Health inspection·March 27, 2025

F 0758 condition. Level of Harm - Minimal harm or potential for actual harm Residents will only receive anti-psychotic medications when necessary to treat specific conditions for which they are indicated and effective. Residents Affected - Few The attending physician and facility staff will identify acute psychiatric episodes, and will differentiate them from enduring psychiatric conditions. Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record, consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders: Schizophrenia Schizoaffective Disorder Schizophreniform Disorder Delusional Disorder Mood Disorders (Bipolar, Depression with Psychotic Features, and treatment refractory Major Depression) Psychosis in the absence of Dementia Medical Illnesses with psychotic Symptoms and/or treatment-related psychosis or mania (e.g. high dose steroids) Tourette's Disorder Huntington's Disease, Hiccups Nausea and vomiting associated with cancer or chemotherapy. Diagnoses alone do not warrant the use of anti-psychotic medication. In addition to the above criteria, antipsychotic medications will generally only be considered if the following conditions are also met: The behavioral symptoms present a danger to the resident or others; and --the symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations; delusions, paranoia or grandiosity); or --behavioral interventions have been attempted and included in the plan of care, except in an emergency. For enduring psychiatric conditions, antipsychotic medications will not be used unless behavioral (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146033 If continuation sheet Page 2 of 6 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 146033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elms, The 1212 Madelyn Avenue Macomb, IL 61455 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 symptoms are: Level of Harm - Minimal harm or potential for actual harm not due to a medical condition or problem that can expected to improve or resolve as the underlying condition is treated; and Residents Affected - Few persistent or likely to reoccur without continued treatment; and not sufficiently relieved by non-pharmacological interventions; and not due to environmental stressors that can be addressed to improve the psychotic symptoms or maintain safety; and not due to psychological stressors or anxiety stemming from misunderstanding related to his or her cognitive impairment that can be expected to improve or resolve as the situation is addressed. Antipsychotic medications will not be used if the only symptoms are one or more of the following: Wandering, Poor self care, Restlessness, Impaired Memory, Mild Anxiety, Insomnia, Inattention or indifference to surroundings, Sadness or crying alone that is not related to depression or other psychotic disorders, Fidgeting, Nervousness or Uncooperativeness. 1. On 3/25/24 at 10:20am, R40 was in bed, was social and appropriate. On 3/26/25 at 12:30pm, R40 was in bed sleeping. Current Physician Order Report indicates R40 has diagnoses that include Unspecified Moderate Dementia with Mood Disturbance, Unspecified Dementia with Behavioral Disturbance, Major Recurrent/Moderate Depressive Disorder and Primary Insomnia. Order Report indicates R40 receives Risperdal (antipsychotic) 0.5mg (milligrams) at bedtime related to Major Depressive Disorder (date initiated 12/20/24 and Risperdal 0.25mg daily related to Unspecified Dementia with Behavioral Disturbance. Psychoactive Medication Informed Consent Form, dated 4/18/24, indicates, Psychotropic Medication prescribed: Risperdal (no dosage documented) for Diagnosis of BPSD (Behavioral and Psychological Symptoms of Dementia). Form did not include the type of psychotropic medication (antipsychotic) being ordered. Specific condition(s) being treated include .: was left blank on the form. Psychiatry Note, dated 1/17/25 and 2/27/25, both indicate R40 receives Risperdal for Agitation related to Dementia. Note indicates R40 continues to have occasional episodes of verbal agitation and No symptoms of depression. Note also indicates no symptoms of psychosis or mania observed/reported. and no symptoms of auditory or visual hallucinations. Note, dated 1/17/25, indicates despite occasional episodes of verbal agitation, no specific episodes or behaviors have been charted thus far this month. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146033 If continuation sheet Page 3 of 6 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 146033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elms, The 1212 Madelyn Avenue Macomb, IL 61455 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 Current MAR (Medication Administration Record) indicates to monitor for the following behaviors: Level of Harm - Minimal harm or potential for actual harm Restlessness, agitation, hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusing care. Residents Affected - Few No documented behaviors of any type, by R40, were noted to have occurred March 1 - March 26, 2025. February 2025 MAR indicates R40 had behavior on 2/11/25. MAR does not include a description of the behavior. MAR indicates when a behavior occurs - a progress note should be documented to describe the behavior in detail. Progress Note dated 2/11/25 at 7:34pm indicates Was a behavior observed? Yes. No description of the behavior was included in the note. January 2025 MAR indicates R40 had behavior on 1/19/25 and 1/24/25. MAR does not include a description of the behavior(s). Progress Note, dated 1/19/25 at 1:01pm, indicates, Yes, a behavior was observed. (R40) was cussing at staff because he requested noogies nicotine pouches. He just had some (earlier) and it is not time for him to have more. Current Care Plan indicates R40 takes an anti-psychotic for Dementia with BPSD/Mood/Behaviors/Disturbances (date initiated 4/19/24). Care Plan also indicates R40 uses psychotropic medications related to behavioral or psychological symptoms of Dementia and Risperdal added on 4/18/24 per (physician). Care Plan does not identify target behaviors or justification for use of an antipsychotic medication. On 3/27/25 at 1:35pm, V3, ADON (Assistant Director of Nursing) stated the behaviors listed on the MAR are not specific to R40, and R40 does not exhibit most of those behaviors. V3 stated the care plan should include target behaviors specific to R40. V3 stated the only behaviors she is aware of for R40 are often mimics other residents and can become agitated related to receiving his nicotine pouches-- Never physical. V3 stated the diagnosis should be consistent throughout the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146033 If continuation sheet Page 4 of 6 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 146033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elms, The 1212 Madelyn Avenue Macomb, IL 61455 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 ensure contact precautions were maintained for one resident (R7) with a known MDRO (Multidrug-resistant organism). This failure had the potential to affect all 14 residents (R1, R6, R7, R8, R12, R14, R18, R32, R35, R48, R54, R60, R65 and R66) with assistancebeing provided by the same CNAs (Certified Nursing Assitants), and failed to perform hand hygiene/don gloves according to standards of practice while administering medications for two residents (R64 and R66) of seven residents reviewed for infection control in a total sample of 40. Residents Affected - Some Findings Include: The Facility's undated Isolation-Categories of Transmission-Based Precautions Policy documents, Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. The Facility's Isolation-Categories of Transmission-Base Precautions policy documents, Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Contact precautions are also used in situations when a resident is experiencing wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and suggest an increased potential for extensive environmental contamination and risk of transmission of a pathogen, even before a specific organism has been identified. Staff and visitors wear gloves (clean, non-sterile) when entering the room. While caring for the resident, staff will change gloves after having contact with infective material; gloves are removed, and hand hygiene performed before leaving the room; Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. 1. On 3/25/25 at 9:30 AM, R6 and R7 were roommates. R6 and R7 were sitting side by side in their wheelchairs in the middle of the room speaking to each other. On the door outside of the room there was a sign that said, Enhanced Barrier Precautions. R6's Physician Order Sheet, dated March 2025, documents, Enhanced Barrier Precautions related to wounds. R7's Physician Order Sheet, dated March 2025, documents, Contact Precautions related to ESBL (Extended Spectrum Beta-Lactamase) in the urine. R7's Urinalysis with Culture and Sensitivity, dated 3/17/25, documents ESBL: Positive. R7's Physician Order Sheet, dated March 2025, documents an order dated 3/17/25 for an antibiotic Nitfrofurantoin 100 mg (milligrams) twice daily for ten days for ESBL in the urine. R7's MDS (Minimum Data Set), dated 1/23/25, documents R7 is frequently incontinent of urine. Throughout the day on 3/25/25, CNAs (Certified Nurse Aids) were noted to be walking in and out of R6 and R7's room for various different reasons with no PPE (Personal Protective Equipment) on. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146033 If continuation sheet Page 5 of 6 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 146033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elms, The 1212 Madelyn Avenue Macomb, IL 61455 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 3/25/25 at 11:30 AM, V5 (Registered Nurse) stated she thought R6 was in Enhanced Barrier Precautions for wounds and, I don't believe (R7) has any (precautions in place.) On 3/25/25 at 1:30 PM, V6 (Certified Nurse Aid) stated both R6 and R7 were in Enhanced Barrier Precautions. V6 reported she wears a gown and gloves when giving cares for R6 and R7, but does not wear any PPE upon entering the room. V6 confirmed both R6 and R7 are incontinent of urine. On 3/26/25 at 10:00 AM, V4 (Registered Nurse/Infection Preventionist) stated, It got missed somehow that (R7) had an active infection of ESBL. (R6) and (R7) should not have been put in the same room. Contact Precautions would require (R7) to have her own room. On 3/25/25 at 1:30 PM, V6, CNA, stated the CNAs that are responsible for providing assistance to the room that R6 and R7 occupy would also be responsible for providing assistance throughout the day to the rooms that are occupied by R1, R6, R7, R8, R12, R14, R18, R32, R35, R48, R54, R60, R65 and R66. 2. On 03/26/25, at 8:20 AM, V5/Registered Nurse, without hand sanitizing/donning gloves, reached into R66's medicine cup, removed a pill capsule-Fluoxetine 10 mg/milligrams capsule x's 3 capsules for a total dose of 30 mg, twisted the capsules apart, and emptied the capsule contents in a cup of applesauce; then administered the medication to R66. On 3/26/25, at 8:30 AM, V5 confirmed, I should have worn gloves and probably should have hand sanitized prior to removing/pulling apart the capsules and dumping them into the applesauce. On 3/26/25, at 8:35 AM, V2/Director of Nursing confirmed V5 should have hand sanitized and worn gloves when touching R66's medication capsules and pulling them apart. On 03/27/25, at 8:05 AM, V7/Licensed Practical Nurse-LPN, without hand sanitation/donning gloves, opened an acetaminophen 325 mg bottle, poured 4 tablets into the cap, held two tablets down with her fingers, dumped the other two tablets in R64's medicine cup, and then dumped the two tablets V7 held with her fingers back into the container. On 3/27/25, at 8:30 AM, V7 confirmed V7 should have performed hand sanitation and worn gloves before touching R64's medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146033 If continuation sheet Page 6 of 6