Inspection·January 29, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Staff encouraged fluids, rest, and nutritional options with no notable relief. V13 Physician here on 1/5/24 and assessed. Orders received for x-rays to left lower extremity as well as Ultrasound/Doppler. V14 in agreement with orders. On 1/25/24 at 3:37 pm, V14 (R4's family) stated V14 isn't sure when R4 got hurt and started having pain specifically because V14 was not notified about it until the beginning of January 2024 but was told at that time that R4 had been hurting for a while. On 1/19/24 at 10:30 am, V4 confirmed R4 had been complaining of pain to the left lower extremity for approximately one week prior to V13 and V14 being notified. V4 stated the facility was providing conservative treatments to R4 such as rest, hydration and proper positioning but when that was not affective, that is when V4 notified V13. The facility's Change in Resident's Condition or Status Policy dated 12/8/23 documents this organization promptly notifies the resident, his or her attending physician/healthcare provider, and the resident's representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician/healthcare provider when there has been a (an): accident or incident involving the resident, discovery of injuries of an unknown source and/or a significant change in the resident's physical/emotional/mental condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146184 If continuation sheet Page 2 of 5 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 01/29/2024 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** 3. R3's Fall Risk assessment dated [DATE] documents R3 is a moderate fall risk. R3's MDS (Minimum Data Set) dated 9/19/23 documents R3 has severe cognitive impairments and requires extensive assistance of one staff for transfers. R3's Unwitnessed Fall Report dated 11/3/23 documents CNA (Certified Nursing Assistant) found R3 sitting on R3's buttocks, on the floor next to the bed, leaning against the bed. R3's call light was on. R3 stated R3 pressed the call light after sliding off the bed and explained R3 was trying to get to the bathroom. R3's bed was very wet from being incontinent and (R3) was trying to get to the bathroom. The facility did not provide a fall investigation with documented root cause of the fall or what new interventions were implemented. R3's Care Plan dated 10/11/23 documents, R3 is at risk for falls due to gait/balance problems and incontinence with interventions including: anticipate and meet needs, be sure call light is within reach and encourage R3 to use it for assistance as needed. Respond promptly to all requests for assistance. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Ensure R3's bed is in lowest position and floor mats are in place. Ensure R3 is sitting in the wheelchair properly. Offer earlier times to get up in the morning if R3 is awake. Staff to get R3 ready for the day at the end of midnight shift due to R3's pattern of wanting to get up earlier and attempting to do so without assistance. Staff to offer snack, drink, and activity while waiting for breakfast. Staff to provide frequent checks to ensure proper alignment in bed. Reposition as needed and use smaller blankets on bed to prevent R3 from getting tangled up in covers. This care plan does not document any new fall interventions since 8/1/23. On 1/29/23 at 12:15 pm, V1 Administrator stated the facility normally investigates falls, especially if there is injury, but did not do one with R3's 11/3/23 fall. V1 also verified that since there was no fall investigation, there were no new post fall interventions implemented. The facility's Fall Prevention and Post Fall Management Policy dated 8/8/23 documents the nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and other members of the multidisciplinary team, will seek to identify and document resident risk factors for falls and establish a resident centered falls prevention plan based on relevant assessment information. The staff will seek to identify environmental factors that may contribute to falling, implement a resident centered fall prevention plan to reduce the specific risks factor(s) of falls for each resident at risk or with a history of falls, and implement relevant interventions to try to minimize serious consequences of falling. Resident responses to interventions will be monitored and if the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change the current interventions. Continue to collect and evaluate information until the cause of the falling is identified or it is determined that the cause cannot be found. When a fall occurs, the following information should be recorded in the resident's medical record: the condition in which the resident was found, assessment of the data including vital signs and any obvious injury, interventions or treatment administered, notification of the family and physician, and appropriate interventions taken to prevent future falls. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146184 If continuation sheet Page 3 of 5 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 01/29/2024 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 Based on observation, interview, and record review, the facility failed to provide appropriate supervision for a dependent resident to prevent a fall, thoroughly investigate a fall, implement post fall interventions, and report a fall timely to the physician and resident representative for three of four residents (R1, R2, R3) reviewed for falls on the sample list of 18. This failure resulted in R1 falling in the bathroom after being left unattended and sustaining a head laceration requiring two staples. Findings include: 1.R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact. This same MDS documents R1 is independent with cares and uses both a walker and wheelchair. R1's MDS in progress dated 1/24/24 indicates R1 requires maximum assistance of one person for toileting, upper and lower body dressing and moderate assistance for chair/bed to chair transfer. R1's undated Face Sheet documents diagnoses of Other Frontotemporal Neurocognitive Disorder, Need for Assistance with Personal Care, History of Falling, Unsteadiness On Feet. R1's Fall Risk Assessment, dated 10/20/23, documents R1 is at risk for falls. R1's Nursing Progress Notes dated 1/3/24 at 4:14 pm document R1 was observed on the bathroom floor next to the toilet. R1 was unable to provide details leading up to the fall. Upon assessment, bleeding was noted to the back of R1's head. Pressure was applied; however, the bleeding was unable to be controlled. R1 was transported to the hospital. R1's ED (Emergency Department) Report dated 1/3/24 documents, R1 had a fall while on the toilet and hit (R1's) head resulting in complaints of pain and a laceration to the back of the head. R1's laceration was repaired and R1 was returned to the nursing facility. R1's Nursing Progress Notes dated 1/3/24 at 10:55 pm documents R1 returned to the facility with two staples in the back of the R1's head with a scant amount of bleeding. On 1/29/24 at 10:30 am, V7 Certified Nursing Assistant (CNA) stated V7 got R1 up from bed for dinner and took R1 to the restroom. V7 explained V7 left R1 alone on toilet to go check on another resident and upon returning to R1's room, noted R1 on the floor. V7 stated R1 had attempted to stand up and pull up R1's own pants. V7 stated R1 has always used the call light to alert staff when R1 needs help but failed to use the call light at this time. V7 stated V7 immediately called the nurse in to access R1 and R1 was sent to the hospital. On 1/29/24 at 1:50 PM, V3 Assistant Director of Nurses (ADON), stated R1 fell on 1/3/24 at 3:30 PM while in the bathroom alone. V3 stated residents should not be left alone in the bathroom. R1's Nurse Progress Note, dated 12/1/23 at 6:37 AM, documents, R1 was calling out and was observed on floor in front of R1's bed, sitting on a pile of blankets and sheets. The progress notes reflect, On coming nurse RN (Registered Nurse) to contact POA (Power of Attorney), On call physician and PCP (Primary Care Provider. There is no further documentation indicating that notifications were completed. On 1/29/24 at 1:50 pm, V3 ADON (Assistant Director of Nursing) stated, in the presence of V1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146184 If continuation sheet Page 4 of 5 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 01/29/2024 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 Administrator and V2 DON (Director of Nursing), family notification is to be documented in the medical chart either in a progress note or in the fall investigation. V3 confirmed there is no progress note stating the family had been notified, only that the night nurse endorsed this task to the dayshift nurse. Residents Affected - Few 2. The facility's Incident by Incident Type Log dated 1/29/24 documents R2 had a fall on 12/9/23. R2's Unwitnessed Fall Report dated 12/9/23 documents the CNA (Certified Nursing Assistant) reported that R2 was on the floor. This report did not contain an investigation identifying the root cause of the fall; however, it does document a post fall intervention of frequent checks to be implemented. R2's Care Plan dated 5/25/23 documents R2 is at high risk for falls related to Confusion, Gait/balance problems, Incontinence, and Psychoactive drug use. This Care Plan does not document the new intervention of frequent checks from R2's 12/9/23 fall. On 1/29/24 at 1:50 PM, V1 Administrator, V2 DON (Director of Nursing) and V3 ADON (Assistant Director of Nursing) all stated that the care plan should be updated to reflect new interventions as listed on the Fall Report. V3 acknowledges that the care plan did not contain the intervention of frequent checks of R2 from the 12/9/23 fall. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146184 If continuation sheet Page 5 of 5