Inspection·August 1, 2024

F 0600 staff. Staff provided continual observations and remained with her until calmed. Level of Harm - Minimal harm or potential for actual harm --4/18/24 at 10:30 AM (R16) seated in recliner in television room when (R4) approached her, grabbing (R16's) Right Hand and pulling her hair. Noted a red spot to (R16's) Right thumb area. Residents Affected - Few V20 Housekeeper's witness statement for R4 to R16 physical abuse investigation dated 4/18/24 documents on 4/17/24 Shortly after lunch, (R4) was in a bad mood and started to verbally assault those around her. (R4's) main target was (R271). (R4) started to pound on (R271's) table, grabbing (R271's) things and yelling at (R271). (R4) ended up grabbing a fork and full ketchup bottle and threw it at (R271). I managed to catch it before any of it hit (R271). This same witness statement documents on 4/18/24 During breakfast, (R4) was again verbally assaulting those around her. (R4's) main targets being (R16 and R271). As (R271) was coming back to breakfast, (R4) attempted to trip her and kicked (R271's) walker to which I wheeled (R4) to her room. V22 Certified Nurse Aide (CNA) witness statement for R4 to R16 physical abuse investigation dated 4/18/24 documents I heard (R16) screaming. I was over by the coffee maker with (V21) CNA. I said (R4) get away from (R16). I turned the corner and saw (R4's) hand on (R16's) hand and hanging on to (R16's) hair. I said back up and lean in between the two (R4, R16) residents. Once (R4) backed up, I fully stepped in between (R4, R16). (V21) CNA was behind me. V21 Certified Nurse Aide (CNA) witness statement for R4 to R16 physical abuse investigation dated 4/18/24 documents On 4/18/24 at around 8:55 AM, when I heard (R16) yell. (V22) Certified Nurse Aide (CNA) ran to (R16). I saw (R4) grabbing (R16's) hand and also grabbed (R16's) hair. I was able to separate both (R4, R16) residents and stayed with them until V19 Social Service Director (SSD) came. On 7/30/24 at 11:00 AM R4 was self propelling in her wheelchair in hallway next to R16 sitting in her wheelchair. On 7/31/24 at 8:15 AM R4 was sitting in the wheelchair in the hallway several feet away from R16 sitting in her wheelchair in the resident lounge. On 8/1/24 at 11:25 AM R4 was sitting in the hallway next to the resident lounge area within a few feet of R16 sitting in her wheelchair. On 7/31/24 at 1:25 PM R16 stated That lady (R4) pulled my hair. That really hurt. On 7/31/24 at 3:30 PM V19 Social Service Director (SSD)/Abuse Coordinator stated staff should report allegations of any kind of abuse to V19 or V2 Director of Nurses (DON) in V19's absence. V19 stated I was notified of (R4's) interaction with ((R271)) on 4/18/24. No one let me know anything happened on 4/17/24. The staff should have reported that to me so I could have investigated that incident. (R4) threw a fork and ketchup bottle at (R271). (R4) was placed on closer supervision for the first day but I don't know what happened after that. On 8/1/24 at 8:45 AM V2 Director of Nurses (DON) stated R4 has had previous behaviors when staff needed to intervene providing interventions to help de-escalate R4 to baseline behaviors. V2 DON stated R4 was being monitored during breakfast by staff assisting other residents in the dining room. V2 DON confirmed R4 did grab R16's Right Wrist and pull R16's hair. V2 DON stated the incident between R4 and R16 on 4/18/24 did occur but she was not informed of R4's earlier behaviors on 4/17/24 nor 4/18/24 until after the incident between R4 and R16. 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 08/01/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on interview and record review the facility failed to complete a level two Pre-admission Screening and Resident Review (PASARR) after a mental health diagnosis was added to R6's electronic medical record. This failure effects one (R6) of five residents reviewed for PASARR in a sample list of 24 residents. Findings include: On 7/31/24 at 9:40 AM, V2 (Director of Nursing) stated the facility does not have a policy for PASARRs, they just follow the regulation as a guideline. R6's Level 1 PASARR completed on 7/24/19 documents that a level two is not recommended. R6's Electronic Medical Diagnosis report dated 7/30/2024 documents a diagnosis of Schizophrenia added May 20, 2023. On 8/1/24 at 10:15 AM, V2 said that no other PASARRs have been completed since 7/24/19 when R6 was admitted . V2 then said that a PASARR should be completed any time there is change in psychiatric diagnosis and that a PASARR should have been completed when the Schizophrenia Effective Disorder was added in May 2023 as a new diagnosis. 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 08/01/2024 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to assess and track behaviors before giving a diagnosis of Schizophrenia for the administration of antipsychotic medications for one (R6) of five residents reviewed for diagnosis without assessment in sample list of 24 residents. Residents Affected - Few Findings include: The Facility Policy Psychotropic Medication Management System dated 10/26/2022 documents Behavior Management focuses on person-centered, non-pharmacological approaches to care to meet the individual needs of each resident. While there may be isolated situations where pharmacological intervention is required first, these situations do not negate the obligation of the community to develop and implement non-pharmacological approaches. Behavior monitoring is initiated on all residents who exhibited behaviors in the past and all residents who are taking any psychotropic medications of any classification whether scheduled or as needed basis. Behavior monitoring involves identifying behaviors, the number of behavior episodes, success of interventions (whether pharmacological or non-pharmacological intervention), the number of PRN psychotropic used, and any side effects from the psychotropic medication. R6's Diagnosis report dated 7/30/24 documents a diagnosis of Schizophrenia was added to the electronic chart on 5/30/23. On 7/30/24 at 1:38 PM, V2 Director of Nursing stated the physician gave R6 a diagnosis of Schizophrenia on May 20, 2023. On 7/30/24 at 10:55 AM, R6 was sitting in activities in a manual wheelchair with a word find puzzle in front of her. R6 was pleasant and answered questions appropriately and with soft speech. On 7/31/24 at 12:28 PM, R6 was sitting in a wheelchair at the dining room table having an appropriate conversation with the staff and residents. At that time, no behaviors or hallucinations were observed. On 7/31/24 at 12:32 PM, V18 (Certified Nursing Assistant) stated she has worked at this facility for a year and has never seen R6 have any behaviors or hallucinations. V18 stated she cares for R6 on a regular basis. On 7/31/24 at 12:42 PM, V15 (Registered Nurse) stated R6 hasn't had any behaviors recently, sometimes R6 gets confused and looks for her husband and kids, but other than that V15 stated she has never observed or heard of any behaviors or hallucinations. V15 stated she has worked here since January. On 8/1/24 at 9:10 AM, V10 Family member stated R6 has never had any mental health issues. V10 stated R6 was independent and fully functioning until 2019 when she had some falls at home. V10 stated after R6's falls with her Parkinson's and Dementia R6 has slowly declined. V10 stated she was not aware that this diagnosis had been added to R6's chart. On 8/1/24 at 10:20 AM, V2 stated R6 was originally put on Seroquel (antipsychotic) in July 2022 for delusional disorder. R6 was on Hospice at this time. In January 2023, R6 was discharged from Hospice. V2 stated the physician gave the diagnosis of Schizoaffective Disorder in May 2023 because R6 was (continued on next page) 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 08/01/2024 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 0658 crying, angry, falling, and exit seeking. V2 confirmed these behaviors are also expected with her Dementia diagnosis. V2 stated R6 has had no documented behaviors since 2022. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 08/01/2024 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 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to provide an individual discharge plan for R18 who was discharged on 7/26/24 to Independent Living . R18 is one of one resident reviewed for discharge planning in sample of 24. Residents Affected - Few Findings include: The Physician Orders Sheet dated July 2024 documents R18 has the following diagnoses: Urinary tract infection and Infection and inflammatory reaction due to Indwelling Urethral Catheter, Subsequent Encounter. R18's Minimum Data Set (MDS) assessment documents his Brief Interview for Mental Status (BIMS) dated 6/12/24 as being cognitively impaired. R18 requires assistance with his activities of daily living. R18 will try to do things for his care and is not able to complete and will required assistance. R18's care plan dated 6/5/24 does not have any information for discharge planning. V19 Social Service Designee stated in interview 7/31/24 at 3:30 PM I was gone on vacation and did not know they were planning on discharging (R18). No, I did not do any discharge planning for him in the care plan. Facility policy Discharge Planning and Summary dated 4/25/2024 state as their Policy Statement: A post-discharge plan and discharge summary is developed to assist the resident with transition. 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 08/01/2024 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to provide shaving care for two residents (R12, R13) dependent on staff assistance of 16 residents reviewed for shaving care from a total sample list of 24 residents. Residents Affected - Few Findings include: The facility provided General Nursing and Personal Care Policy dated 10/26/16 documents that each resident shall have proper daily personal attention including skin, nails, hair and oral hygiene. A resident who is unable to perform Activities of Daily Living will receive the support needed to maintain nutrition, grooming and personal hygiene. 1. R12's care plan dated 4/17/24 documents that R12 requires extensive assistance with activities of daily living due to confusion, disease processes, and impaired balance. On 7/30/24 at 10:34 AM, R12 was not shaved and had beard hair growing approximately one half inch in length. 2. R13's care plan dated 9/20/23 documents that R13 requires assistance with activities of daily living due to dementia. On 7/30/24 at 10:32AM, R13 was not shaved and had beard growth approximately one half inch in length. On 7/30/24 at 10:34AM, V4 Registered Nurse said that all residents should be shaved daily. On 7/30/24 at 10:59AM, V6 Certified Nursing Assistant said that it isn't possible for the staff to get everyone shaved with the heavy care needs on this hall. 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 08/01/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm 2.) R7's Physician Order Sheet (POS) dated July 2024 documents a physician order starting 10/20/2023 to administer Albuterol Sulfate Inhalation Nebulization Solution (2.5 milligram (MG)/3 milliliter (ML) 0.083% (Albuterol Sulfate) every four hours as needed wheezing and shortness of breath. This same POS documents R7's medical diagnoses of Chronic Obstructive Pulmonary Disease (COPD). Residents Affected - Few R7's Medication Administration Record (MAR) dated July 2024 documents R7 was administered Albuterol Nebulizer on 7/23/24. On 7/30/24 at 10:26 AM R7's Nebulizer tubing and mask were not dated and not bagged while laying on top of R7's bedside dresser. R7's Nebulizer mask showed multiple debris on the inside of the mask. Based on observation, interview and record review the facility failed to provide hygienic oxygen masks and tubing and failed to label and contain the oxygen masks and tubing for two (R13, R7) of two residents reviewed for respiratory care from a total sample list of 24. Findings include: 1.) R13's physician orders dated 5/4/23 document Albuterol Sulfate (bronchodilator) 2.5 milligram per 3 milliliters to be inhaled orally via nebulizer every six hours as needed for wheezing, shortness of breath and coughing. On 7/30/24 at 10:56AM, R13's nebulizer mask was laying on the bedside table, unbagged, without a date or time when to be changed and the mask appeared wet. On 7/31/24 at 10:37AM, R13's nebulizer mask remained on the table, unbagged, without a date or time when to be changed and dust was on it. On 7/31/24 at 11:22AM. V2 Director of Nursing said that the facility did not have a policy regarding the maintenance and care of respiratory equipment; however nebulizer masks and oxygen tubing should be rinsed, labeled and bagged to ensure cleanliness. 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 08/01/2024 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 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 observation, interview, and record review the facility failed to identify behaviors and implement non-pharmacological interventions prior to the use of psychotropic medications for one (R6) of five residents reviewed for psychotropic medications on the sample list of 24 residents. Findings include: Facility Policy Psychotropic Medication Management System dated 10/26/2022 documents Behavior Management focuses on person-centered, non-pharmacological approaches to care to meet the individual needs of each resident. While there may be isolated situations where pharmacological intervention is required first, these situations do not negate the obligation of the community to develop and implement non-pharmacological approaches. Behavior monitoring is initiated on all residents who exhibited behaviors in the past and all residents who are taking any psychotropic medications of any classification whether scheduled or as needed basis. Behavior monitoring involves identifying behaviors, the number of behavior episodes, success of interventions (whether pharmacologic or non-pharmacologic intervention), the number of PRN psychotropic used, and any side effects from the psychotropic medication. R6's Physicians Order Sheet (POS) dated 7/30/24 documents an order for Seroquel (anti-psychotic) Oral Tablet 25 milligrams (MG) give one tablet by mouth, two times a day, every Monday, Tuesday, Wednesday, Thursday, Friday, and Saturday for agitation. This POS also documents an order for 25 milligrams of Seroquel (anti-psychotic) every Sunday for agitation. On 7/30/24 at 10:55 AM and on 7/31/24 at 12:32 PM, R6 was sitting in community areas in the facility. R6 was pleasant and interacting with staff and other residents. R6 did not display any type of behavior. On 7/31/24 at 12:32 PM, V18 (Certified Nursing Assistant) stated she has worked at this facility for a year and has never seen R6 have any behaviors. V18 stated she cares for R6 on a regular basis. On 7/31/24 at 12:42 PM, V15 (Registered Nurse) stated R6 hasn't had any behaviors recently, sometimes R6 gets confused looking for her husband and kids, but other than that V15 stated she has never observed or heard of any behaviors from R6. V15 stated she has worked here since January. On 7/31/24 at 1:45 PM V18 provided incontinent care to R6. R6 was cooperative and followed commands without incident. R6's medical record did not contain documentation of behavior tracking or the use of non-pharmacological interventions. R6's psychotropic care plan dated 7/31/24 does not document targeted behaviors or non-pharmacological interventions. R6's Psychiatry note dated 4/28/24 documents to administer Seroquel (anti-psychotic) 25 mg twice a day for a diagnosis of Dementia. On 8/1/24 at 9:10 AM, V10 (Family member) stated R6 has never had any mental health issues. V10 stated R6 was independent and fully functioning until 2019 when she had some falls at home. After R6's (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 08/01/2024 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 0758 falls with her Parkinson's and dementia R6 has slowly declined. Level of Harm - Minimal harm or potential for actual harm On 8/1/24 at 11:10 AM, V2 (Director of Nursing) stated R6 was originally put on Seroquel in July 2022 for delusional disorder. R6 was on Hospice at this time. In January 2023 R6 was discharged from Hospice. V2 said that the physician gave a diagnosis of Schizoaffective Disorder in May 2023 because R6 was crying, angry, falling and exit seeking. V2 Director of Nursing (DON) confirmed these behaviors are also expected with a dementia diagnosis. V2 stated that R6 has had no documented behaviors since 2022. Residents Affected - Few 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 08/01/2024 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 0801 Level of Harm - Minimal harm or potential for actual harm Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, interview, and record review the facility failed to employ a clinically qualified Director of Food and Nutrition. This failure has the potential to affect all 16 residents residing in the facility. Residents Affected - Many Findings include: The Long-Term Care Facility Application for Medicare and Medicaid dated 7/30/24 documents 16 residents reside in the facility. Throughout the survey from 7/30/24-8/1/24, the facility failed to keep the kitchen clean and free of debris in preparation and storage areas, failed to sanitize food preparation areas according to facility's sanitation policy, and failed to cover and contain ice cream canisters in the freezer. Kitchen staff also failed to contain hair while in the kitchen and food preparation areas. On 7/30/24 at 11:00 AM, V11 (Dietary Manager in Training) stated she enrolled in Certified Dietary Manager courses in April 2024, but has not had time to start the modules yet. On 7/30/24 at 11:30 AM V1 (Administrator) confirmed that V11 has not started Certified Dietary Manager training. 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 08/01/2024 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to honor resident food preferences for one of one residents (R5) reviewed for food preferences in a sample list of 24 residents. Findings include: R5's undated Face Sheet documents medical diagnoses of Alzheimer's Disease, Failure to Thrive and Gastroesophageal Reflux Disease (GERD). R5's Minimum Data Set (MDS) dated [DATE] documents R5 as severely cognitively impaired. This same MDS documents R5 requires supervision with eating. R5's Physician Order Sheet (POS) dated July 2024 documents a physician order starting 5/10/24 with no end date for a Mechanical soft textured diet. NO green beans, broccoli or cauliflower. R5's Nurse Progress Note dated 7/30/24 at 2:22 PM documents (R5) had choking episode at lunchtime. (V13) Hospice Certified Nurse Aide (CNA) present with her at the time and had been assisting with meal supervision. (R5) able to cough and clear her throat. The facility dietary inservice form dated 7/10/24, 7/11/24, 7/23/24 and 7/24/24 documents (Staff) need to follow diet list provided in the pantry book, food preferences are on it. On 7/30/24 at 12:30 PM R5 was sitting at the dining room table being assisted by V13 Hospice Certified Nurse Aide (CNA). V13 Hospice CNA was trying and unable to cut through a large four inch long piece of broccoli with R5's fork. V13 Hospice CNA was able to cut off an end piece of broccoli with R5's knife and assisted R5 in eating the broccoli. R5 immediately began coughing. R5 was coughing for approximately ten minutes. R5 did not finish her lunch meal. R5 was assisted to the resident lounge area while coughing and spitting up pieces of broccoli. On 7/30/24 at 12:33 PM V13 stated There aren't any diet tickets so I just trust the staff to serve the right tray. I don't know of any book with diets. On 7/30/24 at 12:55 PM V12 Dietary Aide stated the dietary staff keep a book in the kitchen which is updated with every resident's diet. V12 stated V12 looks at the book when a resident first admits to the facility to see what their diet is but never looks at it after that. On 7/30/24 at 12:58 PM V13 Restorative Certified Nurse Aide (CNA) stated V13 served R5 her lunch meal on 7/30/24. V13 stated There is a diet book with all of the resident diets written in it. We (staff) are supposed to check the book. I did not check the book and unfortunately did not see that part in that book where it said (R5) should not receive broccoli. On 7/30/24 at 1:10 PM V14 Dietician stated the staff were inserviced on serving the residents accurate diets two weeks ago. V14 Dietician stated V12 Dietary Aide was present for the inservice. V14 Dietician stated the person plating the meal should check the resident diet book every meal to make sure there haven't been any updates. V14 stated R5's Physician order that states R5 should not have any broccoli is a resident preference, not any allergy. V14 Dietician stated broccoli is included in a (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 08/01/2024 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 0806 mechanical soft textured diet but should be fork tender. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 08/01/2024 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 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 store dishes in a sanitary manner, clean food preparation areas with appropriate chemicals, ensure staff's hair was secure to prevent food contamination, and ensure ice cream lids were in place to prevent cross contamination. These failures have the potential to affect all 16 residents who reside in the facility. Findings include: The Long Term Care Facility application for Medicare and Medicaid dated 7/30/24 documents 16 long term care residents reside in the facility. The facility policy Manual Cleaning and Sanitizing date revised 6/1/2021 documents Equipment, utensils, and tableware will be washed and sanitized in a method which complies with the Federal Food Code and any state or local ordinances. Sanitize the equipment surface. Make sure the sanitizer comes in contact with each surface. The concentration of the sanitizer must meet the requirements. Scrape or remove food from the equipment surfaces. Wash the equipment surfaces. Use a cleaning solution prepared with an approved cleaner. Wash the equipment with the correct cleaning tool, such as nylon brush or pad, or a cloth towel. Sanitize the equipment surface. Make sure sanitizer comes in contact with each surface. The concentration of the sanitizer must meet requirements. All other surface clean and sanitize by hand with an approved chemical. Allow surfaces to air dry. On 7/30/24 at 9:35 AM, the kitchen staff were preparing food while not wearing hair nets in the kitchen. V8 Dietary Aide said that she was unsure where hairnets were located. On 7/30/24 at 9:45 AM, food crumbs and debris were covering the food tray that contained soup bowls. Food particles and debris were also observed on the soup table which had soup warming to be served at lunch. Two large Ice cream containers were in the freezer with no lids on the containers. On 7/31/24 at 11:13 AM, V11 Dietary Manager tested her sanitation bucket with test strips. The test results were 3.0 out of 5.5 on the PH scale, indicating not enough sanitizer in solution. V11 stated that the strips should be green to show proper amount of sanitation being used. The test strips were orange. On 7/31/24 at 11:12 AM, V17 [NAME] cleaned the food prep area with degreaser solution and stated she did not know where the sanitation solution was. V11 confirmed after testing the bucket of solution that V17 did not follow the facilities cleaning policy. 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 08/01/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R1's Minimum Data Set (MDS) dated [DATE] documents R1 as moderately cognitively intact. Residents Affected - Many R1's Care Plan dated 7/22/24 documents R1 has impaired cognitive function/Dementia or impaired thought processes due to diagnosis of Dementia. On 7/31/24 at 8:08 AM V15 Registered Nurse (RN) handed R1 his morning medication. During the transfer of R1's medications, R1's pre-cut half pill of Metoprolol Tartrate (beta-blocker)12.5 milligrams (mg) dropped on the dining room table. V15 RN picked up R1's contaminated Metoprolol Tartrate with her bare hands and placed it back in R1's palm of his hand. R1 then swallowed the Metoprolol Tartrate. V15 Registered Nurse (RN) then administered R1's Flonase Allergy Relief Nasal Suspension 50 micrograms (MCG) (Fluticasone Propionate (Nasal)) to both of R1's nares without wearing gloves. R1 had clear drainage from both nares just prior to V15 RN administering nasal spray. V15 RN did not wash her hands in between picking up R1's medication and administering nasal spray. On 7/31/24 at 8:45 AM V15 Registered Nurse (RN) stated V15 should have worn gloves when picking up R1's Metoprolol Tartrate off of the dining room table and when administering R1's Flonase nasal spray. V15 RN stated also V15 should have washed hands after picking up R1's contaminated medication and before administering his Flonase. ON 7/31/24 at 12:00 PM V2 Director of Nurses (DON) stated V15 Registered Nurse (RN) should have used appropriate hand hygiene when administering medications. The facility policy titled Handwashing/Hand Hygiene revised 4/25/2023 documents staff are to use an alcohol-based hand rub or alternatively, soap and water for the following situations: before preparing and handling medications. This same policy documents all team members shall follow the hand washing /hand hygiene procedures to help prevent the spread of infections to residents, visitors, and other staff members. Based on observation, interview and record review the facility failed to have an infection control surveillance program in place and failed to prevent cross contamination when administering medications. These failures have the potential to affect all 16 residents who reside in the facility. Findings include: The Long Term Care Facility Application for Medicare and Medicaid dated 7/30/24 documents sixteen long term care residents reside in the facility. The facility provided Infection Prevention and Control Program dated 7/20/23 documents that the goal of the infection control program is to ensure a structured and coordinated approach for the surveillance, investigation, prevention and control of healthcare infections and other infectious diseases. 1.) On 7/30/24 at 12:30PM V5 IP (Infection Preventionist) provided an incomplete infection control log for July 2024 and said that it was the only resident log of infections that she had for surveillance at this time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete 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 08/01/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm On 7/31/24 at 8:49AM, V5 Infection Preventionist (IP) said that logging/surveillance of infections just began in July 2024. I wasn't keeping logs or resident or employee illnesses or following McGreers (protocol for antibiotic use) before July. Residents Affected - Many 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 08/01/2024 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to have an antibiotic stewardship program in place for two (R9, R12) of six residents reviewed for antibiotic stewardship on the total sample of 24 residents. Residents Affected - Few Findings include: The facility provided Antimicrobial Stewardship Policy retrieval date 7/31/24 documents that antibiotic stewardship is the effort to measure and improve how antibiotics are prescribed by clinicians and used by residents. Improving antibiotic prescribing and use is critical to effectively treat infections, protect residents from harms caused by unnecessary antibiotic use and combat antibiotic resistance. Facility Communities recognize McGreer's evidence-based assessment as the standard for infection definition and as a protocol for antibiotic usage. The Medical Director oversees the adherence to antibiotic prescription. The Infection Preventionist monitors antibiotic use and adherence use protocol and works with the medical director and /or infectious disease doctor to review antibiotic resistance patterns in the community, if present. 1.) R9's physician order dated 7/6/24 documents Sulfa/Trimethoprim (antibiotic) 800/160 milligrams for seven days for a wound infection. R9's physician order dated 6/22/24 documents Methenamine (antibiotic) 1 gram twice daily for urinary symptoms. On 8/1/24 at 8:39AM, V5 Infection Preventionist (IP) said that R9's Sulfa/Trimethoprim antibiotic was for a wound infection, We wouldn't have gotten a culture for that and the Methenamine is a prophylactic antibiotic for urinary tract infections, we don't have cultures for those either. 2.) R12's physician order dated 5/22/24 documents Nitrofurantoin (antibiotic) 100 milligrams to be given twice daily for urinary symptoms. On 8/1/24 at 8:45AM, V5 IP said that R12 is on Nitrofurantoin prophylactic. We don't have a culture and sensitivity when they are on antibiotics prophylactically. I wish that (the doctors) wouldn't put them on them, but my doctors don't agree. No antibiotic stewardship documentation including cultures, sensitivities, resident symptoms, McGreers documentation or communication between V5 IP and the physician prescribers could be located at this survey. On 7/31/24 at 8:49AM, V5 IP said that she wasn't keeping antibiotic logs including types of infections, antibiotic usage, cultures and sensitivities or McGreers criteria for cultures before July (2024). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146184 If continuation sheet Page 17 of 17