Inspection·February 28, 2025

F 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Potential for minimal harm Based on observation, interview, and record review the facility failed to ensure the facility's Survey Binder included all prior survey results conducted by the State Agency and was easily accessible to residents. This has the potential to affect all 77 residents residing in the facility. Residents Affected - Many Findings include: The facility Residents' Rights for People in Long-Term Care Facilities policy and procedure documents You have the right to see reports of all inspections by the (State Agency) from the last five years and the most recent review of your facility along with any plan that your facility gave to the surveyors saying how your facility plans to correct the problem. On 2/26/25 at 1:42 pm R32 and R33 from the second floor, R72 from the third floor, and R24 and R35 from the fourth floor attended the Resident Group meeting. R24, R32, R33, R35, and R72 stated they are unaware the facility kept record of State Agency surveys, have not seen this information, and do not know where to locate the Survey Binder. On 2/26/25 at 2:41 pm, The facility Survey Binder was located on the upper level of the receptionist desk, approximately four and half feet from the floor, behind two picture frames. The location of this binder would be difficult, if not impossible for a resident in a wheelchair to see or reach. The last survey in this binder is from 2/22/24. There are no complaint or facility reported incidents included in the binder that were completed on 6/20/24, 9/13/24, 12/20/24, and 2/4/25. On 2/27/25 at 3:00 pm. V1 Administrator confirmed the facility Survey Binder was resting on ledge of the receptionist desk, out of resident view behind two picture frames, and at high level where residents in a wheelchair may not be able to reach. The facility's Long-Term Care Facility Application for Medicare and Medicaid CMS (Centers for Medicare and Medicaid Services) 671 Form, dated 2/25/25, documents 77 residents currently reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145801 If continuation sheet Page 2 of 14 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 02/28/2025 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 0623 Level of Harm - Potential for minimal harm Residents Affected - Many Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. 2. R31's Progress Notes, dated 2/8/25, documents R31 was transferred to the local hospital after a fall with injury. There is no documentation indicating that R31 or R31's representative was given written transfer documents at the time of transfer. 3. R127's Progress Notes, dated 2/12/25, documents R127 was transferred to the local hospital for a change in condition. R127's medical record does not indicate R127 or R127's representative was given written transfer documents at the time of transfer. 4. R1's Progress note, dated 3/10/24, documents R1 was transferred to the hospital due to passing a large clot. There is no documentation indicating that R1 or R1's representative was given transfer documents at the time of transfer to the hospital. 5. R6's Progress notes, dated 3/12/24 and 10/4/24, documents R6 was transferred to the hospital for a change in condition. There is no documentation indicating that R6 or R6's representative was given transfer documents at the times of transfer to the hospital. 6. R11's Progress note, dated 5/27/24, documents R11 was transferred to the hospital post fall. There is no documentation indicated that R11 or R11's representative was given transfer documents at the time of transfer to the hospital. On 2/27/25, at 1:06pm, V1 Administrator stated they do not give a written copy of the transfer form to the resident or resident representative. They are notified of transfer verbally. The facility's Long-Term Care Facility Application for Medicare and Medicaid CMS (Centers for Medicare and Medicaid Services) 671 Form, dated 2/25/25, documents 77 residents currently reside in the facility. Based on interview and record review, the facility failed to notify the resident/resident representative of the reason for transfer in writing for six (R1, R5, R6, R11, R31, R127) of six residents reviewed for emergency hospital transfer in a sample of 38. This has the potential to affect all 77 residents residing in the facility. Findings include: The facility's Admission, Transfer and Discharge Policy, dated 12/11/24, documents: 3. Notice of Transfer: Before a facility transfers or discharges a resident, the facility must- a. Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. 1. R5's Electronic Medical Records documentation indicated that R5 was sent to the hospital on 5/23/24. There was no documentation indicating that R5 or R5's representative was given transfer documents at the time of transfer to the hospital. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145801 If continuation sheet Page 3 of 14 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 02/28/2025 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 0625 Level of Harm - Potential for minimal harm Residents Affected - Many Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. 2. R31's Progress Notes, dated 2/5/25, documents R31 was transferred to the local hospital after a fall with injury. There is no documentation indicating that R31 or R31's representative was given a copy of the facility's Bed Hold policy and procedure at the time of transfer to the hospital. 3. R127's Progress Notes, dated 2/12/25, documents R127 was transferred to the local hospital due to a change in condition. There is no documentation indicating that R17 or R127's representative was given a copy of the facility's Bed Hold policy and procedure at the time of transfer to the hospital. On 2/27/25 at 9:16 am, R127 stated she did not receive any bed hold paperwork when she went out to the local hospital. 4. R1's Progress note, dated 3/10/24, documents R1 was transferred to the hospital due to passing a large clot. There is no documentation indicating that R1 or R1's representative was given a copy of the Bed Hold Policy at the time of transfer to the hospital. 5. R6's Progress notes, dated 3/12/24 and 10/4/24, documents R6 was transferred to the hospital for a change in condition. There is no documentation indicating that R6 or R6's representative was given a copy of the Bed Hold Policy at the times of transfer to the hospital. 6. R11's Progress note, dated 5/27/24, documents R11 was transferred to the hospital post fall. There is no documentation indicated that R11 or R11's representative was given a copy of the Bed Hold Policy at the time of transfer to the hospital. On 2/26/25, at 3:15pm, V14 Social Security Director/SSD stated that the residents only sign a bed hold contract upon admission and not with each hospital transfer/discharge. V14 was unable to produce any bed hold notifications. The facility's Long-Term Care Facility Application for Medicare and Medicaid CMS (Centers for Medicare and Medicaid Services) 671 Form, dated 2/25/25, documents 77 residents currently reside in the facility. Based on interview and record review the facility failed to provide a copy of the Bed Hold Policy for six (R1, R5, R6, R11, R31, R127) of six residents reviewed for emergency hospital transfer in the sample of 38.This has the potential to affect all residents that currently reside in the faclity. Findings include: The facility's Bed Hold Policy-Healthcare Policy, dated 12/4/20, documents: Notice of Bed Hold and readmission Policy will be provided before hospitalization or leave. A second notice will be provided to resident at time of transfer or within 24 hours of emergency. 1. R5's Electronic Medical Records documentation indicated that R5 was sent to the hospital on 5/23/24. There was no documentation indicating that R5 or R5's representative was given a copy of the Bed Hold Policy at the time of transfer to the hospital. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145801 If continuation sheet Page 4 of 14 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 02/28/2025 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 - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to perform hand hygiene, glove changes and perform pressure ulcer dressing change in a manner to prevent cross contamination for one (R48) of four residents reviewed for pressure ulcers in the sample of 38. Residents Affected - Few Findings include: The facility's Infection Prevention and Control Program, dated 7/19/25, documents: Good hand hygiene is a requirement of Standard Precautions. Hand hygiene is performed before and after each care contact for which hand hygiene is indicated by acceptable professional practice, utilizing designated time frames and products. Alcohol based hand rub (ABHR) is the preferred method, however, hands should be washed with soap and water when they are visibly soiled, before or after eating or handling food, after using the restroom and after caring for a resident with known or suspected clostridium Difficile or norovirus infection. Standard Precautions are designed to reduce the risk of transmission of blood borne and other significant pathogens. Standard Precautions apply to all contact with any blood, body fluid, secretion and excretion, except for sweat, from any human being, regardless of diagnosis or presumed infection status. Standard Precautions means that contact with any blood, body fluid, secretion and excretion except for sweat should be avoided. This also includes any items soiled with body substances or fluids. Wear gloves when touching or handling: Blood; All body fluids, secretions, and excretions, except sweat, regardless of whether they contain visible blood; Non-intact skin; Mucous membranes; Surfaces and equipment visibly soiled by these body substances . Gloves should be removed promptly after use and hands should be washed or sanitized to avoid transfer of microorganisms to other individuals or the environment. The facility's Clean Wound Care Treatment Technique, dated 10/11/24, documents guidelines of cleaning a wound and applying dry dressing. These guidelines document the following: Perform hand hygiene and put on PPE, if indicated; Prepare for dressing change; Put on clean, disposable gloves and remove old dressing; After removing dressing, remove gloves and dispose, perform hand hygiene and apply new gloves; Once the wound is cleaned and dry, remove gloves, perform hand hygiene, and apply new gloves; apply treatments with date and time; Remove and discard gloves and perform hand hygiene, remove all remaining equipment and adjust resident position, bed position, remove any remaining PPE and perform hand hygiene. The Order Summary Report for R48, dated 2/28/25, documents the following 1/30/25 physician order as: Coccyx cleanse open area with wound cleanser, pat dry, apply medical honey, calcium alginate, and secure with bordered foam dressing. On 2/27/25 at 9:28 am, V19 RN (Registered Nurse) stated R48 has a small pressure ulcer located in the crease of buttocks coccyx area, treatment is done daily, and R48 goes to the local wound clinic every couple of weeks for follow up. On 2/27/25 at 10:50 am, V18 RN and V19 RN entered R48's room, performed hand hygiene and applied PPE (personal protective equipment). V19 RN set up supplies on an overbed table as V18 RN assisted R48 to stand at her walker. R48 pulled her pants down revealing a superficial open area to R48's buttock crease. V19 RN cleansed R48's coccyx wound. With same soiled gloves V19 RN applied physician ordered ointment, absorbent dressing, and foam dressing. V19 RN removed her soiled gloves and without performing hand hygiene, donned gloves, reached in (V19's) uniform pocket and retrieved a black marker, pulled off the marker cap, signed and dated R48's coccyx wound dressing, and placed marker back (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145801 If continuation sheet Page 5 of 14 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 02/28/2025 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 - Minimal harm or potential for actual harm Residents Affected - Few into (V19's) uniform pocket. V19 RN then removed her soiled gloves and without performing hand hygiene, applied a new pair of gloves, gathered R48's treatment supplies, placed treatment supplies back into R48's closet, reached back into R48's closet for antiseptic wipe, wiped (V19's) soiled scissors, placed scissors in her uniform pocket, and wiped off the overbed table using same soiled wipe. With same soiled gloved hands V19 RN shoved soiled treatment supplies down into the garbage bag, pulled bag from garbage can and tied it up, and placed new garbage bag. V19 RN proceeded to walk out of R48's room with soiled gloves, carrying garbage in her left hand while pushing overbed table into the hall with her right hand, walked across the hallway, opened and entered the soiled utility room to throw garbage bag away and continued to move overbed table down the hallway into another resident room without performing hand hygiene. On 2/27/25 at 3:00 pm, V2 DON (Director of Nursing) confirmed hand hygiene is to be done in between going from soiled to clean, any time after removing gloves, and V19 RN should not have touched anything in the room with soiled gloves or prior to performing hand hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145801 If continuation sheet Page 6 of 14 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 02/28/2025 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure oxygen tubing and humidifier bottles were dated and changed per policy for two (R25 and R127) of four residents reviewed for respiratory care in the sample of 38. Residents Affected - Few Findings include: The facility's Oxygen Policy, dated 3/8/24, documents Oxygen tubing will be changed routinely. 1. The current Order Summary Report for R25, documents the following physician orders dated 1/14/25: O2 (oxygen) 1-3 LPM (liters per minute) per nasal cannula continuously to maintain O2 saturation greater than 90% every shift; and to change and label oxygen tubing and humidifier bottle weekly every Sunday night shift. On 2/25/25 at 10:15 am, R25 was sitting up in a wheelchair with oxygen infusing at 1.5 liters via nasal cannula, by way of oxygen concentrator. A humidifier bottle dated 2/16/25 was attached to the concentrator and there was no visible date on R25's oxygen tubing. 2. The current Order Summary Report for R127, documents the following dated physician orders: 2/23/25 O2 at 2 LPM per nasal cannula continuously to maintain O2 saturation greater than 94% every shift, 3 LPM if needed; and 2/21/25 Change and label O2 tubing and humidifier bottle weekly every Sunday night shift. On 2/25/25 at 10:48 am, R127 was sitting up in recliner in her room with oxygen infusing at 2 liters via nasal cannula by way of oxygen concentrator. A humidifier bottle was attached to the concentrator. The humidifier bottle and R127's nasal cannula were undated. On 2/28/25 at 3:00 pm, V2 DON (Director of Nursing) stated oxygen tubing and humidifier bottles are to be dated and changed weekly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145801 If continuation sheet Page 7 of 14 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 02/28/2025 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 0710 Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Hospice providers provided the facility with written physician orders for one of three residents (R42) reviewed for Hospice services in a sample of 38 residents. Residents Affected - Few Findings include: The Hospice's Agreement for Nursing Facility, Inpatient and Inpatient Respite Services dated [DATE] stated Appendix C Facility Services 1.4 Physician Orders: To the extent permitted by applicable law, rules, and regulations, (Hospice) nurses may receive and transcribe physician orders in the Facility's clinical records for any Residential Hospice Patient. Such physician orders will be countersigned by Facility's Director of Nursing or other Facility nurse. The Physician Orders-Obtaining and Transcribing policy dated [DATE] documented 1. All orders for medications, tests and treatments shall be written on the physician's order form and signed by the physician or physician extender unless entered into EHR (Electronic Health Record). R42's Care Plan documented R42 was admitted to Hospice services on [DATE] with a terminal prognosis related to Advancing Alzheimer's Disease and Severe Protein Malnutrition. R42 expired on [DATE]. On [DATE] at 10:30 AM, V1 (Administrator) stated after R42 expired that the Facility requested R42's Hospice records from the Hospice Agency. V1 stated We didn't have much information (Hospice documentation) in our records. The Hospice record (received post R42's expiration) dated [DATE] documented adjusted meds (medications); [DATE] cut Morphine (medication for pain and restlessness) dose to half 2.5 mg (milligram); [DATE] Aspiration Risk, increase Morphine 0.125 ml (milliliter) every four hours and Morphine 0.125 ml every three hours as needed; [DATE] discontinue oral medications; and [DATE] Morphine every four hours scheduled, as needed Ativan increased to every four hours. R42's Order Summary did not include medication order changes dated [DATE]; did not include an order for Aspiration Risks on [DATE]; did not include an order to discontinue oral medications on [DATE]; nor an order to crush Ativan (antianxiety medication) with instructions on how to administer the medication. The Medication Administration Record dated [DATE] through [DATE] documented R42 received Ativan and Morphine orally [DATE] through [DATE]. On [DATE] at 2:22 PM, V6 (Hospice Nurse) stated R42's Ativan should have been crushed, mixed with water and administered between the gum and cheek for optimal absorption. V6 stated When a resident cannot swallow anymore, the facility nurses should be administering medications between the gum and cheek. Orders are given to the facility nurse's verbally and it's up to them (nurses) to enter the orders into their (facility's) EMR (Electronic Medical Record) and ensure nurses know what routes to use when administering medications. On [DATE] at 11:47 AM, V26 (Registered Nurse) stated Hospice orders are received verbally from the Hospice nurse and the Facility's nurse enterers the order into the Electronic Health Record. V26 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145801 If continuation sheet Page 8 of 14 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 02/28/2025 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 0710 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated orders are every once in a while faxed to the facility but rarely and the Hospice Nurses do not leave their Progress Notes or Plan of Cares at the facility. On [DATE] at 12:00 PM, V2 (Director of Nursing) stated the Hospices sometimes write the orders and sometimes verbally give the orders. V2 agreed the facility nurses are taking verbal orders from the Hospice nurses without written documentation of the order and who the prescribing physician was. On [DATE] at 1:28 PM, V5 (Registered Nurse) stated I didn't know to crush (R42's) Ativan and how to administer it. The (physician) orders did not include an order that (R42) was not to have medications orally and we don't have records (Hospice) available to verify what the Hospice has changed. The Hospice nurses do not have access to our records (Electronic Medical Record/EHR). I've entered orders (into the EHR) the Hospice nurse has given me verbally, but I now understand that is not safe. They should be in writing. That's nursing 101. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145801 If continuation sheet Page 9 of 14 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 02/28/2025 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on interview and record review, the facility failed to ensure facility staff were educated and competent in providing Hospice and End of Life Care for Hospice Residents for nine of nine residents (R14, R23, R40, R43, R51, R52, R61, R62, R65) reviewed for Hospice services in a sample of 38 residents Findings include: The Hospice Agreement for Nursing Facility, Inpatient and Inpatient Respite Care Services dated 8/10/16 documented 4.6 Experience and Competence. It and its employees and personnel providing services pursuant to this agreement are (i) familiar with the administrative and patient care needs associated with hospice patients, (ii) competent in the care of terminally ill persons and in recordkeeping, and (iii) otherwise fully capable of performing its and their obligations hereunder in accordance with generally recognized professional standards of care. The facility's current Matrix 802 documents R14, R23, R40, R43, R51, R52, R61, R62, and R65 receive Hospice care. On 2/26/25 at 12:10 PM, V5 (Registered Nurse/ Date of Hire: 5/14/24) and V9 (Licensed Practical Nurse/Date of Hire: 1/15/25) Training Transcripts did not indicate Hospice or End of Life education had been completed. On 2/26/25 at 12:10 PM, V1 (Administrator) stated I thought End of Life training was completed on all new hires, but I don't see that it was assigned or completed for either of these two (V5 and V9) upon their hiring. On 2/27/25 at 1:28 PM, V5 stated she had not received Hospice or End of Life training since her date of hire. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145801 If continuation sheet Page 10 of 14 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 02/28/2025 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 interview and record review, the facility failed to document clinical rationale for extending PRN (as needed) psychotropic medication for one (R6) of two residents reviewed for psychotropic medications in a sample of 38. Findings include: The facility's Psychotropic Medication Management System policy, dated 10/26/24, documents (Named 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 practice. With administration of a psychotropic medication, the following will be documented: PRN orders are limited to 14 days unless the prescriber believes it is appropriate to extend the order beyond 14 days and documents their rationale in the clinical record and indicates the duration for the PRN order. R6's current Physician Order Statement/POS, dated 2/5/25, documents an order for Alprazolam (psychotropic) oral tablet 0.5mg (milligrams) give one tablet by mouth as needed for Anxiety for 30 Days TID (three times per day). On 2/27/25, at 1:45pm, V16 Licensed Practical Nurse/LPN/Resource Nurse stated We use the 14 days only if there is no stop date. (R6's) order was written by the prescriber to extend out to 30 days instead of 14. When asked if there is a written rationale V16 stated No, it is not written and it is probably so that it doesn't drop off (after 14 days). R6's clinical record does not include a documented rationale for R6's Alprazolam to be extended to 30 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145801 If continuation sheet Page 11 of 14 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 02/28/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure the staff completely covered hair in a sanitary manner while in the kitchen; failed to ensure food items were stored and labeled with dates and identification, and failed to ensure chemical product was not stored in the facility's Dry Food Storage Room. These failures have the potential to affect 76 of the 77 residents who consume food in the facility. Findings include: The facility's Use of Hair Restraints Policy dated 1/17/25 documents: Culinary employees will practice safe food handling to prevent food borne illness. The organization has strict requirements regarding hair restraints: A. Employees will wear hairnets or ball caps that completely cover the hair while in the kitchen or service food. If hair hangs below the ball cap, a hairnet must be worn. B. Beards and mustaches must be covered with effective hair restraint if longer than one-half inch in length, otherwise neatly trimmed close to the face. The facility's Storage Procedures Policy dated 1/17/25 documents: Food and supplies shall be properly stored to keep foods safe and preserve flavor, nutritive value and appearance. A. Food storage areas are used for food and paper supplies. Chemicals/poisonous items are not stored in food storage area. F. Open packages are labeled, dated and covered. The facility's Date Marking Policy dated 1/17/25, documents: All prepared foods that are stored will be properly dated to ensure food safety. Special Notes: 1. All items should include name of product, and two dates as indicated above. On 2/25/25 at 9:15am, V20 Culinary Services Director was noted in the kitchen with a hair bonnet on with hair not completely covered, tendrils of hair hang down on both sides of her face and the nape of her neck. V21 Dietary Aide was noted wearing a cap while doing dish washing task in the kitchen. V21's hair was not covered at the back of his head and sides of his face. V21 stated that he was given a choice to wear a cap or hairnet, and he chose a cap. V22 Dietary Aide had a hairnet on her head that covered all her hair except the entire bangs at the front of her head. V22 stated that she covered her hair but the bangs slide out when I am working. On 2/25/25 at 9:15am, the kitchen staff stated that all their hair was supposed to be covered while in the kitchen. On 2/25/25 at 11:25am while in the kitchen V23 [NAME] wore a cap; V23's hair showed at the front of his head from underneath the cap and his sideburns and beard were not covered. V23 had a surgical mask on; and wore a beard hairnet that was not in place. The beard hairnet was located beneath his chin. On 2/24/25 at 11:35am, V24 Prep [NAME] did not have his hair completely covered while in the kitchen. At this same time, V20 Culinary Services Director stated, All the hair for the kitchen staff should be covered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145801 If continuation sheet Page 12 of 14 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 02/28/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 2/24/25 at 9:25am, a pan of individually wrapped meat loaf portions in the facility's Freezer were not labeled or dated; a half full 50 pound bag of rice in the Dry Food Storage Room was not labeled or dated; a half full pitcher of lemonade with a use by date of 2/24/25 was in the Walk-in Cooler (V20 Culinary Services Director stated that the lemonade should not be in the Walk-in Cooler); a pan of sliced potatoes in the Walk-in Cooler was not labeled or dated, ten containers with sub sandwiches on a rolling cart were not labeled or dated in the Walk-in Cooler; and three medium sized bags of chopped red potatoes in the Walk-in Cooler were not labeled or dated. At this same time, V20 Culinary Services Director stated that labels and dates should be on all the food items. On 2/25/25 at 9:45am, in the facility's Bakery Freezer, a bag of peanut butter cookies and two bags of sugar cookies had no labels or dates. At this time, V25 Kitchen Manager stated, I don't know how old they (cookies) are. On 2/25/25 at 9:50am, a full container of Sanitizer chemical used for dishes was in the facility's Dry Food Storage Room. V25 Kitchen Manager stated that the Sanitizer should not be in the Dry Food Storage Room but should be in the chemical's storage area. The facility's Long-Term Care Facility Application for Medicare and Medicaid (Centers for Medicare and Medicaid Services/CMS 671) Form, dated 2/25/25, documents 77 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145801 If continuation sheet Page 13 of 14 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 02/28/2025 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Hospice's coordinated communication and required documents were available and accessible to the facility staff. This deficiency affects three of four residents (R23, R42, R43) reviewed for Hospice care management in a sample of 38 residents. Findings include: The Hospice Agreement for Nursing Facility, Inpatient and Inpatient Respite Care Services dated [DATE] stated 2.1.5 Medical Record Documentation. Facility shall allow (Hospice) access to appropriate medical records and permit the inclusion of (Hospice) care plans and other appropriate documentation in the Patient's Facility medical record. 2.1.7 Plan of Care (Hospice) shall provide Facility with a copy of a Hospice Plan of Care for each Hospice Patient admitted to Facility. Appendix C Facility Services 1.4 Physician Orders: To the extent permitted by applicable law, rules, and regulations, (Hospice) nurses may receive and transcribe physician orders in the Facility's clinical records for any Residential Hospice Patient. The Hospice Services policy dated [DATE] documented coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by the facility. R42's facility Care Plan documented R42 was admitted to Hospice services on [DATE] with a terminal prognosis related to Advancing Alzheimer's Disease Alzheimer's Disease and Severe Protein Malnutrition. R42 expired on [DATE]. The Facility Matrix documented R23 and R43 were currently receiving Hospice services, and each had a diagnosis of Alzheimer's Disease. On [DATE] at 11:47 AM, R23 and R43's electronic medical nor their Hospice Binder included a Hospice plan of care, prescribers' orders and/or copies of clinical/progress notes. On [DATE] at 12:00 PM, V2 (Director of Nursing) stated Hospice orders are sometimes written and sometimes given verbally. On [DATE] at 10:30 AM, V1 (Administrator) stated I called the Hospice and asked them for (R42's) records. We didn't have much information in our records. On [DATE] at 2:22 PM, V7 (Hospice Registered Nurse) stated the Hospice nurses verbalize new orders or changes in care needs and I don't know if the (Hospice) office gives the facility records but I don't leave my notes at the facility. On [DATE] at 11:47 AM, V26 (Registered Nurse) stated the Hospice binders do not include very much information. Communication is mostly just verbal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145801 If continuation sheet Page 14 of 14