Inspection·October 3, 2024

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few tear or breakdown occurs, an assessment shall be completed under symptom assessment in [the electronic charting]; notification of physician and family, along with any treatment order/s and monitor wound in Treatment Book until healed .5. Measurements of the pressure sore/wound shall be assessed at least once a week and documented in [the electronic charting] under Wound Assessment, follow-up . 2. R41's 7/13/24 Skin/Wound Note from 9:00 PM showed, A 2 cm (centimeter) x 2 cm open area showing the dermis (inner layer of skin) of the skin on the right buttock and there is a 1 cm x 1 cm open area showing the dermis of the skin on the left buttock. These areas show no signs of infection. [foam dressing] dressings applied for protection to these areas. Resident and staff instructed to reposition resident at least 2 hours to prevent future skin breakdown. This writer will notify the day nurse on 7-13-24 to notify [the physician] to obtain an order for dressing changes to buttocks and to notify resident's healthcare POA (Power of Attorney) of the information in this note. R41's 8/3/24 Skin/Wound Note from 1:29 PM, showed, .The [foam dressing] is not intact to the bottom of the area .The area is completely healed, inspected his buttocks and could not find an open wound. I did replace the [foam dressing] and placed zinc oxide cream to the rest of the buttocks. R41's electronic health records showed no documented assessments on or before 7/20/24 and 7/27/24. On 10/02/24 at 2:07 PM, V2 Interim Director of Nursing stated wound assessments are important for tracking the progression of wounds. V2 said assessments will allow the nursing staff to identify if current treatments are effective. V2 said nursing staff should have assessed R41's wound on or before 7/20/24 and 7/27/24. V2 stated there were no documented assessments during this time period. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146140 If continuation sheet Page 2 of 13 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 10/03/2024 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to assess a pressure injury, failed to treat a pressure injury, and failed to notify the physician of a pressure injury. This applies to 1 of 2 residents (R10) reviewed for pressure injuries in the sample of 13. Residents Affected - Few The findings include: On 10/02/24 at 10:15 AM, V4 Registered Nurse (RN) removed R10's adult brief exposing an approximately 1-centimeter (cm) round, non-draining, wound to his right, upper, inner buttock. The area surrounding the wound appeared friable and inflamed. V4 provided a wound treatment and covered the wound with a 4-inch foam dressing. R10's 8/6/24 Skin/Wound Note from 6:58 PM showed, New [foam dressing] placed on upper gluteal crease. Dated for today. Area of concern is clean, no drainage, looks to be a stage 2 [pressure injury]. R10's 8/6/24 Skin/Wound Note from 7:02 PM showed, Wound measures: 0.8cm x 0.4cm, depth is approximately 2mm (millimeter). R10's 8/9/24 Skin/Wound Note from 8:49 PM showed, [Foam dressing] changed to upper gluteal crease. One open area remains, 0.5cm in diameter, 0.2cm in depth. R10's next documented skin/wound note assessment with wound measurements showed on 8/20/24 at 1:17 PM, (11 days after 8/9/24 assessment) Assessed [R10's] pressure injury while he was laying on his right side in bed. Pressure injury to the top of the gluteal crease on the right side: Measurements: 4mm long, 3mm wide and 1mm deep. Scant amount of yellowish drainage on the [foam dressing] placed by [Licensed Practical Nurse] today 8/20. Wound bed with granulation tissue at the edges, is filling in nicely. Cleansed with sterile normal saline and placed a new [foam dressing] on; dated and initialed. I thanked [R10] for laying in bed. R10 8/23/24 Skin/wound note from 2:16 PM showed, With the patient lying on his right side in bed, I donned a gown and put gloves on after washing my hands. I undid his brief. The area of concern is on the right upper inner buttock just off the gluteal fold. The area is improved since the last time this writer has seen it. Wound Measurements: 1.0cm long, 0.4cm wide and 0.1cm deep. The edges appear to be macerated and I can see granulation tissue in the small wound bed. I cleansed it with sterile normal saline and placed a new dated/initialed [foam dressing] on the area. I left the resident on his right side and he said he was going to nap. (Documented wound improved despite wound size increasing.) R10's 8/26/24 skin/wound note from 2:14 PM showed, Had to encourage [R10] to lay down in bed on his side to offload from his pressure ulcer. I then was able to perform wound care/assessment. Wound to the right upper inner buttock about 3 centimeters above the anus: Wound now measures 1cm long x 0.4cm wide and about 0.1cm deep. The edges of the wound are macerated, the wound bed is granulation tissue. No drainage, no odor. Area cleansed with sterile normal saline. Then applied a larger [foam dressing] to the buttock and I dated/initialed it. Around this wound is several reddened areas 1cm round. No open areas. This [foam dressing] covers all the areas. R10's next documented wound assessment was on 9/4/24 a 1:20 PM (9 days later). The note showed the wound was completely healed and no new open areas. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146140 If continuation sheet Page 3 of 13 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 10/03/2024 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R10's August and September 2024 Medication Administration record, Treatment Administration Record, and physician orders sheet showed there were no physician prescribed treatments for R10 pressure injury and no documented treatments were applied. On 10/02/24 at 2:07 PM, V2 Director of Nursing stated wound assessments should be done weekly and should include measurements, wound bed descriptions, and drainage descriptions. V2 said the purpose of wound assessments are to track the progression of a wound and to determine if treatments are effective. V2 said the purpose of physician prescribed treatments are to promote wound healing and prevent infection. V2 said R10 did not have any physician orders for wound treatment until 9/27/24. V2 said there were not documented wound treatments apart from foam gauze treatments in the R10's progress notes. V2 said R10's provider and family should have been notified of the wounds when they were identified. R10's Skin/wound note from 9/11/24 showed (A new wound following the 9/4/24 note when R10's wound was healed), Assessed [R10's] buttocks while on the sit-to-stand (mechanically assisted sit-to-stand lift) from the toilet. On the left upper inner buttock, he has 2 areas of concern: Wound measurements (rough measurement as I had little time to properly measure): Wound #1 0.3cm in diameter, depth approximately 0.1 cm, wound bed beefy red, shallow. Wound #2 is next to it and measures approximately 0.2cm, depth approximately 0.1cm, wound bed beefy red. Wound beds are clean, no drainage. Applied [a gauze foam] after cleansing the area with sterile saline, initialed and dated it. Discussed with the resident [R10] about getting off of his buttocks in the afternoon and laying in bed. He was not happy about that but does verbalize understanding. (No documented provider or family notification.) R10's 9/17/24 skin/wound note from 10:47 AM showed, I assessed [R10's] skin in the shower room. His wound on the right upper inner buttock is healing nicely. It is down to one area, approximate measurements (the resident was on the sit-to-stand) was: 0.4cm in diameter and depth less than 0.1cm. The wound bed is almost healed over. [foam dressing] place, dated and initialed. R10's next documented wound assessment, following the 9/17/24, was documented on the 10/2/24 at 10:45 AM (17 days later). The skin/wound note showed, above observation, on 10/2/24 AM at. The skin/wound note showed, the wound care was observed by the state surveyor and R10's spouse. The note showed, .Wound: #1 Area measures 0.5cm in diameter and is approximately 0.1cm deep, . The wound bed was pink, no drainage. Just above this wound was unopened wounds #2 and #3, they are at the 11 o'clock position and at the 11:30 position and about 1cm from wound #1. These are healed over . R10's Order Summary Report (Physician Order Sheet) showed an order for [Foam] pad. Apply to coccyx/buttock topically as needed for MASD (Moisture Associated Skin Damage) to area on coccyx/buttock change every 2-3 days as needed. This was ordered and started on 9/27/24. R10's September 2024 Medication Administration Record (MAR) showed no documented wound care on 9/27/24, 9/28/24, 9/29/24, or 9/30/24. R10's MAR dressing change was listed only under the as needed section of the MAR. R10's progress notes from 9/27/24 through 10/1/24 showed no documented dressing changes. On 10/02/24 at 2:07 PM, V2 Director of Nursing stated there are no documented assessments for R10 following the 9/17/24 assessment and before the 10/2/24 assessment. V2 stated R10's pressure wound should have been assessed during this time period. V2 stated it is the floor nurses' responsibility to assess wounds and it appears as only one nurse was doing R10's assessments. V2 stated the physician (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146140 If continuation sheet Page 4 of 13 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 10/03/2024 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 0686 Level of Harm - Minimal harm or potential for actual harm and family should be notified whenever a wound develops, and orders should be obtained. V2 said R10 did not have any physician orders for wound treatment until 9/27/24. V2 stated R10's pressure ulcer dressing change order was poorly written and reads as if it should only be changed as needed instead of being completed every 2 to 3 days and as needed. V2 stated the order was listed under the as needed section of the MAR and there are not documented dressing changes from 9/27/24 until 10/2/24. Residents Affected - Few The facility's undated Prevention and Intervention of Skin Breakdown policy showed, .3. If the resident has a pressure ulcer, the nurse shall complete the Wound Assessment initially in [the electronic charting]; notification of physician and family, along with treatment order/s and monitor wound in Treatment Book until healed. 4. The treatment of a pressure ulcer or wound should be determined by stage, size, location, drainage, presence of necrotic tissue, and infection status based on facility's wound care protocol and physician approval. 5. Measurements of the pressure sore/wound shall be assessed at least once a week and documented in [the electronic charting] under Wound Assessment, follow-up . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146140 If continuation sheet Page 5 of 13 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 10/03/2024 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** Based on observation, interview, and record review, the facility failed to ensure resident oxygen tubing was replaced monthly for 2 of 4 residents (R7, R24) reviewed for oxygen in the sample of 13. Residents Affected - Few The findings include: 1. R7's face sheet showed an [AGE] year-old female with diagnosis of obstructive sleep apnea, osteoporosis, heart failure, chronic kidney disease stage 3, fibromyalgia, and hypertension. On 10/01/24 at 09:26 AM, R7 was seated in her room. R7 had an oxygen tubing in her nostrils. The oxygen was administered at 3 liters (l) per hour per nasal cannula (nc) via concentrator. There was no date on the tubing to indicate how long it was in use. On 10/1/24 at 9:26 AM, R7 said she wears her oxygen all the time. On 10/02/24 at 11:41 AM, V3 Infection Preventionist said it is important to change oxygen tubing monthly to avoid moisture and bacteria buildup. There should be a physician order on the care and maintenance of the tubing, so it populates to the resident treatment or administration record. We can't ensure the tubing was changed if there's no documentation. If oxygen tubing is not changed, you risk compromising equipment by overuse, can cause respiratory issues for the resident and other adverse effects. The facility's undated Oxygen Administration & Respiratory Therapy Equipment Policy showed nasal cannulas and masks are changed on the last day of the month of each month, sooner if soiled, clogged or defective. R7's September treatment administration record showed no documentation the oxygen tubing was changed. R7's physician order sheet (POS) showed no current orders for changing or maintain the oxygen equipment. R7's POS showed a 9/4/23 order to administer oxygen at 2 liters as needed to keep oxygen saturation greater than 90%. R7 had no oxygen use care plan. 2. R24's face sheet showed a [AGE] year-old female with diagnosis of obstructive sleep apnea, anxiety disorder, chronic kidney disease, heart failure, hypertension, type 2 diabetes, and atrial fibrillation. On 10/1/24 at 10:27 AM, R24 was seated in a recliner in her room. R24 had oxygen tubing in her nose and the concentrator was running at 2 liters per nasal cannula. There was no date on the tubing to indicate how long it was in use. On 10/01/24 at 10:27 AM, R24 said her oxygen is on all the time except when showering or toileting. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146140 If continuation sheet Page 6 of 13 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 10/03/2024 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 Level of Harm - Minimal harm or potential for actual harm R24's September 2024 treatment administration record (TAR) showed no documentation the oxygen tubing was changed. R24's physician order sheet (POS) showed no current orders for changing or maintain the oxygen equipment. Residents Affected - Few R24 's POS showed a 1/26/24 order to administer oxygen at 2 liters as needed to keep oxygen saturation greater than 90%. R24 had no oxygen use care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146140 If continuation sheet Page 7 of 13 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 10/03/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review the facility failed to have licensed staff administer medicated powder. The applies to 1 of 1 residents (R10) reviewed for pharmacy services in the sample of 13. Residents Affected - Few The findings include: R10's 7/11/24 Physician Communication note from 2:09 PM showed Situation: resident red/yeasty groin. R10's Order Summary Report (Physician Order Sheet) showed an order for Nystatin Powder, apply to groin topically as needed for excoriated areas in groin. The order was started 7/11/24. R10's 7/16/24 skin/wound note from 6:56 AM showed, Open area to right buttocks. Crease of buttocks. Cleansed area with soap and water and applied [foam dressing]. Shower aid found area. 1cm (centimeter) by 3cm. Will report to next shift to contact POA (Power of Attorney) and PCP (Primary Care Provider). Will continue to monitor. R10's 7/20/24 skin/wound note from 10:51 AM showed, AM CNA (Certified Nursing Assistant) put treatment powder to [R10's] buttocks. This RN (Registered Nurse) unable to view as he is in the recliner chair. Will attempt to look at it when he is toileted if I am not with another resident. On 10/02/24 at 2:07 PM, V2 Director of Nursing stated nystatin powder is used to treat fungal infections. V2 stated the warm moist environments, such as the groin and skin folds are prone to fungal infections. V2 stated nystatin is a medication and only nurses are allowed to administer nystatin powders. V2 stated the fungal powder should not be used to treat MASD (Moisture Associated Skin Damage] or pressure injuries. V2 stated based on the note a CNA administered the medicated powder and applied it the buttock wound instead of the groin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146140 If continuation sheet Page 8 of 13 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 10/03/2024 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 observation, interview, and record review, the facility failed to protect a resident (R40) from a significant medication error. This applies to 1 of 8 residents observed in the medication pass. Residents Affected - Few The findings include: R40's electronic face sheet printed on 10/2/24 showed R40 has diagnoses including but not limited to type 2 diabetes, venous insufficiency, chronic kidney disease, and acute embolism and thrombosis of left lower extremity. R40's facility assessment dated [DATE] showed R40 has no cognitive impairment, has diabetes, and receives insulin. R40's care plan dated 6/11/24 showed, (R40) does have a diagnosis of diabetes mellitus. Diabetes medications as ordered by doctor. R40's physician's orders dated 9/21/24 showed, Lantus Subcutaneous Solution (Insulin Glargine) Inject as per sliding scale: If 100-280= 10 units morning and bedtime; 281-500= 25 units morning and bedtime. Follow same orders for noon and evening blood sugar. On 10/1/24 at 11:56AM, V5 (Licensed Practical Nurse-LPN) stated, (R40's) blood sugar is 238 so she has asked me to give her 15 units of her Lantus insulin. She chooses what amount of insulin she gets; she always has when she has been in the facility. We have an order for sliding scale, but she won't follow it, so we allow her to choose her dose. (R40 should have received 10 units of insulin with this blood sugar reading). On 10/1/24 at 2:00PM, R40's MAR (medication administration record) had no documentation that R40 had received 15 units of insulin, nor was there any area for staff to be able to document the medication administration. On 10/1/24 at 2:04PM, V5 (LPN) stated, (R40) came from home & she's always done this where she decides what dose of insulin she gets. Under the order it doesn't give you the option to chart on the noon and evening dose so that isn't documented anywhere. The dose I gave earlier isn't documented, but I guess I should enter a progress note so that it's documented how many units she received. She used to have an order for her to be able to get a total of 20 units sliding scale every day, but the doctor discontinued that. We have still been working off the discontinued order, but we just don't have a spot to document it in. That is definitely a problem because she could get too much insulin if we don't keep track of how much she has had. She's pretty with it though so she would probably tell us. I called her physician last week and told him about her refusing to comply with the dose, but I don't call him every time to get approval to give her the dose she wants. On 10/2/24 at 12:32PM, V2 (Director of Nursing) stated, (R40's) physician knows her history and knows she refuses the sliding scale the way it's supposed to be given. I wouldn't expect the nurses to call the doctor every time she refuses the sliding scale, they should just give it the way she wants it. Technically, we should have an order but that's how she does it at home, so we let her do it the same way. If the nurse's give any medications and there is nowhere to document it on the medication administration record then they should at least enter a progress note. It is not my expectation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146140 If continuation sheet Page 9 of 13 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 10/03/2024 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 for them to just not document anything because then we don't know how much insulin she is receiving. Level of Harm - Minimal harm or potential for actual harm The facility's undated policy titled, Medication Administration/Control of Medications showed, Objectives: 2. To identify policies for storage, dispensing and disposal of medication and controlled substances. 3. To establish safe and accurate nursing procedures for dispensing medications to residents .Procedure: 1. The nursing facility will comply with federal and state laws and regulations relating to the procurement, storage, dispensing, administration, and disposal of medications .15. If for any reason a physician's medication order cannot be followed, a notation shall be made on the resident's record describing the circumstances. The physician shall be notified . Residents Affected - Few The facility's undated policy titled, Insulin Injection Administration showed, Procedure: 1. Check prescriber's order .6. Prepare injection as follows: a. Determine correct amount of insulin to be withdrawn. b. Read MAR again and compare with label on medication .i. Check medication label with MAR a third time .17. Document administration on MAR. 18. If resident refuses medication, indicate on MAR by initialing in appropriate space and circling initial . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146140 If continuation sheet Page 10 of 13 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 10/03/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to store 2 residents (R9,R12) controlled medications under a double lock system. This applies to 2 of 2 residents outside of the sample reviewed for controlled medication storage. The findings include: R9's physician's orders dated 9/23/24 showed, Lorazepam oral concentrate 2mg/ml give 0.2ml sublingually every 1 hour as needed for agitation . R12's physician's orders dated 9/21/24 showed, Lorazepam oral concentrate 2mg/ml give 0.2ml sublingually every 1 hour as needed for anxiety . On 10/3/24 at 10:00AM, V6 (Licensed Practical Nurse) unlocked the medication room and opened the medication refrigerator that had no lock on it. Inside of the medication refrigerator were 1 unopened and 1 partially used bottle of lorazepam with R9's name on them. Another partially used bottle was in the refrigerator with R12's name on it. R9 and R12's lorazepam bottles were not under any additional locks in the medication refrigerator. On 10/3/24 at 10:05AM, V6 stated, Lorazepam has always been stored in this refrigerator and we have never had a double lock on it. I don't think we need to have it double locked, but I could be wrong. On 10/3/24 at 11:34AM, V3 (Infection Preventionist) stated, All controlled medications in the medication room are to under a double lock system. There should either be a lock on the medication refrigerator door or the controlled substances could be in a locked container in the refrigerator. We do not have either of these and I guess I never thought about it until you asked. This will help prevent diversion of these medications and ensure only the residents that they are ordered for are who receives them. The facility's undated policy titled, Storage of Medications showed, Objective: The facility stores all drugs and biologicals in a safe and secure and orderly manner .12. Schedule II-V controlled medications are stored in separately locked, permanently affixed compartments. Security access to controlled medication is separate from access to non-controlled medications . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146140 If continuation sheet Page 11 of 13 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 10/03/2024 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 0851 Level of Harm - Minimal harm or potential for actual harm Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on interview and record review, the facility failed to submit quarterly reports to the Payroll-Based Journal (PBJ). Residents Affected - Many This failure has the potential to affect all residents in the facility. The findings include: The facility's roster dated 10/1/24 showed 44 residents residing in the building. The facility's PBJ report dated April 1-June 30, 2024 showed, Failed to submit data for the quarter. On 10/2/24 at 10:03AM, V1 (Administrator) stated, I was made aware that this data was not submitted and there is no reason why. Our corporate staff usually submit it but for some reason they just didn't. We have already received our notification in the mail from IDPH (Illinois Department of Public Health) regarding this so I already knew about the issue. We don't have any policy regarding the PBJ reporting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146140 If continuation sheet Page 12 of 13 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 10/03/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement their policy regarding Legionella management. This failure has the potential to affect all residents in the building. Residents Affected - Many The findings include: The resident census report dated 10/1/24 showed 44 residents currently residing in the building. On 10/3/24 at 9:38AM, V1 (Administrator) stated, I have been working with (hospital infection preventionist) on our policy but we don't have any plan set yet. We don't have any of the water management program done yet, just the hospital one. We have no diagrams, surveillance process, or testing process completed or initiated yet. If we had a Legionella outbreak, we would probably not have any idea of where to even start looking as we haven't implemented anything yet. On 10/3/24 at 10:37AM, V3 (Infection Preventionist) stated, We have not done anything with legionella that I am aware of. I believe the plan is in process, but we haven't implemented anything yet. The facility's undated policy titled, Legionella and Waterborne Pathogens Policy showed, Objective: I. To establish a water management program which reduces the risk of Legionnaire's Disease, Pontiac Fever, and other infections due to waterborne pathogens associated with the hospital water system. II. To establish a surveillance process and criteria for defining hospital acquired Legionella and other infections due to waterborne pathogens. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146140 If continuation sheet Page 13 of 13