Inspection·June 26, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement fall prevention interventions, complete thorough fall investigations to determine root causes and failed to complete Neurological Assessments post falls for two (R2, R25) residents out of two residents reviewed for accidents in a sample list of 18 residents. Findings include: 1.) R2's undated Face Sheet documents R2's medical diagnoses as Cellulitis of the Right Lower Limb, Chronic Obstructive Pulmonary Disease (COPD), Atrial Fibrillation, Weakness, Repeated Falls and Altered Mental Status. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as severely cognitively impaired. This same MDS documents R2 as requiring moderate assistance for toileting, bed mobility and transferring. R2's Fall Risk assessment dated [DATE] documents R2 as a high risk for falling. R2's Care Plan intervention dated 3/22/24 instructs staff to anticipate and meet the needs of the resident. This same care plan documents R2 should be offered toileting every two hours and as needed. R2's Fall investigation dated 5/31/24 at 6:10 AM documents R2 had an unwitnessed fall from his wheelchair while sitting in his room. This same report documents R2 was observed laying on his Right side with his wheelchair sitting next to him. This same report documents sensor alarms were to be initiated for R2's recliner and wheelchair. This same report does not include the last time staff observed R2. R2's Electronic Medical Record (EMR) documents the last time R2 was toileted or assisted with bed mobility was 5:59 AM 5/30/24. R2's Fall Investigation dated 5/31/24 at 6:40 AM documents R2 was sitting at the nurses station when he leaned forward causing himself to fall out of his wheelchair. This same report documents R2 hit his head due to falling out of wheelchair. This same fall report documents R2's sensor alarm in his wheelchair was not in place. R2's Fall Investigations dated 5/31/24 at 6:10 AM and 5/31/24 at 6:40 AM do not include a root cause of falls. R2's Electronic Medical Record (EMR) documents Neurological Assessments were initiated but not completed for R2's 5/31/24 fall at 6:31 AM nor R2's fall on 5/31/24 at 6:59 AM. R2's Nurse Progress Note dated: -5/31/2024 at 6:31 AM documents (R2) observed on the floor on his Right side and wheelchair nearby (R2). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146049 If continuation sheet Page 2 of 12 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 146049 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Iroquois Resident Home, The 200 Fairman Avenue Watseka, IL 60970 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few -5/31/2024 at 6:59 AM documents (R2) went forward out of wheelchair. (R2) landed on Left side, hit head. (R2) was sent to emergency room (ER). -5/31/24 at 12:11 PM documents (R2) returned from emergency room. No fractures. (R2) has skin tear on top of Right hand from fall. Area is 2 1/2 inches long by 3 1/2 inches wide. Area cleansed and steri stripped. Band aid covering. On 6/26/24 at 11:20 AM V1 Administrator stated R2's two falls on 5/31/24 could have been prevented with closer supervision and implementing fall care plan interventions. V1 Administrator stated We (facility) have a lot of work to do with our fall program. We are going to start with inservicing. On 6/26/24 at 1:15 PM V2 Director of Nurses (DON) stated anytime a resident has an unwitnessed fall the staff should assume there is a possibility of the resident hitting their head and complete Neurological Assessments for three days. V2 DON stated I don't think that is in our fall policy but that is what the standard of care is and that is what our nurses should do. I obviously have some fall training to do with our staff. 2.) R25's undated Face Sheet documents R25's medical diagnoses of history of Right Radius fracture, Cerebral Infarction, Cardiomyopathy and Dementia R25's Minimum Data Set (MDS) dated [DATE] documents R25 as severely cognitively impaired. This same MDS documents R25 is dependent on staff for bathing, dressing, personal hygiene, bed mobility and transfers. R25's Care Plan intervention dated 5/22/24 documents R25 is to use a scoop mattress. This same care plan documents a fall intervention dated 4/16/24 instructing staff to anticipate R25's needs. R25's Fall Risk assessment dated [DATE] documents R25 as a high risk for falling. R25's Fall Investigations dated 6/21/24 at 5:40 AM and 6/21/24 at 11:10 PM do not include a root cause of falls. R2's Nurse Progress Note dated: -6/21/24 at 5:40 AM documents (R25) found on floor. Assisted (R25) with lift (total body mechanical lift) back in bed. Ensure bed in low position and call light in reach. -6/21/2024 at 11:10 PM documents (R25) was found on the floor face down on Left side of bed. Slight scrape on Right knee slightly pink in color. Left knee also pink. Lower Left Rib area pink. (R25) apparently flipped self out of bed. R25's Fall Investigation dated 6/21/24 at 5:40 AM documents R25 had an unwitnessed fall while trying to get out of bed. This same report documents R25 did not have any injuries due to unwitnessed fall. This same fall investigation does not document R25 was laying on a scoop mattress. R25's Fall Investigation dated 6/21/24 at 11:10 PM documents R25 had an unwitnessed fall in his room trying to get out of bed. This same investigation does not document the last time R25 was observed/assisted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146049 If continuation sheet Page 3 of 12 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 146049 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Iroquois Resident Home, The 200 Fairman Avenue Watseka, IL 60970 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 0689 Level of Harm - Minimal harm or potential for actual harm R25's Electronic Medical Record (EMR) does not document any Neurological Assessments completed for R25's 6/21/24 at 5:40 AM fall. This same EMR documents incomplete Neurological Assessments for R25's 6/21/24 11:10 PM fall. This same EMR documents the last time R25 had been observed prior to his 6/21/24 at 5:40 AM fall was 10:00 PM on 6/20/24 and the last time R25 had been observed prior to his 6/21/24 at 11:10 PM fall was 8:03 PM. Residents Affected - Few On 6/26/24 at 11:20 AM V1, Administrator stated R25 fell in his room twice the same day on 6/21/24. V1 stated That is on us. We (facility) should have seen that one coming since (R25) is cognitively impaired and he did not have his fall interventions in place. V1 stated the facility does not really know what happened because the fall investigation was not thorough and there are no root causes determined. V1 Administrator stated when a resident falls and hits their head that resident should be assessed Neurologically for three days total. V1 stated if a resident falls while on Neurological Assessments, then the Neuro's start all over again. V1 Administrator stated We (facility) have a lot of work to do with our fall program. We are going to start with inservicing. On 6/26/24 at 1:15 PM V2 Director of Nurses (DON) stated anytime a resident has an unwitnessed fall the staff should assume there is a possibility of the resident hitting their head and complete Neurological Assessments for three days. V2 DON stated I don't think that is in our fall policy but that is what the standard of care is and that is what our nurses should do. I obviously have some fall training to do with our staff. The facility policy titled 'Fall Prevention Program' reviewed March 2024 documents the facility will identify and implement related care link interventions. The facility will review and discuss potential root cause of fall. The facility policy titled 'Head Injury' reviewed March 2024 documents the facility will complete Neurological Assessments on all residents who have suffered from a head injury. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146049 If continuation sheet Page 4 of 12 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 146049 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Iroquois Resident Home, The 200 Fairman Avenue Watseka, IL 60970 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 Residents Affected - Few 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 failed to position urinary drainage bags in a manner that prevented potential cross contamination for two of two residents (R23, R230) reviewed for catheters on the sample list of 18. Findings include: The facility's Catheter Care Handling policy with a revision date of August of 2022 documents to ensure catheter tubing and drainage bags are kept up off of the floor. 1. On 6/24/24 at 1:25 PM, R23's urinary drainage bag was clipped to the side of a trash can. This drainage bag was not covered and the bottom of the bag was sitting directly on the floor. On 6/26/24 at 11:16 AM, V2 Director of Nursing (DON) stated all urinary drainage bags should be covered and not touching the floor. 2. On 6/24/24 at 2:02 PM, R230 was sitting in a recliner. R230's urinary drainage bag was hooked to the side of the recliner. The urinary drainage bag was not covered and the bottom of the bag was touching the floor. On 6/26/24 at 11:16 AM, V2 DON stated that urinary drainage bags should be below the bladder but not touching the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146049 If continuation sheet Page 5 of 12 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 146049 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Iroquois Resident Home, The 200 Fairman Avenue Watseka, IL 60970 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to assess one (R2) resident for the use of side rails out of one resident reviewed for side rails in a sample list of 18 residents. Findings include: R2's undated Face Sheet documents R2's medical diagnoses as Cellulitis of the Right Lower Limb, Chronic Obstructive Pulmonary Disease (COPD), Atrial Fibrillation, Weakness, Repeated Falls and Altered Mental Status. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as severely cognitively impaired. This same MDS documents R2 as requiring moderate assistance for toileting, bed mobility and transferring. R2's Electronic Medical Record (EMR) does not document a side rail assessment for R2. On 6/25/24 at 2:00 PM R2 was laying in his bed with both siderails in the up position. On 6/26/24 at 10:35 AM V5 Minimum Data Set (MDS) Coordinator stated R2 has never been assessed for siderails. V5 stated (R2) should not have those side rails on his bed. We (facility) are taking them off. The facility policy titled 'Side Rails' revised March 2024 documents all residents who utilize side rails will have a side rail rationale screening completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146049 If continuation sheet Page 6 of 12 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 146049 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Iroquois Resident Home, The 200 Fairman Avenue Watseka, IL 60970 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R230's medical record documents R230 was admitted on [DATE]. R230's physician order dated 6/21/24 documents an order for Citalopram Hydrobromide Tablet 40 milligrams once a day and Trazodone hydrochloride 50 milligrams at bedtime for depression. R230's medical record does not contain a consent for the Citalopram Hydrobromide or the Trazodone. R230's medical record does not contain what symptoms of Depression R230 has or nonpharmacological interventions for R230's symptoms of Depression. R230's medical record does not document that potential side effects of the Citalopram Hydrobromide or Trazodone Hydrochloride are monitored. On 6/26/24 at 11:01 AM, V2 Director of Nursing stated that R230's medical record does not contain consent for his antidepressant medications. V2 stated antidepressants should not be given without a consent. V2 stated there is no documentation that potential side effects of the medication was monitored. V2 stated there is not an assessment documented for the use of R230's antidepressant medications. V2 stated there is no documentation of behaviors/symptom monitoring or the nonpharmacological interventions that could be used for R230. 3.) R232's physician order dated 6/21/24 documents an order for Xanax Oral Tablet 0.5 milligrams as needed every night for anxiety. R232's medical record does not contain an assessment for the use of the Xanax. R232's medical record does not document the symptoms of R232's anxiety or which nonpharmacological interventions should be attempted for R232's anxiety. On 6/26/24 at 11:23 AM, V2 Director of Nursing stated Xanax was ordered on 6/21/24 for R232's anxiety. V2 stated an assessment was not completed for the use of the Xanax. V2 stated R232's medical record does not document the symptoms of R232's anxiety or the nonpharmacological interventions that should be used for R232's symptoms of anxiety. V2 stated there is no monitoring for potential side effects in R232's medical record. Based on interview and record review the facility failed to obtain psychotropic medication consents, assess the need for psychotropic medications, determine symptoms or behaviors warranting use, utilize nonpharmacological interventions, monitor for adverse reactions, establish a psychotropic care plan, and establish parameters for the use of an as needed antianxiety medication for three (R230, 231, 232) of three residents reviewed for psychotropic medications on the sample list of 18. Findings include: The facility's Psychotropic Medication Protocol policy dated 8/31/2022 documents psychotropic/psychoactive medications will not be prescribed without the informed consent of the resident, the resident's guardian, or other authorized representatives, and will be provided with and have signed an Informed Consent for Psychotropic Medications. Information will also be provided with given information regarding the need for, the desired effects and the potential side effects of the medication. Residents will not be given unnecessary medications and shall only be given antipsychotic drugs when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146049 If continuation sheet Page 7 of 12 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 146049 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Iroquois Resident Home, The 200 Fairman Avenue Watseka, IL 60970 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 clinically indicated according to appropriate diagnosis and physician order. The care plan will include alternatives interventions. 1.) R231's physician order summary (POS) dated 6/26/24 documents that R231 was admitted to facility on 6/17/24 from the hospital on hospice care. This POS includes an order for Lorazepam (antianxiety medication) two milligrams per milliliter (ml), give 0.25 ml sublingual every two hours as needed for anxiety. This POS also includes an order for Chlorpromazine Hydrochloride (antipsychotic medication) 0.25 ml by mouth every one hour as needed for restlessness. This POS does not document parameters for the use of the as needed Lorazepam. On 6/26/24 at 9:50 AM, R231 stated she takes a lot of medications but doesn't know what they are and what they are for because no one has talked to her about her medications. R231 stated she was unaware that there are medications available to her if she has pain, feels anxious, and/or is short of breath. R231 stated she doesn't really have any pain but she does feel anxious sometimes and also short of breath which increases her anxiety. On 6/26/24 at 10:15 AM, V2 Director of Nursing stated R231 is alert and oriented and can make needs known. V2 stated that she is aware that R231 is on psychotropic medications but that either hospice or V5 Care Plan Coordinator does the psychotropic assessments and consents. On 6/26/24 at 10:20 AM, V5 stated that she does not complete the psychotropic assessments and that nursing and social services touch on that and that any assessments and consents would be uploaded into the miscellaneous files on R231's chart. On 6/26/24 at 10:50 AM, V6 Social Service Coordinator stated the only assessments she completes with the residents is the new admission packet which does not include any consents for psychotropic medications. R231's medical record did not contain an assessment for the use of the Lorazepam or the Chlorpromazine Hydrochloride. The medical record did not identify what symptoms R231 was experiencing for the use of the Lorazepam or Chlorpromazine. This medical record did not contain what nonpharmacological interventions should be attempted. R231's Care Plan Record dated 6/26/24 does not include a care plan for psychotropic medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146049 If continuation sheet Page 8 of 12 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 146049 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Iroquois Resident Home, The 200 Fairman Avenue Watseka, IL 60970 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 three residents (R23, R25, R230) out of four residents reviewed for Infection Control in a sample list of 18 residents. Residents Affected - Few Findings include: 1. R25's Physician Order Sheet (POS) dated June 2024 documents a physician order starting 4/17/24 for Jevity 1.5 calorie/Fiber liquid. Give 355 milliliters (ml) via Gastrostomy tube (G-Tube) every shift for nutritional supplement. Flush with 50 milliliter (ml) water before and after each feeding. On 6/24/24 at 10:30 AM R25's Electronic Medical Record (EMR) documents R25 has a Gastrostomy tube (G-tube) in use. R25's room was not identified with an Enhanced Barrier Precaution sign. There was no Personal Protective Equipment (PPE) available to enter R25's room. No isolation disposal bins were located in or near R25's room. On 6/25/24 at 2:45 PM V9 Licensed Practical Nurse (LPN) completed R25's Gastrostomy tube (G-tube) dressing change. V9 LPN did not wear Personal Protective Equipment (PPE) gown during R25's G-tube dressing change. 2.) R230's Electronic Medical Record (EMR) documents R230 has a urinary catheter drainage system. On 6/24/24 at 10:40 AM R230's room was not identified with an Enhanced Barrier Precaution (EBP) sign. There was no Personal Protective Equipment (PPE) available to enter R230's room. No isolation disposal bins were located in or near R230's room. 3.) R23's Electronic Medical Record (EMR) documents R23 has a urinary catheter drainage system. On 6/24/24 at 11:00 AM R23's room was not identified with an Enhanced Barrier Precaution (EBP) sign. There were no Personal Protective Equipment (PPE) available to enter R23's room. No isolation disposal bins were located in or near R23's room. On 6/25/24 at 1:00 PM V2 Director of Nurses (DON) stated the facility has not implemented Enhanced Barrier Precautions (EBP). V2 DON stated R23 and R230 have urinary catheter drainage system and R25 has a Gastrostomy tube (G-tube) that would all require EBP. V2 DON stated if EBP were to be implemented for all residents with a history of Multi Drug Resistant Organism (MDRO) 'all of the residents would need to be placed on EBP.' V2 DON stated the facility does not have a policy for EBP. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146049 If continuation sheet Page 9 of 12 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 146049 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Iroquois Resident Home, The 200 Fairman Avenue Watseka, IL 60970 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 0881 Implement a program that monitors antibiotic use. 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 follow their Antibiotic Stewardship Protocol by administering a prophylactic antibiotic for one of four residents (R10) reviewed for Infection Control in a sample list of 18 residents. Residents Affected - Few Findings include: R10's undated Face Sheet documents R10's medical diagnoses as: Alzheimer's Disease, Dementia and a personal history of Urinary Tract Infections (UTI). R10's Minimum Data Set (MDS) dated [DATE] documents R10 as severely cognitively impaired. R10's Physician Order Sheet (POS) dated June 2024 document a physician order starting 12/24/23 for Cephalexin 250 milligrams (mg) daily for recurrent Urinary Tract Infections (UTI). R10's Medication Administration Record (MAR) dated June 2024 documents R10 was administered Cephalexin 250 mg daily for the month of June, 2024. The facility antibiotic tracking log dated January-June 2024 documents R10 was on Cephalexin 250 mg daily prophylactically for a history of UTI's. On 6/25/24 at 1:30 PM V2 Director of Nurses (DON) stated R10 has been on an antibiotic for a history of frequent Urinary Tract Infections (UTI). V2 DON stated Normally the Infection Preventionist (IP) would catch that and make sure the documentation is complete but we (facility) don't have an IP so that got missed. V2's Family insisted that we (facility) put (R10) on the antibiotic long term. I don't think it has helped though because (R10) had a UTI a few months ago when she was already on the prophylactic antibiotic. The facility policy dated November 28, 2017 titled 'Antibiotic Stewardship Program' documents review of laboratory reports for susceptibility and the need to change the current antibiotic will be used. Antibiotic stewardship requires the right antibiotic for the right indication at the right dose and the right duration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146049 If continuation sheet Page 10 of 12 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 146049 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Iroquois Resident Home, The 200 Fairman Avenue Watseka, IL 60970 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 0882 Level of Harm - Minimal harm or potential for actual harm Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on observation, interview and record review the facility failed to employ an Infection Preventionist. This failure has the potential to affect all 27 residents residing in facility. Residents Affected - Many Findings include: The facility Daily Midnight Census dated 6/24/24 documents 27 residents residing in the facility. Observations were made during Annual Licensure and Certification survey from 6/24/24/-6/26/26 with no Infection Preventionist onsite. On 6/25/24 at 12:45 PM V2 Director of Nurses (DON) stated the facility does not currently have an Infection Preventionist (IP). V2 DON stated the previous IP left the facility a month ago. V2 stated V2 is planning on signing up for the IP class but has not yet. On 6/26/24 at 9:05 AM V1 Administrator confirmed the facility does not currently have an Infection Preventionist. V1 Administrator stated I know we (facility) are small but having an IP would be a great benefit. We (facility) do have residents who are prescribed antibiotics, who are on contact isolation and staff who need education and monitoring for proper Personal Protective Equipment (PPE). The 'Facility Assessment' revised January 2024 documents the facility will include an Infection Preventionist (IP) as a staff member to provide support and care for residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146049 If continuation sheet Page 11 of 12 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 146049 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Iroquois Resident Home, The 200 Fairman Avenue Watseka, IL 60970 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 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure bed rails were safely attached to a bed for one of one resident (R2) reviewed for side rails in a sample list of 18 residents. Findings include: R2's undated Face Sheet documents R2's medical diagnoses as Cellulitis of the Right Lower Limb, Chronic Obstructive Pulmonary Disease (COPD), Atrial Fibrillation, Weakness, Repeated Falls and Altered Mental Status. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as severely cognitively impaired. This same MDS documents R2 as requiring moderate assistance for toileting, bed mobility and transferring. R2's Physician Order Sheet (POS) dated June 2024 documents a physician order starting 3/15/24 for bed rails for bed mobility and positioning. R2's Fall Risk assessment dated [DATE] documents R2 as a high risk for falling. On 6/24/24 at 9:35 AM R2 was laying in bed with both legs hanging off of mattress from knees to feet. R2's quarter bed rail on the same side of bed was hanging at a 45 degree angle. On 6/24/24 at 9:36 AM V4 Certified Nurse Aide (CNA) and V3 Licensed Practical Nurse (LPN) both confirmed R2's bed rail was not in place. V4 CNA stated This siderail wiggles back and forth and is not safe for (R2). V3 LPN stated That should have been on a maintenance order and been fixed by now. On 6/26/24 at 10:35 AM V5 Minimum Data Set (MDS) Coordinator stated R2's siderails could be a trip hazard for him causing him to fall. On 6/26/24 at 11:10 AM V7 Maintenance Director stated R2's side rails were not safe for R2 and should be removed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146049 If continuation sheet Page 12 of 12