the following: Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitation services. The components of a restorative program may include goals on range of motion (active and passive), splint and brace, bed mobility, transfer, walking, dressing or grooming, eating or swallowing, amputation/prosthesis care and communication. 1. R36's current medical record documents R36's diagnoses to include: Cerebral Palsy, History of Falling, Need for Assistance with Personal Care, and Generalized Muscle Weakness. R36's Minimum Data Set Assessment (dated 11/14/23), Section GG, Functional Limitation in Range of Motion documents the following: R36 has impairment on one side of her upper extremities; and R36 has impairment on both sides of her lower extremities. R36's Physician's Orders document R36 was discharged from physical therapy on 09/05/23, and was discharged from occupational therapy on 10/20/23. R36's medical record documents R36 is currently participating in the following restorative programs: transfers, and eating/swallowing. R36's medical record has no documentation of any type of range of motion programming in place. On 01/29/24 at 10:45 AM, R36 was sitting in a wheelchair watching television. R36's arms appeared to held close to her body, and R36 could not fully extend her arms when reaching for a box of facial tissue on a nearby table. On 01/31/24 at 09:45 AM, V2 (Director of Nursing) stated the facility does not complete any type of range of motion/contracture assessment, Therapy conducts assessments when a resident is receiving therapy services. Our restorative/range of motion program is on our radar. It kind of went out the wayside with COVID-19 and all of the agency use. (R36) is not receiving range of motion exercises, and she would be one that would benefit from them. On 01/31/24 at 11:00 AM, V4 (Care Plan/Minimum Data Set Coordinator) stated, We don't really have a restorative program at this time. We needed to start from the ground up. Now that we have gotten agency out of the building, we can hire for restorative. (R36) should be receiving range of motion exercises. 2. On 1/30/24 at 10:20 AM, R53 was in his room laying in bed. R53 lifted his left arm with his right hand to show his dialysis port and stated he cannot move it on it's own. R53's left lower extremity is amputated below the knee. R53's current Care Plan, dated 1/31/24, documents R53 has a diagnosis of Hemiplegia and Hemiparesis (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145801 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145801 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant View Luther Home 505 College Avenue Ottawa, IL 61350 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few following non-traumatic subarachnoid hemorrhage affecting left dominant side (Paralysis of the left side of the body following bleeding in the brain). This same Care Plan documents R53 has a plan of care for Passive Range of Motion to the left upper extremity. R53's Range of Motion (ROM) documentation, dated 1/1/24-1/31/24 does not document that any ROM has been provided to R53 for the last 30 days. The same form documents Amount of minutes spent providing Range of Motion (passive). No Data Found. On 1/31/24 at 11:50 AM, V2 (Director of Nursing) confirmed R53 has left sided paralysis and that the documentation for R53's January ROM is blank, indicating R53 has not received any ROM for the past 30 days. V2 stated I am not sure why that is. We have improvements to make with out Restorative and ROM programming. We lost a lot of those programs and we are trying to get them back. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145801 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145801 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant View Luther Home 505 College Avenue Ottawa, IL 61350 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on (observation), interview, and record review, the facility failed to provide justification for the use of an antipsychotic medication and create a care plan for the use of an antipsychotic medication for R34, failed to attempt a gradual dose reduction for an antipsychotic medication for R51 and failed to identify specific target behaviors to warrant the use of an antipsychotic medication for (R34, R47 and R51) three of five residents reviewed for antipsychotics in the sample of 38. Findings Include: The facility policy, Psychotropic Medication Management System, dated (revised) 10/26/2022 directs staff, (The facility) has developed a system to ensure a resident is not given psychotropic medications unless a comprehensive assessment identifies clear indications and parameters for their use, based upon regulatory compliance and best practices. Behavior Management: (the facility) is committed to provide necessary behavioral, mental and/or emotional health care and services to each resident. Behavioral monitoring is initiated on all residents who exhibited behaviors in the past and all residents who are taking any psychotropic medications of any classification whether scheduled or as needed basis. Behavioral monitoring involves identifying behaviors, the number of behavioral episodes, success of interventions (whether pharmacological or non-pharmacological intervention), the number of PRN (as needed) psychotropic used and any side effects from psychotropic medication. 1. R47's current Physician Order Sheet, dated January 2024, includes the following diagnoses: Dementia, Psychosis, Anxiety and Depression. Also included are the following medications: Risperidone 1.5 MG (milligrams) by mouth twice daily. R47's (facility) Psychotropic Consent Form, dated 3/28/2022 documents, Risperidone 1 MG by mouth twice daily. This medication is being administered for the following symptoms: Psychotic Disturbance, Anxiety as related to the following diagnos(es): Dementia, Psychotic Disturbance. This same for includes the following update, 9/8/22 New dosage of same medication is 1.5 MG very 12 hours. On 01/31/24 at 1:15 P.M., V9/Licensed Practical Nurse/Psychotropic Nurse confirmed that R47's behavior tracking listed off a large quantity of generic behaviors that are not specific to R47. V9 stated (R47) does not have any targeted, resident specific behaviors that we monitor. 2. On 1/29/24 at 9:45am R51 was sitting in his chair sleeping. At 11:45am, R51 in the main dining area, quiet and cooperative. R51's Physician order sheet documents for R51 to take Quetiapine 100mg (milligrams) daily at 11:00am. This form documents to take Quetiapine 150mg daily at 7:00pm, for a diagnosis of Parkinson's. R51's Behavior Monitoring and Interventions Reports, dated 11/1/23 through 1/30/24, has no adverse behaviors documented. R51's medical record does not have a gradual dose reduction documented. R51's current care plan documents that pharmacy to consider dosage reductions when clinically appropriate at least quarterly. On 1/30/24 at 10:30am, V9, Licensed Practical Nurse/Psychotropic Nurse, stated that R51's family (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145801 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145801 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant View Luther Home 505 College Avenue Ottawa, IL 61350 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few refuses to allow the facility to attempt psychotropic medication dose reductions. V9 verified that R51 does not have any adverse behaviors. V9 verified that an Antipsychotic medication dose reduction has not been attempted since he has been residing in the facility. On 1/31/24 at 2:30pm, V2, Director of Nursing, stated that R51's family will not allow the facility to attempt a gradual dose reduction on R51's psychotropic medications. V2 also verified that R51 does not exhibit any adverse behaviors. 3. On 1/29/24 at 11:15 AM, R34 was sitting in her room interacting with and being cared for by V7 (Registered Nurse) and V8 (Registered Nurse). R34 was somewhat confused with conversation. R34 was not displaying any behaviors. R34's current Physician Order Sheets, dated 1/31/24, documents R34 has an order for Seroquel (antipsychotic medication) 50 milligrams, take one tablet by mouth at bedtime for depression/ mood swings. This order has a start date of 12/29/23. R34's Psychotropic Consent, dated 12/29/23 documents R34 is being administered Seroquel 50 milligrams every day for the symptoms of Labile moods and Agitation and a diagnosis of Alzheimer's/ Anxiety/ Depression. R34's Psychiatry note, dated 12/13/23 documents Patient was seen in her room at the request of staff for worsening symptoms of anxiety. She (R34) reports feeling just tired. She denies daytime drowsiness and reports good sleep at night. Per staff patient recently completed COVID isolation. Patient is mildly confused, states I am upset because I missed Christmas dinner. I am upset because I am here. There are no reports of AVH (Audio-visual hallucinations), SI (Suicidal ideation's), HI (Homicidal ideation's). R34's current care plan, dated 1/31/24, documents (R34) has a mood problem related to diagnosis of depression and anxiety and uses mediation to help with mood control. This care plan does not document that R34 receives the antipsychotic medication Seroquel or any goals, warnings, tasks or interventions for taking the medication. On 1/30/24 at 1:15 PM, R34 was observed sitting quietly in her room in a wheelchair. R34 was not exhibiting any behaviors. R34's Behavior Monitoring and Intervention sheet for January 2024, documents R34 is being monitored for a variety of generic anxiety/psychosocial behaviors such as: grabbing, hitting, kicking, cursing, expressing frustration, screaming, disruptive sounds, throwing, agitated, anxious, spitting, rummaging, entering others room, public sexual acts and repetitive motions. R34's behavior progress notes for December 2023 and January 2024 document R34 has had some episodes of anger towards her spouse, yelling, crying and agitation. Throughout theses notes no behaviors of psychosis are documented. On 1/31/24 at 10:30 AM, V9 (Registered Nurse/ Psychotropic medication nurse) stated The behaviors we track are canned generic behaviors. When they come to us from the hospital we just track for whatever behaviors are pertinent at that time. The nurses on the floor add the behavior categories for the residents, they all pull up and you can click if they exhibit any. They are not targeted to each resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145801 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145801 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant View Luther Home 505 College Avenue Ottawa, IL 61350 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 1/31/24 at 11:30 AM, V4 (Care Plan/ Minimum Data Set assessment coordinator) stated I don't see where the Psychotropic medication Seroquel has been care planned (for R34) and it should be. On 1/31/24 at 1:06 PM, V2 (Director of Nursing) confirmed R34 does not have a Psychotic diagnosis to warrant the use of an antipsychotic medication. V2 stated (R34's) behaviors are yelling out, mostly related to her husband. He was here then went to Assisted Living and then she would make accusations that he's cheating on her and she would be upset with him. (R34) mostly has the yelling and aggression towards him. I don't know if she's had any specific psychotic behaviors. Event ID: Facility ID: 145801 If continuation sheet Page 9 of 9