Inspection·November 29, 2023

F 0554 suppressant/topical analgesic ointment) to be administered. Level of Harm - Minimal harm or potential for actual harm R1's medical record does not contain a self-administration of medication assessment for R1. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 11/28/23 at 8:32 am, V2 DON (Director of Nursing) stated residents who can self-administer medications/treatments would have a physician order to do so, plus an assessment completed but we {facility} don't have any residents that self-administer at this time. V2 also stated if a (Brand name for cough suppressant/topical analgesic ointment) is being used, there should be an order for it. Event ID: Facility ID: 146095 If continuation sheet Page 2 of 18 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 146095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evenglow Lodge 215 East Washington 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on interview and record review, the facility failed to notify the physician and resident representative with a change in condition for one of two residents (R4) reviewed for skin alterations on the sample list of 25. Findings Include: R4's Progress Notes dated 11/15/23 by V7 (Wound Nurse) document, noted resolving blood blister {on} right foot second toe/chronic gout toe. Area is dry and intact--will use skin prep Q (every) shift x (for) 2 weeks as preventative. R4's Progress Notes from 11/15/23 - 11/27/23 do not document that R4's physician or representative were notified of R4's skin alteration. On 11/29/23 at 10:10 AM, V7 (Wound Nurse) stated the Physician or Nurse Practitioner, and the resident family are normally notified of changes in condition and that is documented in the Progress Notes but V7 did not notify them of R4's blister. Instead, V7 just initiated a standing order for skin prep due to the blister already resolving. The facility's Notification for Change in a Resident's Condition Policy dated 7/28/17 documents the attending physician and the responsible party will be notified promptly of any change in the resident's condition. A change in condition may include but is not limited to a need to alter the resident's treatment. The facility's undated Wound Care Policy documents when a wound is identified, notify the resident's responsible party and physician and document that notification was made. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146095 If continuation sheet Page 3 of 18 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 146095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evenglow Lodge 215 East Washington 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to ensure a level II PASARR (Preadmission Screening & Resident Review) was completed for one (R23) of one residents reviewed for PASARR screenings in the sample list of 25. Residents Affected - Few Findings include: R23's undated Diagnoses List documents Unspecified Psychosis as of 11/1/21. R23's Interagency Certification of Screening Results dated 10/1/21 documents R23 admitted to the facility and was assessed on 10/1/21, R23 has formal diagnoses of mental illness including Chronic Depression and Panic Disorder, and a Level II Screening was not warranted or completed due to R23 being admitted for planned short term stay. There is no documentation that a Level II Screening was completed after R23 did not discharge home after R23 admitted to the facility. On 11/27/23 at 2:05 PM, V3 Social Services Director stated R23 admitted to the facility in October 2021. V3 confirmed R23's Mental Illness Diagnoses including psychosis and that R23 is a long term resident who has not discharged home after R23's admission. V3 confirmed a Level II PASARR was not completed and V3 will need to schedule the screening to be completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146095 If continuation sheet Page 4 of 18 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 146095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evenglow Lodge 215 East Washington 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on interview and record review the facility failed to update a care plan to include interventions to prevent reoccurring Urinary Tract Infections (UTIs) and address an active infection for one (R16) of one resident reviewed for UTIs in the sample list of 25. Findings include: R16's Physician Order dated 11/22/23 documents to administer Keflex (antibiotic) 500 milligrams (mg) by mouth twice daily for 10 days for UTI. R16's Nursing Note dated 11/22/23 at 1:29 PM documents R16 had hematuria (blood-tinged urine) and abdominal discomfort. Keflex was initiated as ordered. R16's Care Plan revised 11/20/23 documents R16 has a history of frequent UTIs but does not include interventions to prevent UTIs or address R16's antibiotics for UTI treatment initiated on 11/22/23. On 11/28/23 at 12:52 PM, V8 (Minimum Data Set (MDS) Coordinator) stated V8 does not update the care plans for active infections and antibiotic use, unless it is within 30 days of the MDS completion date. V8 stated we encourage fluids as an intervention to prevent R16's reoccurring UTIs. V8 confirmed R16's care plan does not document interventions to address R16's frequent UTIs. The facility's Comprehensive Individualized Care Plan dated 11/20/17 documents: The objective is to use assessment data including but not limited to the MDS, resident interview, resident family/representative/legal guardian interview, staff interview, to develop a course of action that moves a resident towards a specific measurable goals utilizing individual resident strengths and interdisciplinary expertise. The care plan is ongoing and will be revised with every change in the resident's care. The care plan can be revised by any staff member with knowledge of the resident's specific needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146095 If continuation sheet Page 5 of 18 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 146095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evenglow Lodge 215 East Washington 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Failures at this level required more than one deficient practice statement. Residents Affected - Few A. Based on observation, interview and record review, the facility failed to complete weekly wound assessments, complete a wound treatment as ordered and prevent potential cross contamination of the wound for one of two residents (R4) reviewed for skin alterations/wounds on the sample list of 25. B. Based on interview and record review the facility failed to ensure the hospice plan of care and visit notes were part of a resident's medical record to ensure coordination of care for one (R16) of one resident reviewed for hospice in the sample list of 25. Findings Include: A.) R4's November 2023 POS (Physician Order Sheet) documents the following orders: 11/15/23 - Skin prep to the right second toe every shift for two weeks at the previous gout site which is now a resolving blister. 11/28/23 - Bacitracin Ointment 500 units/gm (gram) - apply to right second toe daily and cover with an adhesive bandage. The facility's Skin Care Record dated 11/15/23 documents Preventative care of monitoring R4's right second toe. The 11/23/23 Skin Care Record documents the same with an added treatment order for skin prep to the area. There is no assessment of the resolving blister or gout site upon observation of it on 11/15/23 (the date the treatment was obtained) that documents the size, specific location, or condition of the surrounding tissue. R4's medical record does not contain any assessments of R4's gouty right second toe or the wound on the right second toe. On 11/28/23 at 1:26 PM, R4 was reclined back in R4's recliner wearing slip on slippers. V9 (Registered Nurse/RN) entered R4's room and removed R4's right slipper to complete the ordered treatment of skin prep to the right second toe. Upon removal of the slipper, R4's toe presented with an open sore approximately 0.5 cm (centimeters) with a white/yellowish colored center located on the knuckle of the right second toe. The peri wound and entire toe was red, and the upper part of the toe was swollen. R4 stated ouch when the nurse cleansed the area with sterile water. After cleansing the toe wound, V9 then applied skin prep to the peri wound and stated, we aren't really treating the wound, just the area around the wound. At this time, V9 stated the toe has been open like this for several weeks but the V7 (Wound Nurse) assesses it weekly on Wednesdays so V9 will make sure V7 looks at it again on 11/29/23 to see if R4's treatment needs to be changed. On 11/29/23 at 8:15 AM, V7 entered R4's room to complete R4's right second toe treatment. R4 had an adhesive bandage in place and V7 stated that is from the new order from yesterday for TAO (Triple Antibiotic Ointment). V7 washed V7's hands, donned gloves and removed the adhesive bandage to reveal the above-described open area. V7 states the open area to the right second toe is gout and has been there for years and explained it flares up, will drain, then heal but that crater was left. V7 then proceeded to cleanse the toe with normal saline, applied TAO to the wound and rubbed it in with V7's gloved finger (the order is for Bacitracin Ointment), then applied an adhesive bandage, all without (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146095 If continuation sheet Page 6 of 18 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 146095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evenglow Lodge 215 East Washington 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few performing hand hygiene or changing gloves after removing the soiled initial adhesive bandage. At this time, V7 also stated V7 has not completed any assessments of the gout/open area, nor has V7 been assessing or documenting the crater that has been on the knuckle for years. On 11/29/23 at 12:11 PM, V2 (Director of Nursing/DON) stated it is not acceptable to apply ointment with your finger and hand hygiene should be completed after removing the soiled dressing prior to moving forward. The facility's undated Wound Care Policy documents the nurse who discovers or is told of the wound will assess the wound and document in the resident's clinical record the location, size, drainage, odor and cause of the wound. The wound will then be assessed weekly and as needed thereafter and the same documentation will be recorded. B.) R16's Physician Order dated 11/20/23 documents new admit to hospice and does not identify which hospice company R16 utilizes. R16's medical record was reviewed and did not include the hospice plan of care or hospice visit notes. On 11/28/23 at 10:25 AM, V9 (RN) stated R16 receives hospice nurse and Certified Nursing Assistant visits once per week. V9 stated usually the facility has a separate chart for the resident to file hospice documentation and visit notes. V9 was unable to locate R16's hospice documentation after V9 reviewed R16's medical record and searched the 2nd floor nurse's station. On 11/28/23 at 11:35 AM, V2 (DON) stated the hospice plan of care and hospice notes should be in the resident's paper chart. V2 reviewed R16's medical record and stated V2 was unable to locate any hospice documentation. At 12:01 PM, V2 provided R16's hospice notes. V2 stated V2 just obtained R16's hospice visits electronically and confirmed they were not part of R16's medical record or located at the nurse's station for staff to access prior to today. On 11/28/23 at 12:52 PM, V8 (Minimum Data Set Coordinator) stated V8 obtains the hospice plan of care and incorporates it into the resident's plan of care. V8 confirmed R16's hospice plan of care and documentation was not obtained until 11/28/23. The Patient Service Agreement between (hospice company) and (facility) dated 10/10/15 documents both hospice and the facility will prepare and maintain record keeping of the hospice patient's medical records in accordance with state and federal law/regulations. This agreement documents hospice will develop a resident's hospice plan of care and provide it to the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146095 If continuation sheet Page 7 of 18 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 146095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evenglow Lodge 215 East Washington 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement physician ordered hand splints and implement restorative nursing services for range of motion and splint application following discharge from therapy services for one (R23) of one resident reviewed for range of motion in the sample list of 25. Findings include: On 11/27/23 at 11:15 AM, R23 was sitting in a wheelchair with R23's arms in a bent position, R23's hands were contracted and there was no washcloth or device in R23's palms. V18 (R23's Spouse) stated R23 has no functional movement of R23's hands. V18 demonstrated R23 required V18 to open R23's hands and R23's fingers and thumbs were stiff and contracted inward. V18 stated R23's left thumb stays in R23's palm and R23 used to use a ball in R23's palms to keep R23's hands open, but now the staff are supposed to use a rolled-up washcloth. V18 stated V11 (Restorative Certified Nursing Assistant/CNA) massages R23's hands and performs range of motion a few times per week. On 11/28/23 at 9:33 AM, R23 did not have a washcloth or device in R23's palms, and R23's hands were contracted. R23's undated Diagnoses List documents contractures of left- and right-hand muscles as of 7/14/22. R23's Minimum Data Set, dated [DATE] documents R23 has short- and long-term memory loss, does not have impaired range of motion to upper extremities, and restorative nursing program of active range of motion for at least 15 minutes was provided daily during the seven-day lookback period. There is no documentation in R23's medical record of restorative nursing programs provided with participation minutes between June 2023 and November 2023. R23's Care Plan updated 8/25/22 documents an intervention to wear bilateral hand splints when awake and as tolerated. R23's care plan does not address R23's arm/hand contractures or that R23 is provided restorative nursing programs. R23's Physician Order Sheets dated 1/19/23 document an order to apply braces to bilateral hands daily at breakfast and remove before lunch. R23's Occupational Therapy (OT) Evaluation & Plan of Treatment dated 6/6/23-7/5/23 documents the following: R23 was referred to therapy due to increased contractures of upper extremities with goals for good positioning of upper extremities while sitting to prevent position that encourages contracture development, device placement in left hand to maintain thumb in neutral position to avoid contracture development, and staff/family to change positioning of upper extremities when sitting to avoid elbow contracture development. R23 has impaired upper extremity function but has active control with inability to follow commands due to dementia. R23 has intrinsic plus type position (fingers contracted in downward position) as the resting state of hands, with the left thumb flexed into the palm. R23's Occupational Therapy Discharge summary dated [DATE] documents staff were educated on proper positioning when sitting in a chair and staff/family are independent in placement of device in left hand and includes recommendations to continue with staff and family education for positioning following discharge from therapy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146095 If continuation sheet Page 8 of 18 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 146095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evenglow Lodge 215 East Washington 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The Restorative Resident Lists for November 2023 includes R23 as participating in bike, passive and active range of motion, but does not document R23's specific restorative nursing programs with goals and interventions including specified exercises/task, repetitions, and minutes of participation. On 11/27/23 at 2:12 PM, V12 (CNA) stated R23 used to use a ball in R23's hands, but it was stopped per R23's family request. V12 stated sometimes a washcloth is placed in R23's palms. V12 confirmed R23 did not have washcloths or devices applied to R23's palms today and this is not done on a routine basis. On 11/27/23 at 2:15 PM, V10 (CNA) stated a washcloth is only placed in R23's palms in the evening after R23's showers. On 11/28/23 at 10:48 AM, V20 (CNA) stated R23 has had hand contractures for at least a year. On 11/28/23 at 12:43 PM, V11 (Restorative CNA) stated R23 participates in restorative programs over the past year that include riding the bike and passive range of motion to arms, elbow, and fingers. V11 stated R23 has limited left shoulder mobility and R23's fingers are starting to curl so gentle flexion is provided. V11 stated some residents have a restorative program form where V11 documents the resident's participation that is filed in the resident's medical record. V11 stated V11 does not have this restorative program form for R23 to document R23's restorative programs and participation. At 12:57 PM, V11 stated V11 does not have any documentation to provide for range of motion programs for R23's upper extremities. On 11/28/23 at 10:50 AM, V19 (Director of Rehabilitation/Certified Occupational Therapy Assistant) stated R23 has been evaluated and treated by therapy two or three times for R23's hand contractures and they continue to develop/progress despite interventions and treatment. V19 stated R23 last received therapy services in June 2023. R23 admitted to the facility with arm/hand contractures, but they were not as bad as they are now. V19 stated a ball was used for R23's hands but R23 sometimes removed the balls. They were stopped/removed due to complaints of pain, and we switched to using a washcloth. V19 stated R23 should still be using washcloths in R23's palms, which is used for both range of motion and skin protection. V19 stated therapy provided range of motion with water and the CNAs should be doing this as part of restorative nursing services. At 11:19 AM, V19 provided and reviewed R23's therapy notes. V19 stated during R23's October 2021 therapy treatments R23 was instructed and provided hand over hand repetitions, and then R23 was able to continue with two to three repetitions on R23's own. V19 stated at that time R23 was able to remove goggles placed on R23 by therapy staff, confirming R23 had some active range of motion functioning to R23's hands. V19 stated R23's hands had a pill rolling type of posture and V19 demonstrated thumb to fingers position. V19 stated therapy was not focusing on the degree of hand/arm contractures until June 2023, because prior to that therapy was focusing on R23's functioning abilities including having R23 picking up items. V19 stated in June 2023, R23 had contractures of elbows, hands, wrists, and shoulders and would sit in a wheelchair with arms in a bent position. V19 stated therapy provides recommendations for restorative programs, and prior to June 2023 therapy recommended restorative programs for hand washing, grooming including holding a hairbrush and toothbrush, and reaching items during meals and utilizing a handled cup during mealtimes with hand over hand movements and cueing. V19 stated R23 was unable to maintain that functioning, and implementing restorative programs would not have prevented R23's contractures. On 11/28/23 at 10:58 AM, V8 (MDS Coordinator) stated V8 completes the MDS section for assessment for range of motion and contractures, and R23 is on restorative nursing programs. On 11/29/23 at 10:15 AM, V8 confirmed there are no formal restorative nursing programs with goals, interventions, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146095 If continuation sheet Page 9 of 18 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 146095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evenglow Lodge 215 East Washington 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete participation minutes to address R23's upper extremity range of motion for R23 between June 2023 and November 2023. V8 stated R23 has been coding restorative services on the MDS based on the CNAs providing routine cares such as dressing, and not based on an actual restorative program. On 11/28/23 at 11:45 AM, V2 (Director of Nursing) stated splint placement should be documented on the Treatment Administration Record and the nurses should be documenting resident refusals as a 9 or a checkmark to confirm application. V2 confirmed R23's active order for daily hand splint application. On 11/29/23 at 10:15 AM, V2 stated therapy communicates verbally to V11 recommendations to implement restorative programs. Event ID: Facility ID: 146095 If continuation sheet Page 10 of 18 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 146095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evenglow Lodge 215 East Washington 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to date oxygen tubing and humidifier bottles. The facility also failed to secure and store portable oxygen cylinders appropriately for one of one resident (R4) reviewed for oxygen on the sample list of 25. Residents Affected - Few Findings Include: R4's November 2023 POS (Physician Order Sheet) documents the following orders: Check R4 after meals to ensure R4's oxygen is in use, change oxygen tubing weekly and check humidification bottle daily. On 11/27/23 at 9:21 AM, R4's oxygen tubing was draped over the top of oxygen concentrator, not covered. There was no label with a date on the tubing or humidifier. On 11/28/23 at 1:21 PM, R4 was reclined back in R4's recliner with R4's oxygen tubing lying next to R4 and the oxygen concentrator on at three liters per minute. At this time, V9 (Registered Nurse/RN) reapplied the oxygen tubing and cannula onto R4. The tubing and humidifier were not dated. V9 stated the tubing and humidifier are to be dated when they are changed. Also at this time, behind R4's room door, there was a portable transportation cart for oxygen cylinders with one cylinder in it and another oxygen cylinder sitting on the floor, outside of the cart and unsecured. V9 stated, oxygen cylinders should be in the cart and secured to prevent them from falling over. The facility's Oxygen Policy and Procedure dated 11/3/14 documents the nasal cannula or mask, extension tubing, the pre-filled humidifier bottle and the baggie are to be changed weekly and as needed. The baggie and the pre-filled humidifier are to be dated. Unused (empty or full) oxygen tanks are to be stored in the oxygen room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146095 If continuation sheet Page 11 of 18 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 146095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evenglow Lodge 215 East Washington 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** Based on observation, interview, and record review the facility failed to monitor and record fluid intake for a physician ordered fluid restriction for one (R5) of one resident reviewed for dialysis in the sample list of 25. Residents Affected - Few Findings include: On 11/27/23 at 9:44 AM, R5 stated R5 receives dialysis on Tuesdays, Thursdays, and Saturdays, and R5 is on a fluid restriction. R5 stated R5's doctor tells R5 that R5 does not drink enough water. There was a water pitcher on R5's overbed table. On 11/28/23 at 9:39 AM, there was a water pitcher filled with water on R5's overbed table. On 11/29/23 at 12:17 PM, R5 was eating in the dining room. R5's meal included a disposable container of ice cream, a glass of water, and a glass of iced tea. R5's Minimum Data Set (MDS) dated [DATE] documents R5 as cognitively intact. R5's November 2023 Physician Orders document R5 has orders for a 1500 milliliter (ml) daily fluid restriction and routine dialysis. R5's Care Plan dated 9/12/23 documents R5 has Chronic Kidney Disease Stage Four and receives dialysis three times weekly and includes an intervention to provide regular No Added Salt diet with renal precautions and 1500 ml fluid restriction. There is no documentation in R5's medical record that R5's total daily fluid consumption is recorded or monitored. On 11/28/23 09:22 AM, V12 (Certified Nursing Assistant) stated fluid intakes are recorded by the CNAs as part of their electronic charting. On 11/28/23 at 9:27 AM, V9 (Registered Nurse) stated R5 receives dialysis three times weekly and R5 is on a 1500 ml daily fluid restriction. V9 stated fluid intake is not recorded, dietary just gives the assigned amount that dietary has written down. V9 entered the kitchenette and referenced the sign on the cabinet. The sign documents at breakfast give R5 150 ml coffee, 150 ml juice, and 100 ml water. At lunch give R5 150 ml water, 150 ml juice and 100 ice cream. At dinner give R5 ice cream 100 ml, iced tea 100 ml, and juice 100 ml. This sign notes that R5 is allowed to have 100 ml between meals. V9 stated the 100 ml between meals is the amount nursing gives. On 11/29/23 at 12:20 PM, V8 (MDS Coordinator) stated residents on dialysis with fluid restrictions do not have fluid intakes recorded since dietary is responsible for giving the allotted fluid amounts. V8 stated nursing is supposed to give medications with drinks served during meal times. V8 stated R5 should not have a water pitcher in R5's room, and confirmed the water pitcher amounts are not included in R5's designated fluid amounts. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146095 If continuation sheet Page 12 of 18 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 146095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evenglow Lodge 215 East Washington 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 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** Based on observation, interview, and record review the facility failed to document behaviors and implement nonpharmacological interventions prior to administering psychotropic medications, failed to document clinical rational to extend an order for PRN (as needed) antianxiety medication, and failed to ensure appropriate justification for use of an antipsychotic for one (R12) of five residents reviewed for unnecessary medications in the sample list of 25. Findings include: On 11/29/23 at 9:18 AM, 9:30 AM and 10:40 AM R12 was asleep sitting in a recliner near the 2nd floor nurse's station. R12's undated Diagnoses List documents R12's diagnoses include Dementia without behavioral disturbances (5/5/16), unspecified psychosis (7/26/23), major depression, and anxiety disorder. R12's November 2023 Physician Order Summary documents orders for Celexa (antidepressant) 20 milligrams (mg) by mouth daily related to Anxiety Disorder, Lorazepam (antianxiety) 0.5 mg by mouth as needed twice daily for 120 days beginning 9/15/23, and Seroquel (antipsychotic) 25 mg by mouth twice daily for unspecified psychosis initiated on 10/30/23. R12's Physician Order with start date 7/26/23 and stop date 7/28/23 documents Seroquel 25 mg twice daily. R12's Physician Order with start date of 7/28/23 and stop date of 10/30/23 documents Seroquel 25 mg once daily. R12's active Electronic Profile documents special instructions- Medication: Lorazepam, Seroquel---DX (Diagnoses): Anxiety, Atypical Psychosis--- Target Behaviors: Restlessness, Bewildered, Whole Body Shaking, Unsteady of feet, SX (signs/symptoms) of Panic (wide eye, pale, reaching to staff), Freq (frequent) Need of Reassurance---Non-pharmacological Interventions: 1-1 (one to one) activities, walk with someone, family visits, hugging dolls in room, watching TV, lights on in room, offer drinks/food, check urostomy bag. R12's Minimum Data Set (MDS) dated [DATE] documents R12 has severe cognitive impairment and did not exhibit behaviors during the 7 days look back period. R12's Care Plan revised 10/30/23 documents R12 receives psychotropic medications and Seroquel was increased on 10/30/23 due to increased behaviors. R12's Social Services Note dated 10/20/2023 at 12:32 PM documents V3 (Social Services Director) attended the weekly behavior meeting and R12's medications were reviewed. R12 continues to have periods of anxiety and tearfulness and the PRN Lorazepam does not appear to be effective. R12's nonpharmacological interventions that work occasionally include group activities, one to one with staff, family visits, and coloring. The pharmacist recommended to increase Seroquel to 50 mg. R12's Nursing Note dated 10/23/2023 at 2:54 PM documents the pharmacy recommended to increase R12's Seroquel dosage and R12's family declined the recommendation at that time due to prior side effects of lethargy, inability to walk, inability to wake for meals when R12 was on this dose in July 2023. R12's Nursing Note dated 10/30/2023 at 2:01 PM documents R12's family agreed to the order to increase Seroquel to twice daily. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146095 If continuation sheet Page 13 of 18 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 146095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evenglow Lodge 215 East Washington 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R12's Behavior Tracking dated 7/1/23-11/29/23 documents the following R12's behaviors include repetitive movements, crying, and yelling/screaming, but does not document nonpharmacological interventions attempted in response to these behaviors. R12's Nursing Notes dated 7/1/23-11/29/23 do not consistently document R12's behaviors and nonpharmacological interventions that were attempted and unsuccessful prior to the administration of PRN Lorazepam. R12's Nursing Notes document the following: Lorazepam was administered 11 times between 7/1/23 and 7/24/23. R12's Progress Notes document Lorazepam was ineffective on 7/10/23 at 3:35 AM and 7/24/23 at 12:20 PM, and the remaining administrations are documented as effective. Lorazepam was administered with effective results five times during September. Lorazepam was administered 11 times in October, and 10 of those times are listed as effective results. Lorazepam was administered four times in November for anxiety/crying/calling out, and without documentation of nonpharmacological interventions that were used and unsuccessful prior to administering Lorazepam. R12's Consultant Pharmacist Communication to Physician dated 5/30/23 documents a stop date and rational is needed for R12's PRN Lorazepam Order. This form is signed by V5 Nurse Practitioner and documents an order for Lorazepam 0.5 mg by mouth every 4 hours as needed for 120 days but does not document the clinical rationale to extend this order past the 14-day time frame. On 11/29/23 at 9:12 AM V10 (Certified Nursing Assistant) stated R12 gets anxious when sitting and gets real shaky and this happens at various times of the day, but mostly in the evening. V10 stated sometimes R12 asks to go home, and staff tell R12 that R12 lives in the facility now and that the staff take care of R12, which helps R12 relax. V10 stated R12 has no other behaviors and staff walk with R12 which seems to calm R12. V10 stated sometimes the nurses must give R12's medication to calm R12. On 11/29/23 at 10:08 AM V2 (Director of Nursing) stated the nurses should document in a nursing note the behaviors and the nonpharmacological interventions that were attempted and failed prior to giving Lorazepam. V2 stated when PRN psychotropic medication orders are extended past the 14-day time frame we usually just update the order. On 11/29/23 at 10:15 AM V8 (MDS Coordinator) confirmed R12's Seroquel was started in August 2023 and R12's behaviors are a fear of being lost, calling out for R12's mom, gets shaky, has no safety awareness, seeks out staff, and gets up on R12's own. V8 stated R12 has unspecified psychosis diagnosis to warrant the use of Seroquel, and R12 did not admit to the facility with that diagnosis. V10 confirmed this diagnosis was added when Seroquel was ordered. V10 stated the nonpharmacological interventions that were attempted prior to starting Seroquel are listed at the top of R12's electronic profile, and it would help a lot if R12 could always have someone with R12 but that is not feasible. V10 confirmed the last time R12's Lorazepam was scheduled to give routinely was in May 2023. V10 stated R12's Seroquel was increased in October due to R12 having increased fear and crying and the Lorazepam was ineffective. V10 stated the facility has not had the physician/practitioner document a clinical rational when ordering PRN Lorazepam past the 14-day time frame. At 11:27 AM V10 stated R12's behavior tracking logs do not document nonpharmacological interventions used in response to R12's listed behaviors. The facility's undated Psychoactive Medication Use policy documents: Before considering the use of an anti-psychotic medication, staff will first determine whether there is an underlying medical, physical, functional, psychosocial, emotional, psychiatric, or environmental cause of the behavior(s). Documentation should include the reason the medication was given, any nonpharmacological interventions that were tried and ineffective, and the outcome after giving the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146095 If continuation sheet Page 14 of 18 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 146095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evenglow Lodge 215 East Washington 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to administer medications according to Physician Orders and Manufacture's Recommendations for two of six residents (R11, R34) reviewed for medication administration on the sample list of 25. The facility had two errors out of 33 opportunities for a medication error rate of 6.06%. Residents Affected - Few Findings Include: 1. R11's November 2023 POS (Physician Order Sheet) documents an order for Carafate (Antiulcer) 1 gm (gram) - administer one tablet before meals and at bedtime. On 11/28/23 at 11:45 am, R11 was sitting at the dining room table eating lunch and stopped V17 (Registered Nurse/RN) stating, I (R11) haven't had my Carafate yet and I'm supposed to have it 30 minutes before I eat. R11 explained R11 was served lunch around 11:30 am and has been eating since that time. V17 stated V17 forgot, even though V17 had a reminder alarm set, but would get it for R11. At 11:48 am, V17 administered R11's Carafate. The Carafate Instructions for Use dated April 2004 document Carafate is to be given on an empty stomach. 2. R34's November 2023 POS (Physician Order Sheet) documents morning medications that include Advair Diskus (Corticosteroid) 10-50 mcg (micrograms) - one inhalation BID (twice a day). On 11/29/23 at 7:45 am, V17 (RN) entered R34's room with R34's ordered medication including the Advair. V17 handed the inhaler to R34 and instructed R34 how to activate the inhaler. R34 inhaled the medication then V17 instructed R34 how to close the inhaler, which R34 did. V17 then left R34's room without instructing or ensuring R34 rinsed R34's mouth out after using the inhaler. The Instructions for Use for Advair dated 2008 documents localized infections of Candida Albicans can occur in the mouth and throat due to the use of Advair therefore patients need to be advised to rinse their mouth following inhalation of the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146095 If continuation sheet Page 15 of 18 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 146095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evenglow Lodge 215 East Washington 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to ensure proper food storage by failing to label foods with a date, ensure the walk-in cooler contained a thermometer, and ensure foods were not expired prior to serving. These failures have the potential affect all 32 residents residing in the facility. Findings include: On 11/27/23 from 8:00 AM until 8:18 AM an initial tour of the kitchen was conducted. The walk-in cooler did not contain a thermometer inside the cooler. The temperature gauge on the wall located outside of the cooler next to the door was not functioning and read 0 degrees Fahrenheit (F.) The walk-in cooler contained a plastic container of mixed fruit that was covered with plastic wrap and was not labeled with a date. There were two boxes of prepared coleslaw with use by date of 11/24/23. There was an unopened plastic package of bologna lunchmeat that did not contain a use by or expiration date. Sliced ham was in a zipper locking plastic bag that was not dated. Sliced turkey was in metal roasting pans covered with plastic wrap and undated. There were two boxes of prepared pre-mixed pasta salad. One box was unopened with a use by date of 11/5/23. The other box with use by date of 11/5/23 was opened and contained a handwritten date 11/23/23. V13 (Dietary Manager) entered the walk-in cooler and stated the turkey was from Thanksgiving (11/23/23) and needs to be thrown out. V13 confirmed all foods in the cooler should be labeled with a date and expired items should be discarded and not used. V13 stated there should be a thermometer in the walk-in cooler. V13 searched the walk-in cooler for a thermometer and was unable to locate the thermometer. The facility's Week at a Glance Week 2 Menu documents on Thursday (11/23/23) pasta salad was part of the supper meal. The facility's Resident Listing Report dated 11/27/23 documents 32 residents reside in the facility. The facility's Dietary Services Policy dated as revised June 2008 documents: There is an accurate thermometer in each refrigerator and freezer and in storerooms for perishable foods. Dating and labeling of all foods not in original containers, opened to re-use, and foods dished for service will have a date when opened or dished up. A 3 day in/out policy for these foods is the accepted practice. In some instances, a use by date will be acceptable when written on tag or item. Daily salad bar/dessert items for service must be wrapped and dated by end of shift. Items not dated and labeled will be discarded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146095 If continuation sheet Page 16 of 18 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 146095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evenglow Lodge 215 East Washington 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 record review and interview the facility failed to implement their infection control program by failing to complete infection control logs and by failing to track, trend, and analyze infection data within the facility. This failure has the potential to affect all 32 residents that reside within the facility. Residents Affected - Many Findings include: The Infection Prevention and Control Program dated 5/18/2018 documents it will include a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents. The facility provided their ongoing Infection Control binder that did not contain information on the culture and sensitivity of infections/pathogens, whether the infection was healthcare acquired or community acquired, nor any follow up labs after antibiotic completion. The infection control binder also did not contain a list of infections or tracking/trending data. On 11/29/23 at 1:35 PM, V4 (Infection Preventionist) stated V4 does not have any Culture and Sensitivity reports from any infection in the Infection Binder, nor did V4 have any tracking or trending information available at this time. The facility's Resident Listing Report dated November 27, 2023 documents 32 residents reside at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146095 If continuation sheet Page 17 of 18 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 146095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evenglow Lodge 215 East Washington 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to implement its Antibiotic Stewardship Program for one (R23) of three residents reviewed for antibiotic use in the sample list of 25. Residents Affected - Few Findings include: The facility's Antibiotic Stewardship policy with revised date 5/8/18 documents: It is the policy that this facility's Antibiotic Stewardship Program will promote the appropriate use of antibiotics for quality of care, successful resident outcomes and reduction of potential adverse consequences related to antibiotic use. Antibiotics will be prescribed for the correct indication, dose, and duration to appropriately treat the resident while attempting to reduce the development of antibiotic-resistant organisms or other adverse consequences or outcomes. The facility will monitor antibiotic use to identify appropriate use of antibiotics to improve resident outcomes and reduce antibiotic resistance. In the event that the prescribing physician orders an antibiotic without identification of infection criteria, the physician will be requested to identify rationale for ordered antibiotic. The Medical Director will be contacted for further direction. The Infection Preventionist will track antibiotic use and monitor adherence to evidence-based criteria, including a. Documentation related to antibiotic selection and use b. Tracking antibiotics used to review patterns of use and determination of the impact of the antibiotic stewardship interventions. During the quarterly QAA (Quality Assessment and Assurance) Committee Meeting, The Pharmacist, Medical Director, Infection Preventionist and IDT (Interdisciplinary Team) will analyze the antibiotic use in the facility to collaborate with nursing and clinical leaders for identification of potential QAPI (Quality Assurance Performance Improvement) process action plan related to analysis of the tracking and trending of data for quality outcomes. R23's Physician Order dated 10/2/21 documents Keflex (antibiotic) 500 milligrams (mg) by mouth once daily for chronic Urinary Tract Infections (UTIs). There is no documentation of an assessment for use of this medication or follow up with the physician regarding antibiotic stewardship and rationale for continued use of this medication. The facility's Healthcare-Associated Infection Summary Report by Resident Days dated July 2023-November 2023 does not include R23's antibiotic use. On 11/29/23 at 11:35 AM, V4 (Infection Preventionist) stated V4 reviews orders for antibiotics and completes a checklist form that documents symptoms to ensure appropriate use of antibiotics. V4 stated these forms are reviewed by the Director of Nursing and Medical Director and reviewed during the QA meetings. V4 stated prophylactic antibiotic use is not tracked or logged and there is no form/tool used to assess for the use of prophylactic antibiotics. V4 stated V4 has not followed up with R23's physician regarding the rational for continued use of Keflex as a prophylactic antibiotic for chronic UTIs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146095 If continuation sheet Page 18 of 18