Inspection·June 4, 2025

F 0628 5/26/25. Level of Harm - Minimal harm or potential for actual harm The facility could not provide documentation that R63's representative was provided a written copy of the Bed Hold Policy when R63 was transferred to the emergency room on 3/29, 4/11, 4/16 and 5/26/25. Residents Affected - Some On 6/3/25 at 10:58am V4 Social Service director stated that the resident or resident representative signs the bed reserve-policy notification form upon admission. V4 stated that nursing staff do not provide a bed hold policy form when residents are transferred out of the facility. V4 stated that V7 Admissions will follow up with the resident in the hospital. On 6/3/24 at 11:08am V13 Licensed Practical Nurse stated that when V13 transfers a resident out of the facility to the emergency room, V13 does not provide the resident with a bed hold policy. V13 stated V7 admission or V4 Social Service follows up with that paperwork. On 6/3/25 at 11:30am R63 stated that the nurse did not give R63 any bed hold policy or paperwork when R63 was transferred to the hospital. R63 stated that R63 has been to the hospital several times in the last couple months and was never given a bed hold notice. 5. R74's Nursing Notes document R74 left the facility for a procedure on 4/21/25. Progress Notes dated 4/21/25 - 4/25/25 document R74 was hospitalized . R74's medical record does not contain documentation that a bed hold notice, or a written notice of transfer was provided to R74's representative for R74's leave. The facility could not provide documentation that R74's representative was provided a written copy of the Bed Hold Policy when R74 left the faciity on 4/21/25. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146010 If continuation sheet Page 2 of 8 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 06/04/2025 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a person-centered comprehensive care plan. This failure affects one (R50) of 19 residents reviewed for care plans in the sample list of 35. Findings include: The facility's Care Planning Policy (revised June 2024) documents the following: To utilize the results of the comprehensive assessment to develop, revise and review resident's care plan. To provide a method for all staff to have needed information in caring for the residents. Each resident will have a plan of care to identify problems, needs and strengths that will identify how the interdisciplinary team will provide care. The resident care plan is the tool used to coordinate all care provided to the resident to be sure care is necessary, appropriate, and planned to meet the individual needs of the resident consonant with the physician's plan of care. The resident care plan must be kept current at all times. On 6/1/25, 6/2/25, 6/3/25, and 6/4/25 during intermittent observations throughout the survey period, R50 was observed with a nasal cannula in place in R50's nares. R50's Face Sheet dated 6/4/25 documents R50 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease and Atrial Fibrillation. R50's Physician Order Sheet (current) documents the following orders: O2 (Oxygen) 2 liters via nasal cannula as needed to keep O2 saturation above 90% and Apixaban (Anticoagulant) oral tablet 2.5 milligrams, give 1 tablet by mouth two times a day for blood thinner. R50's Minimum Data Set, dated [DATE] documents R50 is receiving oxygen therapy and taking an anticoagulant. R50's Care Plan (current) does not include R50's oxygen use and/or monitoring. This same record does not include anticoagulant medication use and/or monitoring. On 6/4/24 at 11:10am, V1 Administrator stated care plans are to be updated with any change in condition and should include R50's anticoagulant and oxygen use. V1 confirmed R50's care plan does not include oxygen therapy and anticoagulant use and interventions for monitoring. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146010 If continuation sheet Page 3 of 8 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 06/04/2025 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 provide numerous showers as scheduled for dependent residents. These failures affect two residents (R34 and R63) of six reviewed for activities of daily living in the sample list of 35. Residents Affected - Some Findings include: The facility's Bath/Shower Policy dated 8/2023 documents: Purpose: To provide a procedure for bathing/showering the resident. Policy: A bath/shower for cleanliness and comfort will be scheduled at least weekly for all residents. Responsibility: It's the responsibility of the nursing assistants to provide the bath/shower to each resident per schedule. It is the responsibility of the Charge Nurse to ensure that bath/shower schedule is followed, and residents receive bath/shower per facility schedule. 1. R34's Facility Census documents R34 was admitted to the facility on [DATE] and has the following medical diagnosis; Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, Aphasia, Lack of Coordination, Convulsions, Major Depressive Disorder, Delusional Disorders, Need for Assistance with Personal Care, Unsteadiness on Feet and Abnormalities of Gait and Mobility. R34's Minimum Data Set (MDS) dated [DATE] documents R34's Brief Interview for mental Status (BIMS) score 0, severe cognitive impairment and needs substantial/maximum assistance from staff with Activities of Daily Living (ADLs). R34's Shower Schedule dated April 3, 2025 - June 6, 2025, documents R34 is scheduled for showers on Tuesday, Thursday and Saturdays. R34 did not receive showers on 4/29, 5/1, 5/6, 5/13, 5/17, 5/20, 5/27, 5/29 and 6/3/25. 2. R63's Facility Census documents R63 was admitted to the facility on [DATE] and has the following medical diagnosis; Muscle Wasting and Atrophy, Cognitive Communication Deficit, Lack of Coordination, Multiple Fractures, Acute and Chronic Respiratory Failure and Unsteadiness on Feet. R63's Minimum Data Set (MDS) dated [DATE] documents R63's Brief Interview for mental Status (BIMS) score 15, cognitively intact and is dependent on staff with Activities of Daily Living (ADLs). R63's Shower Schedule dated April 3, 2025 - June 6, 2025, documents R63 is scheduled for showers on Thursday and Sundays. R34 did not receive showers on 4/17, 4/20, 4/24, 4/27, 5/1, 5/4, 5/8, 5/11, 5/15, 5/18 and 5/25/25. On 6/3/25 at 11:30am R63 stated that R63 does not get two showers a week. R63 stated R63 is lucky to get any. R63 stated that staff always have an excuse to why they can't give R63 a shower. R63 stated R63 needs assistance from staff to get a shower. On 6/3/25 at 11:08am V13 Licensed Practical Nurse stated Certified Nursing Assistant's should be providing the residents their showers per the residents scheduled shower, which are two showers a week. V13 stated after giving the resident a shower, the CNA should be documenting it in the resident's chart. V13 stated that if a resident refuses a shower, the CNA should be notifying the nurse so they (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146010 If continuation sheet Page 4 of 8 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 06/04/2025 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete can speak with the resident in an attempt to provide the scheduled shower. V13 stated that if the resident still refuses, the refusal should be documented by the CNA in the resident's chart. On 6/3/25 at 1:20pm V17 Certified Nursing Supervisor stated that all residents are scheduled to receive two showers a week. V17 stated that all showers are documented under the tasks in the resident's chart. V17 stated that if it's not documented in the resident's chart, then the resident did not receive a shower. V17 stated staff can also document if the resident received a bed bath or refused the shower. V17 confirmed that R34 and R63 did not receive all scheduled showers and did not have any documented refused showers or bed baths. Event ID: Facility ID: 146010 If continuation sheet Page 5 of 8 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 06/04/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview and record review the facility staff failed to provide complete incontinence care for R18. R18 is one of one resident sampled for incontinence care in a total sample of 35. Residents Affected - Few Findings include: The Electronic Medical Record under the section Medical Diagnoses dated 6/3/25 documents the primary diagnosis for R18 is Unspecified Cord Compression. Progress Notes dated 5/13/25 and 6/3/25 document R18 received antibiotics for urinary tract infections. V18, CNA (Certified Nurse Assistant) performed incontinence care for R18 on 6/3/25 at 2:40 PM. V18, used wash clothes to cleanse, rinse and dry R18's inner and outer labia. V18 then stated she was completed with perineal care for R18. V18 was asked about cleaning the groin area and the buttocks. V18 said Yes I should of cleaned R18's buttock's area. R18 stated on 6/3/25 at 2:35 PM she was feeling strange and she had started a new antibiotic today (6/3/25) for another urinary tract infection. V1, Administrator stated on 6/3/25 at 3:15 PM Yes, they are supposed to clean the entire area front and back when staff complete peri (perineal) care. The Facility policy dated Toileting and Incontinent Care revision date 8/2023 documents #8 Wash all soiled skin areas and dry very well, especially between skin folds. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146010 If continuation sheet Page 6 of 8 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 06/04/2025 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 0698 Provide safe, appropriate dialysis care/services 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** 2. R13's Medical Diagnosis sheet which is current has the following two diagnoses for R13, Dependence on Renal Dialysis and End stage Renal Disease. Residents Affected - Few R13's Physician's Order Sheet (POS) dated June 2026 does not document dialysis treatment orders for R13. V24, LPN (Licensed Practical Nurse) stated on 6/1/25 at 10:30 AM R13 has dialysis five times a week and R13 goes to Dialysis every morning Monday thru Friday. V16, Regional QA (Quality Assurance) stated on 6/4/25 at 10:30 AM that R13's dialysis order must of fallen off the physician's orders sheet. V16 stated (R13) goes to dialysis every morning Monday thru Friday. Based on interview and record review, the facility failed to have an order for the provision of dialysis treatments for two (R13 and R46) of two residents reviewed for dialysis in the sample list of 35. Findings include: The facility's Long-Term Care Facility Renal Dialysis Affiliation Agreement dated 11/8/2019 documents the Dialysis Facility shall accept medically stable residents into its home Renal Dialysis program, within the limits of its programs and facilities, Each such resident accepted into the Dialysis Facility's home hemodialysis program is referred to herein as a Dialysis Resident. The medical management of the Dialysis Residents will be under the direction of each Dialysis Resident's attending physician. The LTC Facility retains primary responsibility for the development and implementation of each Dialysis Resident's overall plan of care. Coordination of care may include coordination of the following: Day(s), date(s), and time(s) of appointments with the Dialysis Facility and dialysis access orders. The facility's Dialysis Residents list documents R13 and R46 as Dialysis Residents. 1. R46's Face Sheet (current) documents R46 was readmitted to the facility on [DATE] with diagnoses: End Stage Renal Disease, Stage 4 Chronic Kidney Disease, and Dependence on Renal Dialysis. R46's Physician Orders (current) do not document any dialysis treatment orders for R46. R46 did not have dialysis treatment orders from 3/22/25 until 6/3/25. On 6/3/25 at 1:37pm, R46 stated R46 receives dialysis treatments in the facility Monday through Friday. On 6/3/25 at 2:21pm, V15 Licensed Practical Nurse confirmed R46 does not have any dialysis treatment orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146010 If continuation sheet Page 7 of 8 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 06/04/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP) for two (R2 and R275) of seven residents reviewed for EBP on the sample list of 35. Residents Affected - Few Findings include: The facility's Enhanced Barrier Precautions policy dated 10/21/22 documents EBP expands the use of gloves and gowns to be worn during high-contact care activities that provides opportunities for Multidrug Resistant Organisms (MDROs) to be transferred between staff hands or clothing and between residents during these high-contact cares. This policy documents residents with wounds and indwelling medical devices are at high risk of acquisition and colonization of MDROs. This policy documents to wear gown and gloves when assisting residents on EBP with high-contact care activities, including dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, providing device care or wound care. R2's care plan dated 4/8/24 documents that staff will always maintain EBP during high-contact resident care areas. R2's physician's orders dated 9/17/2024 documents an order for EBP when providing cares involving R2's indwelling medical device. On 6/2/25 at 12:08 PM, there was a sign posted on R2's room door that documented EBP and to wear a gown and gloves for the high-contact care activities listed. On 6/2/25 at 12:10 PM, V10 Certified Nurse Assistant (CNA) emptied R2's urine collection bag but did not put on a gown. On 6/2/25 at 12:25 PM, V10 stated that staff are supposed to wear gowns when emptying R2's urine collection bag. V10 stated that she should have put on a gown. R275's care plan dated 6/2/25 documents that staff will always maintain EBP during high-contact resident care activities. R275's physician's orders dated 6/2/25 documents an order for EBP when providing cares involving R275's indwelling medical device. On 6/1/25 at 12:08 PM, V11 Registered Nurse emptied R275's urine collection bag. V11 was not wearing a gown. On 6/3/25 at 10:00 AM, V2 Director of Nursing stated that all staff should wear a gown and gloves during high-contact resident care activities. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146010 If continuation sheet Page 8 of 8