Health inspection·December 19, 2022

F 0600 Level of Harm - Actual harm Residents Affected - Few On 12/14/22 at 9:39 AM, V2, Director of Nursing (DON) stated on 5/31/2022 at 10:45 PM an abuse allegation occurred between R41 and R206, and V2 was notified at 6:30 AM on 6/1/2022 of this abuse allegation. V2 states that V4, Licensed Practical Nurse (LPN) was the employee who witnessed the sexual abuse on 5/31/2022 at 10:45 PM between R41 and R206. V2 states that R206 had multiple sexual behaviors with staff prior to this occurrence and that R206 has had multiple medication changes to decrease this behavior. V2 states she is not aware of what R206 stated to R41. V2 states she did not ask V4 what R206 said to R41. V2 stated that V4 was an agency nurse and no longer works at the facility. The Facility's Abuse, Prevention and Prohibition Policy, revised November 2018, documents the Statement of Intent as Each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family member or legal guardians, friends, or other individuals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146051 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 146051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Barry Healthcare & Sr Living 1313 Pratt Street Barry, IL 62312 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse for 2 of 13 residents (R41 and R206) reviewed for abuse investigations in the sample of 23. Residents Affected - Few Findings include: R41's Progress Note dated 5/31/2022 10:45 PM documents Walked around nurses' station to find male resident fondling res. breast. Male res. redirected and sent to room. Will inform Day shift nurse to inform proper persons. R206's Progress Notes dated 5/31/2022 at 10:45 PM documents Walked around nurses station found res. with his hand inside a female residents shirt fondling her breast, res. redirected and sent to his room. R41's and R206's Resident Abuse Investigation Report, with date of investigation completed as 6/6/22, contains documentation of interview with V4, Licensed Practical Nurse who witnessed R206 fondling R41's breast. The Investigation Report contains no documentation that R206 was interviewed regarding this incident although R206 is cognitively intact and the perpetrator. There are no documentation other residents were interviewed, or other staff were interviewed regarding this incident. On 12/14/22 at 9:39 AM V2, Director of Nursing (DON) states on 5/31/2022 at 10:45 PM there was an abuse situation which occurred between R41 and R206, and she was notified at 6:30 AM on 6/1/2022 of abuse allegation. V2 states that V4 was the employee who witnessed the occurrence on 5/31/2022 at 10:45 PM between R41 and R206, and that V4 was educated on notifying V1 and V2 immediately of abuse allegation. V2 states all employees were re-in serviced on immediate notification of abuse allegations. V2 states that an interview was conducted with R206 by the Social Service director who is no longer employed at the facility, and they do not have documentation of that interview with R206. V2 states she is not aware of what R206 stated to R41. V2 states she did not ask V4 what R206 said to R41. V2 states she does not have any documentation that she spoke to other residents. V2 states she does not have any documentation that she spoke to other staff members working during the occurrence on 5/31/2022. V2 states she does not have any documented interviews with R206 and R41 is not interviewable. Facility abuse prevention and prohibitions policy, Revision date November 2018, page 3 titled investigation documents Every employee will be interviewed who was working on the specific hall/wing the affected resident resides on. If the allegation occurred on a specific shift, all staff for the identified shift only will complete a questionnaire and complete as statement if indicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146051 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 146051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Barry Healthcare & Sr Living 1313 Pratt Street Barry, IL 62312 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 provide pressure ulcer treatments per physician's orders and provide pressure ulcer treatment in a manner to promote healing and prevent contamination for 1 of 1 resident (R22) reviewed for pressure ulcers in the sample of 23. Residents Affected - Few Findings include: R22's admission Profile, print date of 12/19/22, documents, that R22 was admitted on [DATE] and had diagnoses of left and right pressure ulcers of the heels, Peripheral Vascular Disease, Heart Failure and Edema. R22's Physician's Order (PO), dated 11/3/22, documents Wound Care: Cleanse left heel with wound cleanser, apply calcium alginate with Silver to wound bed, cover with dry gauze, wrap with Kling. Change daily, every day shift. R22's PO, dated 11/30/22, documents, Wound Care: Apply betadine paint to right heel. Leave open to air. No outer dressing required. On 12/13/22 at 1:15 PM, V9, Assistant Director of Nurses, stated, Upon (R22's) admission his legs have looked like this. He has no circulation in the left leg at all and the NP is trying to get him to agree to go to the vascular surgeon to see if there is anything that can be done. The open areas on the top of his feet, his shins and the back of his left leg were all caused because he gets large blisters and then they burst. His legs constantly weep because of all the edema. He refuses to put his feet up because he states that it causes him pain. He also has heel pressure ulcers. He was admitted with the one on the right heel and acquired the one on the left while here at the facility. On 12/13/22 at 1:15 PM, V9 provided wound and pressure ulcer care for R22. V9 placed a disposable waterproof bed pad under R22's feet. V9 removed the old dressings from R22's bilateral lower legs and feet. Some of the old bandages needed to be sprayed with wound cleanser to get the bandages wet so tissue wound not be pulled from R22's wounds. The disposable waterproof bed pad became soiled by wound cleanser and debris when R9 removed the old bandages. V9 did not remove the soiled disposable waterproof bed pad after it became contaminated. R22's heels were laying directly on this contaminated cloth. R22's had an unstageable right heel pressure ulcer the approximate size of a half dollar. The wound bed was 30% eschar tissue and a small amount of necrotic tissue. The rest of the wound bed was moist yellow tissue. R22 had an unstageable left heel pressure ulcer the size of quarter. This wound bed had a small amount of necrotic tissue, and the rest of the wound bed was moist and bright red. V9 cleansed the leg wounds and pressure ulcers with a spray wound cleanser. After V9 cleansed R22's heels, R22 placed his feet back onto the soiled disposable waterproof pad. V9 placed calcium alginate with silver on all open areas and on both heel pressure ulcers. V9 wrapped both feet and lower legs with gauze and then cover that with ace bandages. V9 did not paint R22's right heel with Betadine and leave open to air. During this procedure V9 changed gloves 7 times without hand hygiene in between. On 12/15/22 at 10:30 AM, V2, Director of Nurses, stated that a new clean disposable plastic lined cloth should have been put down after R22's heels were cleansed. The policy Pressure Ulcer Injury Prevention, dated4/2018, did not address/document that pressure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146051 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 146051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Barry Healthcare & Sr Living 1313 Pratt Street Barry, IL 62312 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 0686 ulcers should be treated per physician's orders or address staff should maintain a clean environment to prevent cross contamination during pressure ulcer treatment. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146051 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 146051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Barry Healthcare & Sr Living 1313 Pratt Street Barry, IL 62312 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 - Some 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** Based on interview and record review, the facility failed to provide resident centered medical management including monitoring and evaluation of residents' responses to psychotropic medications and failed to limit use of as needed (PRN) psychotropic medications without physician justification to 14 days for 4 of 5 residents (R13, R35, R38, R47) reviewed for psychotropic medications in the sample of 23. Finding include: R47's admission Profile, print date of 12/14/22, documents that R47 was admitted on [DATE] with diagnoses of Alzheimer's Disease with Late Onset, Psychotic Disorder with Delusions, Anxiety, Major Depressive Disorder and Dementia. R47's Care Plan Focus, created on 9/16/21, documents The resident has a behavior problem. The Care Plan Focus does not document what the behaviors R47 specifically displays. The Care Plan Interventions documented Administer antipsychotic mediations as ordered. Monitor/document for side effects and effectiveness. The Intervention, initiated date of 9/16/21, documented Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons, involved and situation. Document behavior and potential causes. R47's Care Plan Focus, with revisions on 6/22/21, documents I have dx of depression. I reported feeling down and having trouble sleeping. The Interventions document Bupropion as ordered. Caregivers to closely observe for increased suicidal thinking and behavior as well as hostility, agitation, and depressed mood and to contact health care provider immediately should these occur. The Interventions continued to Monitor/document/report to MD prn ongoing s/sx (signs/symptoms) of depression, unaltered by antidepressant meds: sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, neg (negative mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/ appetite, fear of being alone or with other, unrealistic fears, attention seeking, concern with body functions, anxiety, constant reassurance. The Care Plan documents Administered medications as ordered, monitor/document for side effects and effectiveness. R47's Order Summary Report, print date of 12/14/22, documents, Escitalopram Oxalate Tablet 10 MG (milligram). Give 1 tablet by mouth one time a day for Depression with start date of 6/23/22. The Report documents Seroquel Tablet 50 MG. Give 100 mg by mouth at bedtime for dementia with psychosis with start date of 5/18/22. The Report documents Wellbutrin XL Tablet Extended Release 24 Hour 300 MG. Give 1 tablet by mouth one time a day related to Anxiety Disorder, Major Depressive Disorder with start date of 10/1/21. The Report documents Xanax Tablet 0.25 mg by mouth every 8 hours as needed for anxiety. Start date of 1/3/22. R47's Medication Administration Record (MAR), dated 12/2022, documents that R47 has been given 8 doses of the as needed Xanax from 12/1 through 12/12/22. R47's Electronic Medical Record does not document how the facility is documenting/monitoring R47's specific resident-centered behaviors to provide justification for the use of the psychotropic medications and their effectiveness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146051 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 146051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Barry Healthcare & Sr Living 1313 Pratt Street Barry, IL 62312 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 On 12/14/22 at 2:25 PM, V2, Director of Nurses (DON), stated, We do not have resident or drug specific behavior tracking. 2. R13's admission Record, print date of 12/14/22, documents that R13 was admitted on [DATE] and has diagnoses of Dementia with other behavioral disturbance, anxiety, Depression and Anxiety. Residents Affected - Some R13's Order Summary Report, dated 12/14/22, documents, Alprazolam Tablet. Give 0.25 mg by mouth in the afternoon for anxiety with start date of 7/13/22. R13's Order Summary Report, dated 12/14/22, documents, Alprazolam Tablet. Give 0.25 mg by mouth in the morning for anxiety with start dated of 7/1/22. R13's Order Summary Report, dated 12/14/22, documents, Alprazolam Tablet. Give 1mg by mouth in the evening related to Unspecified Dementia with behavioral disturbance with start date of 11/22/22. R13's Order Summary Report, dated 12/14/22, documents, Amitriptyline HCL Tablet 50 MG. Give 1 tablet by mouth at bedtime related to Depression with start date of 1/28/22. R13's Order Summary Report, dated 12/14/22, documents, Bupropion HCL ER (XL) Tablet Extended Release 24-hour 300 mg. Give 1 tablet by mouth in the morning related to Depression with start date of 1/29/22. R13's Order Summary Report, dated 12/14/22, documents, Duloxetine HCL Capsule Delayed Release Sprinkle 60 mg with start date of 1/29/22. R13's Order Summary Report, dated 12/14/22, documents, Quetiapine Fumarate Tablet 50 mg. Give 50 mg by mouth two times a day for increased agitation with start date of 7/6/22. R13's Care Plan Focus, initiation date of 2/4/22, documents that R13 has actual/potential for verbally and physically aggressive behavior problem related to dementia with behavior disturbances. The Focus documents R13 has diagnoses of anxiety and depression. The Care Plan focus documents that R13 has been noted to be verbally and physically aggressive with others. R13's Care Plan Intervention, initiated on 11/25/22, document Administer medications as ordered. Monitor/document for side effects and effectiveness.' R13's Care Plan Intervention, initiated on 11/25/22 documents Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, person involved, and situations, document behavior and potential causes. R13's Electronic Medical Record does not document how the facility is documenting/monitoring R13's specific resident-centered behaviors to provide justification for the use of the psychotropic medications and their effectiveness. 3. R35's admission Record, print date of 12/14/22, documents that R35 was admitted on [DATE] with a diagnosis of Major Depressive Disorder. R35's Order Summary Report, dated 12/14/22, documents, Lexapro Tablet 10 MG (milligram) (Escitalopram Oxalate). Give 1 tablet by mouth one time a day related to MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE with start date of 4/2/21. R35's Care Plan Focus, initiated on 10/6/20, documents I have a dx (diagnosis) of depression. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146051 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 146051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Barry Healthcare & Sr Living 1313 Pratt Street Barry, IL 62312 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 - Some Care Plan Intervention, initiated on 10/6/20, documented Care Management Committee will review my medication quarterly and sooner as needed to address effectiveness and possible GDR (gradual dose reduction). R35's Care Plan Intervention, initiated on 10/6/20, documents Administer Lexapro as ordered. Monitor/document for side effects and effectiveness. Black Box Warning. R35's Electronic Medical Record does not document how the facility is documenting/monitoring R35's specific resident-centered behaviors to provide justification for the use of the psychotropic medications and their effectiveness. R38's Face Sheet, undated, documents R38 has a diagnoses of Vascular Dementia, Major Depressive Disorder and Anxiety Disorder. R38's Care Plan, dated 3/30/33, documents R38 has anxiety with an intervention to monitor/document side effects and effectiveness. The care plan goes on to state that R38 has Depression with an intervention to monitor/document as needed any ongoing signs or symptoms of depression: sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, negative mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, constant reassurance. R38's Medication Administration Record (MAR), documents orders for the following: 9/2/22 - Alprazolam 0.5mg at bedtime; 9/2/22 - Alprazolam 0.25mg every 24 hours as needed for anxiety and 8/17/22 - Lexapro 10mg daily for Major Depressive Disorder. R38's MAR has no documentation that the facility is monitoring the side effects, effectiveness or signs or symptoms of depression. R38's Electronic Medical Record does not document how the facility is documenting/monitoring R38's specific resident-centered behaviors to provide justification for the use of the psychotropic medications and their effectiveness. On 12/19/22 at 11:10 AM, V2, Director of Nurses, stated that she was unaware the residents that are on psychotropics need behavior tracking for the medications and their specific behaviors. The Facility's Psychotropic Medication Use Policy, reviewed 2/2021, documents The staff will observe, document, regarding the effectiveness of any interventions, including psychotropic medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146051 If continuation sheet Page 8 of 8