Health inspection·April 4, 2023

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few located on the left calcaneus. The wound measures 1 cm length x 0.8 cm width x 0.1 cm depth; 0.628 cm^2 area and 0.0063 cm^3 volume. The Wound Note documented Plan: Wound # 1 left Calcaneus: cleanse wound with cleaner, protect peri wound with skin prep, cover wound with bordered foam, change every 72 hours, change PRN for soiling and/or saturation. Nutrition: discussed nutrition and its impact on wound healing. Pressure Relief/Offloading: Follow Facility Pressure Ulcer prevention policy/protocol, pressure redistribution mattress per facility policy/protocol, wheelchair pressure redistribution cushion per facility policy/protocol, offload heels per facility policy/protocol. R1's Wound note dated 03/27/23 at 1:00 PM documents Wound # 1 status is open. Original cause of wound is pressure injury. The date acquired is 03/08/23. The wound has been in treatment 2 weeks. The wound is currently classified as a category/stage III wound with etiology of pressure ulcer and is located on the left calcaneus. The wound measures 0.9 cm length x 0.6 cm width x 0.1 cm depth; 0.424 cm^2 area and 0.0042 cm^3 volume. The Wound Note documented Plan: Wound # 1 left Calcaneus: cleanse wound with cleaner, protect peri wound with skin prep, cover wound with bordered foam, change every 72 hours, change PRN for soiling and/or saturation. Nutrition: discussed nutrition and its impact on wound healing. Pressure Relief/Offloading: Follow Facility Pressure Ulcer prevention policy/protocol, pressure redistribution mattress per facility policy/protocol, wheelchair pressure redistribution cushion per facility policy/protocol, offload heels per facility policy/protocol. On 03/30/23 at 2:29 PM, R1 was sleeping in bed. R1's left heel was not floated or offloaded. R1's left heel was lying flat on mattress. On 03/30/23 at 3:35 PM, R1 was still sleeping in bed in the same position with R1's heels lying flat on mattress with no pressure relief. On 03/31/23 at 1:17 PM, R1 was lying in bed flat on her back. R1's left heel was not floated and lying directly on the mattress without pressure relief. On 03/31/23 at 8:47 AM, V8, Corporate Wound Nurse stated, I would expect them to be floating her heel on a pillow when she's in bed. On 04/04/23 at 12:05 PM, V14, Wound Physician, stated that she would expect the facility to be floating R1's heel on pillow to offset the pressure. Facility's policy Wounds: Treatment of Pressure and Non-pressure Injuries, including Staging and Documentation dated 09/2022 documents To provide guidelines for use in wound assessment, treatment, and documentation. A. 6. Interventions should be taken to reduce edema and pressure related to the wound such as offloading heels and repositioning. 2. R3's Electronic Medical Record, documents R3 was admitted on [DATE]. R3's MDS dated [DATE] documents alert, requires extensive assistance of two+ persons physician assist for bed mobility. The MDS documents R3 requires extensive assistance of one-person physical assist for dressing, requires total dependence with two+ persons physical assist for toilet use. R3's MDS documents R3 requires limited assistance of two+ persons physical assist for personal hygiene. R3 MDS documents R3 has a catheter and has 2 Stage III pressure ulcers and one Stage IV pressure ulcer. The MDS document skin and injury/treatments: pressure reducing device for chair and bed, turning/repositioning program, and nutrition/hydration intervention to manage skin problems. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145121 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 145121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alton Memorial Rehab & Therapy 1251 College Avenue Alton, IL 62002 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 - Minimal harm or potential for actual harm Residents Affected - Few R3's Undated Care Plan, documents I admitted with a multiple pressure injures. I have a history of MASD (incontinence moisture skin damage.) I have been educated about the risks of sitting and apply pressure to my sacral area and how it will impede wound healing. I have been non-compliant with turning and reposition. I also sit up in my chair for extended amounts of time. I have been non-compliant with frequency in dressing changes. Interventions: treatments as ordered by MD (physician), notify my nurse if my dressings are not intact, check my skin daily and notify my nurse of changes, RD (registered dietitian) to follow for nutritional support, assistance, and encouragement to turn and reposition as needed, LAL (low air loss mattress) wound physician to follow. Please let the nurse know if my dressing is not intact OR any new areas of redness an/or impairment. My goal is to reduce the risk for skin impairment and/or optimize wound healing through this next review period. R3's Physician's Order Sheet, dated 3/2023 documents 2/14/2023: sacrum pressure ulcer BID (twice a day) cleanse wound to sacrum, pack with Nova Gran damp gauze BID and PRN (when needed). May use Nova Gran if Dakin's unavailable. 2/27/2023: Left gluteal fold pressure ulcer cleanse area to with wound cleanser (WC) dry, cover with Aquacel extra, cover with foam. Change q (every) 3 days and PRN. R3's Undated Wound Care Treatment Administration Record (TAR), documents had no documentation the pressure ulcer treatment was administered per physician's orders for R3's sacral ulcer on 3/2/2023 at 8:00 PM, 3/16/2023 8:00 AM and 8:00 PM, 3/20/2023 at 8:00 AM and 8:00 PM, 3/22/2023 at 8:00 PM, 3/23/2023 at 8:00 PM, 3/24/2023 at 8:00 PM, 3/25/2023 8:00 AM and 8:00 PM, and 3/26/2023 8:00 PM. R3's Wound Visit Report, dated 3/27/2023 documents sacral PU (pressure ulcer) remains extensive. Failed NPWT (negative pressure wound therapy), returned to packing with Novagran or Dakins if out of Novagran. History: sacral abscess debrided, then discharged to SNF (skilled nursing facility) where ulcer worsened and required surgical debridement, osteomyelitis noted and treat with multiple courses of abx (antibiotics), developed bacteremia with sepsis due to this ulcer. Clostridum cadaveris bacteremia. Because of this, therapy will not be able to do any advanced modalities. Noncompliant with offloading. Less friable bleeding tissue but remains deep with undermining. Ordered for BID changes due to amount of exudate (drainage); Left buttock/gluteal fold PU 3 (stage III) worse again this week and foam dressing daily ordered but foam not large enough - will change to ABD (absorbent dressing) instead. Has foley in, but this sometimes leaks. Non ambulatory and WC (wheelchair) bound at baseline. Again, discussed with patient need to reposition (weekly discussion), but she continues to lay in bed on her back or sit up in bed. Plan of care: appropriate treatments for moist wound healing, offloading. Goals for wound: maintenance. Frequency of encounters: weekly. Duration of expected treatment: until closure, discharge, or transfer. Potential to heal: poor. Sacrum wound is currently classified as Stage IV. The wound measures 6.2 centimeters (cm) length x 5.3 cm x 4 cm with fat layer and fascia exposed. There is no tunneling noted, however there is undermining starting at 12:00 and ending at 6:00 with a maximum distance of 6.5 cm. There is a large amount of sanguineous drainage noted. There is a large (67%-100%) red granulation within the wound bed. There is no necrotic tissue within the wound bed. The periwound skin appearance had no abnormalities noted for texture, moisture, color, or temperature. The periwound has tenderness on palpation. Wound progress: unchanged. Left gluteal fold pressure ulcer is classified as a Stage III measures 3.5 cm length x 9.5 cm width x 0.3 cm depth. There is fat layer exposed. There is no tunneling, or undermining noted. There is a large amount of serosanguineous drainage noted. The wound margin is indistinct and nonvisible. There is large pink granulation within the wound bed. There is a small (1% - 33%) amount of necrotic tissue within the wound bed including adherent slough. The peri wound skin appearance has no abnormalities noted for texture, moisture, color, or temperature. The peri wound has tenderness on palpation. Wound progress: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145121 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 145121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alton Memorial Rehab & Therapy 1251 College Avenue Alton, IL 62002 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 worsening. Level of Harm - Minimal harm or potential for actual harm On 3/30/2023 at 11:00 AM V4, Certified Nurse Assistant (CNA), V5, CNA and V6, CNA, entered R3's room to provide activities of activity living (ADL) care. V5 assisted R3 to roll to her left side. There were two dressings, one over R3's sacrum and one over an area on R3's left gluteal fold, both dressings were saturated in wound drainage and were not intact. There was urine on R3's incontinence pad that was under her and V4 asked R3 if her catheter was leaking and R3 stated 'If there is urine down there then my catheter must be leaking somewhere.' V4 assisted R3 to roll to her right side and V5 applied hand sanitizer and gloves then she took approximately 4 4x4 gauze and put them against R3's open sacrum wound. V5 stated this will have to do until the nurse can dress the wounds. Residents Affected - Few On 3/20/2023 at 1:15 PM V5 stated she always puts 4 x 4s on R3's wound to soak up the wound drainage until the nurse can dress the wounds. On 3/30/3023 at 1:25 PM, V5 and V7 Licensed Practical Nurse (LPN) entered R3's room to provide wound care. V7 stated the dressings were not intact due to excessive wound drainage. V7 stated the dressings rarely stay in place due to the wound drainage. V7 stated the wound on R3's sacrum and left lower gluteal fold were pressure ulcers. V7 washed her hands and applied gloves. V7 open a gauze roll and sprayed wound cleanser (WC) directly into the gauze roll packet. V7 stated the physician's order is to saturate the gauze roll with WC and pack it in R3's sacrum pressure ulcer. V5 assisted R3 to roll to her left side and V7 removed the non-intact dressings from R3's sacrum and left lower gluteal fold pressure ulcers. V7 failed to remove gloves after removing the saturated dressings from R3's sacrum and left gluteal fold pressure ulcers. V7 sprayed WC on several 4x4s and sprayed WC directly into the deep sacrum pressure ulcer and wiped the WC with the same gloves with 4x4 gauze. V7 then sprayed WC directly on the actively bleeding left gluteal fold pressure ulcer and wiped it with the same gloved hands with dry 4x4s. V7 then packed the entire saturated WC gauze roll in R3's sacrum pressure ulcer and did not administer a dressing. V7 cleansed the left gluteal fold pressure ulcer with WC again then applied Santyl and a foam dressing to the bloody pressure ulcer. V5 and V7 assisted R3 to turn on her right side, while R3 turned the WC saturated gauze roll came out of the sacrum wound and V5 wrapped it in the incontinence pad and threw it away. On 3/30/2023 at 3:16 PM V7 stated no staff reported to her that R3's pressure ulcer dressings were not on and intact, that her catheter was leaking urine and she didn't instruct a CNA to apply 4x4 gauze to R3's sacrum pressure ulcer. She expects staff to report when wound dressings are not on and intact and when a catheter is leaking so she can go fix it. On 3/31/2023 at 8:00 AM R3 lay in bed positioned on her back. R3 stated her wounds were treated once yesterday and no nurse looked at her catheter. R3 stated her catheter was still leaking, and staff know her catheter is leaking but they don't do anything about it. R3 stated no staff have been in her room to provide care this morning other than to drop her breakfast tray off. R3 stated no staff have offered or encouraged her to turn and reposition and no staff have assessed if her catheter is leaking or changed the pad under her. On 3/31/2023 at 9:45 AM V9, CNA stated R3 has a colostomy bag and a catheter, so she doesn't need incontinence care but that she does provide catheter care once a shift. V9 stated she wasn't assigned to R3 this morning that V4, CNA was assigned to her and that this was the first time she was going into R3's room. On 3/31/2023 at 9:51 AM V9 entered the resident's room at the request of the IDPH surveyor. V9 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145121 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 145121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alton Memorial Rehab & Therapy 1251 College Avenue Alton, IL 62002 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 - Minimal harm or potential for actual harm Residents Affected - Few assisted R3 to turn to her left side. The incontinence pad under R3 was saturated with urine, there was no dressing over the Stage IV pressure ulcer on R3's sacrum and the dressing on the Stage III pressure ulcer on R3's left gluteal fold was not intact. V9 stated she didn't know R3's catheter was leaking and that she was laying in urine. On 3/31/2023 at 9:54 AM V7, LPN entered R3's room and observed the urine saturated incontinence pad. V7 stated she didn't know that R3's catheter was leaking and that the dressings were not on or intact. On 3/31/2023 at 10:15 AM V4 stated she was not assigned to R3 today and that she provided no care for her. On 3/30/2023 at 2:34 PM V8, Corporate Wound Nurse stated she does weekly rounds with the wound physician at the facility on Mondays. V8 stated R3 was admitted approximately a year ago and she was admitted with the sacrum pressure ulcer, but the lower left gluteal fold pressure ulcer was facility acquired. V8 stated R3 is non-compliant with offloading and won't turn and reposition, R3 wants to lay on her back so she can do crafts. V8 stated the coccyx pressure ulcer is classified as a stage IV pressure ulcer and the treatment is supposed to be Nova Gran hydrochloric acid which helps protect against bacteria buildup and biofilm, if the facility doesn't have Nova Gran for some reason they can sub Dakin's Solution. V8 stated wound cleanser isn't a substitute for Nova Gran and shouldn't be used in its place as wound cleanser just cleans the wound bed, it doesn't help protect against bacteria buildup or biofilm. V8 stated staff are supposed to dampen gauze with Nova Gran then cover the coccyx pressure ulcer with an ABD (large absorbent dressing.) (R3's) left gluteal fold pressure ulcer is classified as a Stage III acquired pressure ulcer and the treatment was apply aquacel extra which is a white hydofiber which helps collect drainage and allows dressing to stay on longer, this was dressing is supposed to be changed every 3 days and PRN. Per V8 there is no physician's order for Santyl to be applied to the left gluteal fold pressure ulcer. V8 expects staff to administer pressure ulcer treatment per physician's orders. On 3/31/2023 at 2:24 PM V2, Director of Nursing (DON), stated she expected staff to follow physician's orders and follow the facility's policies. V2 wasn't aware staff were not following physician's orders for R3's pressure ulcers and wasn't aware the treatment to R3's sacrum pressure ulcer wasn't being administered BID per physician's order, she stated the sacrum pressure ulcer treatment was now changed to once a day. V2 expected the pressure ulcer dressings to be on and intact and if they aren't staff should notify the nurse and the nurse should do the pressure ulcer treatment as soon as they can. On 3/31/2023 at 10:00 AM V10, Nurse Practitioner (NP) stated she expects the facility to follow policies and procedures and physician's orders. V10 stated when a CNA observes a wound dressing is not on and intact, she expects the CNA to report that to the nurse and the nurse should redo the dressing as soon as they can. A resident laying in urine for long periods of time can cause the skin to breakdown further. V10 didn't know R3 doesn't have a dressing ordered for the sacrum pressure ulcer but that R3 is being assessed by a wound physician, so she doesn't address R3's wounds. On 4/4/2023 at 11:53 AM V14, Wound Physician stated she expects staff to follow facility policies and physician's orders. V14 stated the following: she assesses R3's sacrum and left gluteal fold pressure ulcers every Monday. They are both chronic and are status quo, they are not getting better but not getting worse either. The sacrum pressure ulcer is classified as a Stage IV. The treatment is an unrolled gauze roll sprayed with an antiseptic solution and pack it in the sacrum wound, an ABD (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145121 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 145121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alton Memorial Rehab & Therapy 1251 College Avenue Alton, IL 62002 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 - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete (large absorbent dressing) would help to keep the packed gauze in the wound but isn't necessary because the disposable pad under R3 is a secondary dressing. The left gluteal fold is classified as MASD and a Stage III pressure ulcer. It should be cleansed with wound cleanser and a hydrofiber dressing should be applied. The sacrum pressure ulcer treatment was to be changed twice a day and the gluteal fold dressing once a day. When staff observe a dressing is not on and intact, they should notify the nurse and the treatment should be reapplied as soon as possible. V14 stated she doesn't know what to say about staff not packing the sacrum pressure ulcer by just placing a wound cleaner soaked gauze roll in the wound, wound cleanser doesn't have antiseptic properties and isn't designed to be packed in a wound and when staff rolled R3 over and the gauze roll fell out of the sacrum pressure ulcer staff should have told the nurse and should have redone the treatment. Santyl is a physician's order, and it is not ordered for R3 and she doesn't know why staff are applying Santyl to the left gluteal fold pressure ulcer. Event ID: Facility ID: 145121 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 145121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alton Memorial Rehab & Therapy 1251 College Avenue Alton, IL 62002 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 observation, interview, and record review the facility failed to provide services to address a leaking catheter for one of 3 residents (R3) reviewed for catheters in a sample of 9. Residents Affected - Few Findings include: R3's Undated Care Plan, R3 had a catheter in place to promote wound healing along with retention of urine. The Care Plan documented Please perform foley care as needed. On 3/30/2023 at 11:00 AM V4, Certified Nurse Assistant (CNA), V5 CNA and V6 CNA entered R3's room to provide activities of activity living (ADL) care. V5 assisted R3 to roll to her left side. The incontinence pad under R3 was saturated with urine. Observation showed R3 had an indwelling catheter. V4 asked R3 if her catheter was leaking and R3 stated 'If there is urine on my pad my catheter must be leaking.' On 3/30/2023 at 11:35 AM V4 stated she comes into work at 6:00 AM. (R3) has a colostomy bag and a urinary catheter so she doesn't need incontinence care. V4 emptied (R3's) catheter bag earlier and gave R3 her breakfast tray but she didn't provide incontinence care. V4 stated she didn't know R3's catheter was leaking and R3 didn't tell her she was wet. On 3/30/2023 at 3:16 PM V7, Licensed Practical Nurse (LPN) stated no staff reported to her that R3's catheter was leaking urine. V7 stated she expects staff to report when a catheter is leaking so she can go check on it. On 3/31/2023 at 8:00 AM R3 lay in bed. R3 stated no nurse looked at her catheter on 3/30/2023. R3 stated her catheter was still leaking, and staff know her catheter is leaking but they don't do anything about it. R3 stated no staff have been in her room to provide care this morning other than to drop her breakfast tray off. R3 stated no staff have assessed if her catheter is leaking or changed the pad under her. On 3/31/2023 at 9:48 AM V13, CNA stated R3 has a catheter and a colostomy bag, so she doesn't need incontinence care. On 3/31/2023 at 9:51 AM R3 lay in bed. V13 entered R3's room and assisted her to roll to her left side. The incontinence pad under R3 was saturated with urine at that time. V13 stated she wasn't assigned to R3 all morning that V4 was and that she just took over the assignment. She didn't know R3's catheter was leaking and wasn't aware R3's incontinence pad was saturated with urine. V7 entered the room and stated she wasn't aware R3's catheter was leaking or that her incontinence pad was saturated with urine. On 3/31/2023 at 9:54 AM V4 stated she wasn't assigned to R3 today, that V13 was assigned to her and that she didn't provide any ADL care to R3 this morning. On 3/31/2023 at 2:24 PM V2, Director of Nursing, DON stated she expects staff to follow the facility policies and procedures. V2 stated R3's catheter leaks often and nursing is aware of that, they notify R3's physician and they change the catheter, but they don't send her out to the hospital every time her catheter leaks. V2 stated staff do rounds on all residents every 2 hours, she expects staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145121 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 145121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alton Memorial Rehab & Therapy 1251 College Avenue Alton, IL 62002 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete to check on residents with catheters at that time as well to ensure they are clean and dry. V2 stated she wasn't aware R3's catheter was leaking and that she was sitting on a urine saturated pad on 3/30/2023 and 3/31/2023. On 3/31/2023 at 10:00 AM V10, Nurse Practitioner (NP), stated she expects the facility to follow policies and procedures and physician's orders. V10 stated she didn't know the facility's incontinence policy but that she assumes staff round on residents every 2 hours and provide incontinence care then. V10 stated residents that have a catheter should also be rounded on every 2 hours and when needed. V10 stated R3 is alert and oriented and staff are in and out of her room throughout the day. V10 stated she's aware R3's catheter leaks often and she's had the catheter a long time. V10 stated when a CNA observes the catheter is leaking, she expects the CNA to alert the nurse and the nurse should assess R3's catheter as soon as they can. V10 stated staff should check and change the pad under R3 when it was observed with urine on it when they observe it. Event ID: Facility ID: 145121 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 145121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alton Memorial Rehab & Therapy 1251 College Avenue Alton, IL 62002 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure medications were given as ordered. There were 35 opportunities with 5 errors resulting in a 14.29% medication error rate. The errors involved 3 residents (R7, R8, R9) in the sample of 9 out of 3 residents observed during medication administration. Residents Affected - Few Findings include: 1. On 3/31/2023 at 8:20 AM, Licensed Practical Nurse (LPN), administered medications to R7. V7 failed to administer potassium 10 mEq (milliequivalents), Fluticasone nasal spray and glipidize XL 10 milligrams (mg) to R7. R7's Physician's Order Sheet (POS), dated 3/2023 documents the physician's orders to administer potassium 10 mEq twice a day (BID) for replenishment, Fluticasone nasal spray 2 sprays once a day for allergies and Glipidize XL (extended release) 10 mg once a day for diabetes. 2. On 3/31/2023 at 8:30 AM, V7, LPN, administered medications to R8. V7 failed to administer Duloxetine 40 mg to R8. R8's POS, dated 3/2023 documents a physician's order for Duloxetine 40 mg once a day for bipolar. 3. On 3/31/2023 at 8:41 AMmV7, LPN, administered medications to R9. V7 failed to administer Polyethylene Glycol 17 grams to R9. R9's POS, dated 3/2023 documents a physician's order for Polyethylene Glycol 17 grams once a day for constipation. On 3/31/2023 at 12:30 PM V7 (LPN) stated she knew there were several medications were not available during the morning medication pass including R7's potassium and nasal spray. V7 stated the facility has a backup medication kit, but it's usually empty so she didn't look to see if any of the medications were in there. V7 stated residents not having medications available at the facility is unfortunately common. V7 stated when a nurse is passing medications, they are supposed to pull the tab when there are only a few pills left on the medication card and send the information to pharmacy, so they know to send a new medication card but not all staff do that, so they run out of medications often. On 3/31/2023 at 2:24 PM, V2, Director of Nurses (DON), stated, I expect staff to administer medication to residents per physician's orders. I was aware (R7) didn't receive his potassium and nasal spray this morning but no one reported to me that other residents didn't receive physician prescribed medications. There is a backup medication system at the facility and I expect staff to use it if a resident's medication isn't available. The Facility's policy Administration of Medication dated 08/2022 documents To provide general guidelines for staff to follow in the administration of medications. It continues under A. 2. Each resident will have his/her own supply of medications, excluding stock medications. It further documents under H. 7. If the medication is unavailable at time, the Nursing Supervisor should be contacted and may obtain medication from the emergency drug supply or contact the physician to try to obtain an alternate order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145121 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 145121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alton Memorial Rehab & Therapy 1251 College Avenue Alton, IL 62002 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review the facility failed to provide protective oversight leaving a resident's medications on the bedside table for 1 of 4 residents (R3) in a sample of 9. Findings include: On 3/30/2023 at 8:00 AM, R3 was lying in bed. A cup of pills was on her breakfast tray. R3 stated V7, Licensed Practical Nurse (LPN), came in her room, dropped off the pills and ran out of her room. On 3/30/3023 at 8:10 AM, V7, LPN, stated R3 doesn't want to take her medications on an empty stomach so she left the medications with her to take them. V7 stated she doesn't do this all time, R3 just didn't have her breakfast tray yet and she needed to continue to medication pass. On 3/31/2023 at 8:05 AM, R3 was lying in bed. A medication cup filled with medications was on her breakfast tray. On 3/31/2023 at 8:15 AM, V7 stated, (R3) won't take her medications without eating breakfast first so I left the medications in there for her to take, I can't control when (R3) takes her medications. On 3/31/2023 at 2:34 PM, V2, Director of Nursing (DON), stated, I expect staff to observe residents take their medications because we have to provide protective oversight and to ensure the resident takes their medications. The Facility's policy Administration of Medication dated 08/2022 documents, Do not leave medications in the room or on a food tray. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145121 If continuation sheet Page 10 of 10