Inspection·October 12, 2023

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 ensure restorative programs including ROM (range of motion) were being provided regularly for 2 of 5 residents (R6 & R33) reviewed for range of motion in the sample of 14. The findings include: 1. On 10/10/23 at 9:41 AM, R6 was sitting in a custom wheelchair in her room with a mechanical lift sling under her. R6 had a positioning device on the left side of her upper body and a neck pillow in place. R6 stated she doesn't get ROM exercises anymore because there isn't enough staff to do it. R6 stated she used to go to the therapy room and use the hand pulleys to exercise her arms. R6 stated she used to go to the group exercises but that stopped too. R6 stated the programs stopped about a month ago. The Diagnosis Report dated 10/11/23 for R6 showed medical diagnoses including multiple sclerosis, neuromuscular dysfunction of the bladder, type 2 diabetes mellitus, anemia, hyperlipidemia, hematuria, urinary tract infection, and diverticulitis. The MDS (Minimum Data Set) assessment dated [DATE] showed no cognitive impairment; extensive assistance needed for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. The September 2023 Restorative documentation for R6 showed for R6's group exercise program and arm pulley restorative program it was provided on 13 out of 30 days. The October 2023 Restorative documentation from 10/1/23 - 10/11/23 showed for R6's group exercise program and arm pulley restorative program it was provided on once. The Care Plan dated 9/7/23 for R6 showed she has limited physical mobility related to the disease process of multiple sclerosis. Provide gentle range of motion as tolerated with daily care. Restorative - Active ROM Program #1 Group. Restorative - Active ROM Program #2 pulleys. The resident has multiple sclerosis affecting all of her extremities. R6 is chair bound at this time and is dependent on staff for transfers and toileting. R6 is able to self propel her chair, she is able to adjust her position in bed and she remains able to feed herself with adaptive dishware. On 10/11/23 at 11:35 AM, V2 DON (Director of Nursing) stated the CNA's (certified nursing assistant) on the daily ROM programs when they are done. V2 stated she documents the quarterly ROM/Restorative notes. V2 stated restorative programs are only being done a couple of times per week because she is the only person in the therapy room. V2 stated they had 2 restorative CNA's but they had to pull them to the floor so they would have enough staff to provide care. V2 stated it was the one program that she felt they could cut in order to have staff on the floor to provide care. V2 stated she knows the residents miss it. V2 stated she is not able to provide the restorative programs right now. The Restorative Nursing Care policy 5/11/21 showed, nursing personnel are trained in restorative care, and our facility has an active program or restorative nursing care which is developed and coordinated through the resident's care plan. The facility's restorative nursing care program is designed to assist each resident to achieve and maintain an optimal level of self-care and independence. Restorative nursing care is performed daily for those residents who require such services. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146140 If continuation sheet Page 2 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146140 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Galena Stauss Nursing Home 215 Summit Street Galena, IL 61036 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 2) R33's electronic face sheet printed on 10/11/23 showed R33 has diagnoses including but not limited to atrial fibrillation, type 2 diabetes, hyperparathyroidism, hypertension, heart failure, obstructive sleep apnea, anxiety disorder, and spinal stenosis. R33's facility assessment dated [DATE] showed R33 has no cognitive impairment and receives restorative therapy. R33's care plan dated 8/29/23 showed, (R33) has limited physical mobility related to weakness. On 10/11/23 at 9:44AM, R33 stated, Someone is supposed to come in and do exercises with me; however, since the shortage of certified nursing assistants has occurred, the exercises aren't offered on a regular basis, only when they have enough time. I do them on my own as much as I can but I can't lift my legs very well so I need someone to do that part for me. I use a stand lift for all transfers so I would like to keep my leg and arm strength as long as I can so I don't have to use a full lift for transfers. R33's undated restorative program showed R33 is to have Active Range of Motion- Seated Exercises in Room. R33's restorative program task showed R33 only received restorative therapy 8 times within the past 30 days. All other days for R33 were marked as Not Applicable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146140 If continuation sheet Page 3 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146140 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Galena Stauss Nursing Home 215 Summit Street Galena, IL 61036 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** 4. On 10/10/23 at 1:18 PM, R27's CPAP machine, tubing, head strap and face mask was sitting on the tall heat register in his room. The CPAP face mask was not covered. Residents Affected - Some The Physician Orders dated October 2023 for R27 showed, Clean CPAP equipment monthly with soap, water, and sanitizer. CPAP on at bedtime and off in the AM for obstructive sleep apnea. The Care Plan dated 8/16/23 for R27 did not show a plan in place for the use and maintenance of CPAP for his obstructive sleep apnea. On 10/11/23 at 10:01 AM, V2 DON (Director of Nursing) stated the cleanliness of the mask is on the treatment administration record. V2 stated CPAP machines should be on their designated table for CPAP. V2 stated it was not okay to have the CPAP machine on the register. V2 stated they don't cover the masks they just leave them out and not on the floor. V2 stated they don't cover the masks to prevent contamination. The Diagnosis Report dated 10/11/23 for R27 showed diagnoses including alzheimer's disease, sleep apnea, morbid obesity, hypertension, fecal incontinence, weakness, major depressive disorder, atherosclerotic heart disease, and arthritis. The MDS (Minimum Data Set) dated 8/8/23 for R27 showed severe cognitive impairment. The facility's Care of CPAP Machine policy (no date) showed, the objective was to keep CPAP machines free and clear of debris and potential infectious materials. Clean the mask and tubing weekly by using mild soap with warm water. Hang the mask and equipment in a designated and clean area of the resident's room when not in use. Based on observation, interview, and record review, the facility failed to obtain physician's orders for a resident (R8) to utilize a CPAP (Continuous Positive Airway Pressure) machine, failed to obtain physician's orders for 3 resident's (R8,R23,R33) CPAP pressure settings, failed to perform routine respiratory assessments for 3 resident's (R8,R23,R33) who utilize a CPAP machine, failed to store 4 resident's (R8,R23,R27,R33) CPAP machines in a manner to prevent contamination. These failures apply to 4 of 5 resident's reviewed for CPAP therapy in the sample of 14. The findings include: 1) R8's electronic face sheet printed on 10/11/23 showed R8 has diagnose including but not limited to Diagnosis: unspecified cirrhosis of liver, type 2 diabetes, ascites, obstructive sleep apnea, and herpes viral ocular disease. R8's facility assessment dated [DATE] showed R8 has no cognitive impairment and requires the use of a non-invasive mechanical ventilator (CPAP). R8's physician's orders dated 10/11/23 showed, Clean CPAP mask and tubing weekly with soap and water. No physician's orders were present for previous dates for R8's mask and tubing to be cleaned. R8's physician's orders for October 2023 showed no orders present for R8 to utilize a CPAP machine. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146140 If continuation sheet Page 4 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146140 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Galena Stauss Nursing Home 215 Summit Street Galena, IL 61036 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 R8's electronic medical record had no routine respiratory assessments documented. Level of Harm - Minimal harm or potential for actual harm On 10/10/23 at 9:46AM, R8 stated, The facility doesn't do anything with my CPAP machine. I'm the one that handles it and makes sure it's cleaned and set to the right settings. They probably don't even know how often it's supposed to be cleaned or what my settings are. I don't use it all the time but I have been better about wearing it the past few months. (R8's CPAP mask was hanging over the side of R8's bedside table and was uncovered). Residents Affected - Some On 10/12/23 at 9:53AM, V1 (Administrator) stated, We do not have a policy regarding the management of a CPAP machine, only a policy showing how often to clean the machines. We now know this is something we need to work on and ensure that we have a policy and the care for residents with a CPAP machine are completed. (V2-Director of Nursing) advised me that we do not perform routine respiratory assessments on our residents unless we have a concern with them. Having a CPAP does not cause a concern for the nurse's. 2) R23's electronic face sheet printed on 10/12/23 showed R23 has diagnoses including but not limited to atherosclerotic heart disease, hypertension, hyperlipidemia, depression, and gastroesophageal reflux disease. R23's facility assessment dated [DATE] showed R23 has no cognitive impairment and utilizes a CPAP machine. R23's October 2023 physician's orders showed, 10/20/22 CPAP. Keep CPAP machine at bedside to wear at night. (No physician's orders were present showing the ordered pressure for R23's CPAP machine). R23's October 2023 physician's orders showed, 4/21/23 Clean CPAP equipment monthly with soap, water, and sanitizer. 10/11/23 Clean CPAP tubing and mask with soap and water weekly. (The facility's policy showed CPAP equipment is to be cleaned on a weekly basis). On 10/10/23 at 9:51AM, R23 stated, They usually just lay my mask wherever there is room. It's never covered or in a drawer or anything. It doesn't have a designate space, just where it can fit. They don't clean it often but I know it's supposed to be done at least once a week. 3) R33's electronic face sheet printed on 10/11/23 showed R33 has diagnoses including but not limited to atrial fibrillation, type 2 diabetes, hyperparathyroidism, hypertension, heart failure, obstructive sleep apnea, anxiety disorder, and spinal stenosis. R33's facility assessment dated [DATE] showed R33 has not cognitive impairment and requires the use of a CPAP machine. R33's physician's orders dated 4/21/23 showed, Clan C-PAP equipment monthly with soap, water, and sanitizer. R33's care plan dated 8/29/23 showed, (R33) has altered respiratory status/difficulty breathing related positive COVID-19 diagnosis on 3/4/23 . CPAP SETTINGS: full face mask every night at HS On 10/12/23 at 8:45AM, R33 stated, I had a sleep study done a few years ago and that's how my settings were determined. I just got this new machine a few weeks ago and they just use the old settings with oxygen bled in every night. They don't assess my respiratory status unless I ask them to or if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146140 If continuation sheet Page 5 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146140 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Galena Stauss Nursing Home 215 Summit Street Galena, IL 61036 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 there is a concern with my breathing. Level of Harm - Minimal harm or potential for actual harm On 10/12/23 at 10:21AM, V3 (Infection Preventionist-Registered Nurse) stated, The ordered pressure for all CPAP's should be located within the physician's orders. You need to make sure it is put there so that the nurse's know which pressure to check for. It is important to make sure it is set at the correct pressure because that is what prevents the resident from becoming apneic while sleeping. We clean the masks and tubing weekly, at least that's what our protocol is so I hope that's what is happening. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146140 If continuation sheet Page 6 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146140 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Galena Stauss Nursing Home 215 Summit Street Galena, IL 61036 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent a significant medication error for 1 of 1 residents (R36) reviewed for medication errors in the sample of 14. Residents Affected - Few The findings include: R36's electronic face sheet printed on 10/12/23 showed R36 has diagnoses including but not limited to Alzheimer's disease, hypertension, major depressive disorder, hyperlipidemia, type 2 diabetes, anxiety disorder, and mood disorder. R36's facility assessment dated [DATE] showed R36 has severe cognitive impairment. R36's physician's orders showed R36 had Amlodipine 5mg daily ordered on 11/16/22 and was discontinued on 9/30/23. R36's nursing progress notes dated 9/28/23 showed, (R36) was eating her supper meal when suddenly she became warm, clammy, and unresponsive for a short period of time. Blood pressure 70/46 .Staff escorted (R36) to her room and laid her down in bed. Notified primary physician regarding the incident. He diagnosed the incident as postprandial hypotension. He recommended to monitor her this evening. Hold blood pressure medication in the morning . R36's nursing progress notes dated 9/30/23 showed, Primary physician here this morning and discontinued amlodipine. R36's nursing progress notes dated 10/3/23 showed, Situation: Medication error; Amlodipine was discontinued on 9/30/23, however medication was not pulled from October medications and was administered in error on 10/1 and 10/2 .BP results on 10/1/23: 104/62 10/2/23: 162/89. Card was removed from medication cart on 10/3/23. On 10/12/23 at 10:21AM, V3 (Infection Preventionis-Registered Nurse) stated, All medications are given per physician's orders. The nurse's pull up the resident's medication administration records that will show what medications are due, pull the medications out of the drawer, and compare the medications with the medication list. The nurse then administers the medications and confirms in the medication administration record that the resident took the ordered medications. (R36) experienced a hypotensive episode and then was given atenolol after it was discontinued. We were monitoring her blood pressure during that time so I can't say it was a significant medication error. If it was significant then she would have had an adverse outcome but she didn't. She could have, but she didn't. The facility's undated policy titled, Medication Administration/Control of Medications showed, Objectives: 3. To establish safe and accurate nursing procedures for dispensing medications to residents .13. Medication administration records (MARs) for all medications and treatments shall be reviewed at least monthly by a licensed nurse. MARs shall be checked with the previous month's MAR for accuracy, paying particular attention to any changes in orders .22. Each dose administered is properly recorded on the MAR by the person who administered the dose . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146140 If continuation sheet Page 7 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146140 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Galena Stauss Nursing Home 215 Summit Street Galena, IL 61036 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on interview and record review, the facility failed to develop and maintain a facility assessment. This failure has the potential to affect all residents in the facility. The findings include: The Resident Census and Condition Report dated 10/10/23 showed 44 residents residing in the building. On 10/11/23 at 10:46AM, V1 (Administrator) stated, We do not have a facility assessment; I know we are supposed to have one and I am learning how to do it. We are doing research on exactly what we need to be doing so we can ensure we have the correct number of staff and that those staff are trained on any specialized needs our resident's might have. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146140 If continuation sheet Page 8 of 8