Inspection·April 24, 2023

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and concerns that residents have, which is usually about the food. V18 stated V18 mentions the concerns to the departments the concerns pertain. V18 stated V18 has not had success with emails in the past, so V18 has not been emailing as it had not been effective. V18 stated V18 usually brings up the resident council concerns in the morning Interdisciplinary Meetings. V18 stated V18 does not follow up on the concerns from resident council and that old business is not always reviewed because sometimes residents are too sleepy. V18 stated R5 and R6 frequently complain of multiple concerns with dietary services and food. On 4/19/23 at 10:20am, V19, Diet Aide stated V20, R1's family has voiced concerns related to food service. V19 stated V20 types up a menu off what is available at the facility and V19 tapes those menus up in the kitchen weekly and available for staff to follow. V19 stated V19 has been reporting dietary concerns to V8, Culinary Director but V19 feels like concerns are not followed up on because the same concerns keep happening. V19 stated R1 and R5 are two residents who have specific needs/requests that are not followed and continue to be concerns. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146184 If continuation sheet Page 2 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luther Oaks 601 Lutz Road Bloomington, IL 61704 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on interview and record review, the facility failed to notify resident representatives of a significant weight loss for two of three residents (R2, R3) reviewed for notification of change of condition on the sample list of six. The facility also failed to notify the physician and resident representative of a change in a residents condition for one of three residents (R1) reviewed for a change in condition on the sample list of six. Findings Include: The facility Change of Condition and Emergency Evaluation of Resident Policy dated 5/15/14 documents residents with a change of condition must be evaluated and then notify the physician and HCPOA (Health Care Power of Attorney)/family. 1. R1's Progress Notes dated 12/27/23 at 8:23am document R1 had a small amount of amber emesis. This note documents R1's stomach is upset and R1 seems confused and pointed outside and said, look the planes are out and there was no plane in the air. This note documents an unidentified physician was notified. There is no documentation of which physician was notified or of follow-up/response from a physician. There is no documentation V20, R1's family was notified. R1's Facsimile Sheet to V15, R1's Physician documents on 12/27/23, R1 had a small amber liquid emesis with signs and symptoms of confusion pointing to the sky saying look a plane when nothing was there. There is no documentation of date/time this sheet was sent to V15. There is no documentation V15 received/acknowledged the facsimile or that this change in condition was followed-up on. On 4/20/23 at 1:40pm, V2, Director of Nursing (DON) stated the facility should have called to notify V15 of R1's change in condition if V15 had not responded/responded promptly. V2 stated for changes in condition that may require medical intervention, V15 should be called and notified. V2 stated V20 should have been notified and the details should be charted in the resident's medical record. 2. R2's ongoing computerized weight history documents the following weights: April 2023 - 104.6 pounds, March 2023- 109 pounds, February 2023- 112.6 pounds, January 2023- 115.6 pounds, December 2022 120.6 pounds, November 2022- 126 pounds, and October 2022 - 129.4 pounds. This calculates to be a weight loss of 19.17% from October 2022 - April 2023. R2's Nursing Progress Notes dated 1/12/23, 2/8/23, 3/8/23 and 4/12/23 all document R2's weight loss with notification to the physician and/or dietician but does not document R2's family was notified of the weight loss. 3. R3's ongoing computerized wight history documents the following weights: February 5, 2023 - 183.1 pounds, March 13, 2023 - 159.2 pounds, March 19, 2023 - 157.3 pounds, March 26, 2023 - 157.5 pounds. This calculates to be a weight loss of 13.05% from February 5, 2023 - March 13, 2023. R3's Nursing Progress Notes document the following: 3/16/23 documents R3's monthly weight as of 3/13 is 159.2 pounds. A re-weigh has been requested. weight loss of 13% in one month. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146184 If continuation sheet Page 3 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luther Oaks 601 Lutz Road Bloomington, IL 61704 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3/20/23 - weight this month after re-weigh is 157.3 pounds, re-weigh consistent with initial monthly weight. wt. loss of 14% in one month. R2's weight has been 170's/180's until this month. regular diet. RN (Registered Nurse) to notify physician of weight change. On 4/17/23 at 10:30 am, V4 RN stated when a resident has a significant weight loss, the physician and dietician are notified. V4 also stated families should be notified as well but V4 is not sure if that is being done or not. V4 verified that there is no documentation in R2 or R3's medical record that their representatives were notified of their weight loss. On 4/17/23 at 1:46 pm, V2 DON (Director of Nursing) stated families should be notified of weight losses and notification should be documented in the progress notes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146184 If continuation sheet Page 4 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luther Oaks 601 Lutz Road Bloomington, IL 61704 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on interview and record review, the facility failed to ensure grievances regarding food service were documented, that dietary was notified of the concerns or that the grievances were investigated/resolved. These failures affect one of four residents (R1) reviewed for food services concerns on the sample of six. Findings include: The facility's Grievances policy dated 1/18/23 documents the Grievance Official is an individual who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusion and issuing written grievance decisions to the resident. This policy documents the community will train and designate an individual who acts as the Grievance Official. Responsibilities include overseeing the grievance process, receiving and tracking all grievances through to conclusion, leading any necessary investigations by the community and completing written grievance resolutions to the resident involved. On 4/13/23 at 8:40am, V3, Assistant Director of Nursing (ADON) stated V20, R1's family, has voiced complaints of food service issues but could not elaborate on details. On 4/19/23 at 10:20am, V19, Diet Aide stated V20, R1's Family voiced concerns related to food and food services. V19 stated V20 types up a menu for R1 off what the facility has, and those are taped up in the kitchen. V19 stated one concern is V20 stated R1 keeps getting vegetables, R1 does not want them. V19 stated V19 has been reporting the concerns/complaints to V8, Culinary Director but V19 stated V19 feels it is being dropped because the concerns have not been followed up on after V19 has notified V8 multiple times. The facility's grievance log does not document food related grievances or concerns from January 2023 through 4/20/23. There is no documentation of V20's concerns related to food service issues. There is no documentation V8, Culinary Director was made aware of V20's concerns related to food/food services. On 4/19/23 at 12:20pm, V7, Grievance Official stated family or residents may contact V7 with concerns/grievances. V7 stated if another staff member hears the concern, their supervisor is made aware or they come to me. V7 stated V7 will follow up with resident and all involved. V7 stated the facility puts a plan of action in place and notifies family and/or resident. V7 stated V7 completes a follow up with supervisors who are in the area of the concern and follows up with families. Staff are supposed to send an email when concerns/grievances arise, otherwise sometimes the Interdisciplinary Team (IDT) meeting is another time V7 is notified of grievances. V7 does not remember being notified of dietary concerns. V7 stated V18, Life Enrichment Coordinator is supposed to set date for resolution of the resident council grievances and let the family/resident know what is going on. V7 stated V7 believes the Life Enrichment Coordinator is supposed to track concerns from resident council meetings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146184 If continuation sheet Page 5 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luther Oaks 601 Lutz Road Bloomington, IL 61704 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 0659 Provide care by qualified persons according to each resident's written plan of care. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement physician's orders for one of three residents (R1) reviewed for falls and skin concerns on the sample of six. Residents Affected - Few Findings include: R1's undated Standing Orders Sheets signed by V15, Physician document to follow orders sent from the hospital. R1's After Visit Summary (AVS) dated 1/1/23 documents R1's orders including Ibuprofen 400mg (milligrams) every 6-8 hours with food for pain/inflammation for mild to moderate pain. This AVS documents to apply ice to sore area of the body for the next 72 hours and alternate hot cold therapy. There is no documentation R1's orders for Ibuprofen and alternating heat/ice were transcribed to R1's Physician's Orders at the facility. R1's Communication Form dated 4/8/23 at 10:00pm documents R1 has excoriation and rash under the right breast. Please provide PRN (as needed) order. This form documents on 4/11/23, okay for Nystatin powder to be applied to affected area twice daily and PRN (as needed) excoriation. R1's Electronic Medical Record Physician's Order Summary documents an order dated 4/11/23 that documents, Nystatin External Cream 100000 UNIT/GM (Nystatin (Topical)) apply to rash under right breast as needed, instead of the powder twice daily and PRN as ordered. There is no documentation this medication has been administered twice daily or PRN as ordered. On 4/20/23 at 1:40pm, V2, Director of Nursing (DON) stated staff should ensure all physician's orders from emergency room visits are transcribed to the facility's electronic medical records. V2 stated the facility should ensure when transcribing physician's orders, they are transcribing them accurately so that the medication/treatment can be implemented/administered accurately/correctly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146184 If continuation sheet Page 6 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luther Oaks 601 Lutz Road Bloomington, IL 61704 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to complete ordered lab work for two of three residents (R1, R3) reviewed for laboratory testing on the sample list of six. Residents Affected - Few Findings Include: 1. R1's medical record documents undated Standing Orders signed by V15, R1's Physician to obtain a urinalysis (U/A) and culture and sensitivity if patient exhibits more than 3 signs/symptoms of a Urinary Tract Infection (UTI). On 4/13/23 at 9:30am, V20, R1's Family stated R1 wasmore confused with some additional concerns for possible UTI and on August 5, 2022, V20 asked for urine specimen to be collected but the facility never collected the specimen. V20 stated the facility told V20, we dropped the ball. On 4/17/23 at 11:15am, V4, Registered Nurse (RN) stated V20, R1's Family requested a urine specimen to be collected in August 2022. V4 stated R1 kept stating R1 can only pee at 2:30pm and had tried several attempts and straight catheterization to obtain a urine specimen, but not successful. V4 stated the collection of the urine specimen to be sent for testing was clearly dropped. R1's medical records do not document a urine specimen was collected as per R1's Standing Orders in August 2022. 2. R3's Physician Order Form dated 4/6/23 documents an order for R3 to have a CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel), and Hemoglobin A1C completed due to poor wound healing. R3's Medical Record contained the laboratory results for the CBC and CMP but not the Hemoglobin A1C. R3's Nursing Progress Notes dated 4/8/23 document V17 (R3's family) was updated that V16 APN (Advanced Practice Nurse) had ordered laboratory testing per V17's request to check R3 for diabetes but that the Hemoglobin A1C was not obtained due to a non-supportive diagnosis code. On 4/17/23 at 10:30 am, V4 RN (Registered Nurse) stated V4 was the nurse on duty when the Lab came to draw R3's ordered tests. V4 explained R3's Hemoglobin A1C was not drawn, stating the lab said a new diagnosis code was needed as the code for a non-healing wound was not acceptable. V4 stated V4 called V15 Physician with an update and V15 gave a new diagnosis of hyperglycemia. V4 explained V4 did not call the lab back to the facility or complete a new lab request but did pass it on to the next shift. V4 stated V4 did not write an order or document the diagnosis of hyperglycemia in R3's medical record because V4 was uncomfortable doing that, even though V15 gave a new diagnosis, because R3 isn't a diabetic, as far as V4 knows. On 4/17/23 at 10:57 am, V2 DON (Director of Nursing) stated V4 should have written up a telephone order with the new diagnosis code that was given and filled out a new lab request. V2 was not aware that the laboratory needed a new diagnosis and that the ordered test had not been completed. On 4/18/23 at 9:55 am, V2 stated V2 checked the online laboratory results and R3's Hemoglobin A1C has not been completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146184 If continuation sheet Page 7 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luther Oaks 601 Lutz Road Bloomington, IL 61704 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident did not develop a pressure ulcer, failed to complete an initial or weekly wound assessments and failed to refer resident to the dietician for an evaluation of nutritional interventions to promote healing for one of three residents (R3) reviewed for pressure ulcers on the sample list of six. This failure resulted in R3 acquiring an unstageable pressure ulcer to the right heel on 1/11/23 and not receiving nutritional interventions to promote healing until 3/21/23. Residents Affected - Few Findings Include: The facility's Skin Integrity-Pressure Ulcers/Pressure Injury Policy dated 12/4/2017 documents any resident who is admitted without a pressure ulcer/pressure injury will not develop a pressure ulcer/pressure injury unless clinically unavoidable and a resident who has a pressure ulcer/pressure injury will receive care, services to promote healing, prevent infection (to the extent possible), and prevention of additional pressure ulcers/pressure injury. A pressure ulcer/Injury refers to the localized damage to the skin and/or the underlying soft tissue usually over a bony prominence or related to a medical device or other device. Avoidable means the resident developed a pressure ulcer/injury and that the facility did not do one of more of the following: evaluate the resident's clinical condition and pressure ulcer/pressure injury risk factors; define and implement interventions that are consistent with the resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. Unstageable encompasses three different scenarios: having a non-removable dressing in place that cannot be removed, slough and/or eschar, known but not stageable due to coverage of the wound bed by slough and/or eschar, or suspected deep tissue injury in evolution. Eschar is dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. To prevent a pressure ulcer/pressure injury, the facility will identify whether the resident is at risk for developing or has a pressure ulcer/pressure injury upon admission and thereafter; evaluate resident specific risk factors for changes in the resident's condition that may impact the development and/or healing of a pressure ulcer/pressure injury, implement/monitor/modify interventions to attempt to stabilize, reduce or remove the underlying risk factors. Using the Skin Risk Breakdown Assessment Tool which includes categories for sensory perception, moisture, activity, mobility, nutrition and friction, make consideration of those individual scores that place a resident at risk and refer to the prevention guidelines for interventions. R3's MDS (Minimum Data Set) dated 1/2/23 documents R3 requires extensive assist of two staff for bed mobility and transfers and is at risk for pressure ulcers. R3's Skin Breakdown Risk assessment dated [DATE] documents R3 is at high risk for skin breakdown. R3's Care Plan dated 12/29/22 documents R3 is at risk for potential pressure ulcer development related to urinary incontinence and immobility with interventions to educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements, importance of taking care during ambulating/mobility, good nutrition and frequent repositioning, monitor/document/report PRN (as needed) any changes in skin status; appearance, color, wound healing, sign/symptoms of infection, wound size (length, width, and depth) and stage of wound, and thoroughly cleanse and dry peri area with each incontinent episode. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146184 If continuation sheet Page 8 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luther Oaks 601 Lutz Road Bloomington, IL 61704 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 R3's Nursing Progress Notes document the following: Level of Harm - Actual harm 12/29/22 - R3 was admitted to the facility status post hospitalization for a fractured right hip. There is no documentation of any pressure ulcers upon admission, only of a surgical wound to the right hip. Residents Affected - Few 1/11/23 - R3 noted to have a wound to the right heel, which was measured and logged in the wound documentation. Dry dressing applied. R3 tolerated well. Complaints of pain to area when touched. There is no documentation in R3's medical record that the RD (Registered Dietician) was notified of R3 having a wound until 3/28/23. R3's 3/28/23 Nutritional Assessment by V13 RD documents R3 is receiving a magic cup daily, has a fractured hip and blister to the right heel and is experiencing right foot pain. R3's laboratory results dated [DATE] document an albumin level of 2.7, normal is 3.5 - 5.0 and a total protein level of 4.9, normal is 6.3-8.3. R3's Only Wound Evaluations/Assessments in R3's Medical Record are as follows: 1/11/23 - R3 has a wound measuring 0.56 cm (centimeters) by 0.97 cm but does not document the size, stage or characteristics of the wound. 1/15/23 - R3 has a blister to the right heel, in house acquired, of unknown age measuring 5 cm by 4.43 cm but does not document the stage or characteristics of the wound. 1/28/23 - R3 has a blister to the right heel, in house acquired, of unknown age, measuring 3.21 cm by 3.79 cm. 3/26/23 - R3 has a blister to the right heel, in house acquired, of unknown age, measuring 2.1 cm by 3.57 cm. 4/1/23 - R3 has a blister to the right heel, in house acquired, measuring 3.95 cm by 2.37 cm. R3's Wound Care Telemedicine Initial Evaluation Notes dated 2/10/23 by V14 Wound Physician documents R3 has an unstageable, full thickness, pressure ulcer to the right heel measuring 5 cm by 4 cm covered in 50% thick adherent devitalized necrotic tissue and 50% dermis with moderate serous drainage. R3's Wound Care Telemedicine Follow Up Evaluations document the following: 3/3/23 - unstageable, full thickness, pressure ulcer to the right heel measuring 5 cm by 4 cm, covered 100% by a thick adherent devitalized necrotic tissue with light serous drainage. No change to the wound. 4/14/23 - unstageable, full thickness, pressure ulcer to the right heel measuring 5 cm by 3 cm, covered 100% with thick adherent devitalized necrotic tissue with no exudate. No change to the wound. R3's April 2023 Physician Orders documents an order to Cleanse the right heel wound with normal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146184 If continuation sheet Page 9 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luther Oaks 601 Lutz Road Bloomington, IL 61704 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 - Actual harm Residents Affected - Few saline and pat dry. Then apply betadine and wrap with gauze three times per week. These orders also document an order dated 3/21/23 for a Magic Cup {Nutritional Supplement} QD (daily), which was then increased to BID (twice a day) on 4/12/23. R3's March 2023 MAR (Medication Administration Record) documents R3 did not receive the ordered magic cup on the 21st, 24th, 25th and 26th. R3's April 2023 MAR does not document R3 received the magic cup BID {with breakfast and supper} as ordered from the 12th - 16th. On 4/17/23 at 9:05 am, R3 was brought breakfast and did not receive the ordered magic cup. On 4/17/23 at 10:30 am, V4 RN (Registered Nurse) confirmed R3 was supposed to get a magic cup as a nutritional supplement but did not get it at times due to the supplier being out of them. V4 stated the magic cups are served with meals and come out of the kitchen. On 4/17/23 at 10:38 am, V12 Dietary Aide confirmed the facility was out of magic cups for a while but currently has them. V12 stated V12 is not sure why R3 did not receive it today with breakfast. On 4/13/23 at 1:45 pm, R3 was lying in bed, on a regular mattress. V4 RN (Registered Nurse) removed the dressing to R3's right heel to reveal an approximate. 4 cm x 3 cm hard black eschar area to the right heel. V4 completed the dressing change as ordered. On 4/17/23 at 1:13 pm, V13 RD stated normally V13 is notified of wounds by V2 DON (Director of Nursing) or the nursing staff and if a resident has a wound, I (V13) normally throw the kitchen sink at them; reviewing their intakes, weight history, any current supplements, if they are taking them or not, and if the wound isn't healing, what else needs changed. Just try to find the breakdown. V13 stated V13 will write a progress note and/or complete a nutritional assessment for the resident when V13 is notified of skin breakdown, and with no assessment completed until 3/28/23, V13 guesses V13 wasn't notified until 3/28/23 but will have to check V13's records. V13 stated V13 isn't sure what V13 would have recommended at the time for R3 when R3 developed the pressure ulcer to the right heel., V13 stated, I (V13) would have done something, probably liquid protein. V13 also stated V13 hates to say R3 not receiving the supplement when the wound first developed, or as ordered since it was started, is contributing to the wound not healing because nutrition is just one corner stone of the healing process but with R3's albumin level and total protein level being low and the fact R3 has an unstageable pressure ulcer and significant weight loss, R3 needs something more than what (R3) is getting. On 4/17/23 at 1:46 pm, V2 DON stated, when a resident develops a new pressure ulcer, the nurses should measure the wound, call family, and the physician to get order for treatment or a wound consult visit. The floor nurses should also call the RD or email the RD for possible interventions. V2 also stated the facility at times will put residents into a specialty mattress if the wound is a recurring problem or if it isn't getting better with the current treatments but hasn't investigated doing that for R3. On 4/17/23 at 2:22 pm, V2 DON stated the Wound Evaluations of R3's pressure ulcer that were provided are the only ones the facility has completed. V2 explained V2 would like the evaluations to be done weekly but that is a work in progress. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146184 If continuation sheet Page 10 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luther Oaks 601 Lutz Road Bloomington, IL 61704 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 - Actual harm Residents Affected - Few On 4/18/23 at 10:01 am, V14 Wound Physician stated V14 has seen R3 via Telemedicine visits only and the facility staff are providing the measurements and condition of the wound to V14. V14 stated V14 is being told the pressure ulcer isn't draining anymore and that is what V14 was managing is the drainage aspect, so in that case, the pressure ulcer is now stable. Nutritional interventions such as Vitamin C, multivitamins, and/or extra protein would help to heal the wound. On 4/18/23 at 11:29 am, V13 RD stated after looking back on V13's notes, V13 had not been informed of the pressure ulcer when it first developed, it wasn't until R3 also had a weight loss that V13 was notified. I have already spoken with V2 and V3 ADON (Assistant Director of Nursing) and we are coming up with a new way for V13 to be notified so that this doesn't happen again in the future. V13 explained, supplements absolutely aid in healing of the wound and had I (V13) been notified of the wound upon development, I (V13) would have at least put (R3) on a multivitamin and possibly liquid protein also but you have to look at the whole picture. At that point, I (V13) believe (R3) was eating well because (R3's) weight was stable. (R3) had just broken (R3's) hip prior to the development so that is part of looking at the whole picture of what is going on with someone. Hopefully we {facility} will start to see some improvement in the wound now with these additional supplements. On 4/18/23 at 1:50 pm, V2 DON in the presence of V1 Executive Director and V3 ADON stated looking back on R3's situation and with R3 just having a fractured hip and not being mobile, R3 would have been a candidate for a special pressure relieving mattress and that R3 should have had one. V2 confirmed there were no pressure relieving interventions in place upon admission to prevent R3 from developing a pressure ulcer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146184 If continuation sheet Page 11 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luther Oaks 601 Lutz Road Bloomington, IL 61704 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete thorough post fall investigations for two residents (R1, R4). The facility also failed ensure a resident was supervised and using the appropriate transfer devices to prevent a fall for one of three residents (R1) reviewed for falls on the sample of six. This failure resulted in R1 falling while standing unassisted in the bathroom, sustaining a head laceration requiring four staples. Findings include: The facility's Fall Reduction Policy dated last revised on 1/5/2021 with next review dated 1/5/2022 documents that this policy is intended to ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes identifying, evaluating and analyzing hazards and risks, implementing interventions to reduce hazards and risks and monitoring effectiveness and modifying interventions when necessary. The policy states that all residents will be assessed on admission, following a fall, quarterly per guidelines or if the Interdisciplinary Team (IDT) recognizes a change in condition and that all residents are assessed on admission using the admission Nursing Evaluation and following Minimum Data Set (MDS) protocol thereafter. The policy states residents identified as being at risk for falls will have individualized care plan intervention. IDT Falls Committee will meet on an ongoing basis to review fall analysis. This policy documents procedure following a fall is outlined in the Incident Reports policy which includes completion of Incident Report, documentation in IDT notes, 72-hour monitoring, Fall Risk Evaluation Tool, and review and update of Plan of Care. The facility's Incident Reports - Clinical Department policy dated 9/3/2009 documents an incident is any happening which is not consistent with the routine operation of the facility or the care of a particular resident. It may be an accident or a situation which might result in an accident. The nurse should complete an incident report after each incident for example falls. The policy states this facility shall notify the Department of Public health of any accident or incident, which has, or likely to have a significant effect on the health, safety, or welfare of our resident and in implementing this policy the following shall apply to ensure appropriate follow-up care in the event of an accident/incident. The residents power of attorney for health care, physician, and supervisor should be notified. After the residents cared for, the incident report and incident management investigation tool should be completed in its entirety by the nurse. Any recommended intervention should be carried out to prevent event from reoccurring. A complete report will be filed on the approved incident form. No incident report or copies are to be placed in the medical record. Incident reports are to be reviewed by the director of health care services or designee and the administrator as appropriate. Incidents resulting in injury should be forwarded to corporate director of risk management for example falls resulting in serious injury/illness or death. The policy states a descriptive summary of each incident or accident shall be recorded in the progress notes or nurses notes for each resident involved and the facility shall maintain a file of all written reports of incidents or accidents involving residents. The facilities Incident Reports - Clinical Department policy does not include the facility is to complete 72-hour monitoring, Fall Risk Evaluation Tool, and review and update of Plan of Care as the facility's Fall Reduction Protocol documents the Incident Reports - Clinical Department policy will (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146184 If continuation sheet Page 12 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luther Oaks 601 Lutz Road Bloomington, IL 61704 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 outline. Level of Harm - Actual harm 1. R1's Minimum Data Set (MDS) dated [DATE] documents R1's balance during transitions and walking as, not steady, only able to stabilize with staff assistance. Residents Affected - Few R1's Incident Report dated 1/1/23 at 2:36pm documents R1 had a witnessed fall on 1/1/23 at 9:35am. This report documents V21, Certified Nursing Assistant (CNA) called V4, Registered Nurse (RN) to R1's room. R1 was laying on R1's back on the floor in R1's bathroom with bright red blood on the back of R1's head, which was actively bleeding. V21 stated V21 was providing care, turned for a brief moment and R1 lost R1's balance and fell straight back. There is no documentation into an investigation of details of what care was being provided, where R1 was and what R1 was doing just before R1 fell, or why/where V21, CNA turned away from R1. R1 told V21 immediately after the fall, I (R1) can't see. Within a few seconds R1 was able to see the CNA. This report documents R1 was unable to provide further details. This report documents V4, RN and V21 attempted to sit R1 up after assessing R1. R1 cried out in pain to the lower back. This report documents predisposing physiological factor of gait imbalance and that R1 was ambulating without assist. There is no documentation that a gait belt was in place while R1 was standing in R1's bathroom. This report documents R1's Care Plan was reviewed and implemented a new intervention post fall to have Physical Therapy evaluate and treat. There is no documentation of the root cause of this fall. R1's medical records do not document 72-hour post fall monitoring as per the facility's policy. R1's Neurological check documentation is incomplete. R1's Hospital Records dated 1/1/23 document R1's Computed Tomography of the Head or Brain without Contrast results dated 1/1/23 document no acute Intracranial abnormality and a right posterior parietal scalp hematoma. These records document R1's X-ray of the left hip with pelvis results dated 1/1/23 at 2:43pm documenting there is no fracture or acute abnormality. This report documents degenerative changes of the lower lumbar spine. There is no documentation of additional lumbar spine radiology tests on 1/1/23. R1's Hospital Records dated 1/9/23 document R1 arrived at the local emergency room with complaints of increased confusion ongoing since 1/1/23 after sustaining a fall and that R1 had been seen at another local emergency room on 1/1/23 where R1 was diagnosed with a Urinary Tract Infection (UTI) and staples were placed in R1's head. R1 has chronic pain but R1's lower back pain has increased. These records document R1's initial Computed Tomography (CT) scan was abnormal in which R1 was evaluated by neurosurgery at the bedside. These records document R1 was also found to have L1 (Lumbar Vertebrae) compression fracture. These records document CT of Abdomen and Pelvis with Contrast Results dated 1/9/23 at 3:13pm documenting, there is a slight concave compression of the L1 inferior endplate with slight increased density of this segment. Consider MRI (Magnetic Resonance Imaging) if indicated for a questionable subtle acute compression fracture of the L1 vertebral body. These records also document CT of the Brain without Contrast results including Low-density/chronic left subdural fluid collection/hemorrhage and that this report flagged for provider attention. These records document Assessment/Plan including L1 Compression Fracture and a Left Convexity Subdural Hygroma VS Subdural Hematoma. R1's Neurosurgery Consultation dated 1/9/23 documents R1 has a Mild Compression Fracture of unknown Chronicity and a small left convexity Subdural Hygroma verses Chronic Subdural Hematoma. This consultation documents R1 is not a candidate for kyphoplasty at this given time and no neurosurgical intervention indicated at this time. The handwritten report notes dated 1/10/23 from the local hospital document the facility received (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146184 If continuation sheet Page 13 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luther Oaks 601 Lutz Road Bloomington, IL 61704 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 information that R1 had a L1 compression fracture in addition to a Urinary Tract Infection. Level of Harm - Actual harm On 4/17/23 at 11:15am, V4, Registered Nurse (RN) stated V4 was notified that R1 was on the floor. R1 was on R1's back with a wound to right side of R1's head that was bleeding. V4 stated V21, CNA said V21 was within arm's reach of R1 and saw R1 falling and was not able to reach R1. V21 stated V21 was by R1's recliner and R1 was at the sink in the bathroom. V4 stated R1 requires a stand by assist while standing and ambulating and that V21 was aware as V4 notified V21 on 1/1/23 before the fall. V4 stated V21 was also aware that V21 was to stay with/right beside R1 when R1 was standing. V4 stated R1 hit R1's head pretty hard. V4 stated R1 complained of (R1's) back hurting, tried to sit (R1) up a little but (R1) was in excruciating pain to R1's back. V4 stated R1 was crying out in pain to R1's back so they did not move R1 and called 911 to transport R1 to the hospital. V4 stated R1 has a history of chronic back pain, but never the level of severity R1 had after falling on 1/1/23. Residents Affected - Few On 4/20/23 at 1:40pm, V2, Director of Nursing (DON) stated the fall investigations are completed by the floor nurses. V2 stated the Interdisciplinary team (IDT) meetings discuss and decide appropriate interventions related to each fall. V2 stated, if needed V3, Assistant Director of Nursing (ADON) and V2 look in to the fall more and get additional information if needed and update care plan. V2 stated the IDT works on the root cause of the fall together and there is a page in the electronic charting for incidents where that is documented. I do not recall what the root cause of R1's fall was on 1/1/23. The box that is empty on the fall report is where that information should be regarding the root cause. I think V3 talked to V21, CNA. V2 thinks V21 told V2 that V21 turned around to grab some type of linen and that V21 was right next to R1. V2 stated R1 was standing at R1's sink with R1's walker but did not have a gait belt on and should have. V2 was unsure if R1 was wearing R1's shoes. V2 stated V21, CNA was terminated, due to the fall as well as issues with other staff. 2. R4's Fall Risk assessment dated [DATE] documents R4 is a high risk for falling. R4's Progress Notes dated as follows document: 2/6/23 at 4:57pm - Diagnosis: Right elbow fracture, post fall 2-1-23. Alert to self only, confused. Right arm in splint with ace wrap. 2/14/23 at 4:28pm - Description of event: R4 noted to be sitting on the floor in front of recliner with back leaning against recliner. Staff states R4 had been transferred to the recliner 5 minutes prior to watch television. Current Evaluation: R4 denies pain at this time. Assessment for Injury: No acute injury. New interventions put in place: (blank) R4's Incident report documents on 2/14/23 at 4:10pm, R4 was found sitting on the floor in front of recliner with R4's back leaning against the recliner. Staff stated R4 had been transferred to R4's recliner 5 minutes prior to watch television. This report documents R4 was unable to give a statement, R4 was assessed for injury and assisted in to the wheelchair. This report documents there were no witnesses found. This report documents added to care plan to provide (R4) with activities that serve as distractions to help prevent R4 from falling. There is no documentation of witness statements from staff as to when R4 had been toileted, if R4 was incontinent at the time of the fall or if R4's call light was in reach. There is no documentation as to if R4 was wearing proper footwear. There is no documentation as to the root cause of R4's fall on 2/14/23. R4's medical records do not document a fall risk assessment post R4's fall on 2/14/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146184 If continuation sheet Page 14 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luther Oaks 601 Lutz Road Bloomington, IL 61704 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 - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 4/20/23 at 1:40pm, V2, DON stated V2 did not believe the facility documented which staff were responsible for R4 at the time of R4's fall on 2/14/23. V2 stated V2 does not believe any witness statements were received from staff. V2 stated R4 kept stating R4 had to urinate, even with the urinary catheter being in place, even though it was draining okay, of which none of that information is documented in the investigation. V2 stated the facility policies are needing reviewed and that there have been a lot of corporate changes and that is who reviews/updates policies. Event ID: Facility ID: 146184 If continuation sheet Page 15 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luther Oaks 601 Lutz Road Bloomington, IL 61704 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide a therapeutic diet and nutritional supplements as ordered to ensure resident weights were maintained for two of three residents (R2, R3) reviewed for meals on the sample list of six. Residents Affected - Few Findings Include: 1) R2's ongoing computerized weight history documents the following weights: April 2023 - 104.6 pounds, March 2023- 109 pounds, February 2023- 112.6 pounds, January 2023- 115.6 pounds, December 2022 120.6 pounds, November 2022- 126 pounds, and October 2022 - 129.4 pounds. This calculates to be a weight loss of 19.17% from October 2022 - April 2023. R2's April 2023 Physician Orders document R2 is to receive a High Calorie/High Protein diet, Regular texture for a diagnosis of Unspecified Protein - Calorie Malnutrition. This Physician Order Sheet also documents an order on 4/12/23 to discontinue R2's TID (three times a day) health juice {nutritional supplement}, which was originally ordered on 11/25/22, and replace it with a health shake {nutritional supplement} to BID (twice a day) pending confirmation. R2's March 2023 MAR (Medication Administration Record) documents R2 did not receive the ordered Health Juice three times a day as ordered on the 1st, 2nd, 6th, 7th, 11th, 12th, 15th, 16th, 18th, 20th, 21st, 24th, 25th, 26th, 29th or 30th. R2's April 2023 MAR documents R2 did not receive the ordered Health Juice three times a day as ordered on the 3rd, 4th and 7th. R2's April 2023 MAR does not document that R2 received the ordered Health Shake BID at all from the 12th - 16th. On 4/13/23 at 1:15 pm, V8 Culinary Director prepared R2's lunch which consisted of 2 BBQ (Barbeque) ribs, baked beans, coleslaw, a chocolate chip cookie. An unidentified CNA (Certified Nursing Assistant) provided R2 with a grape drink and water. The facility Diet Extensions: Thursday Week 2 documents for a High Calorie High Protein diet, R2 was to have Beer Cheese Soup and 8 ounces of whole milk, in addition to what R2 was served. The facility Diet Extensions: Monday Week 3 documents for breakfast, R2 was to have 6 ounces of juice, 8 ounces of whole milk, a hot beverage, 2 slices of French Toast, 2 sausage, and fresh fruit. For lunch, R2 was to have sausage and cabbage soup, spaghetti with meat sauce, green beans, garlic bread, 8 ounces of whole milk and a hot beverage. On 4/17/23 at 9:15 am, V12 Dietary Aide prepared R2's breakfast, with V8 present, which consisted of 2 slices of French toast, 3 slices of bacon, and fresh mixed fruit. An unidentified CNA provided R2 with coffee that contained creamer and sugar. R2 was not served milk. On 4/17/23 at 10:57 am, V2 DON (Director of Nursing) with V1, Executive Director present stated, Pending Confirmation on orders means the order was put in by someone other than the nurse and the nurse just needs to go in and confirm the order. R2 should be receiving the supplement, even when the order is in pending status. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146184 If continuation sheet Page 16 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luther Oaks 601 Lutz Road Bloomington, IL 61704 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 4/17/23 at 12:25 pm - V4 RN (Registered Nurse) stated R2's order for the health shake is showing up as pending confirmation and therefore R2 has not been receiving it. V4 stated V4 was not aware that if orders were showing as pending confirmation that V4 needed to confirm the order and be giving it, nobody has ever told me that. On 4/17/23 at 12:27 pm, V12 prepared R2's lunch, with V8 present, which consisted of spaghetti with meat sauce, green beans, and garlic bread. An unidentified CNA provided R2 with juice. No milk or soup was served. On 4/17/23 at 12:30 pm, V8 stated V8 is unsure why R2 didn't get soup last Thursday {4/13/23} or today, it was down here and some residents got it. V8 stated V8 was not aware R2 was to get whole milk (per menu). V8 stated, if it's on the menu, R2 should be getting it. V8 stated dietary staff should be looking at the menu spreadsheet to see what to serve according to the specific diet. 2) R3's ongoing computerized wight history documents the following weights: February 5, 2023 - 183.1 pounds, March 13, 2023 - 159.2 pounds, March 19, 2023 - 157.3 pounds, March 26, 2023 - 157.5 pounds, April 2, 2023 - 150.2 pounds. This calculates to be a weight loss of 13.05% from February 5, 2023 - March 13, 2023. R3's April 2023 Physician Orders document an order for a magic cup {Nutritional Supplement} QD (daily) dated 3/21/23 - 4/12/23, at which point it was increased to BID (twice a day). R3's March 2023 MAR (Medication Administration Record) documents R3 did not receive the ordered magic cup on the 21st, 24th, 25th and 26th. R3's April 2023 MAR does not document R3 received the magic cup BID as ordered from the 12th - 16th. On 4/17/23 at 10:30 am, V4 RN (Registered Nurse) confirmed R3 was supposed to get a magic cup due to R3's significant weight loss and stated R3 did not get the magic cup at times though due to the supplier being out of them. V4 stated the nutritional supplements are normally served out of the kitchen. On 4/17/23 at 10:38 am, V12 Dietary Aide stated the facility currently has magic cups but did confirm they were out of them for a while. V12 confirmed the kitchen sends the magic cups out with the meal trays and is unsure why one was not sent out last week {4/13/23} or today {4/17/23}. On 4/17/23 at 1:13 pm, V13 Dietician stated if the facility was having a hard time obtaining a certain nutritional supplement, they should have reached out to V13 and V13 would have recommended something different, that they were able to get. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146184 If continuation sheet Page 17 of 17