Health inspection·August 23, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few following: PURPOSE: To provide all residents with a home like environment that promotes dignity and respect to the residents of the facility. POLICY: To ensure that all residents are provided with dignity and privacy. RESPONSIBILITY: It is the responsibility of all staff to ensure that all residents have privacy and dignity. the same policy documents: PROCEDURE: 4. Privacy will be maintained for resident's receiving ADL care such as bathing, dressing and pericare, with the resident room/shower room door closed and curtain drawn., 5. Medically necessary procedures will be conducted in the resident's room/private setting., 7. All resident's rights will be honored throughout the resident's daily routine as listed on the Resident Rights for People in Long term Care Facilities. A. On 8/20/24 at 1200 PM, V5 (R377's family) was sitting at the dining room table next to R377 and had a small service dog, wearing a red service dog vest, on V5's lap. At this time V3 LPN (Licensed Practical Nurse) asked V5 to remove the service dog from the dining room. V5 stated the dog is a certified service dog and has papers certifying it as a service dog while lifting a lanyard towards V3 that contained the certification. V3 walked away from V5 and entered V1's (Administrator) office. R377 then stated I (R377) don't understand why the dog can't be here with me (R377), he {dog} is a service dog, and this is my home. At 12:08 PM, V3 exited V1's office and approached R377 and V5 and said something that could not be heard, then an unidentified staff member gathered R377's remaining lunch and escorted R377 and V5 along with the service dog to R377's room to finish their lunch. On 8/21/24 at 12:58 PM, V1 with V2 (Director of Nursing) present stated the facilities dietary consulting company recommended not have the service dog in the dining room during meals. V1 acknowledges that on 8/20/2024 when V5 was asked to leave the dining room the only people at that table, where the service dog was located, was R377 and V5. V1 stated that the facility does not currently have a policy for service dogs. V1 stated that all residents are given a Resident Rights pamphlet at the time of admission for their rights while in the facility. On 08/21/24 at 2:30 PM, V1 provided Understanding How to Accommodate Service Animals in Healthcare Facilities guide dated 08/16/2024 from HHS (Health and Human Services) website. This guide documents health care facilities must permit the use of a service animal by a person with a disability. On 8/21/24 at 3:30 PM, V1 provided an undated Resident Rights for People in Long-Term Care Facilities, which is what the residents are given at the time of admission, that documents residents have the rights to make their own choices, be treated with dignity and respect in a home like environment. On 8/22/24 at 3:30 pm V1 and V2 provided, V5,'s Identification Dog Handler Registration card that documents Access is required by Federal law. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146010 If continuation sheet Page 2 of 11 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 146010 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Healthcare of Pontiac 300 West Lowell Pontiac, IL 61764 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 Based on observation, interview, and record review the facility failed to obtain an order for a therapy recommended arm sling and failed to assist in applying the arm sling for one of one resident (R377) reviewed for Limited Range of Motion in the sample list of 26. Residents Affected - Few Findings include: On 8/20/2024 at 10:36 AM, R377 was sitting in wheelchair with V5 (family) present. V5 stated R377 had a fall while at home and sustained a fractured right shoulder and should have an immobilizer on. At this time R377 states R377 was sitting on the arm sling. R377's Occupational Therapy Evaluation and Plan of Treatment dated 8/14/2024 documents R377 was admitted to the facility following a mechanical fall and sustaining a comminuted transverse fracture of the right humeral neck. This evaluation also documents R377 has a brace and/or splint with instructions for the right shoulder sling to be worn to prevent subluxation (separation of the joint). R377's August 2024 Physician Orders do not document an order for an arm sling. On 08/20/2024 at 12:00 PM and 2:16 PM, R377 was not wearing the sling. At 2:16 PM when asked why R377 was not wearing the arm sling, R377 states, I haven't gotten someone to put it back on. On 8/21/2024 at 8:00 AM, R377 was propelling self in wheelchair into the therapy room without the right arm sling in place. On 8/21/2024 at 8:10 AM, R377 was in therapy working with V13 PTA (Physical Therapy Assistant) with no sling in place. On 8/21/24 at 1:14 PM, V14 OTR (Occupational Therapist-Registered) with V1 (Administrator) present confirmed there is no order written for an immobilizer or sling, but V14's recommendation has been that R377 is to wear an arm sling on the right arm to prevent subluxation and would expect nursing services to obtain the order. On 8/22/24 at 12:46 PM, V23 (Nurse for V24 (Orthopedic Physician Assistant)) stated the orders that V24 received from the hospital emergency room were for sling to be worn for 24 hours per day with gentle hand/wrist range of motion and non-weight bearing. V23 explained noncompliance with the sling could cause the fracture to shift and to not heal correctly however R377 has not been seen in the office yet so V23 is unsure how it is healing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146010 If continuation sheet Page 3 of 11 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 146010 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Healthcare of Pontiac 300 West Lowell Pontiac, IL 61764 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 - Actual harm Based on observation, interview, and record review the facility failed to implement an ordered nutritional supplement and failed to notify a resident representative of the significant weight loss for one of two residents (R379) reviewed for nutrition in the sample list of 26. These failures resulted in R1's severe weight loss of 10.8% in 12 days. Residents Affected - Few Finding include: On 8/20/2024 at 11:55 AM, R379 was sitting in a wheelchair in the dining room eating lunch with V17 (family) present. No nutritional supplements were present on the tray. At this time, V17 states R379 has lost a lot of weight since his surgery, which was prior to being admitted to the facility. V17 is not aware of any ordered nutritional supplements and has not been notified by the facility of any weight loss since R379 being admitted . V17 stated V17 is at the facility for most of R379's meals and acknowledges that R379 has a decreased appetite and intake. R379's ongoing Census documents R379 was admitted to the facility of 8/07/2024. R379's ongoing Weight Log documents a weight of 149.8 pounds on 8/07/2024 and 133.6 pounds on 8/19/2024. This weight loss calculates as a 10.8% weight loss in 12 days. R379's Dining RD Request for Diet Change report dated 8/08/2024 documents (R379) is at risk for altered nutrition status r/t (related to) reduced meal intake, recent surgery, and dx (diagnosis) of Dementia. Recommend {to} add house supplement 1 dly (daily) and liq (liquid) pro (protein) 30ml (milliliters) dly (daily). Monitor wt (weight). This report recommendation was signed and accepted by V11 (Nurse Practitioner) on 8/09/2024. R379's ongoing August 2024 Physician Order Sheet does not contain the accepted dietary recommendations for nutritional supplements. On 8/21/2024 at 8:35 AM, R379 was sitting at the dining room table eating breakfast which consisted of: scrambled eggs with cheese, cornflakes, toast, milk, and coffee. R379 consumed: 100% of coffee, 10% of eggs, 0% toast, 0% cornflakes, 0% milk. No nutritional supplement was present at breakfast. On 8/21/2024 at 8:40 AM, V6 CNA (Certified Nursing Assistant) states I am not aware of any nutritional supplement (R379) is supposed to get but I (V6) usually work in the evenings. V6 acknowledged that if R379 was getting a supplement it would be on the tray. On 8/21/2024 at 08:45 AM, V4 RN (Registered Nurse) confirms that R379 has not received any nutritional supplements. V4 looked in the EMR (Electronic Medical Record) and confirmed there was no order transcribed for a nutritional supplement. On 8/21/24 at 10:55 AM, V8 RD (Registered Dietitian) confirmed that V8 recommended the above nutritional supplements on 8/09/2024 for R379, and states V8 would have expected the supplement to be given by now. V8 also stated if R379 was receiving the nutritional supplements as recommended and ordered, it could have possibly prevented R379's additional weight loss. On 8/21/24 at 12:38 PM, R379 was in the dining room with V17 eating lunch with no nutritional supplement present. On 8/21/24 at 12:52 PM, V1 (Administrator) with V2 (Director of Nursing) present stated that V8 had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146010 If continuation sheet Page 4 of 11 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 146010 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Healthcare of Pontiac 300 West Lowell Pontiac, IL 61764 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 notified V1 that the ordered supplement was not implemented because V8 sent the signed recommendations to an invalid email address. Level of Harm - Actual harm Residents Affected - Few R379's computerized Medical Record does document a history of CHF (Congestive Heart Failure), however R379's Progress Notes do not document any signs and symptoms of CHF. V10's (Nurse Practitioner) Progress Notes on 8/12/2024 and 8/19/2024 do not document any CHF signs or symptoms, nor does V11's (Nurse Practitioner) Progress Note on 8/08/2024, 8/12/2024, and 8/16/2024. On 8/22/24 at 8:10 AM, V8 confirmed that the order for the nutritional supplement was not implemented and that it was an error on V8's part due to sending the signed recommendation to an invalid email address. The facilities policy Fortified Foods, Supplements, and Snacks dated 2020 documents residents who cannot consume adequate amounts of regular foods at meals to meet their nutritional needs may be considered for Fortified Foods, snacks, or supplements in order to increase nutritional intake. Residents will be evaluated by the Registered Dietitian when additional nutritional intervention is warranted. Commercially prepared supplements, including liquid high calorie and high protein supplements, will be ordered by the physician. Fortified foods, house supplements, or snacks will be provided within the specifications of the diet order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146010 If continuation sheet Page 5 of 11 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 146010 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Healthcare of Pontiac 300 West Lowell Pontiac, IL 61764 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 - 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 adequate pain management was provided for one of two residents (R29) reviewed for pain on the sample list of 26. Residents Affected - Few Findings Include: The facility's Pain Management Policy dated August 2017 documents the facility's mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. The purpose of the policy is to accomplish that mission through an effective pain management program, providing residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. The same policy documents pain is defined as whatever the experiencing person says it is, existing whenever the experiencing person says it does. The physician will be notified of resident's complaint of pain when not relieved by medication as ordered by the physician. Thorough communication with the physician will ensure an appropriate pain management plan. R29's Minimum Data Set (MDS) dated [DATE] documents R29 is cognitively intact. R29's Physician Order Set (POS) dated August 2024 documents R29 is prescribed Acetaminophen 500 milligrams three times a day for chronic pain (started on 5/30/2024) and Ibuprofen 200 milligrams every 8 hours as needed for mild or more severe pain (started on 8/21/2024). R29's Psychiatry Note dated 7/9/24 documents R29 reports she has not been sleeping well due to pain and continues to show impulsive behaviors. Staff reported R29 hasn't been sleeping and often requests pain medications to get out of bed. R29's Care Plan dated November 2022 documents R29 has potential for pain related to Lumbar Degenerative Disc Disease and Fibromyalgia. Staff are to administer pain medications as ordered by physician and notify the physician if interventions are unsuccessful. R29's Medication Administration Record (MAR) dated August 2024 documents R29 reported a pain rating of 10/10 twice on 8/16/24, and once on 8/19/24 and 8/21/24. On 8/20/24 at 1:20 PM R29 was lying in bed with a blanket over her head and when asked how she was feeling, R29 stated she was in pain and her back hurt, and the staff aren't getting her the medication that would actually relieve her pain. R29 stated she gets Acetaminophen, and she needs something stronger. R29 has told the nurses but they say they will talk to the doctor and she never hears anything else about it. R29 stated she asks for pain medicine but what they give her doesn't help. R29 stated she needs something stronger, but they won't give it to her because they are afraid, she will become addicted. R29 stated she hurts at about an 8/10 most of the time. On 8/23/24 at 10:45 AM V1 Administrator and V2 Director of Nurses (DON) confirmed R29's repeated complaints of uncontrolled pain need to be addressed. V2 DON confirmed if R29 is in significant pain something more needs to be done to assist in making R29 more comfortable. On 8/23/24 at 12:25 PM V11 Nurse Practitioner stated R29 has multiple medical diagnoses contributing to her chronic pain. These include Intervertebral Disc Degeneration in the Lumbar Region, Fibromyalgia, and Weakness. V11 stated R29 also has Dementia. V11 stated R29 is prescribed scheduled (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146010 If continuation sheet Page 6 of 11 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 146010 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Healthcare of Pontiac 300 West Lowell Pontiac, IL 61764 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 - Minimal harm or potential for actual harm Acetaminophen 1000 milligrams three times per day and V11 just started Ibuprofen 400 milligrams every eight hours as needed for pain on 8/21/24. V11 stated she was not made aware by facility staff that R29 was complaining of significant pain of 10/10 until 8/21/24. V11 stated she does not want to prescribe a narcotic pain medication for R29's chronic pain and does not know what else the facility has tried to help relive R29's constant pain. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146010 If continuation sheet Page 7 of 11 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 146010 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Healthcare of Pontiac 300 West Lowell Pontiac, IL 61764 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 - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review the facility failed to dispose of discontinued medications for one (R9) of 22 residents reviewed for physician orders in the sample list of 26. Residents Affected - Few Findings include: On 8/21/24 at 4:30 PM, the bottom drawer of the [NAME] Wing Medication Cart contained a medication bottle without a label. Inside of this bottle, there were three new Haldol {Antipsychotic} 5mg (milligrams)/ml (milliliters) vials that had a sticker on the bottles with R9's name. At this time, V2 (Director of Nursing) stated the Haldol was a one-time order and should have been destroyed or sent back to the pharmacy. R9's July 2024 Physician Order Sheet documents an order received on 7/15/2024 for Haloperidol {Haldol} Lactate Injection Solution 5mg/5ml (Haloperidol Lactate)Inject one ml intramuscularly, every 8 hours as needed for agitation and aggression, for 14 Days with instructions of may give IM (Intramuscularly) when not given PO (by mouth). The facilities Destroying Medication policy date 9/2023 documents, all discontinued medications or medications of discharged residents will be destroyed as soon as possible. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146010 If continuation sheet Page 8 of 11 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 146010 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Healthcare of Pontiac 300 West Lowell Pontiac, IL 61764 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review the facility failed to ensure residents medications, including Schedule II controlled substances, were stored appropriately within visual control of the nurse. This failure affects four of 22 residents (R2, R31, R35, R25) reviewed for medication storage for the sample list of 26. Findings include: On 8/21/2024 at 4:09 PM, the [NAME] Wing Medication Cart was unlocked and not secured to the wall. There were no staff present. There was an opened stock bottle of Melatonin 5 mg (milligrams) sitting on top of medication cart. On 8/21/2024 at 4:10 pm, V16 LPN (Licensed Practical Nurse) exited the [NAME] Wing Medication Room and walked down the hall and into a resident room, leaving the unsecured medication cart in the hallway, unlocked and out of V16's sight. V16 returned to the medication cart at 4:12 PM, gathered supplies and walked away from the cart again at 4:17 PM and entered another resident room, leaving the cart unlocked, unattended and out of V16's sight until 4:20 PM. V16 returned to the cart at 4:21 PM to gather supplies, then left the cart again, leaving it unlocked, unsecured and out of V16's sight while in a resident room. At 4:22 PM, V2 (Director of Nursing) approached the medication cart and confirmed the Melatonin should not be on top of the medication cart and states the medication cart should be locked when staff are not within sight. At 4:25 PM, upon V16's return to the medication cart, V2 stated, do you see we are in your cart; it should have been locked. Included in the unlocked medication cart were the following controlled substances: Norco (Narcotic) 10/325 mg for R31, Norco (Narcotic) 7.5/325 mg for R2, Methylphenid (Central Nervous System Stimulant) 20 mg for R35, Reprexain (Narcotic) 10mg/200mg for R25; all which are classified as Schedule II narcotics. The facilities Storage of Medications policy dated 10/2023 documents all medications will be safe and properly stored at all times. All medications for all residents shall be stored in or near the nurse's station, in a locked cabinet, a locked medication room, or in locked, secured medication cart. Mobile medication carts, when not in the visual control of the nurse, shall be stored in a locked room affixed in such a way to render them immobile. All scheduled II controlled substances shall be stored in the drawer of the medication cart which is separately keyed and locked. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146010 If continuation sheet Page 9 of 11 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 146010 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Healthcare of Pontiac 300 West Lowell Pontiac, IL 61764 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 maintain the facility kitchen food service areas, and equipment in a clean, sanitary condition to prevent potential cross-contamination and food-borne illness to residents. This failure has the potential to affect all 76 residents residing in the facility. Findings include: On 08/20/24 at 9:50 am, during the initial tour of the facility kitchen, accompanied by V7, Dietary Manager (DM), the commercial table mounted can opener had a build-up of a grease-like substance in the gears. Adhering to the grease-like substance were metal fragments, and rust. The commercial can opener also had the silver laminate missing from the bottom inch of the blade. The commercial can opener blade had exposed bare metal and rust at the tip of the blade. V7, DM confirmed the observation and stated he would have to get the build-up debris and blade tip cleaned properly before using the can opener. During the same initial tour, the facility flat-top grill and stove burners had a range hood that spanned over all cook surfaces. The range hood had six separated metal framed filters. Each of the six metal enclosed filters had a build-up of dark and light brown, grease-like substance adhering to the surface. The grease-like substance had scattered strands of a dust-like substance, that dangled down one to two inches, and directly over the cooking areas. V7, DM stated the facility has a cleaning service that cleans the range hood filters every three months. V7 confirmed the soiled condition of the range hood screen like filters. V7 said he will have to clean the filter, and the contracted cleaning service will need to clean the filter more often. On 8/22/24 at 10:45 am during subsequent tour of the kitchen, V7, Dietary Manager confirmed the following: The 15 foot long, metal food preparation table had caulking at the wall junction. The caulking had embedded brown and black sticky, food-like substance that adhered to the top and bottom of the caulking. The caulking had food-like particles that were crusted in patches. V7, DM confirmed the caulking debris build-up was a potential contaminate to the food preparation areas as V7 easily scraped off the crusted food debris with V7's finger. The facility three well, wash, rinse and sanitizer water had a windowsill that set directly above it. V7 confirmed that above the three well sink window had screens on the lower half of the window. The screens had copious amount of dust-like buildup and a build- up of grease and dust across the windowsill. Above the window there was a three-inch deep window frame, that junctions with the ceiling. The ceiling and wall junction of the window frame had rust and chipped paint across the full six foot width of the frame. The frame hung over the three well sink. The clean area of the dishwasher station, next to the three well sink was also exposed to chipped paint and thick clusters of dust-like strands and cobwebs on the ceiling above the clean racks of dishes. V7 confirmed these areas were heavily soiled and need to be cleaned to prevent cross contamination. The facility policy Cleaning Instructions: Hoods and Filters dated 5/2021 documents the following: Policy: Stove hoods and filters will be cleaned according to a cleaning schedule, or at least monthly. Procedure: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146010 If continuation sheet Page 10 of 11 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 146010 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Healthcare of Pontiac 300 West Lowell Pontiac, IL 61764 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 1. Remove the screens from the hoods. Level of Harm - Minimal harm or potential for actual harm 2. Place the screens in soapy water in the sink. Scrub thoroughly. Rinse. (Or run through the dish machine if appropriate.) Residents Affected - Many 3. Air dry screens after cleaning. 4. Replace the screens into the hoods. 5. To clean the interior and exterior of the hood, use a clean cloth soaked in soapy detergent water. Rinse thoroughly and air dry. A more abrasive cleaning agent may be needed in some cases. A cleaning agent that can handle grease may be needed. 6. Hoods and filters should be cleaned professionally at least yearly The facility Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 08/20/24 documents 76 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146010 If continuation sheet Page 11 of 11