Inspection·April 12, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some when she came back from the bathroom R43 was tipped over backwards with her body in the chair and her head on the floor. V16 said in her opinion the chair should never have reclined back like that. V16 said she has never seen a beautician chair recline all the way back to the floor. V16 said she keeps that chair in the corner in the shop now because she won't use it. V16 said R43 told her she was not hurt that the fall just really scared her. V16 said the chair should only recline to maybe 45 degrees. V16 said she had spoken with maintenance about the chair before but he said the chair was fine. V16 said even after it happened, he looked at it again and said the chair was fine. V16 said the maintenance man at the time said R43 must have pulled the lever but V16 said she does not think R43 would have been able to do that because it would have been difficult to reach the lever while sitting in the chair. On 4/11/24 at 9:12 AM, V1 (Administrator) provided surveyor with his investigation into the incident R43 had in the beauty salon. The investigation included one employee statement. The employee statement provided was a written statement by V1 Administrator (himself) and showed, Investigation concluded that resident or person accidentally pushed lever on chair, resulting in the incident that occurred with [R43]. V1 said this was all he had for the investigation because the investigation was complete by their previous maintenance person and there is no record of the investigation he did. V1 said the chair was not broken. On 4/11/24 at 1:41 PM, V1 (Administrator) entered the Beauty Salon with two surveyors. V1 said they are not using that chair anymore because he does not trust the chair and cannot put residents at risk. V1 said the maintenance guy looked at it and said it is not broken. The surveyor sat in the chair and the back of the chair slowly reclined backwards without pulling the lever. With no one in the chair the surveyor pulled the lever and the backrest of the chair reclined completely backward until the top of the backrest was against the floor. The facility's policy and procedure related to maintenance of facility equipment was requested and not received. 2) R3's electronic face sheet printed on 4/11/24 showed R3 has diagnoses including but not limited to muscle weakness, history of falling, insomnia, dementia with behaviors, and Alzheimer's disease. R3's facility assessment dated [DATE] showed R3 has severe cognitive impairment, use a walker, requires partial assistance to go from sitting to standing, and has a history of falls. R3's fall risk assessment dated [DATE] showed R3 is at risk for falls. R3's care plan dated 3/4/24 showed, I had an actual fall due to poor balance, poor communication/comprehension, and unsteady gait. Falls on 10/3/23, 11/29/23, 1/8/24, 1/16/24, 2/13/24, and 2/26/24. A (non-slip pad) was placed in recliner to aide in non-slipping. R3's nursing progress notes dated 1/9/24 showed, Resident observed sitting on her buttocks in front of her recliner with recliner chair up. Interventions: (non-slip pad) placed in recliner chair to prevent sliding. On 4/9/24 at 10:22AM, R3 was sitting up in her recliner in her room. R3 leaned over in the chair and showed surveyor there was not a non-slip pad underneath of her. On 4/11/24 at 11:42AM, R3's recliner did not have a non-slip pad in the chair to prevent her from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146114 If continuation sheet Page 2 of 17 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 146114 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lena Living Center 1010 South Logan Street Lena, IL 61048 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 sliding out. Level of Harm - Minimal harm or potential for actual harm On 4/10/24 at 9:09AM, V8 (Certified Nursing Assistant) stated R3 should have a non-slip pad in her recliner if that is what her care plan says because it is one of her fall interventions. Residents Affected - Some On 4/11/24 at 11:52AM, V10 (Registered Nurse) stated, (R3) has a history of falls and has had a fall out of her recliner so she should have the (non-slip pad) underneath of her anytime she is in the recliner to prevent falls. (R3) has been ambulating independently so she is able to get herself to her room and sit herself in the recliner. On 4/11/24 at 12:20PM, V2 (Assistant Director of Nursing) stated, If (R3) has an intervention to put a (non-slip pad) in her recliner then that is what staff should be doing for her safety. She has had several falls and has many interventions in place and if we don't follow them then we are putting her at risk for more falls. All residents that have fall interventions ordered and on their care plan should have those interventions in place to prevent further falls from occurring. The facility's policy titled, Fall Management-Evaluation dated 3/3/20 showed, It is the policy of this center to evaluate residents for their fall risk and develop interventions for prevention. 3) R20's electronic face sheet printed on 4/11/24 showed R20 has diagnoses including but not limited to lack of coordination, muscle weakness, dementia with behaviors, and need for assistance with personal cares. R20's facility assessment dated [DATE] showed R20 requires assistance with transfers and utilizes a bed and chair alarm daily. R20's fall risk assessment dated [DATE] showed R20 has had 1-2 falls in the past 3 months and is at risk for falls. R20's physician's orders dated 11/20/23 showed, Ensure bed/chair alarm are in place and functioning at all times. R20's care plan dated 11/25/22 showed, I am at risk for falls related to deconditioning and gait/balance problems. R20's care plan dated 10/16/23 showed, I require a bed/chair alarm related to I have a history of falls with attempted ambulation. Bed/Chair alarm at all times while in chair, wheelchair, and bed. On 4/10/24 at 9:09AM, V8 and V9 (Certified Nursing Assistants) transferred R20 from her wheelchair to her bed. When R20 rose from her wheelchair, there was no alarm underneath of her. After V8 and V9 transferred R20 to her bed, covered her up, and verbalized they were finished with cares and moving onto the next resident, surveyor questioned if R20 required an alarm while she was in bed. V9 then stated, Yes, she is supposed to have an alarm on while she is in the wheelchair and in bed because she has had falls in the past and is a high fall risk. I would have forgotten to put the alarm under her if you hadn't said anything. V9 then obtained R20's bed alarm from the spare bed in her room and placed it underneath of her. V9 stated all residents that are ordered to have alarm should have them in place to alert staff when resident is trying to get up so they can go an provide assistance to them and prevent falls from occurring. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146114 If continuation sheet Page 3 of 17 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 146114 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lena Living Center 1010 South Logan Street Lena, IL 61048 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 - Some 4) R50's electronic face sheet printed on 4/11/24 showed R50 has diagnoses including but not limited to pneumonia, difficulty in walking, unsteadiness on feet, dementia without behaviors, repeated falls, and syncope and collapse. R50's facility assessment dated [DATE] showed R50 has severe cognitive impairment and utilizes a bed and chair alarm daily. (Surveyor interviewed R50 on 4/10/24 and determined that R50 was interviewable based on his ability to recall his name, location, and time of day as well as what he ate at his last meal and why he was in the facility). R50's fall risk assessment dated [DATE] showed R50 has had 1-2 falls within the past 3 months and is at risk for falls. R50's care plan dated 11/9/23 showed, I require a bed/chair alarm related to I have a history of falls with attempted independent transfers and ambulation. Bed/chair alarm at all times while in chair, wheelchair, and bed. On 4/9/24 at 11:45AM, R50 was sitting up in his wheelchair in the dining room with no chair alarm in place. On 4/10/24 at 11:38AM, R50 was wheeling himself to the dining room and had no chair alarm in place on his wheelchair. R50 stated he transferred himself from his bed to his wheelchair. On 4/10/24 at 10:03AM, R50 stated, I am supposed to have the alarm hooked onto the back of my wheelchair when I am up in it but they rarely put it on me. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146114 If continuation sheet Page 4 of 17 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 146114 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lena Living Center 1010 South Logan Street Lena, IL 61048 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 0692 Provide enough food/fluids to maintain a resident's health. 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 reassess for preferences and nutritional needs after a resident was readmitted with a diet change for 1 of 1 resident (R22) reviewed for dietary services. Residents Affected - Few The findings include: R22's face sheet showed he was admitted to the facility on [DATE] (65 days ago) with diagnoses to include dementia without behavioral disturbance, candidal esophagitis, gastro-esophageal reflux disease, atherosclerosis, and a non-pressure chronic ulcer of part of the foot. R22's April 2024 Physician Order Sheet showed, . 4/2/24 Regular diet, Full Liquid texture, thin consistency . Dietary Supplements: House Supplement three times a day, 237 mililiters (1 carton) three times a day . R22's care plan initiated 2/9/24 showed, The resident is on a regular diet . Administer medications as ordered. Monitor/Document for side effects and effectiveness. Provide and serve diet as ordered. No changes were made to R22's care plan after his diet change to a liquid diet. R22's dietary card provided by V5 (Dietary Manger) showed, Diet Order: Full Liquid, *Standard Diet, Fluids thin . Breakfast: 6 fluid ounces chicken broth (x2), 4 fluid ounces fruit juice, 8 fluid ounces of milk 2% . Lunch: 4 fluid ounces of lemonade, 8 fluid ounces of milk 2%, ½ cup of pudding, 4 fluid ounces of tomato juice (soup x 2) . Dinner: 4 fluid ounces lemonade, 8 fluid ounces milk 2%, ½ cup pudding, 4 fluid ounces tomato juice (soup x 2). R22's dietary card showed no dietary supplements being provided. On 4/10/24 at 1:13 PM, R22 was in the resident group meeting with the surveyor. R22 said he is on a liquid diet and can only eat liquids and tomato soup. R22 said he did not know why he is on a liquid diet but knows he has to go see a GI (gastrointestinal doctor). On 4/11/24 at 10:51 AM, V5 (Dietary Manger) said R22 had a choking incident and went out to the hospital. V5 said R22's diet is considered full liquid. V5 said she has not looked into what R22 can eat that would be considered a liquid diet. V5 said R22 he has been asking for certain things and the cooks have it all memorized. V5 said she thinks R22 has been on this new diet for about 2 weeks now and he goes in for another appointment with someone but does not know when. V5 said the appointment is probably in the next couple of weeks. V5 said she has not really spoken with R22 since he returned from the hospital with the new diet order but that she did talk to him when he was originally admitted and he said he was not a fussy eater so he would eat about anything. V5 said R22 has told them he will be on this diet until he gets his whatever done. V5 said the Registered Dietitian will be in the facility on 4/12/24. On 4/11/24 at 10:55 AM, V6 (Cook) said he has offered R22 pudding and yogurt but he has refused it. V6 said for breakfast R22 has chicken broth, for lunch he has tomato soup, and for supper he usually has 2 tomato soups to make sure he gets enough. V6 said last night R22 did ask for pudding too. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146114 If continuation sheet Page 5 of 17 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 146114 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lena Living Center 1010 South Logan Street Lena, IL 61048 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The facility's policy and procedure dated 3/8/2020 showed, Nutritional Intervention . Policy: It is the policy of this center that residents, who have been identified as being at nutritional risk, will be monitored for nutritional status and assessed by a consultant dietitian for individual nutritional needs . The Director of Nursing/designee will notify the Consultant Dietitian within 72 hours after a significant change is identified, a resident is admitted or readmitted with a tube feeding and or unusual/complex diet order, physician ordered consult or any other dietary issue or concern . Event ID: Facility ID: 146114 If continuation sheet Page 6 of 17 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 146114 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lena Living Center 1010 South Logan Street Lena, IL 61048 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain physician's orders for a resident on CPAP (Continuous Positive Airway Pressure) therapy for 1 resident (R410), failed to store nebulizer and CPAP masks in a sanitary manner for 4 residents (R6, R24, R50, R410). These failures apply to 4 of 8 residents reviewed for respiratory care in the sample of 23. Residents Affected - Some The findings include: 1) R410's electronic face sheet printed on 4/11/24 showed R410 has diagnoses including but not limited to pneumonia, history of COVID-19, anxiety disorder, and gastroesophageal reflux disease. On 4/9/24 at 9:58AM, R410 had a CPAP machine on his bedside table with the CPAP mask laying out on top of the table, uncovered. R410 stated his machine came from home and the staff assist him to apply it every night before bed. R410 stated he is unsure of what the settings are supposed to be but thought staff at the facility knew what they were. R410's physician's orders showed no active orders for R410 to utilize a CPAP machine or any CPAP settings. R410's admission nursing assessment dated [DATE] showed no documentation related to R410 utilizing a CPAP machine. R410 had no care plan related to CPAP and the facility assessment had not yet been completed due to R410 being a new admission to the facility. On 4/11/24 at 11:52AM, V10 (Registered Nurse) stated, All residents with respiratory equipment should have the masks or cannulas stored in a plastic bag for infection control and to prevent any bacteria from getting onto the respiratory supplies. (R410) should have orders in his chart for him to utilize his CPAP machine as well as the settings so that when the nurse applies it she can ensure the resident is getting the respiratory assistance he needs. On 4/11/24 at 12:20PM, V2 (Assistant Director of Nursing) stated, All residents that are receiving nebulizer treatments or CPAP therapy should have the masks stored in a plastic bag and ideally placed inside their bedside table to protect the masks from bacteria. This is especially important with residents who have a respiratory infection because we don't want them to get more bacteria inside their body. (R410) should have orders for his CPAP settings so we can ensure he is getting the right treatment. That is a treatment that requires a physician's order just like any other respiratory therapy. The facility's policy titled, Respiratory-BiPAP/CPap dated 2/17/20 showed, It is the policy of this center that Bi-level Positive Airway Pressure (BiPap) and/or Continuous Positive Airway Pressure (CPAP) will be set up by a respiratory therapist with a physician's order. 2) R6's electronic face sheet printed on 4/11/24 showed R6 has diagnoses including but not limited to dementia without behaviors, urinary tract infection, altered mental status, and attention deficit (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146114 If continuation sheet Page 7 of 17 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 146114 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lena Living Center 1010 South Logan Street Lena, IL 61048 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 hyperactivity disorder. Level of Harm - Minimal harm or potential for actual harm R6's physician's orders showed, 4/8/24 cefpodoxime proxetil 200mg twice daily for upper respiratory infection, 4/5/24 azithromycin 250mg one time a day for upper respiratory infection, 500mg on day 1 and 250mg on day 2-5, ipratropium-albuterol 0.5-2.5mg/3ML four times a day for upper respiratory infection . Residents Affected - Some On 4/10/24 at 9:58AM, R6's nebulizer mask was sitting out on her bedside table open to air and not covered. The facility's policy titled, Respiratory Therapy Equipment dated 3/22/20 showed, It is the policy of this center that residents on respiratory therapy will have appropriate treatment. Only trained licensed staff will administered respiratory therapy. Respiratory equipment used to provide therapy will be maintained appropriately .Medication Nebulizers/Continuous Aerosol .8. Store circuit in plastic bag, marked with date and resident's name, between uses. 3) R24's electronic face sheet printed on 4/11/24 showed R24 has diagnoses including but not limited to sepsis, dementia with behaviors, and respiratory syncytial virus (RSV). R24's physician's orders dated 4/1/24 showed, Albuterol sulfate inhalation solution 2.5mg/3ML 0.083% inhale 1 vial 3 times daily for RSV. R24's care plan dated 3/30/24 showed, I have RSV. Maintain droplet precautions, emphasize good handwashing techniques for all direct care staff. On 4/10/24 at 8:06AM, R24's nebulizer mask was laying out on his over the bed table, uncovered and open to air. 4) R50's electronic face sheet printed on 4/11/24 showed R50 has diagnoses including but not limited to pneumonia, difficulty in walking, unsteadiness on feet, dementia without behaviors, repeated falls, and syncope and collapse. R50's physician's orders dated 10/25/23 showed, Ipratropium-albuteraol inhalation solution 0.25-2.5mg/3ML 1 inhalation every 4 hours as needed for cough/wheezing. On 4/9/24 at 9:42AM, R50's nebulizer mask was laying out on his over the bed table, exposed to air and uncovered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146114 If continuation sheet Page 8 of 17 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 146114 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lena Living Center 1010 South Logan Street Lena, IL 61048 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 0712 Ensure that the resident and his/her doctor meet face-to-face at all required visits. 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 ensure a resident was assessed by a physician within the first 30 days after admission for 2 of 2 residents (R22, R9) reviewed for physician visits outside of the sample. Residents Affected - Few The findings include: R22's face sheet showed he was admitted to the facility on [DATE] (65 days ago) with diagnoses to include dementia without behavioral disturbance, atherosclerosis, and a non-pressure chronic ulcer of part of the foot. R22's record showed he was seen by a Nurse Practitioner on 2/15/24, 3/18/24, and 4/1/24. On 4/10/24 at 1:13 PM, R9 and R22 were in the group with the surveyor. R22 said he was upset that the facility does not have a doctor that comes in and sees the residents. R22 said he and R9 have only been seen by a nurse practitioner. R22 said the facility staff told him a nurse practitioner is a doctor. On 4/11/24 at 11:46 AM, V10 RN said the facility has nurse practitioners that come in every week. V10 said R9 and R22's physician does come into the facility maybe every couple of months. V10 said she knows there are certain people who he needs to see. V10 said V17 (Clinical Coordinator) keeps track of and schedules the resident's appointments. On 4/11/24 at 11:50 AM, V17 (Clinical Coordinator) said she created a spreadsheet so I could keep up with the appointments. V17 said she has a spreadsheet for each of the physicians that come in and see residents. V17 said the physician has to see each resident within the first 30 days of admission. V17 said the nurse practitioners that come into the facility for each physician keep track of whether or not they can do the visit with the resident or if the physician needs to be the one. V17 said when a physician comes in to see a resident they fax the facility a copy of their visit notes and those get uploaded into the resident's medical record. On 4/11/24 at 12:04 PM, V17 said she checked with the Nurse Practitioner and verified that both R22 and R9 had not yet been seen by the physician since admission. The facility's policy and procedure dated 3/8/2020 showed, Physician Services; Policy: It is the policy of this center that all residents will have a primary physician upon admission to the center . Procedure: . 10. A physician may not delegate a task when the regulations specify that the physician must perform it personally, or when the delegation is prohibited under State law or by the center's own policies. 11. The DON/Administrator will be responsible to monitor physician visits to assure that the resident is receiving appropriate care and services. 12. Physician visit will be made within the first 30 days after a resident is admitted . 2. R9's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include anxiety, mood disorder, bipolar disorder, hydrocephalus, gastro-esophageal reflux disease without esophagitis, constipation, spinal stenosis, urinary tract infection, and chronic kidney disease. R9's facility assessment dated [DATE] showed she has no cognitive impairment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146114 If continuation sheet Page 9 of 17 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 146114 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lena Living Center 1010 South Logan Street Lena, IL 61048 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 0712 On 4/10/24 at 1:13 PM, R9 said she has not been seen by a physician since her admission to the facility. Level of Harm - Minimal harm or potential for actual harm R9's record showed she was seen by a Nurse Practitioner on 2/15/24 and 3/18/24. There was no evidence found in Residents Affected - Few R9's record of being assessed by a physician since her admission to the facility on 2/8/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146114 If continuation sheet Page 10 of 17 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 146114 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lena Living Center 1010 South Logan Street Lena, IL 61048 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a scheduled medication was available for administration for 1 of 1 resident (R10) reviewed for medications in the sample of 23. The findings include: R10's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include unspecified dementia without behavioral disturbance, pain in right leg, muscle wasting and atrophy, lack of coordination, anxiety disorder, need for assistance with personal care, hypertension, chronic kidney disease, and osteoarthritis. R10's facility assessment dated [DATE] showed she has severe cognitive impairment and is requires moderate to substantial assistance from staff for all cares. R10's care plan initiated 5/23/23 showed, I use anti-anxiety medications related to anxiety disorder . Administer Anti-Anxiety medications as ordered by physician. Monitor for side effects and effectiveness every shift. R10's August 2023 Physician Order Sheet showed and order dated 5/22/23 for Alprazolam 0.25 milligrams to be administered three times per day. R10's 8/24/23 Order Administration Note entered at 1:17 PM showed R10's Alprazolam was not given due to narc (narcotic) box on med cart is not opening and [the convenience supply] is not working. R10's 8/25/23 Order Administration Note entered at 4:18 PM showed R10's Alprazolam was not given due to med unavailable and unable to access [convenience supply]. R10's 8/26/23 Order Administration Note entered at 4:45 AM showed R10's Alprazolam was not given due to being on order. On 8/26/23 at 4:56 PM an order administration note showed Alprazolam not given due to medication not delivered from pharmacy. R10's 8/28/23 Order Administration Note entered at 3:58 PM showed, This RN (Registered Nurse) called [pharmacy] and left voicemail asking about refill for Xanax [Alprazolam] TID (three times daily) and resident has been out of medication since Friday 8/25/23. R10's 8/28/23 Behavior Note entered at 4:04 PM showed, Resident has been attempting to get out of chair, CNA (Certified Nursing Assistant) reported to this RN that she attempted to put resident to bed after lunch and had to get her back up in chair. Resident has been out of Xanax [Alprazolam] since Friday 8/25/23. R10's 8/28/23 Communication with Physician Note entered at 4:14 PM showed notification was made to the Nurse Practitioner of need for continuance of therapy prescription. R10's 8/29/23 Nurses Note entered at 2:35 PM showed, This RN called [pharmacy] and spoke with [pharmacist] asking why the Alprazolam for resident was not received last night because provider was going to send script and resident has been out of medication since last Friday. [Pharmacist] informed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146114 If continuation sheet Page 11 of 17 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 146114 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lena Living Center 1010 South Logan Street Lena, IL 61048 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 0755 this RN that provider needs to send script and pharmacy will send medication . Level of Harm - Minimal harm or potential for actual harm R10's 8/30/23 Progress Note entered at 11:07 AM showed, Notified [Nurse Practitioner] to send prescription for Alprazolam 0.25 mg tab to [pharmacy]. Residents Affected - Few R10's 8/31/23 Order Administration Note entered at 4:28 AM showed R10's Alprazolam was not given due to being on order. R10's August 2023 eMAR (electronic medication administration record) showed her Alprazolam was not administered from 8/25/23 at 12:00 PM through 8/31/23 at 5:00 AM resulting in 18 missed doses. On 4/11/24 at 2:11 PM, V2 ADON (Assistant Director of Nursing) said she would expect the medication to be documented as to why it was missed. If the medication is not available V2 said the nurse should call the pharmacy and get a stat (as soon as possible) delivery. V2 said if the medication is still not received there should be follow up phone calls in order ensure the medication gets sent. V2 said she would also contact the physician to see if there is anything else they can do to get the medication and take care of the resident while they wait for the medication. V2 said if a new prescription is needed they should contact the doctor and follow up as needed. V2 said nursing staff could reach out to administrative nurses for help obtaining the medication as well. V2 said Alprazolam is an anxiety medication, so we obviously would want to control their anxiety and they could experience withdrawals. The facility's policy and procedure dated 2/17/2020 showed, Medication Administration . Policy: It is the policy of this home that medications will be administered and documented as ordered by the physician and in accordance with state regulations. Procedure: . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146114 If continuation sheet Page 12 of 17 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 146114 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lena Living Center 1010 South Logan Street Lena, IL 61048 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to ensure vegetables were not overcooked, leaving them with a soft mushy texture and a bland flavor. This applies to 2 of 2 residents (R1, and R13) reviewed for food preparation in a sample of 23. Residents Affected - Few The findings include: On 04/11/24 at 11:48 AM, This surveyor sampled the mixed vegetables from the kitchen as V6 (Cook) was serving them to the residents. This surveyor found the vegetables too soft and was able to masticate (smash up) using my tongue and the roof of my mouth. The vegetables had a bland taste. On 04/11/24 at 12:44 PM, trays throughout the dining area had most of the vegetable uneaten after the residents left the table. 04/10/24 at 01:04 PM, V6 said, he cooks the mixed vegetables by boiling them for 45 minutes in water, then he removes them from the water a puts them in the oven at 275 degrees Fahrenheit to keep them warm. On 4/11/24 at 1:30 PM, V5 (Dietary Manager) said, we don't put salt in like the recipe says to because a lot of residents are on a low sodium diet. On 4/10/24 at 2:00 PM, R13 said, she does not eat the vegetables because they cook them to the point of being mushy and flavorless. I won't eat them. On 4/09/24 03:39 PM, R1 said, The veggies are cooked until they're mushy. I like my veggies firmer. 04/11/24 at 8:45 AM V3 (Dietitian), said, vegetable should not be boiled until mushy. The 9/12/23 recipe for cooking mixed vegetables shows to add salt, pepper, and margarine. It does not mention how long to cook the vegetables. The menu for Tuesday 4/9/24 shows winter mixed vegetables and for Wednesday 4/10/24 shows California vegetables. R1's care plan shows that R1 should eat 75% of her ordered diet every day. The Intervention shows to modify R1's diet as appropriate according to her food preferences. R13's care plan shows that R1 should eat 75% of her ordered diet every day. The Intervention shows to modify R13's diet as appropriate according to her food preferences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146114 If continuation sheet Page 13 of 17 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 146114 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lena Living Center 1010 South Logan Street Lena, IL 61048 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to ensure the Director of Nursing and Infection Preventionist attended the quarterly Quality Assurance and Performance Improvement (QAPI) meetings. This applies to all residents in the facility. Residents Affected - Many The findings include: The CMS 671 dated 4/11/24 shows 56 residents residing in the facility. On 4/11/24 at 12:55PM, V1 (Administrator) said the facility has a formal QAPI meeting quarterly. V1 said the Medical Director, Administrator, a leader from nursing, and dietary are required to attend the quarterly meetings. V1 said there were a couple meetings the DON had to cover the floor and couldn't attend. V1 did not identify that the Director of Nursing and Infection Preventionist should attend all quarterly meetings. On 4/11/24 at 1:15PM, V2 (Assistant Director of Nursing) said she is the Infection Preventionist. V2 said she has attended the quarterly QAPI meetings, but it's been awhile. She would attend if they were scheduled on the days she was in the building, working. If I attended the meeting, I would sign the sheet. I was off for a while on maternity leave. V2 said she was not sure who attended for nursing. V2 said when she was here full time she was expected to attend. She would look at infections, such as UTI, and CDiff and look for creative ways to educate staff to get them to follow through when not being watched. V2 reviewed the quarterly QAPI Agenda - Attendance sign in sheets for 4/27/23, 8/30/23, 11/27/23, and 3/19/24 and verified her name was not on the sheet. V10 (RN- previous Director of Nursing) said she was the previous Director of Nursing. V10 said she resigned as the DON in March after being the DON for 2 years. V10 said she attended most of the quarterly QAPI meetings. She said she may have missed some if she was working the floor as a nurse, or if she worked the night before. She scheduled the meetings and planned to attend. V10 reviewed the quarterly QAPI Agenda - Attendance sign in sheets for 4/27/23, 8/30/23, 11/27/23, and 3/19/24. V10's signature was only on the 11/27/23 sign in sheet. V10 verified she also attended the 4/27/23. (No DON attended the 8/30/23 or 3/19/24 quarterly meeting.) On 4/11/24 at 3:56PM, V1 reviewed the QAPI Agenda - Attendance sheets for 4/27/23, 8/30/23, 11/27/23, and 3/19/24. V1 verified an Infection Control Preventionist only attended the 8/30/23 and 11/27/23 quarterly meeting. The undated facility Quality Assurance and Performance Improvement (QAPI) policy states: It is the policy of the facility to develop a QAPI plan .to describe how the facility will address clinical care, resident quality of life and residents' choice and is based on the scope and complexity of services defined by the Facility Assessment. 5. The QAPI Committee consists at a minimum of: a. The Director of Nursing b. The Medical Director or his/her designee (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146114 If continuation sheet Page 14 of 17 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 146114 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lena Living Center 1010 South Logan Street Lena, IL 61048 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 0868 c. At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member, or other individual in a leadership role Level of Harm - Minimal harm or potential for actual harm d. The infection preventionist. Residents Affected - Many 6. QAPI meetings will be held monthly but at a minimum of quarterly . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146114 If continuation sheet Page 15 of 17 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 146114 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lena Living Center 1010 South Logan Street Lena, IL 61048 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure the correct personal protective equipment (PPE) was worn while providing care for resident in contact isolation with a multi drug resistant organism (MDRO). This applies to 1 of 8 (R54) residents reviewed for infection control in the sample of 23. Residents Affected - Few The findings include: R54's admission Record showed an original admission date of 3/28/24 with diagnoses to include a MRSA (an MDRO) (onset date 4/6/24), an abscess, and diabetes. R54's 4/10/24 Infection/Viral Charting showed she was ordered two antibiotics for her MRSA infection. R54's Care Plan showed Contact precautions maintained. Date initiated: 4/6/24. On 4/10/24 at 1:06 PM, V15 Registered Nurse performed wound care for R54's abscess to her upper/middle back. The dressing had bloody and yellow discharge on the dressing. The wound had a 2 inch incision from the 7 O'clock to 1 O'clock position. The wound appeared as if it had been a large abscess that had been surgically drained. The skin surrounding the incision was dark maroon/purple in color and was the size of a large orange. The wound had undermining of the boarders and required packing. On 4/10/24 at 11:00 AM, R54's room had signage on her door showing she was in contact isolation and gown and gloves were required. V15 entered R54's room without a gown to check R54's blood sugar. R54 was in bed. V15 then removed her gloves, exited the room, and prepared R54's insulin. V15 then entered R54's room with the insulin syringe. During the insulin administration, V15's scrub pants came in contact with R54's bedding. On 4/10/24 at 3:09 PM, V2 Infection Preventionist/Assistant Director of Nursing stated the PPE required for contact isolation is gown and gloves. V2 stated she believed R54 was in contact isolation for the MRSA infection to the abscess on her back. V2 said gown and gloves are required whenever staff enter a contact isolation room. V2 said nursing staff need to wear gown and gloves when checking blood sugars and administering insulin to residents in contact isolation. V2 said the purpose of PPE is to prevent the spread of infection to staff and to other residents. The facility's Infection Control-Precaution and Notices (Infection control policy, dated 3/3/2020) showed, In addition to Standard Precautions, Contact Precautions must be implemented for residents known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or patient care items in the resident's environment . The National Institutes of Health published study from 2015 titled Transmission of MRSA to Healthcare Personnel Gowns and Gloves during Care of Nursing Home Residents showed, when staff provided care to MRSA positive residents, MRSA was transferred to staff gowns 7 percent of the time during medication pass and 24 percent of the time during linen changes. The Centers for Disease Control website titled Methicillin-Resistant Staphylococcus Aureus (MRSA) (reviewed 1/31/19) showed How is MRSA spread? People who have MRSA germs on their skin or who are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146114 If continuation sheet Page 16 of 17 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 146114 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lena Living Center 1010 South Logan Street Lena, IL 61048 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete infected with MRSA may be able to spread the germ to other people. In addition to being passed to patients directly from unclean hands of healthcare workers or visitors, MRSA can be spread when patients contact contaminated bed linens, bed rails, and medical equipment. The policy continued, How can doctors prevent it? To prevent MRSA infections, healthcare personnel: .use contact precautions when caring for patients with MRSA .Healthcare providers will put on gloves and wear a gown over their clothing while taking care of patients with MRSA . Event ID: Facility ID: 146114 If continuation sheet Page 17 of 17