Inspection·January 19, 2023

F 0686 shift and prn (as needed) to R (right) buttocks .Dx: Pressure ulcer of unspecified buttock, stage 2. Level of Harm - Actual harm On 1/17/23 at 10:17 AM, V5 and V6 (CNAs-Certified Nurse Aides) were observed while performing incontinence care for R29. V5 put on gloves, opened the urine soaked brief, and washed R29's groin area. V5 and V6 rolled R29 from side to side to remove the wet brief. V5 continued wearing the contaminated gloves to roll R29 while touching the bed linens and resident's gown. An eraser size open wound was observed on the right buttock. R29's buttocks and backside were visibly wet with moisture and urine. V6 applied barrier cream to the buttocks and R29 was again rolled from side to side while V5 continued wearing contaminated gloves. R29's new brief was put on with the buttocks still contaminated from the urine. V5 and V6 were asked by the surveyor to remove R29's socks for heel observations. A golf ball size, dark purple-reddish area was present on the right inner heel. V6 stated the discolored area had been there for a while so they try to keep the heel elevated. V5 and V6 put R29's socks back on, covered him with the blanket, and exited the room with the heels flat on the bed. Residents Affected - Few On 1/17/23 at 11:25 AM and 2:34 PM, R29's heels were flat on the bed. On 1/18/23 at 8:39 AM and 11:27 AM, R29's heels were flat on the bed. On 1/19/23 at 8:55 AM, V7 (CNA) stated aides do skin checks during all resident cares. It is a full head to toe observation on shower days. We watch the buttocks, heels, and other high-pressure points carefully. Changes need to be reported immediately to stop it from becoming more severe. Incontinent residents are never left with urine on the skin. It can cause skin breakdown and infection. Dirty gloves are changed before touching clean areas to stop cross contamination of germs. On 1/19/23 at 8:20 AM, V4 (Registered Nurse) stated she had done the weekly skin check for R29 just yesterday (1/18). V4 said there was an opening on his bottom which was being treated with a zinc barrier cream. V4 said that is the only skin issue R29 has and there was nothing noted on his feet. V4 said the weekly skin checks are done by the floor nurses. It is a head-to-toe assessment. Any skin issues are immediately measured, and the doctor is notified for treatment orders. V4 said the CNAs do skin checks during all daily cares. Any skin changes or new areas found are to be reported immediately to the nurse. On 1/19/23 at 8:30 AM, V4 and the surveyor went to R29's room. R29 was lying in bed with his heels flat on the bed. R29's socks were removed and V4 stated, Wow, this is something new. V4 stated she would get another nurse for a second opinion and to get a tape to measure the wound. V4 and V3 (Registered Nurse) entered the room. Both nurses assessed and measured R29's right heel. Measurements were recorded by V4 as 3 centimeters by 3.5 centimeters, purple rusty. V4 stated she wound classify this as an unstageable pressure ulcer. V3 and V4 stated it was the first time they had knowledge of the pressure ulcer to the heel, and nothing had been reported prior to today. V3 and V4 said there are no treatment orders or interventions in place for the unstageable pressure ulcer to the heel. V3 and V4 said the aides should have reported it right away to prevent it from getting worse. On 1/19/23 at 10:46 AM, V2 (Director of Nurses) stated gloves should be changed between dirty and clean areas. Incontinence care involves cleansing both the front and back of residents. Urine left on open pressure wounds has the potential for infections and further skin breakdown. V2 said any new skin changes need to be reported immediately so it doesn't get worse. Skin that is dark purple or red and still closed like a blister is classified as unstageable. Finding wounds at advanced stages have the potential of becoming infected, residents can become septic, and have increased pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146193 If continuation sheet Page 2 of 10 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 146193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Rochelle 2203 Flagg Road Rochelle, IL 61068 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 R29's care plan showed a focus area of risk for increased pressure injuries relate to dementia, gout, depression, decreased mobility and generalized weakness. Interventions included weekly skin checks as ordered, provide incontinent care after each incontinent episode and compression socks on each morning and off each night. Residents Affected - Few R29's 1/19/23 wound assessment (performed after report by surveyor) showed a 3 x 3.5 centimeter and 100% necrotic tissue area to the right heel. The report also showed two additional wounds discovered during the same assessment, one to the bottom of the right foot and another to the right great toe. The facility's Pressure Ulcer Prevention and Treatment Protocol policy revision dated 7/16 states under the objective section: To ensure that measures are taken to prevent skin breakdown and to provide guidelines for treatment of any pressure injury that might develop. The policy further states under the principles section: 3. All high and moderate risk residents may have the following, and if so, they will be addressed on the Care Plan. E. Skin checks. The facility was unable to provide any policy related to the frequency, process, or reporting for skin checks. The facility's Perineal Care policy revision dated 11/18 states: 4. Begin cleansing from the cleanest area in front to the most soiled area in back. The facility's Standard Precautions policy revision dated 8/09 states under the glove section; c. Change gloves between tasks and procedures on the same resident after contact with material that many contain infectious agents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146193 If continuation sheet Page 3 of 10 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 146193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Rochelle 2203 Flagg Road Rochelle, IL 61068 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on interview and record review, the facility failed to complete a physicians order for UA (urinalysis) and C&S (culture and sensitivity) in a timely manner. Residents Affected - Few This applies to 1 of 3 residents (R45) reviewed for Catheter/UTI. The findings include: R45's Face sheet shows her diagnoses to include, UTI (urinary tract infections), cognitive communication deficit, and dementia. R45's Progress Notes shows the following time line: On 12/21/22 at 11:04 AM, the Physician ordered UA and C&S. On 12/21/22 at 2:54 PM, An attempt to get the necessary urine from the resident failed. On 12/22/22 at 1:20 PM, An attempt to get the necessary urine from the resident failed. On 12/22/22 at 9:25 PM, UA obtained and placed in the refrigerator. (This surveyor asked the facility to provide the results of the UA, and C&S from this specimen but the results could not be found). On 12/27/22 at 2:48 PM, an attempt to get the necessary urine from the resident failed. On 12/29/22 at 2:44 PM, an attempt to get the necessary urine from the resident failed. On 12/30/22 at 1:07 AM, urine sample was obtained via straight catheterization. On 1/2/23 at 4:04 PM, UA result was sent to the Physician. On 1/3/23 at 2:53 PM, The facility received Physician orders for R45 to start an antibiotic for a UTI. On 01/19/23 at 12:28 PM, V3 RN (Registered Nurse) said, she does not know what happened to the first specimen. V3 said, if the normal laboratory doesn't pick the sample up, then the facility should have sent it to the (local hospital) lab. V3 said, it's important to do Physician ordered labs as ordered because the labs could show us what's going on with the resident like infection or chemical imbalances. Delaying the labs could delay treatment to the resident. On 01/19/23 at 10:08 AM, V2 DON (Director of Nursing) said, she doesn't know what happened to that specimen obtained on 12/22/22. V2 said, it was a holiday weekend so maybe our normal lab didn't pick it up, so it should have been sent to our local hospital lab. V2 could find no results for the specimen drawn on 12/22/22. R45's 12/30/22 urinalysis shows turbid (cloudy) urine that was positive for nitrates, and leukocytes. The culture for the same date shows greater than 100,000 colonies/milliliter of Escherichia coli. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146193 If continuation sheet Page 4 of 10 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 146193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Rochelle 2203 Flagg Road Rochelle, IL 61068 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm The Lab/Diagnostic Policy and Procedure (Revised 11/28/17) shows, it is the Policy to provide means of quality diagnostic lab services for the residents. The Purpose is to provide residents a means of diagnostic service promptly and conveniently. The same document shows under the category, Procedures, a. Provision has been made for promptly and conveniently obtaining required clinical laboratory .services from a clinical laboratory or diagnostic services. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146193 If continuation sheet Page 5 of 10 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 146193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Rochelle 2203 Flagg Road Rochelle, IL 61068 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident received respiratory care and services that is in accordance with professional standards of practice for 3 (R7, R34, R44) of 4 residents reviewed for oxygen therapy in the sample of 15. Residents Affected - Few The findings include: 1. R44's face sheet provided by the facility on 1/19/23 showed she was last admitted to the facility on [DATE] with diagnoses to include acute respiratory disease, pulmonary hypertension, malignant lungs, and rheumatic tricuspid insufficiency. R44's Physician order report dated 12/19/22 to 1/19/23 showed, 1/7/23, O2 (oxygen) 2L (liters) NC (nasal cannula), continuous for SOB (shortness of breath). R44's facility assessment dated [DATE] showed that she is cognitively intact (Brief Interview for Mental Status Score 15) and was on oxygen therapy. R44's care plan revised on 1/10/23 showed, R44 has a diagnosis of COPD (chronic obstructive pulmonary disease)/emphysema/asthma. The same care plan showed an intervention to administer oxygen at current rate as ordered. On 01/17/23 at 12:13 PM, in R44's room, the nebulization mask with its medication container was on the night stand, open to air (not covered in a bag). There was no date on the O2 tubing. On 01/18/23 at 9:15 AM, in R44's room, the nebulization mask had medication in its medication container. The mask with the container was on the night stand, open to air (not covered in a bag). No staff was present in the room. On 01/18/23 at 10:55 AM, R44 was sitting near the exit of the unit on a chair. R44's portable O2 concentrator was hanging on her walker and the nasal cannula was in her nostrils. R44 said that she is using O2 at 2L continuously. The O2 concentrator showed that it was set at 2L, but the dial on the concentrator showed that it was empty (needle on the red color of the indicator). V10, unit nurse, looked and said that the machine does show that it was empty. V10 asked R44 if she can feel the air coming from the nasal cannula. R44 said that she is not sure. On 01/18/23 at 2:35 PM, R44 was sitting at her bedside with O2 being administered at 2L continuous via NC connected to the bedside O2 concentrator. R44's walker was nearby with the portable concentrator and the nasal cannula attached to it. The NC hanging on the walker was open to air and was not covered/bagged. 2. R34's face sheet provided by the facility on 1/19/23 showed she was last admitted to the facility on [DATE] with diagnoses to include transient cerebral ischemic attack, acute respiratory disease, fracture of left femur and dementia. R34's Physician order report dated 12/19/22 to 1/19/23 showed, 12/6/22, O2 (oxygen) per NC (nasal cannula) PRN to keep saturation at >92%. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146193 If continuation sheet Page 6 of 10 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 146193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Rochelle 2203 Flagg Road Rochelle, IL 61068 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 R34's facility assessment dated [DATE] does not indicate that R34 is on oxygen therapy. Level of Harm - Minimal harm or potential for actual harm R34's current care plan (revised on 10/11/22) is not updated to address the diagnosis of acute respiratory disease. Residents Affected - Few On 01/18/23 at 10:00 AM, R34 was sitting on the recliner in her room. The O2 concentrator at her bedside was turned off. No date was on the humidifier bottle or tubing. One set of n/c was hanging on the flowmeter knob, uncovered/not bagged. Another set of n/c & tubing was laying on the floor next to the concentrator. V4 (RN-registered nurse) was informed about the nasal canula on the floor. V4 came to the R34's room, saw the NC and tubing on the floor and the ones hanging on the knob uncovered/not bagged. V4 said that R34 is on O2 PRN (as needed). 3. R7's face sheet provided by the facility on 1/19/23 showed she was last admitted to the facility on [DATE] with diagnoses to include pneumonia and congestive heart failure. R7's Physician order report dated 12/19/22 to 1/19/23 showed, ipratropium-albuterol solution for nebulization: 1 vial inhalation while awake, three times a day R7's facility assessment dated [DATE] does not indicate that R7 is on oxygen therapy or on treatment with ipratropium-albuterol. R7's current care plan (revised on 1/17/23) is not updated to address the diagnosis of pneumonia and the MD orders for nebulization therapy. On 1/17/23 at 10:40 AM, A nebulization mask with the container for the medication was on the bedside table uncovered/not bagged in R7's room. 1/18/23 at 09:45 AM, A nebulization mask with the container for the medication was on the bedside table uncovered/not bagged in R7's room. 1/19/23 at 10:00 AM, A nebulization mask with the container for the medication was on the bedside table uncovered/not bagged in R7's room. On 1/19/23 at 11:00 AM, V2, (DON - Director of Nursing) stated that it is the nurse's responsibility to check if the portable concentrator is full or needs a refill. V2 also stated that Nebulization masks and nasal cannulas should be kept bagged when not in use so that it does not collect dust & be a potential portal for infection. The facility's policy titled 'oxygen therapy and safety' with a revision date of 4/9/20 stated, Procedure 1. Safety is the responsibility of all staff 4. Oxygen therapy. b. Turn on flowmeter to 2 L/min to test for appropriate flow of oxygen . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146193 If continuation sheet Page 7 of 10 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 146193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Rochelle 2203 Flagg Road Rochelle, IL 61068 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** 3. R18's Resident Face Sheet, provided by the facility on 1/19/23, showed he had a diagnosis of diabetes mellitus. R18's Physician Order Report dated 12/19/23-1/19/23 showed he had an order for insulin lispro three times a day per sliding scale (based on blood sugar levels). Residents Affected - Some R258's Resident Face Sheet, provided by the facility on 1/19/23, showed he had a diagnosis of type II diabetes mellitus. R258's Diabetes care plan showed a goal that his blood sugar will be maintained within normal limits. The care plan showed Accuchecks (blood sugar levels) as ordered. R260's Resident Face Sheet, provided by the facility on 1/19/23, showed he had a diagnosis of diabetes mellitus due to an underlying condition with diabetic nephropathy. R260's Physician Order Report dated 12/19/23-1/19/23 showed an order for Accuchecks twice weekly. R260's Diabetes care plan showed R260's blood sugar will be maintained within normal limits during this quarter. The care plan showed Accuchecks as ordered. On 1/18/23 at 11:07 AM, V10 (Registered Nurse-RN working the Bounce Back Unit of the facility on 1/18/23) obtained a blood sample from the right third digit of R18's right hand to check his blood sugar levels with a glucometer (a device used to test blood sugar levels). After obtaining the blood sugar level, V10 walked back down to the medication cart and placed the glucometer inside the top drawer of the medication cart, directly on top of the other glucometer that was in the medication cart. V10 placed the container that held the test strips for the glucometer directly on top of the glucometer she used to test R18's blood sugar levels. V10 did not disinfect the glucometer after obtaining the blood sample from R18. At 12:05 PM, V10 said she should have disinfected the glucometer after using it to prevent the spread of disease and germs. On 1/18/23 at 12:16 PM, V2 (Director of Nursing-DON) said the nurses should disinfect the glucometer after use by wiping the glucometer down with a disinfectant and keeping the glucometer wet per manufacturer's instructions. V2 said it is important to do this to prevent the spread of bacteria and blood borne pathogens. V2 was asked to provide the instructions for the disinfectant that should be used to clean the glucometers after use. On 1/19/23 V2 provided a container of Micro-Kill One germicidal alcohol wipes, along with a printed copy of the instructions for use. The instructions showed: Disinfecting: To disinfect hard, non-porous surfaces, use one or more wipes, as necessary, to thoroughly wet the surface to be treated. Treated surface must remain visibly wet for one minute to achieve complete disinfection of all pathogens listed on this label. On 1/19/23, V2 provided a list of residents currently residing on the Bounce Back Unit of the facility that received Accuchecks to determine their blood sugar levels. The list showed R18, R258 and R260 were the residents on the unit that received Accuchecks. V2 said the glucometers in the medication cart on that unit would only be used for the residents on that unit. The facility's policy and procedure titled Standard Precautions, with a revision date of 08/09, showed 5. Resident-Care Equipment: a. Handle resident-care equipment soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposure, contamination of clothing, and transfer of other infectious agents to other residents and environments. b. Ensure that reusable equipment is not used for the care of another resident until it has been appropriately (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146193 If continuation sheet Page 8 of 10 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 146193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Rochelle 2203 Flagg Road Rochelle, IL 61068 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 cleaned and single use items properly discarded. Level of Harm - Minimal harm or potential for actual harm The facility's policy and procedure titled Glucose Monitoring (Even Care G2), with a revision date of 11/15, showed How to Clean/Disinfect the EvenCare G2: The EvenCare G2 machine should be disinfected between uses, using a validated disinfecting agent . Residents Affected - Some Based on Observation, Interview, and Record Review the facility failed to cleanse and sanitize hands and equipment to prevent cross contamination for 4 of 4 residents (R18, R51, R260, and R258) reviewed for infection control in the sample of 15. The findings include: 1. R18's Physician order report dated 12/19/22 to 1/19/23 (last admitted on [DATE]) showed, 1/12/23, Gentamycin in NaCl (sodium chloride) piggyback; 100 mg/100 ml; IV (intravenous); 100 ml/hour; once a day. R18's facility assessment dated [DATE] showed that he is cognitively intact (Brief Interview for Mental Status Score 15) and was on IV medications. On 01/18/23 at 9:00 AM, V10 (RN-registered nurse) collected her supplies and entered R18's room. V10 did not wash her hands or use hand sanitizer before putting on a pair of gloves. V10 adjusted the clothing of R18 to be able to access the IV site, re-positioned his arm and changed her gloves without performing any hand sanitization. V10 withdrew half a milliliter of blood in a syringe, placed it on the bedside table, flushed the IV line with NSS (normal saline solution) and started the gentamycin infusion. After the procedure, V10 removed her gloves, picked up all of the unused supplies (one syringe of NSS flush) and the contaminated items (used alcohol swabs, used gloves, syringe with half a milliliter of blood in it) and walked out of R18's room. V10 went to the medicine cart, pulled open the top drawer, placed the unused syringe of NSS in it, put her hands in her pocket and then used hand sanitizer for her hands. 2. R51's face sheet provided by the facility on 1/19/23 showed that he was last admitted to the facility on [DATE] with diagnoses to include post-surgical infection and long-term use of anti-coagulants. R51's Physician order report dated 12/19/22 to 1/19/23 showed PT/INR test, one time, 07:00 AM. R51's facility assessment dated [DATE] showed that R51 has severe cognitive impairment (Brief Interview for Mental Status Score 6). On 1/18/23 at 9:30 AM, V10 was in R51's room, in the process of drawing blood into the pipette to test his PT/INR. V10 had gloves on. Only a quarter of the pipette was filled. R51's finger was bloody. V10 cleaned the finger with alcohol swab & placed the blood-stained swab on R51's bed. With the used gloves on, V10 removed the strip from the PT/INR test machine & reinserted the same strip. With the same used gloves on and with the pipette with blood in her hand, V10 walked up to the door of the room & turned on the light switch. Then she came back to R51's bedside and placed the pipette on the machine to insert the blood from the pipette into the machine. V10 said that the machine did not give a reading and that she will repeat the procedure after some time. V10 removed her used gloves and placed them on R51's bed. V10 did not clean the machine or wash her hands or use hand sanitizer. V10 placed the machine and the box of strips back into its pouch, closed the pouch, picked up all the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146193 If continuation sheet Page 9 of 10 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 146193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Rochelle 2203 Flagg Road Rochelle, IL 61068 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 used items including the used gloves and the used pipette and left the room. Level of Harm - Minimal harm or potential for actual harm On 1/19/23 at 11:00 AM, V2 (DON-Director of Nursing) stated that PT/INR machine should be cleaned after use and before storing it. V2 stated that V10 should not have turned on the light switch with her used gloves on. V2 stated that V10 should have brought in a sharps container along with her supplies for the procedure and discarded the used lancets, pipettes, blood-stained swabs into the sharps container before leaving the room. V2 stated that V10 should have discarded her used gloves in the trash container. V2 stated that V10 should have washed her hands with soap and water after the procedure. V2 stated that V10 should have washed her hands with soap and water before starting an IV medication. V2 stated that V10 should have taken a sharps container to discard the used syringe with blood in it. V2 stated that other than sharps or blood-stained items, V10 should have discarded all other used items in the trash and washed her hands before leaving the room. V2 stated that with contaminated hands V10 should not have touched any other surfaces like the medicine cart, or her pockets. V2 stated that hand washing is necessary to prevent cross contamination and potential infection. Residents Affected - Some The facility's policy titled 'standard precautions' with a revision date of 08/09 stated, Procedure 2. Gloves . c. change gloves between tasks and procedures d. remove gloves promptly after use . 5. a. Handle resident care equipment soiled with blood, In a manner that prevents skin . exposure . and transfer of other infectious agents to other residents and environments. The facility's policy titled 'PT/INR Portable Draw' states to wash hands before and after the procedure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146193 If continuation sheet Page 10 of 10