Inspection·April 21, 2022

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 4/20/22 at 1:16PM, V7 (Registered Nurse) stated, (R19) is supposed to have a palm protector to her right hand to prevent contractures. She wears the carrot in her hand at night but the palm protector should be on during the day. She does not have any history of refusing it or taking it off by herself. The facility's Splint Placement In-service, dated 3/8/22, showed, This is an example of proper splint placement for (R19). Please make sure that the strap on the top is not pulled too tight as this could cause skin breakdown. Attached to this document were photographs showing proper splint placement for R19. Event ID: Facility ID: 146147 If continuation sheet Page 2 of 15 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 146147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Stockton 501 Front Street Stockton, IL 61085 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 - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. 2. R6's admission Record (Face Sheet) showed an original admission date of 7/15/2020, with diagnoses to include: Alzheimer's, abnormalities of gait, weakness, impaired balance (ataxia), lack of coordination, and need for assistance with personal care. R6's 2/25/22 Post Fall Evaluation showed, Reason for fall; was trying to get something to drink .Conclusion: Need to make sure that fluids are available at bedside. On 4/19/22 at 9:03 AM, R6 was asleep and laying on R6's back in bed. R6 had a nutritive shake in R6's hand, which was open and had a straw in it. R6 had no bedside table, and R6's nightstand was a few feet outside of R6's reach. R6 had no cups of water in R6's room. (With the exception of R6's call light, R6 was in the same condition at 1:04 PM and 2:25 PM.) On 4/20/22 at 11:02 AM, R6 did not speak; however, when asked where R6's call light was located, R6 was able to point to it's location in R6's bed. R6 had no bedside table, the nightstand was as described previously, and R6 had no water or nutritive shake. On 4/20/22 at 12:41 PM, R6 was on the floor between R6's bed and R6's night stand antempting to crawl or roll to R6's nightstand. While R6 was on the floor, R6 had an out stretched arm attempting to reach something on R6's nightstand. R6 had no water in R6's room, no bedside table, and R6's nightstand was in the same location as before. While R6 was on the floor, no alarm was sounding, and there was no alarm in R6's bed. R6's Care Plan (as of 4/20/22 at 11:10 AM) showed R6 was a high risk for falls with interventions to include: .Be sure (R6's) call light is within reach .Bed pad alarm (alarm was entered twice in the care plan), .have cups available within reach .ensure bedside table is within reach . R6's updated care plan, provided on 4/21/22, showed the bedside table intervention was removed and replaced with nightstand. On 4/20/22 at 1:52 PM, V7, Registered Nurse, stated R6 does occasionally use R6's call light. R6 said it would be important for R6 to have R6's nightstand next to R6, water available to R6, and to have R6's call light within reach to prevent falls. On 4/20/22 at 12:56 PM, V13, Certified Nursing Assistant, stated R6 doesn't use the call light often, but R6 does use it occasionally. V13 said R6 did not have any cups of water in R6's room (V13 was the CNA who responded to R6 being on the floor at 12:41 PM), and having R6's nightstand with water near her is important to prevent falls. The facility's Fall Prevention Program (implemented 2/1/22) showed protocols to prevent falls include Call light and frequently used items are within reach . Based on observation, interview, and record review, the facility failed to ensure fall prevention interventions were in place for 2 of 3 residents (R27,R6) reviewed for falls in the sample of 13. The findings include: 1. R27's electronic face sheet, printed on 4/21/22, showed R27 has diagnosis including but not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146147 If continuation sheet Page 3 of 15 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 146147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Stockton 501 Front Street Stockton, IL 61085 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 limited to: COVID-19, Parkinson's disease, repeated falls, sciatica, Alzheimer's disease, and major depressive disorder. R27's facility assessment, dated 2/20/22, showed R27 has no cognitive impairment and requires 1 person assistance for transfers. Residents Affected - Few R27's care plan, dated 7/26/21, showed, (R27) has an activities of daily living self-care performance deficit related to disease processes: Parkinson's disease, Alzheimer's dementia, gait instability, and history of falls. (R27) requires 1 assistance by staff to move between surfaces. Refuses assistance. R27's care plan, dated 4/19/22, showed, (R27) is a high risk for falls related to confusion, gait/balance problems, and history of falls. Resident appears to be intentionally falling at times related to behaviors. Resident states I want to fall 200 times before I die. I am at 113. Falls on 3/9/22 and 3/16/22 with no injury. Falls on 4/11/22 and 4/17/22. Keep wheelchair out of room, ensure bed is in low position, floor mats next to bed, follow fall protocol, large print signage in room, educate resident to use call light for staff to remove floor mat to get up. R27's certified nursing assistant daily tasks for April 2022 showed no documentation of R27's refusals for assistance with activities of daily living or poor safety awareness. R27's nursing progress notes, dated 4/18/22, showed, Fall was not witnessed. Fall occurred in the resident's room. Did injury occur as a result of the fall: Yes. Staples to back of resident's head. On 4/19/22 at 1:25PM, R27 stated, I had a fall over the weekend. I sat up and fell over and hit my head on the nightstand. The fall mat is supposed to be on the floor in case I fall out of bed. It is supposed to be put it down whenever I'm in bed. R27's fall mat was folded up and leaning against the wall opposite of R27's bed. R27 was lying in bed at this time. No large print signage was observed in R27's room. On 4/20/22at 8:16AM, R27 was lying in bed. R27's fall mat was folded up and leaning against the wall opposite of his bed. No large print signage was observed in R27's room. On 4/20/22 at 1:08PM, V7 (Registered Nurse) stated, (R27) is a fall risk and has had a recent fall with injury. Fall prevention measures for him are to ensure his call light is within reach, gripper socks when ambulating, education about safety reminders, walker, assistance with making his bed, removed shelf, large print signage in room, and floor mats are to be removed by staff when resident wants to get up. If the fall prevention measures are not present in his room then he could fall and get injured. The facility's policy titled, Fall Prevention Program, implemented 2/1/22, showed, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146147 If continuation sheet Page 4 of 15 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 146147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Stockton 501 Front Street Stockton, IL 61085 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review, the facility failed to offer and provide incontinence care in a manner to prevent a urinary tract infection for 1 resident (R7) with a history of urinary tract infections. These failures apply to 1 of 1 residents reviewed for bowel and bladder incontinence in the sample of 13. The findings include: R7's electronic face sheet, printed on 4/21/22, showed R7 has diagnosis including, but not limited to: unspecified diastolic congestive heart failure, type 2 diabetes, chronic obstructive pulmonary disease, cerebral infarction, and peripheral vascular disease. R7's care plan, dated 6/30/21, showed, (R7) has mixed bladder incontinence: stress incontinence due to leakage and obesity, urge incontinence related to diabetes mellitus, and functional incontinence related to needing assistance with mobility and clothing management, osteoarthritis, and pain. (R7) has exhibited some stubborn behavior with bladder incontinence. When staff has offered to toilet her she stated, I'm 83 y/o and who gives a sh*t. Offer and encourage toileting upon rising, after meals, at bedtime, and as needed. Wash, rinse, and dry perineum. Change clothing as needed after incontinence episodes and monitor for signs and symptoms of urinary tract infection. R7's facility assessment, dated 4/8/22, showed R7 has no cognitive impairment, requires 1 staff member assistance for hygiene, and is frequently incontinent of bowel & bladder. R7's medication administration record for March 2022 showed R7 completed a 7 day course of antibiotics for a urinary tract infection. On 4/19/22 at 2:08PM, V8 and V9 (Certified Nursing Assistants) were providing incontinence care for R7. R7 stated R7 has not receive incontinence care or been offered toileting assistance or incontinence care since R7 got out of bed this morning. R7 usually gets out of bed around 9-9:30AM. V8 and V9 stated they were unsure of when R7 last received incontinence care or offered toileting assistance. V9 then began providing perineal care to R7, and wiped 3 times down front of vaginal area with the same side of a soap filled washcloth. R7 was then turned over on R7's side and V9 wiped 3 times with the same side of the washcloth & over R7's vaginal area. V9 removed R7's shirt that was soiled with urine, and R7's urine saturated incontinence brief. V9 applied a clean incontinence brief and clean shirt to R7, with the same gloves V9 provided incontinence care with. V9 stated the staff offer and provide toileting and bathroom assistance every 2 hours or as needed for residents. V9 stated, (R7) does call when she is ready to lay down and get changed, but staff should be checking in on her too and offering toileting assistance. She has a history of skin breakdown so it's important to make sure she is being changed and getting out of her soiled clothing. Gloves should be changed when going from soiled to clean tasks due to the risk of infection. I should have flipped the washcloth and towel over to a new area before wiping because those are soiled areas once they have touched her. On 4/20/22 at 1:06PM, R7 stated, I was changed this morning around 9:30AM or so when I had my shower. They haven't offered to change me since then. I know I'm wet, but hopefully I get to lay down soon. R7's certified nursing assistant daily tasks for April 2022 showed no bowel and bladder elimination (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146147 If continuation sheet Page 5 of 15 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 146147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Stockton 501 Front Street Stockton, IL 61085 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete assistance or personal hygiene assistance were completed on 4/19/22. On 4/20/22, no documentation was present for either task until 9:30PM. The facility's policy titled, Incontinence, dated 2/1/22, showed, Based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services .4. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible. Event ID: Facility ID: 146147 If continuation sheet Page 6 of 15 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 146147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Stockton 501 Front Street Stockton, IL 61085 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview and record review, the facility failed to track and document behaviors for a resident receiving an antipsychotic medication for 1 of 4 residents (R22) reviewed for antipsychotic medications in the sample of 13. The findings include: R22's electronic face sheet, printed on 4/21/22, showed R22 has diagnoses including, but not limited to: anxiety disorder, delusional disorders, major depressive disorder, and dementia without behaviors. R22's care plan, dated 12/8/21, showed, The resident uses psychotropic medications related to behavior management. Discuss with physician and family regarding ongoing need for use of medication. Consult with pharmacy, physician to consider dosage reduction when clinically appropriate at least quarterly. R22's facility assessment, dated 2/22/22, showed R22 has severe cognitive impairment. R22's Psychotropic evaluation, dated 3/28/22, showed, -on occasion can be combative & agitated with care. R22's physician's orders for April 2022, showed, Risperdal 0.25mg with meals for delusional disorder and Risperdal 0.5mg at bedtime for delusional disorder. On 4/21/22 at 11:08AM, V8 (Certified Nursing Assistant) stated, Behavior documentation is located in the certified nursing assistants (CNA's) charting. (R22) has behaviors like aggression and rejection of cares. There should be an area in her chart to document that and the CNA's should be documenting every shift when she has behaviors. R22's CNA task documentation for the past 30 days showed no behavior documentation. On 4/21/22 at 11:12AM, V7 (Registered Nurse) stated, When behaviors are reported to the nurses, the documentation is put in the residents chart as a behavior note or a health status note under progress notes. There are a few residents that have behavior tracking on their medication administration record but I don't see that (R22 has that on hers). (R22) mainly has sun downing behaviors that occur at night. She has good days and bad days, some days she sleeps all day and other she is alert and awake. R22's nursing progress notes showed no behavioral progress notes since 10/2021. On 4/21/22 at 11:46AM, V1 (Director of Nursing) stated, (R22) does not have behavior tracking documented because it looks like someone entered it as an as needed task for the aides to document. I know she has behaviors, but I don't see them documented in her medical record. The nurse's notes are not consistent regarding behavior documentation. I agree that it is hard to show necessity for a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146147 If continuation sheet Page 7 of 15 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 146147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Stockton 501 Front Street Stockton, IL 61085 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete psychotropic medication when there are no behaviors documented. They should be documented so that the pharmacist and physician can justify continued need for the medication. The facility's policy titled, Gradual Dose Reduction of Psychotropic Drugs, dated 2/1/22, showed, Residents who use psychotropic drugs receive gradual dose reduction and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Event ID: Facility ID: 146147 If continuation sheet Page 8 of 15 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 146147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Stockton 501 Front Street Stockton, IL 61085 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to follow the facility's lunch menu on 4/19/22, and did not follow the recipe for pureed ham, provide pureed bread for residents, or measure the portion sizes for the ham. This applies to all 33 facility residents. The findings include: The facility's CMS (Centers for Medicare & Medicaid Services) form 672 Resident Census and Condition of Residents, dated April 19, 2022, showed 33 residents reside in the facility. On 4/19/22 at 11:13 AM, V5 (Cook) took the ham out of the oven, cut off some pieces of ham and placed them into a food processor. V5 did not weigh the ham to see if the portion size was correct. V5 took a glass, put cold 2% milk in it and added it to the ham in the food processor to puree the ham. V5 turned on the food processor. V5 looked at the consistency of the ham, and it was still chunky. V5 grabbed more 2% milk and added it to the ham. V5 continued to use the food processor to puree the ham. V5 dumped the ham that was supposed to be pureed into a pan. The ham did not look completely pureed and milk was visible. On 4/19/22 at 11:34 AM, V5 took the ham out of the oven and carved the ham into random sized slices. V5 used tongs to place different sized pieces of ham on residents plates. V5 served ham, roasted potatoes, corn bread, peas and carrots for the regular consistency diets. V5 plated up the food for the three residents (R1, R14 & R25) on pureed diets, and they did not receive any pureed cornbread. On 4/19/22 at 11:53 AM, V5 stated It is an estimated guess when it comes to the meat as to how much the resident is going to get. V5 stated V5 forgot about making the pureed cornbread. On 4/19/22 at 1:05 PM, V3 (Dietary Manager) stated V3 should have used the ham juice and not milk to puree the ham. V3 stated V3 heard V5 did not make the pureed cornbread. V3 stated they should follow the menus. The Pureed Glazed Ham recipe (winter 2021-2022, day 24) showed, Dissolve pork base in water to make broth. Place prepared meat in a sanitized food processor. Gradually add broth; blend until smooth. The regular consistency Glazed Baked Ham recipe (winter 2021-2022, day 24) showed, Using a meat slicer, slice the ham into 3 ounce portions. Set the dial on #13-15; weigh slices randomly to maintain 3 ounce portion control. On 4/20/22 at 10:30 AM, during the group interview, the residents stated sometimes the portions of food that are served look skimpy. They stated the food trays do not have the same amount of food on them; one person may get more food than another person. The Diet Spreadsheet week 4 for the winter 2021-2022 menu showed on 4/19/22 residents on a regular diet should have received 3 ounces of baked ham. Residents on pureed diets should have received pureed cornbread. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146147 If continuation sheet Page 9 of 15 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 146147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Stockton 501 Front Street Stockton, IL 61085 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 0803 Level of Harm - Minimal harm or potential for actual harm The facility's Puree Food Preparation policy (2/1/22) showed, Residents receiving puree diets should always receive portions equivalent to those served on the regular or therapeutic diet ordered per the facility policy and procedure. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146147 If continuation sheet Page 10 of 15 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 146147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Stockton 501 Front Street Stockton, IL 61085 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, and record review the facility failed to ensure the ham was pureed to the correct consistency for the lunch meal on 4/19/22 for 1 of 1 residents (R1) reviewed for pureed diets in the sample of 33 and 2 residents (R14 & R25) outside of the sample. The findings include: On 4/19/22 at 11:13 AM, V5 (Cook) took the ham out of the oven, cut off some pieces of ham and placed them into a food processor. V5 did not weigh the ham to see if the portion size was correct. V5 took a glass, put cold 2% milk in it and added it to the ham in the food processor to puree the ham. V5 turned on the food processor. V5 looked at the consistency of the ham and it was still chunky. V5 grabbed more 2% milk and added it to the ham. V5 continued to use the food processor to puree the ham. V5 dumped the ham that was supposed to be pureed into a pan. The ham did not look completely pureed and milk was visible. On 4/19/22 at 12:20 PM, a test tray of pureed food was obtained. The pureed ham was sitting in milk and was not the correct texture. The ham was stringy and had to be chewed. The Pureed Glazed Ham recipe (winter 2021-2022, day 24) showed, Dissolve pork base in water to make broth. Place prepared meat in a sanitized food processor. Gradually add broth; blend until smooth. If product needs thinning, gradually add an appropriate amount of liquid to achieve a smooth, pudding or soft mashed potato consistency. On 4/19/22 at 1:05 PM, V3 (Dietary Manager) stated V3 should have used the ham juice and not milk to puree the ham. V3 stated they should follow the menus. V3 stated the texture of a pureed diet should be like baby food. The facility's Puree Food Preparation policy (2/1/22) showed, Each resident must receive and the facility must provide food that is prepared by methods that conserve nutritive value, flavor, and appearance. Puree foods should be prepared in a manner to prevent lumps or chunks. The goal is a smooth, soft, homogenous consistency similar to soft mashed potatoes. Puree food preparation guidelines per serving: Meats: add 1 teaspoon of beef broth or beef gravy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146147 If continuation sheet Page 11 of 15 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 146147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Stockton 501 Front Street Stockton, IL 61085 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure the kitchen was cleaned on a regular basis. The facility failed to ensure the kitchen did not have grease on walls, cobwebs and thick dust to surfaces. The facility failed to ensure staff wear hair nets in the kitchen. This applies to all 33 facility residents. The findings include: The facility's CMS (Centers for Medicare & Medicaid Services) form 672 Resident Census and Condition of Residents, dated April 19, 2022, showed 33 residents reside in the facility. On 4/19/22 at 8:53 AM, the handwashing sink in the kitchen had a brown build up around the drain and the white sink had brown dried buildup all over it. The faucet on the handwashing sink had a white crusty substance on it. Thick dust and cobwebs were on the ceiling, walls, ceiling fans, and exposed pipes including pipes above the food preparation areas. There was crusty debris on stainless steel 3 compartment sink rubber mat where pans and other kitchen items dry. V5 (Cook) was standing at the 3-compartment sink washing, rinsing and sanitizing pans. On 4/19/22 at 9:05 AM, V3 (Dietary Manager) stated, My sink, all my pipes, ceiling fan, corners and ceiling need to be cleaned. It's on my list and I am working on it, but I am trying to get stuff done in here and still have other stuff to do out there. On 4/19/22 at 9:10 AM, V3 stated the facility just got the new chemical sanitizer system on 3/10/22, and they ran out of sanitizer on 4/14/22. V3 stated bleach was being used as a sanitizer right now in the 3-compartment sink. V3 used a test strip to check for levels of chlorine, dipped it into the sink with sanitizer, and it read 200 ppm (parts per million). V3 stated the water was cold, and the test strip should read 50 ppm for the bleach. V3 stated the temperature of the water in the sink should be 110 degrees Fahrenheit. V3 stated V3 needed to add more water to the sink with the sanitizer. A sign was posted above the 3-compartment sink that showed, Wash in water at, at least 110 degrees Farenheit with a good detergent; rinse thoroughly in clean hot water after washing to remove cleaners and abrasives; sanitize in warm water with sanitizer for one minute 110 degrees at least 50 ppm, air dry - sanitizer contact time is important. do not towel dry. V3 stated the sign was for the chlorine sanitizer and not the new sanitizer system. On 4/19/22 at 9:15 AM, there was grease and dust built up on the wall behind the oven/stove. On 4/19/22 at 9:20 AM, V4 (Dietary Aide) was not wearing a hair net when V4 walked in and out of the kitchen several times. V4 brought resident food trays in to clean them off and place them in the washing station directly across from the food prep station and oven/stove area. On 4/19/22 at 9:40 AM, V3 (Dietary Manager) tested the chemicals in the single rack, low temperature dishwasher. The test strip read at 25 ppm. V3 stated the reading should be at 50 ppm, and the dishwasher sanitizes using a chlorine-based product called sodium hypochlorite. V3 stated they have always used the chlorine test strips to test the sanitizer. V3 stated, The dishwasher doesn't keep its temperature. It will show 101 on the outside and is 4 degrees hotter. It has been doing this for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146147 If continuation sheet Page 12 of 15 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 146147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Stockton 501 Front Street Stockton, IL 61085 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many last 3-4 weeks. The sensor has been out in the dish machine, and it is not reading correctly. The dishwasher hasn't sanitized right in the last 2 years. I have worked here for 20 years in kitchen and recently took over as Dietary Manager. On 4/19/22 at 9:45 AM, the bucket with cleaning solution with a rag in it that was sitting in a kitchen sink was tested by V3 and read 200 ppm. V3 stated it was bleach that was used in the sanitizer bucket. V3 stated the rag in the bucket is used to wipe down tables, counters etc, and should be at 50 ppm. On 4/19/22 at 1:05 PM, V3 (Dietary Manager) stated the Daily/Weekly Cleaning Schedule, dated 4/7, showed it was documented the walls of the kitchen were cleaned. V3 stated that the walls were only cleaned on the bottom portion, but not the upper part of the walls. V3 stated there weren't any Daily/Weekly Cleaning Schedules for the facility prior to April 2022. V3 stated hair nets are to be worn in the kitchen so no hair gets in the food or on the surfaces. V3 stated the dishwasher was a single rack, low temperature machine that reads 105, but the temperature was 109 degrees Fahrenheit. V3 stated the dishwasher temperature should be 120 degrees Fahrenheit. V3 stated, During the day the temperature of the dishwasher won't maintain its temperature when I have to fight laundry for hot water. The temperatures are better in the evening than in the day; but they are still on the low side. The heating sensor element is out, and maintenance can't find a replacement part. I have talked to the different maintenance people we have had, and they can't either get the part and/or don't want to work on it. The facility's Sanitation Inspection policy (2/1/22) showed, It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations. All food service area shall be clean, sanitary, free of litter, rubbish and protected from rodents, roaches, flies and other insects. The department shall establish a sanitation program for food services based on applicable state and federal requirements. The dietary manager shall develop and provide food service personnel with standard operating procedures for sanitation daily inspections. The facility's policy Manual Warewashing-3 Compartment Sink policy (2/1/22) showed, Third sink sanitizing - fill with hot water (171 degrees Fahrenheit) or use chemical sanitizer: . chlorine at 50-100 ppm. Confirm appropriate temperature or concentration prior to washing and record on sanitation control log. The sanitizing sink should be monitored for the proper temperature, if hot water sanitization is used and for proper chemical concentration if chemical sanitization is used. The facility's policy Dishwasher Temperature policy (2/1/22) showed, For low temperature dishwashers (chemical sanitization): The wash temperature shall be 120 degrees Fahrenheit. The sanitizing solution shall be 50 ppm hypochlorite (chlorine) on dish surface in final rinse. The facility's Sanitizing Buckets policy (4/2017) showed, Sanitizer concentration will be checked using a test kit. The following sanitizer concentrations are recommended and use of test strips to monitor accuracy of the sanitizer. Chlorine 50 - 100 ppm. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146147 If continuation sheet Page 13 of 15 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 146147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Stockton 501 Front Street Stockton, IL 61085 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to offer and provide influenza vaccinations between October 1, 2021 and March 31, 2022. Residents Affected - Many This applies to all 33 facility residents. The findings include: On 4/20/22 at 11:30 AM, five residents (R3, R6, R15, R28 & R32) were reviewed for the receipt or declination of the influenza vaccination. There was no documentation to show the residents were offered the influenza vaccination, consented, or declined receiving it. There was no documentation showing the residents received the administration of the influenza vaccine between October 1, 2021 through March 31, 2022. On 4/20/22 at 12:00 PM, V1 (Administrator) stated, We are looking for immunization information but I don't know where the previous DON (Director of Nursing) put it. On 4/20/22 at 12:20 PM, V2 (Assistant Administrator) stated, Some consents and/or refusals for vaccinations are scanned into the computer and some are not. We are looking for them. On 4/20/22 at 2:30 PM, V6 (Corporate Regional Nurse) stated, I know the DON was instructed to give residents the Influenza vaccine. On 4/21/22 at 10:05 AM, V7, RN (Registered Nurse), stated, They were looking for the consents for influenza last night. There were 7 residents that did not get the flu shot and it was given yesterday. The DON that was here said that she gave them. There is a 4 month window that they are to receive them. V10, LPN (Licensed Practical Nurse), gave the immunizations yesterday. They they should have been given earlier. On 4/21/22 at 10:18 AM, V10, LPN, stated, I was given this list yesterday and I was told to give the flu shot. The DON was in charge of the program. I don't know why it was not done. You would have to ask her and she isn't here anymore. I know (V1) and (V2) were working on getting the consents done yesterday. Normally we give it in October or November. Its supposed to be given between October and March every year. I know I have two more residents to give the flu shot to today. V10 gave a copy of the Flu Vaccine Temperature Log, dated 4/20/22, and it showed 20 residents had received the influenza vaccine on 4/20/22. On 4/21/22 at 10:21 AM, V1 (Administrator) stated, (V12, RN) the old DON supposedly got consents. I cant find them. I called pharmacy and they said she got the consents. I asked if they (influenza vaccination) were given and they said we have the vaccine but it was never given. I called the medical director and he said we could still give it until the end of May so we got consents and/or declinations yesterday. We started giving the flu vaccine yesterday. The DON did not implement and follow the influenza program. She was supposed to get a consent or refusal and give the immunization. V1 confirmed the facility's policy is to offer the influenza vaccination between October 1, 2021 and March 31, 2022. The facility's Influenza Vaccination policy (2/1/22) showed, It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from influenza by offering (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146147 If continuation sheet Page 14 of 15 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 146147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Stockton 501 Front Street Stockton, IL 61085 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 0883 Level of Harm - Minimal harm or potential for actual harm our residents, staff members, and volunteer workers annual immunization against influenza. Influenza vaccinations will be routinely offered annually from October 1st through March 31st unless such immunization is medically contraindicated, the individual has already been immunized during this time period, or refuses to receive the vaccine. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146147 If continuation sheet Page 15 of 15