Inspection·December 17, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm hearing distance, regardless of an individuals' age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146037 If continuation sheet Page 2 of 4 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 146037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Meadows Senior Living 400 West Washington Chrisman, IL 61924 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to prevent cross contamination during wound care of one (R2) residents Right Ankle Arterial wounds out of three residents reviewed for wound care in a sample list of eight residents. Findings include:R2's MDS dated [DATE] documents R2 as severely cognitively impaired. This same MDS documents R2 requires moderate assistance with transfers and supervision with walking up to 50 feet. R2's Care Plan intervention dated 8/21/25 instructs staff to provide treatment to areas as ordered. R2's Physician Order Sheet (POS) dated December 2025 documents a physician order starting 11/26/25 to Clean R2's Right Ankle Arterial wound with wound cleanser, apply barrier ointment to the surrounding wound, apply Vaseline soaked gauze to the open wounds and cover with absorbent pad and gauze wrap daily and as needed. The facility daily staffing sheets show contract nurses were scheduled as R2's nurses from 10/16/25-10/20/25. R2's Hospital Record dated 10/20/25 documents R2 does have localized Right Lower Extremity wrap and when unwrapped the hospital staff noted Erythema and Cellulitic appearance to lower leg. This same record documents there was localized maggots on wound when unwrapped with the appearance that it had not been changed in some time as the gauze was adhered to the skin and difficult to remove with sterile water. Adult Protective [NAME] (APS) was contacted due to maggots found on lower extremity cellulitic wound. On 12/9/25 at 12:25 PM V5 Registered Nurse (RN) stated R2 was seen in the emergency room initially for a resident to resident altercation that occurred at the facility. V5 stated upon completing a skin check on R2 V5 and V6 Nurse Practitioner (NP) found that R2 had an open wound on his ankle. V5 stated there was a dressing on R2's ankle that was very dry and hard to remove due it stuck to R2's skin. V5 stated R2's dressing was not labeled/dated. V5 stated when V5 removed R1's dressing there were multiple maggots crawling on R2's wound and inside of the dressing. V5 RN stated R2's open ankle wound had a large amount of slough and was very red with minimal drainage. V5 RN stated R2 was started on an antibiotic for his ankle wound prior to R2 being sent to a psychiatric facility to address his behaviors. On 12/11/25 at 11:30 AM V10 Licensed Practical Nurse (LPN) completed wound care for R2's Right Lower Extremity Arterial wounds. R2 has three seperate open areas each the size of a baseball. R2's open Arterial wounds were all red with moderate drainage and red periwounds. V10 LPN used the same piece of gauze to cleanse all three of R2's Arterial wounds. V10 LPN wiped R2's Arterial wounds dry by rubbing the same piece of dry gauze over each wound, periwounds and around the dry skin around R2's entire Right Ankle/Foot. R2's prior dressing was not dated/initialed. On 12/11/25 at 12:20 PM V11 Registered Nurse (RN) and V10 Licensed Practical Nurse (LPN) both stated the nurses who work directly for the facility do the dressing changes for R2 as ordered but the contracted nurses do not do the treatments. V11 RN stated she works part time she will change R2's dressing as ordered, then be off work for three to four days and return to see her same dressing on R2's Ankle. V10 LPN stated R2 will allow her to complete his dressing change and also sees her own dressing on R2's ankle two to three days after she has been off and then returns to work. Both V10 LPN and V11 RN stated the facility is aware of this and they are told that V21 Wound LPN will return soon and be able to monitor dressing changes. V21 RN stated she does not want to get the facility ‘in trouble' but believes the residents ‘deserve better care' than what the contracted nurses are providing. V21 RN stated the contracted nurses should be held accountable for signing off treatments as being done when they are not doing them. On 12/17/25 at 11:00 AM V2 Director of Nurses (DON) stated R2 has an Arterial wound on his Right Ankle. V2 DON stated V21 Wound Nurse/LPN is on leave so V2 DON has been overseeing the wound program in V21's absence. V2 DON stated she does not observe the resident wounds/dressings. V2 DON stated the last time Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146037 If continuation sheet Page 3 of 4 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 146037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Meadows Senior Living 400 West Washington Chrisman, IL 61924 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete V2 DON visualized R2's Right Ankle wounds was two weeks prior to R2 being sent to the emergency room. V2 DON stated My nurses are adults and know to do the dressings. I shouldn't have to follow them around. V2 DON stated she reviews the Treatment Administration Record (TAR) to see that the wound treatments are signed off but does not have a system in place to ensure the dressings are being completed and/or the dressings are being dated or monitored. V2 DON stated there is no audit system in place for wound dressings. V2 DON stated the facility utilizes ‘a lot' of contract nurses. V2 DON confirmed R2 was seen by V17 Wound NP on 10/26/25 and from 10/16/25-10/20/25 was assigned all contract nurses. V2 DON confirmed R2's treatment was signed off as being completed on 10/20/25 prior to R2 being sent to the emergency room where he had to have his dressing soaked off due to adherence to his skin. On 12/17/25 at 1:00 PM V1 Administrator stated the facility currently has a Performance Improvement Plan (PIP) for wound care due to problems were identified with treatments not being completed. V1 Administrator stated the contracted nurses are responsible for providing wound care to any resident they are assigned to. V1 Administrator stated any nurse who works in the facility should follow the Physician orders for every resident. V1 Administrator stated the facility will revisit the monitoring of the wound program to ensure all residents are being provided wound care ordered by the physician. On 12/17/25 at 6:00 PM V17 Wound Nurse Practitioner (NP) stated she provides weekly assessments of R2's Right Ankle Arterial wounds at the facility. V17 NP stated the facility staff removes the dressings and has the resident sitting in his recliner with his Right Foot elevated prior to V17 assessing R2's wounds. V17 stated she does not see the previous dressing, but only sees the wound itself. V17 stated after completing R2's wound assessment she then travels to the next resident without seeing what dressing is applied. V17 stated she does not know if the correct dressing is being utilized, does not know if the dressing is dated or if the facility is applying the treatment as ordered and/or monitoring R2's wounds. V17 NP stated she has not seen any maggots in R2's wound and would document any such observation in her progress notes. V17 NP stated she had no concerns of any type of pests contaminating R2's wounds. V17 NP stated she does not believe the facility caused harm to R2. V17 NP stated she has not seen anything directly that would make her the facility was not following the physician orders. Event ID: Facility ID: 146037 If continuation sheet Page 4 of 4