Health inspection·November 30, 2023

F 0565 R1's MDS, dated [DATE], documents R1 is cognitively intact with a BIMS of 15. Level of Harm - Minimal harm or potential for actual harm 5. On 11/28/23 at 3:35 PM, R5 stated, I have been here since June 2023, and I have never heard of a Resident Council Meeting and have not been invited to such a meeting. Residents Affected - Some R5's EMR, visit list, documents R5 was admitted to the facility on [DATE] and has a Diagnosis of Type 2 Diabetes Mellitus (DM), Mild protein-calorie malnutrition, Moderate protein energy malnutrition. R5's MDS, dated [DATE], documents R5 is cognitively intact with a BIMS of 13. 6. On 11/28/23 at 3:40 PM, R214 stated, I have not heard of a meeting called Resident Council, and I was never invited to that meeting. R214's EMR, visit list, documents R214 was admitted to the facility on [DATE] and has a Diagnosis of Type 2 DM. R214's MDS, dated [DATE], documents R214 has a moderate cognitive impairment with a BIMS of 8. 7. On 11/28/23 at 3:45 PM, R19 stated, I have been here since May 2023, and I have not been invited to a meeting called the Resident Council. I have not heard of this meeting before. R19's EMR, visit list, documents R19 was admitted to the facility on [DATE] and has a Diagnosis of Type 2 DM. R19's MDS, dated [DATE], documents R19 has a moderated cognitive impairment with a BIMS of 11. On 11/28/23 at 3:05 PM, V16, Activity Director, stated, I have had a meeting every month with those residents who want to attend. There are times when we are eating while meeting. I am not sure why residents would say that we have not had any meetings. I go down the hall and ask every resident if they want to attend the meeting and usually only get one or two. On 11/28/23 at 3:08 PM, V1, Administrator, stated, I think we will send out an actual invitation to every resident to attend the resident council meeting. Going forward, V16 will have a list of items that she will need to address with those attending the resident council meetings. The Facility's Resident Rights and Responsibilities Policy, dated 6/2022, documents 8. Right to make independent choices: f. Organize and participate in a resident council. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145121 If continuation sheet Page 2 of 18 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 11/30/2023 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 0679 Provide activities to meet all resident's needs. 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 provide an ongoing program of activities for 6 of 6 residents (R1, R5, R6, R13, R18 and R19) reviewed for activities in a sample of 33. Residents Affected - Some Findings include: 1. On 11/28/23 at 1:30 PM, a Resident Council Meeting was held in a dining room with R1, R6, R13, and R18 was in attendance. On 11/28/23 at 1:40 PM, R6, Resident Council President, stated, I think the activities are cutting short. The activity girl drives the bus and does other jobs and our activities are slowing down. R6's electronic medical record, visit list, documents R6 was admitted to the facility on [DATE]. R6's Minimum Data Set (MDS), dated [DATE], documents R6 is cognitively intact with a Basic Interview for Mental Status (BIMS) of 15. A Score of 13-15 indicates an intact cognitive response, 8-12 indicates a moderate cognitive impairment, and 0-7 indicates a severe cognitive impairment. On 11/28/23 at 1:42 PM, R13 stated, The activities here are slowing down. We used to play bingo almost every day and everyone likes to play Bingo. Now we may play a couple times a week if we're lucky R13's electronic medical record, visit list, documents R13 was originally admitted to the facility on [DATE]. R13's MDS, dated [DATE], documents R13 has a moderate cognitive impairment with a BIMS of 12. On 11/28/23 at 1:44 PM, R18 stated, We don't do as many activities as we used to do. I think they are just too busy lately. R18's electronic medical record, visit list, documents R18 was originally admitted to the facility on [DATE]. R18's MDS, dated [DATE], documents R18 is cognitively intact with a BIMS of 13. On 11/28/23 at 1:46 PM, R1 stated, We need to have more activities here. R1's electronic medical record, visit list, documents R1 was originally admitted to the facility on [DATE]. R1's MDS, dated [DATE], documents R1 is cognitively intact with a BIMS of 15. 2. R5's Care Plan, dated 5/22/23, documents that R5 would do best to come to activities to be around other people. R5's MDS, dated [DATE], documents that R5 is cognitively intact. The facility provided R5's Activities Detail Report, print date 11/29/2023, for October 2023 and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145121 If continuation sheet Page 3 of 18 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 11/30/2023 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some November 2023. The report does not document activity participation or invitation for R5 for the following dates: 10/1, 10/2, 10/3, 10/4, 10/5, 10/7 through 10/11/23, 10/13, 10/14, 10/16/23 through 10/31/203. The report does not document activity participation and/or invitation for R5 for the following dates: 11/1 through 11/5/2023, 11/10, 11/11, 11/13 through 11/28/23. On 11/29/2023 at 9:00 AM, R5 stated that no one comes in room to get him for activities and that no one comes in and sits and talks with him or provided one on ones with him. R5 stated he has not gotten out of the bed since his prosthesis were taken. R5 stated he would like to go to an activity. R5 stated at this point he is only laying in the bed watching television. R5 stated there is nothing else to do. 3. R13's Care Plan, dated 8/15/23, documents R13's daughter comes every other day to see her, R13 has been coming out to activities, talking to other residents, and helping them when she can, she would benefit to still come to activities to be with the other people. R13's MDS, dated [DATE], documents R13 is cognitively intact. The facility provided R13's Activities Detail Report, print date 11/29/2023, for October 2023 and November 2023. The report does not document activity participation or invitation for the following dates: 10/1, 10/2, 10/3, 10/4, 10/5, 10/7, 10/8, 10/10/23 through 10/31/203. The report does not document activity participation and/or invitation for the following dates: 11/1 through 11/5/2023, 11/8, 11/9, 11/13 through 11/28/23. On 11/29/2023 at 8:50 AM, R13 stated the facility has a 2PM activity. R13 stated she has not been out to or invited to an activity that occurs before then. R13 stated she gets bored because she is confined to a wheelchair and needs staff help at times. R13 stated the bingo occurs in the dining room across from her room. R13 stated she keeps her door open so she can see what's going on in the hall and the dining room. R13 stated she has not seen any activities before 2 PM. R13 stated she has not been invited to any morning activity. On 11/29/2023 at 9:00 AM, R13 was in room in wheelchair. On 11/29/2023 at 9:00 AM, No activity performed on [NAME] Hall. 4. R19's Care Plan, dated 8/28/23, documents R19 would do best coming to activities to be around all the other people. R19's MDS, dated [DATE], documents R19 is cognitively intact. The facility provided R19's Activities Detail Report, print date 11/29/2023, for October 2023 and November 2023. The report does not document activity participation or invitation for the following dates: 10/1, 10/2, 10/3, 10/4, 10/5, 10/7, 10/8, 10/10/23 through 10/31/203. The report does not document activity participation and/or invitation for the following dates: 11/1 through 11/5/2023, 11/8, 11/10, 11/13 through 11/28/23. On 11/29/2023 at approximately 10:38 AM, R19 stated he does not get out of the bed. R19 stated he has not been invited to go to an activity. R19 stated he lays in the bed all day and would like to go to an activity. R19 stated he lays in the bed and watch tv all day. R19 stated he gets the Daily Chronical and reads it sometimes and sometimes he doesn't. R19 stated he does not think it's an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145121 If continuation sheet Page 4 of 18 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 11/30/2023 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 0679 activity. R19 stated he is not sure when the activities are. Level of Harm - Minimal harm or potential for actual harm The facility's Resident Activities, dated 9/22, documents Policy: Each residence will provide an ongoing program of activities, which identifies each resident's interest and needs and individualizes activities based on comprehensive care plan and the preferences of each resident. The program shall support residents in their choice of activities, both residence sponsored, group and individual activities and independent activities, designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145121 If continuation sheet Page 5 of 18 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 11/30/2023 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 - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide complete incontinent care for 6 of 6 (R1, R4, R5, R25, R205, R212) residents reviewed for incontinent care in a sample of 33. Findings include: 1. On 11/28/2023 at 3:00 PM, R1 stated she was supposed to have a test for her urine and there wasn't a urine collector in the toilet and now she had an accident and wet herself. R1 was sitting in her wheelchair, out in the hallway in front of her room. The front of R1's pants were wet in front from the right groin area over to her pelvic and abdominal fold area. At 3:17 PM, V17, Certified Nurse Assistant (CNA) took R1 into her room. V17 donned gloves without benefit of hand hygiene. V18, Licensed Practical Nurse (LPN) then entered R1's room, donned gloves without benefit of hand hygiene. V17 collected items needed to perform incontinent care on R1 then placed gait belt on R1. V17 and V18 assisted R1 to a standing position in the bathroom. V18, pulled down R1's pants and removed the urine-soaked incontinent brief. V17 was standing behind R1 and took wet wash cloths with soap and cleansed front to back R1's perineal area but did not cleanse R1's bilateral groin or abdominal fold. V17 then retrieved a dry wheelchair pad without benefit of hand hygiene or glove change. R1 then asked to sit down in her wheelchair and R1 did so without the soap being rinsed off her skin. After a brief rest period, R1 was assisted back to a standing position and a clean incontinent brief and clean pants were put on. R1's Minimum data set (MDS), dated [DATE], documented her cognition was intact, she was occasionally incontinent of urine, and always incontinent of her bowels. It also documented R1 required partial to moderate assistance with toileting hygiene. R1's CORP-Resident Profile Report, dated 11/29/2023, documented, Due to my incontinence please make sure my peri care is done properly as I am susceptible to UTI's (urinary tract infections) and skin breakdown. R1's Resident Information sheet, dated 11/29/2023, documented a diagnosis of overactive bladder. On 11/29/2023 at 3:30 PM, V24, CNA, stated she would cleanse and dry all areas including the abdominal folds, groin areas, buttocks and hips when performing incontinent care. V24 stated she would perform hand hygiene and glove changes when she contaminates her gloves during incontinent care. On 11/29/2023 at 3:40 PM, V25, CNA, stated when a resident is incontinent, she would cleanse and dry abdominal folds, groins, buttocks and hips and she would perform hand hygiene and glove changes during incontinent care. 2. On 11/28/2023 at 9:15 AM, V14, CNA, with the assistance of V13, CNA, performed incontinent care, on R4, who was incontinent of both urine and stool. V14 cleansed R4 outer and inner labia and bilateral groin with soap and water and did not cleanse R4's abdominal fold. R4 then was rolled onto her right side and V14 then cleansed R4's peri rectal area and left buttock. V14 then cleansed R4's exposed partial right buttock and then dried the areas. V14 did not cleanse R4's bilateral hips, thighs nor did she completely cleanse R4's right buttock. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145121 If continuation sheet Page 6 of 18 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 11/30/2023 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 - Some R4's CORP-Resident Profile Report, undated, documented, I am frequently to always incontinent of bladder and bowel. I need assistance with toileting and skin care for my incontinence. Monitor me for changes in bladder. bowel elimination and skin appearance. Report all observed changes to nurse. I receive a diuretic daily. Encourage daily fluid intake and report any changes in fluid or meal intake to nurse. My goal is to regain my independence with toileting and skin and remain free from potential complications related to daily diuretic medication use. My goal is to maintain my current level of continence, remain clean and dry and minimize the risk of skin breakdown thru this next review period. R4's MDS, dated [DATE], documented, R4 was always incontinent of her bowels and of urine. R4's Resident Information sheet, dated 11/29/2023, documented diagnosis of chronic kidney disease. On 11/29/2023 at 3:30 PM, V24, CNA, stated she would cleanse and dry all areas including the abdominal folds, groin areas, buttocks and hips when performing incontinent care. On 11/29/2023 at 3:40 PM, V25, CNA, stated she when a resident is incontinent, she would cleanse and dry abdominal folds, groins, buttocks and hips. On 11/29/2023 at 3:45 PM, V1, Administrator, stated she would expect staff to perform incontinent care according to the facility's policy. 3. R5's Care Plan, dated 8/4/23, documents, I am incontinent of bowel and bladder, and I am a bilateral amputee. I use dignity briefs. Please provide peri care after episodes of incontinence. I require staff assistance with toileting, monitor me for changes in my elimination and report observed changes to nurse. I am prone to urinary elimination changes and infection. R5's MDS, dated [DATE], documents R5 is cognitively intact, always incontinent of bowel and bladder and requires partial/moderate assistance with toileting. On 11/28/2023 at 11:20 AM V12, CNA, and V7, CNA, performed incontinent care. R5 was incontinent of bowel. Using wet wash cloths and peri wash V12 cleansed R5's groin, penis and scrotum. V12 and V7 then turned R5 onto his right side. V12, using a wet washcloth and cleansed R5's left buttock, anal area, and partial right buttock. V12 then placed a clean brief and incontinent pad beneath R5. V12 and V7 then turned R5 onto his left side and fastened the brief. V12 did not cleanse R5's entire right buttock. 4. R25's Care Plan, not dated , documents, I am always incontinent of B&B (bowel and bladder). I use dignity briefs. Please provide peri care after episodes of incontinence. My goal is to maintain my current level of continence, remain clean and dry and minimize the risk of skin breakdown thru this next review. R25's MDS, dated [DATE], documents that R25 is severely cognitively impaired, is incontinent of bladder and requires substantial assist with toileting. On 11/27/2023 at approximately 11:20 AM observed V7, Certified Nurse's Assistant (CNA), perform incontinent care. R25 was incontinent of urine. During incontinent care R25 began to urinate wetting himself and the bed. V7 and V6, LPN, utilized a garbage bag in attempt to contain the urine. R25's bed was soiled with urine. V7, using a washcloth with soap, cleansed R25's groin and penis. V7 then (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145121 If continuation sheet Page 7 of 18 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 11/30/2023 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 - Some assisted R25 onto his left side and cleansed the back of R25's scrotum. V7 and V8, CNA, then applied the clean incontinent brief. V7 did not cleanse R25's buttocks or front of R2's scrotum. 5. R205's admission Record, undated, documents R205 was admitted to the facility on [DATE]. R205's Electronic Medical Record, Diagnosis and Problems, documents R205's diagnosis include: Acute Kidney Failure (AKF), Cachexia, Cardiomegaly, Hypertension (HTN), Left femur fracture, Congested Heart Failure (CHF), Left Bundle Branch Block (LBBB), Hyperlipidemia, Aortic stenosis, Idiopathic osteoporosis, Type 2 Diabetes Mellitus (DM), Osteoarthritis, Dementia, Cerebral infarction, and Urinary Tract Infections (UTI). R205's Care Plan, dated 11/3/23, documents R205 is at risk for falls related to a fall with injury prior to admission. Interventions: Ensure bed is at appropriate height at all times, ensure call light is within reach when in my room, mats on floor while in bed. R205 is occasionally incontinent. Intervention: Use dignity briefs, provide peri care after episodes of incontinence. R205 is at risk for skin impairment related to immobility, incontinence, dependent on care and positioning. Interventions: check skin daily with care, let nurse know if dressing is not intact or new areas of redness/impairment, treatments as ordered by Medical Doctor (MD), reposition as needed, wound consult as ordered. R205's MDS, dated [DATE], documents R205 has a severe cognitive impairment and requires dependent on staff for toileting, dressing, and transfers. R205 is occasionally incontinent of urine and is frequently incontinent of bowel. On 11/28/23 at 11:07 AM, V11, CNA, and V10, CNA, pushed R205 to her room for toileting. Both CNA's donned gloves, and a gait belt was placed around R205. R205 was assisted to stand up and pivot to the toilet. V10 and V11 removed R205's incontinence brief, which appeared saturated with urine, and then her pants. R205 was lowered to the toilet. R205 stated she did not have to go again, so V10 gave R205 some toilet paper to wipe herself. R205 reached between her legs and wiped three different times from back to front, with the toilet paper appearing soiled after each wipe. R205 was then assisted to stand, and a new incontinence brief was applied, and her pants were pulled up with neither CNA checking, wiping or further cleaning R205. V11 stated R205 had already urinated in her incontinence brief before they put her on the toilet. 6. R212's admission Record, undated, documents R212 was admitted to the facility on [DATE]. R212's Electronic Medical Record, documents R212's Diagnosis include: CHF, ASHD, Cardiomegaly, Atrial Fibrillation, HTN, Hemiplegia/Hemiparesis, Cerebral Infarction, Hypothyroidism, Paralytic gait, Spondylosis, Type 2 DM. R212's Care Plan, dated 11/13/23, documents ADLs: R212 requires assistance with ADLs, one-person assist with dressing, bathing, and grooming, two-person assist with transfers. Skin: R212 is at risk for skin impairment due to incontinence. Interventions: Keep skin warm and dry, turn and reposition as needed, barrier cream after incontinent episodes, encourage to shift weight while in bed, cushion to wheelchair, pressure reducing mattress. R212's MDS, dated [DATE], documents R212 has a severe cognitive impairment and requires substantial/maximal assistance for toileting, bathing, dressing, transfers, and mobility. R212 is occasionally incontinent of urine and always continent of bowel. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145121 If continuation sheet Page 8 of 18 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 11/30/2023 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 - Some On 11/28/23 at 10:34 AM, V10, CNA, and V11, CNA, entered R212's room to assist her with toileting. Both CNAs put gait belt around R212, and R212 was pushed to the restroom in her wheelchair. R212 was assisted to stand up and then pivoted to the toilet, her incontinence brief and pants were pulled down, and then R212 was lowered down to the toilet, and left in private to void and have a bowel movement. On 11/28/23 at 10:47 AM, R212 was done using the restroom and both V10 and V11 entered to assist R212 off the toilet. Both CNAs held onto the gait belt while R212 stood up. Both CNAs pulled up R212's incontinence brief and pants without wiping or checking to see if R212 was clean, then pivoted R212 to her wheelchair and lowered. R212 stated she wiped herself a little before the CNAs came in. On 11/30/23 at 9:45 AM, V7, CNA, stated, If I'm helping a resident while toileting, and they want to wipe themselves, I will make sure they have all the supplies needed to do it, but I will offer assistance and will make sure they are completely clean and dry before I leave them. On 11/30/23 at 9:05 AM, V2, DON, stated, I talked to the CNAs about helping residents with peri-care and they said some of the residents want to do it themselves. I did tell them they should at least offer to assist them and explain it is going to help them maintain their skin integrity. If a resident is incontinent, then they should be cleaned up all over. The Facility's Perineal Care Policy, dated 10/2022, documents, Perineal care is to be done as needed for incontinence for residents who are unable to perform self-care. Perineal care is done to cleanse the perineum to prevent growth of bacteria, prevent skin breakdown and promote good personal hygiene. Standard precautions and sound aseptic technique will be used when performing peri-care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145121 If continuation sheet Page 9 of 18 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 11/30/2023 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 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** 6. On 11/27/2023 at 9:09 AM, R35's Oxygen tubing and humidifier was not dated and there was no water was in the humidifier. R35 stated it hadn't been changed since she was admitted . Residents Affected - Some On 11/29/2023 at 11:11 AM, R35's Oxygen tubing and humidifier was not dated and there was no water in the humidifier bottle. R35 stated she thinks they changed it yesterday and that when her daughter comes in, she will have her add water to it. R35 stated she really needs water in it because her nose gets so dry. R35's Resident Information sheet, dated 11/29/2023, documented she was admitted to the facility on [DATE]. It also documented diagnoses of Acute on Chronic respiratory failure and chronic obstructive lung disease. R35's Physicians order sheet, dated 11/29/2023, documented an order, dated 11/1/2023, (Oxygen at 4 liters) per nasal cannula to maintain (pulse ox greater than) 90%. R35's CORP-Resident Profile Report, dated 11/15/2023, documented, I use oxygen at 4 (liters) via (nasal cannula as needed). R35's Minimum data set (MDS) dated [DATE], documented that her cognition was intact. The facility's policy, Oxygen Administration, dated 10/2022, documented, 8. Fill the humidifier bottle with tap water to the fill line. It continues, Care of oxygen supplies. Change the set up (mask, cannula, extension tubing and humidifier bottle monthly and (as needed)), It continues, Document Change of set ups in the resident's medical directory. Based on observation, interview, and record review, the facility failed to change and date the oxygen tubing and humidification water bottles on the oxygen concentrators and failed to store needed equipment in a safe and sanitary manner for 6 of 6 (R1,R17, R35, R37, R204, R255) residents reviewed for respiratory care in a sample of 33. Findings include: 1. On 11/27/23 at 8:50 AM, R255 was observed resting in bed. R255 was receiving O2 (oxygen) via nasal cannula at 2 LPM (liters per minute) as documented on the physician order records. The oxygen tubing was attached to a bottle of water connected to an oxygen concentrator. There was no date on the oxygen tubing, nor was the bottle of water dated that connected to the oxygen concentrator. On 11/29/23 at 8:30 AM, R255 was in bed with O2 running at 2 LPM via nasal cannula connected to a bottle attached to the oxygen concentrator. The bottle did not contain any water for humidification. There was no date on the bottle or the oxygen tubing. R255's electronic medical record/diagnosis & problems list, undated, documents R255 has diagnosis of acute pulmonary edema, chronic diastolic (congestive) heart failure, chronic obstructive pulmonary disease, anxiety disorder, and atherosclerosis. R255's physician orders, dated 11/16/23, documents oxygen therapy at 2 LPM per nasal cannula. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145121 If continuation sheet Page 10 of 18 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 11/30/2023 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. On 11/29/23 at 8:33 AM, R37 was sitting up in a wheelchair in her room. R37 was receiving oxygen via nasal cannula attached to a bottle with water connected to an oxygen concentrator. There was no date on the oxygen tubing, or the bottle of water connected to the concentrator. R37's electronic medical record/diagnosis & problems list, undated, documents diagnosis of chronic diastolic heart failure, acute pulmonary edema, atherosclerotic heart disease, bauxite fibrosis of lung, chronic respiratory failure, hyperlipidemia, hypokalemia, hypothyroidism, irritable bowel syndrome, moderate protein energy malnutrition, nonexudative age-related macular degeneration, aortic valve disorder, pleural effusion, pulmonary hypertension, and diabetes mellitus. R37's physician orders, dated 11/1/23, documents oxygen therapy at 4 LPM per nasal cannula. 3. On 11/29/23 at 8:38 AM, R17, was observed with an oxygen concentrator in the room. The concentrator was not in use. The oxygen tubing attached to the concentrator did not have a date. The nasal cannula was not contained in a bag and was laying on the floor. R17's electronic medical record/diagnosis & problems list, undated, documents diagnosis of cervical-occipital neuralgia, chronic kidney disease, chronic pain syndrome, degenerative lumbar spinal stenosis, essential hypertension, major depressive disorder, malnutrition, neuropathy, neurogenic dysfunction, overactive bladder, restless legs, retention of urine, and senile dementia. R17's physician orders, dated 7/14/23, documents oxygen therapy at 4 LPM per nasal cannula, prn (as needed). 4. On 11/29/23 at 8:40 AM, an oxygen concentrator was observed in R1's room. The concentrator was turned on and had an empty humidifier bottle attached to it. The oxygen tubing and nasal cannula was laying in the floor. The nasal cannula was not contained in a bag for storage. There was no date on the oxygen tubing or the humidification bottle. R1 stated she wears the oxygen occasionally. R1's electronic medical record/diagnosis & problems, undated, documents diagnosis of anemia, chest pain (unspecified), chronic diastolic (congestive) heart failure, constipation, cough, degenerative disorder of macula, dementia, essential (primary) hypertension, gastroesophageal reflux disease, generalized anxiety disorder, glaucoma, hiatal hernia, hypokalemia, hypothyroidism, neuropathy, osteoarthritis, overactive bladder, pneumonia, and restless legs. R1's physician orders, dated 5/3/23, documents oxygen therapy, prn, 2-4 l/m, titrate to maintain O2 saturation above 90%. 5. On 11/29/23 at 8:45 AM, R204 was sitting in a wheelchair in his room. R204 was receiving oxygen per nasal cannula. The oxygen was attached directly to the oxygen concentrator. There was no bottle attached to the concentrator. There was no date on the oxygen tubing. R204's electronic medical record/diagnosis & problems, undated, documents diagnosis of cardiomyopathy, chronic hypoxemic respiratory failure, chronic systolic heart failure, gastroesophageal reflux disease, and mixed hyperlipidemia. R204's physician orders, dated 11/18/23, documents oxygen therapy, routine, 3 LPM, per nasal cannula. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145121 If continuation sheet Page 11 of 18 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 11/30/2023 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 - Many 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 11/27/2023 at 09:22 AM, R35 had Fluticasone nasal spray on her overbed table and it was within her reach. R35's Physicians order, dated 11/2/2023, documented, Fluticasone nasal 50 (microgram)/(inhalation) nasal spray. 2 sprays, Nasal, form: spray daily 1st dose 11/2/23. indication: Seasonal Allergy. There was not an order to keep medication at the bedside. R35's Physician order sheet, dated 11/2023 documented an admission date of 11/01/2023. R35's MDS dated [DATE] documented that her cognition was intact. Based on observation, interview, and record review, the facility failed to properly store medications and label tuberculin vials and insulin pens. This has the potential to affect all 40 residents living in the facility. Findings include: On 11/27/2023 at 11:00 AM the facility's [NAME] Wing Medication Storage Room was inspected. The medication room contained the following medication: 1. A multi-dose vial of Tubersol (TB) with no open date. V6, Licensed Practical Nurse (LPN), verified the medication was open and in use. On 11/27/2023 at 11:07 AM, V6 stated the multi-dose vial was open and in use. V6 stated when she opens the vial, she places an open date. V6 stated this is the facility process. V6 stated she was not sure if the vial had an open date as she had not opened it. V6 stated the vial of Tubersol should have an open date. V6 stated Tubersol has a different expiration date once the bottle is opened. V6 stated it (Tubersol) is good for 30 days. V6 stated placing the open date on the bottles tells them when the expiration date is. V6 stated the Tubersol is not specific to one resident and is used for all the residents admitted to the facility. V6 stated each resident is given a series of TB unless they have an allergy and the Tubersol in the refrigerator is used for this process. The Tuberculin Purified Protein Derivative (Mantoux) Tubersol package insert, dated April 2016, documents, A vial of TUBERSOL which has been entered and in use for 30 days should be discarded. On 11/27/2023 at 11:38 AM the [NAME] Hall medication cart was inspected. The cart contained: 2. R5's Lispro insulin pen. No open date in place on bag or pen. 3. R19's Glargine insulin pen. No open date in place on bag or pen. On 11/27/2023 at 11:40 AM, V6 stated both insulin's were open and in use. V6 stated the insulin pens have a short time once open to be used. V6 stated the expiration date is different from the manufactures date once opened. V6 stated the open date should be written on the pen or bag when opened. V6 stated this is how they know what the expiration date is. V6 stated they would not know what the expiration date is without the open date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145121 If continuation sheet Page 12 of 18 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 11/30/2023 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 - Many On 11/29/2023 at 2:34 PM, V2 stated the multi-dose vial of Tubersol and insulin pens are to be labeled with open date when open. V2 stated the date should be on the bottle, vial, or pen. V2 stated the written date on the medication is to let the nurse know the expiration date. V2 stated once open the Tubersol and insulin have shorter expiration dates than the manufacturer. The facility's Storage and Expiration Dating of Medications, Biological, dated 3/7/23, documents Procedure 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened. 5.3 If a multi-dose vial of an injectable medication has been opened or accessed (e.g., needle-punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for opened vial. The facility's General Dose Preparation and Medication Administration, dated 10/18, documents Practice: 1d. The nurse who opens the vial of insulin/insulin pen will be responsible for checking the manufacturer's expiration date and will date the bottle indicating the expiration date once opened. This will be 14-42 days after opening for most products or manufacturer's expiration date, whichever comes first. The Long-Term Care Facility Application for Medicare and Medicaid, dated 11/27/23, documents the total number of residents 40. 6. R206's admission Record, undated, documents R206 was admitted to the facility on [DATE]. R206's Electronic Medical Record, Diagnosis and Problems, document R206's diagnosis include: Anemia, Obesity, Congestive Heart Failure (CHF), chronic kidney disease (CKD), Esophageal Varices, Hypertension (HTN), Gastroesophageal Reflux Disease (GERD), Hepatorenal Syndrome, Hyperlipidemia, Osteopenia, Rheumatoid arthritis, COVID-19, Systemic Lupus, Thrombocytopenia, Type 2 Diabetes Mellitus (DM), Cirrhosis - non-alcoholic, and Right Bundle Branch Block (RBBB). R206's Care Plan, dated 11/18/23, documents ADLs: R206 requires some assistance with ADL. One person set-up for hygiene, dressing, bathing, and transfers. R206 uses Continuous Positive Airway Pressure (CPAP) at night based on home settings. Please monitor my compliance with this device, ensure that mask is fitting correctly, change tubing monthly, rinse my mask daily. R206's MDS, dated [DATE], documents R206 is cognitively intact and requires substantial/maximal assistance for toileting, bathing, dressing, and personal hygiene. R206 is occasionally incontinent of both bowel and bladder. On 11/27/23 at 9:10 AM, R206, lying in bed with a bottle of Fluticasone Nasal Spray sitting on her bedside table with no name or date on the bottle. R206 does not have a Physician Order to have medications at her bedside. R206's Physician Order, dated 11/19/23, documents, Fluticasone Nasal Spray, 1 spray Daily for 7 days. This order was discontinued on 11/26/23. 11/30/23 at 9:41 AM, V26, LPN, stated, We can leave medications like eye drops or inhalers in a resident's room, if we have a Physician's order for it. Sometimes the resident's family will bring (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145121 If continuation sheet Page 13 of 18 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 11/30/2023 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 something in and leave it with them, but if we find it, it should be locked up until we get a Physician's order to keep it in the room. 7. On 11/28/23 7:45 AM, V9, Licensed Practical Nurse (LPN), performing medication pass on the East-Hallway. Residents Affected - Many R213's admission Record, undated, documents R213 was admitted to the facility on this occurrence on 11/19/23. R213's Electronic Medical Record, documents R213's Diagnosis include: Atherosclerotic Heart Disease (ASHD), chronic kidney disease (CKD) stage 4, Hypertension (HTN), Anemia, Peripheral Vascular Disease (PVD), Sick Sinus Syndrome (SSS), Type 2 Diabetes Mellitus (DM), and Atrial Fibrillation. R213's Care Plan, dated 11/19/23, documents ADLs: R213 requires limited assist with ADLs, requires one person assist with dressing and bathing, set-up assist for meals. R213 is at risk for falls related to possible increase weakness. Interventions: keep call light within reach, adequate lighting, keep items frequently used within reach, anticipate needs prior to exiting room. Bladder and Bowel: R213 is continent of bowel and bladder, takes diuretic medication which can increase the frequently, volume, and urgency of urine for several hours following dosage. Please toilet me more frequently during this time. R213's MDS, dated [DATE], documents R213 is cognitively intact and is independent of all Activities of Daily Living (ADLs). On 11/28/23 at 8:30 AM, R213 had a bottle of Systane eye drops on his bedside table with no resident name or date opened. R213 does not have a Physician Order to keep medications at his bedside. R213 does not have a Physician Order for the Systane Eye Drops that was seen sitting on his bedside table. On 11/28/23 at 8:20 AM, V9, LPN, stated, If a resident is alert, some of them are allowed to keep their inhalers and Flonase with them in their rooms. The facility's Administration of Medications Policy, dated 6/2023, documents, General Guidelines: 1. There will be five storage areas of oral medications: a) active working (routine cards); b) Routine liquids; c) PRNs; d) Backup (refills); e) Refrigerator for medications requiring refrigeration. The active working medications will be kept in the appropriate designated storage area. It continues Medication Administration: b. Also refer to Bethesda policies and procedures Hand Hygiene in the Long-Term Care manual under the infection control tab and medication error reporting tin the nursing policy and procedure manual. g. Do not leave medications in the room or on a food tray. The facility's CMS 671, dated 11/27/23, documents there were 40 residents residing in the facility. 5. On 11/27/23 at 10:50 AM, an open bottle of Fluticasone nasal spray was observed on R260's bedside table. R260 was resting in bed with the bottle of Fluticasone within reach. On 11/28/23 at 10:15 AM, the bottle of Fluticasone nasal spray was again observed on R260's bedside (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145121 If continuation sheet Page 14 of 18 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 11/30/2023 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 table. The bottle of Fluticasone was within the reach of R260. Level of Harm - Minimal harm or potential for actual harm R260's Physician orders, dated 11/22/23, documents an order for Fluticasone nasal spray, 1 spray, daily for rhinitis. The order does not document may keep at bedside. Residents Affected - Many R260's MDS (Minimum Data Set), dated 11/28/23, documents R260's cognition is intact. On 11/29/23 at 11:56 AM V22, LPN (Licensed Practical Nurse), stated, Flonase can be kept at the bedside if they have an order. I do not see an order for that resident (R260) to have Flonase or any medications to be kept at bedside. On 11/30/23 at 8:25 AM, V2, DON (Director of Nursing), stated, I would expect medications to be stored in the medication cart unless the resident has an order to keep at bedside. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145121 If continuation sheet Page 15 of 18 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 11/30/2023 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 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** 4. On 11/28/2023 at 3:00 PM, R1 stated she was supposed to have a test for her urine and there wasn't a urine collector in the toilet and now she had an accident and wet herself. R1 was sitting in her wheelchair, out in the hallway in front of her room. The front of R1's pants were wet in front from the right groin area over to her pelvic and abdominal fold area. At 3:17 PM, V17, Certified Nurse Assistant (CNA) took R1 into her room. V17 donned gloves without benefit of hand hygiene. V18, Licensed Practical Nurse (LPN) then entered R1's room, donned gloves without benefit of hand hygiene. V17 collected a items needed to perform incontinent care on R1 then placed gait belt on R1. V17 and V18 assisted R1 to a standing position in the bathroom. V18 pulled down R1's pants and removed the urine-soaked incontinent brief. V17 was standing behind R1 and took wet wash cloths with soap and cleansed front to back R1's perineal area. V17 then retrieved a dry wheelchair pad without benefit of hand hygiene or glove change returned to assist R1 with putting on a clean incontinent brief and her pants. Residents Affected - Some R1's Minimum data set (MDS), dated [DATE], documented R1's cognition was intact, she was occasionally incontinent of urine and always incontinent of her bowels. It also documented R1 required partial to moderate assistance with toileting hygiene. R1's CORP-Resident Profile Report, dated 11/29/2023, documented, Due to my incontinence please make sure my peri care is done properly as I am susceptible to UTI's and skin breakdown. R1's Resident Information sheet, dated 11/29/2023, documented a diagnosis of overactive bladder. On 11/29/2023 at 3:30 PM, V24, CNA stated she would perform hand hygiene and glove changes when she contaminates her gloves during incontinent care. On 11/29/2023 at 3:40 PM, V25, CNA stated she would perform hand hygiene and glove changes during incontinent care. On 11/29/2023 at 3:45 PM, V1, Administrator, stated she would expect staff to perform hand hygiene and glove changes during incontinent care according to the facility's policy. 5. On 11/28/2023 at 3:30 PM, V19, Registered Nurse, donned gloves without the benefit of hand hygiene, took the intravenous (IV) tubing, removed the cap from the spike end of the tubing and then spiked R104's vancomycin solution bag. V19 took the IV tubing and primed it with the solution, opened the IV pump door with the same gloved hands, and fed the IV tubing through the pump, closed the pump door and set the IV pump. With the same gloved hands, V19, then opened an alcohol cleansing wipe package, took the alcohol wipe out of the package, removed, R104's, cap from the end of her peripherally inserted central catheter (PICC), cleansed the end of R104's PICC line and inserted the end of the IV tubing into her PICC line all without the benefit of hand hygiene or glove changes. On 11/28/2023 at 3:45 PM, R104, stated the nurses usually wear gloves but she did not know if they wash their hands prior to putting gloves on. R104's, Physicians Orders, dated 11/18/2023, documented an order, Vancomycin (vancomycin 750 (milligrams)/150 (milliliters)-Sodium Chloride 0.9% intravenous solution) 750 mg IV (every) 24 (hours). Indication: osteomyelitis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145121 If continuation sheet Page 16 of 18 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 11/30/2023 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 0880 R104's Minimum Data Set (MDS), dated [DATE], documented her cognition was intact. Level of Harm - Minimal harm or potential for actual harm On 11/29/2023 at 3:47 PM, V19, RN stated he should have performed hand hygiene and changed gloves before he cleansed the PICC line access with the alcohol wipe. Residents Affected - Some On 11/29/2023 at 3:45 PM, V1, Administrator stated she would expect the staff to follow the facility's policy on glove changes and hand hygiene. The facility's policy, Infection Control Hand Hygiene, dated 09/2022, documented, Practice: 1. CDC recommends use of an alcohol-based hand rub to routinely clean hands between resident contacts as longs as hands are not visible dirty. It continues, After contact with inanimate objects (including medical equipment) in the immediate vicinity of the resident. Based on observation interview and record review the facility failed to perform proper hand hygiene and glove changes per current standards of practice and failed to secure a catheter bag off the floor for 5 of 5 (R1, R20, R104, R209, R213) residents reviewed for infection control in a sample of 33. Findings include: 1. R209's admission Record, undated, documents R209 was admitted to the facility on [DATE]. R209's Electronic Medical Record, documents R209's Diagnosis includes: Abdominal Aortic Aneurysm (AAA), Acute Cystitis, Acute Kidney Failure (AKF), Anemia, Arteriosclerotic Heart Disease (ASHD), Cardiomegaly, Candida Stomatitis, CHF, COPD, Chronic resp. failure, Diverticulosis, Flaccid neuropathic bladder, Mesothelioma, Hyperlipidemia, macular degeneration, Portal Hypertension (HTN), Thrombocytopenia, Dementia, Fracture right humerus. R209's Care Plan, dated 11/8/23, documents Bladder and Bowel: R209 is incontinent of bowel at times. Interventions: provide peri-care after episodes of incontinence, has a urinary catheter due to neurogenic bladder, keep bag and tubing to gravity, catheter care daily and PRN (as needed). Skin: R290 is at risk for skin impairment related to immobility, incontinence, dependent on care and positioning. Interventions: check skin daily with care, let nurse know if dressing is not intact or any new areas of redness. R209's Minimum Data Set (MDS), dated [DATE], documents R209 has a severe cognitive impairment and requires substantial/maximal assistance for ADLs. R209 has urinary catheter in place. On 11/27/23 at 9:40 AM, R209 was seen lying in bed and is not answering questions appropriately. R209 had a urinary catheter with amber colored urine lying on the floor with a wheel of the bed on top of the bag. On 11/30/23 at 9:47 AM, V7, CNA, stated, All urinary catheters should be covered up or in a bag, should always be hooked on the bed or chair and kept below the level of the resident's waist, and should never be lying on the floor. The Facility's Perineal Care Policy, dated 10/2022, documents, Perineal Care with Catheter: 17. Be sure to check catheter and drainage tubes for leaks, kinks, level of drainage bag below level of bladder, color and characteristics of the urine. Verify that the drainage bag is securely attached to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145121 If continuation sheet Page 17 of 18 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 11/30/2023 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 0880 the bedframe. Level of Harm - Minimal harm or potential for actual harm 2. On 11/28/23 7:45 AM, V9, Licensed Practical Nurse (LPN), was seen passing medications to R20 with no hand hygiene performed before or after medications given. Residents Affected - Some 3. On 11/28/23 at 8:10 AM, V9, LPN, was seen passing medications to R213 with no hand hygiene performed before or after medications given. On 11/30/23 at 9:43 AM, V26, LPN, stated, Nurses should be washing our hands before and after we pass medications to a resident and moving on to the next resident. That's why we have a bottle of the gel hand hygiene on the cart and hand hygiene by each door. The Facility's Hand Hygiene Policy, dated 9/2022, documents, It is the responsibility of all employees to follow this policy regarding hand hygiene for infection control. 1. CDC recommends use of an alcohol-based hand rub to routinely clean hands between resident contacts as long as hands are not visibly dirty. Do not opt for an alcohol-based hand rub when hands are visibly soiled or contaminated with blood or body fluids. The facility's Administration of Medications Policy, dated 6/2023, documents, b. Also refer to Bethesda policies and procedures Hand Hygiene in the Long-Term Care manual under the infection control tab and medication error reporting tin the nursing policy and procedure manual. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145121 If continuation sheet Page 18 of 18