Inspection·June 9, 2025

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The facility policy Pressure Ulcer prevention, identification and treatment dated, revise 8/31/2023 documents the purpose is to provide guidelines that will assist nursing staff in prevention, identification, and appropriate treatment for pressure ulcers. The policy documents unstageable: Full thickness, tissue loss in which the base of ulcer is covered by slough (yellow, tan, gray, or brown) and/or eschar (tan, brown, or black) in the wound bed. The policy documents (when eschar is present, accurate staging of the pressure ulcer is not possible until the eschar has sloughed, or the wound has been debrided.) The policy documents color identification red: pale pink to beefy red with or without healthy granulation tissue. Yellow: whitish yellow, creamy yellow, yellow-green or beige. Black: Black, stringy gray, or gray scab. The policy documents it is the responsibility of the Charge nurse/designee to care for pressure areas, and to provide treatments as ordered. The policy documents it is the responsibility of the Charge nurse/designee to measure and document on the pressure areas weekly. The policy documents it is the responsibility of the Charge nurse/designee to monitor healing progress and ensure appropriated treatment are in use. It is recommended that Director of Nursing (DON)/Designee make frequent pressure rounds with charge nurse. The policy documents it is the responsibility of the Certified Nursing Assistant to report any skin conditions to the charge nurse immediately upon identification. Event ID: Facility ID: 145273 If continuation sheet Page 2 of 15 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 145273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jacksonville Skld Nur & Rehab 1517 West Walnut Street Jacksonville, IL 62650 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide restorative services to prevent reduction in range of motion (ROM) for 1 of 4 residents (R58) reviewed for restorative therapy/Range of Motion (ROM) in the sample of 41. Findings include: R58's admission Record, dated 6/5/25, documents R58 was admitted to the facility on [DATE] with diagnoses of Polyneuropathy, Morbid Obesity, Buerger's Disease, Myiasis, Major Depressive Disorder, and Arthropathy. R58's Care Plan, dated 6/3/25, documents R58 Restorative: At risk for decline in their ability to complete bed mobility due to reduced physical function. Interventions: Assist R58 with completing bed mobility tasks with verbal cueing to participate to fullest potential. Provide R58 with verbal cues to use her side rails to assist in rolling in the bed. Provide R58 with hands on assist as needed. It continues R58 is a Long Term stay in Facility for Rehabilitation. R58's Minimum Data Set (MDS), dated [DATE], documents R58 is cognitively intact and is dependent on staff for toileting, dressing, and transfers. R58 is always incontinent of both bowel and bladder. On 6/2/25 at 10:00 AM, R58 stated I wish I could get PT (Physical Therapy) or some kind of therapy to work with me more. They said they were done with me and now, no one does anything with me. R58's Physician Order (PO), dated 3/27/25, documents PT to d/c (discharged ) from skilled PT interventions effective date 3-17-2025 due to max potential met. By (V19, Physical Therapist). R58's PO, dated 3/17/25, documents Patient to d/c from skilled OT (Occupational Therapy) interventions due to max potential met. R58's General Note, dated 4/21/25 at 10:09 AM, documents Seen by (physician). Resident is requesting more therapy even though she is at the maximum amount provided. Resident voiced understanding. The Therapy Department's Therapy to Nursing Recommendations dated 3/17/25, documents Therapy's Recommendation for R58 to continue to have Passive and Active ROM, Bed Mobility, and Transfers. On 6/4/25 at 2:10 PM, V19, Physical Therapist (PT), stated (R58) was discharged from therapy because she plateaued and was not improving. (R58) never wanted to get out of bed for PT to work with her with walking or anything like that. When we discharged (R58) we gave the nursing staff the Therapy to Nursing Recommendation form which told the nursing staff what we recommended after therapy. The problem here is there is no restorative staff here and they don't really work with the residents. I think that (R58) really needs ROM (range of motion) and exercises, especially since she doesn't do much on her own. On 6/4/25 at 2:15 PM, V20, Physical Therapy Assistant (PTA), stated We try to educate the staff on what the resident was working on in therapy. I know they are all licensed and should be educated and able to perform ROM and exercises with the residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145273 If continuation sheet Page 3 of 15 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 145273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jacksonville Skld Nur & Rehab 1517 West Walnut Street Jacksonville, IL 62650 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 6/5/25 at 8:55 AM, V21, Registered Nurse (RN), stated We don't have any Restorative Aides here. The Certified Nursing Assistants (CNAs) are responsible for doing restorative care on the residents, but I don't think they are doing it. On 6/5/25 at 9:00 AM, V13 CNA, stated There are no restorative aides here. It is listed on the tasks list which residents need restorative care. R58's Tasks from her electronic health record, does not show any task related to ROM or exercises as recommended by therapy. On 6/5/25 at 3:20 PM, V1, Administrator, stated I would expect the staff to provide restorative therapy to the residents in need as recommended by therapy. We do not have specific restorative staff; however, all staff are trained to provide restorative care. The Facility's Restorative Program/Range of Motion policy, dated 2/3/22, documents in part Purpose: To provide resident with limited range of motion appropriate treatment and services to increase or prevent further decrease in range of motion. The facility protocol for ROM is ten repetitions daily, seven days a week for prevention of contractures. It is the responsibility of the nurse who completes the quarterly restorative assessment to identify resident's need for ROM exercise. It is the responsibility of the CNA to perform exercises as identified. It is the responsibility of the Care Plan Coordinator for addressing on the Care Plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145273 If continuation sheet Page 4 of 15 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 145273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jacksonville Skld Nur & Rehab 1517 West Walnut Street Jacksonville, IL 62650 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement an intervention to prevent falls for 1 of 4 residents (R41) reviewed for falls in the sample of 41 Findings include: 1. R41's Fall's Details report dated 5/2/2025 documents R41 was found on floor lying on stomach on mat beside bed. R41's report documents environmental conditions as bolsters were not clipped to bed. Report document R41 sustained a 3 centimeter (cm) long scratch to left cheek. R41's care plan dated 4/9/2021 documents R41 is at risk for falls r/t (related to) cognition deficit and history of fall with a fracture. Impaired mobility and lack of safety awareness due to diagnosis of dementia. R41's care plan documents the following interventions: 4/19/2025 bolster to bed for positioning. R41's Minimum Data Set, MDS, dated [DATE] documents R41 is severely cognitively impaired. On 6/5/2025 at 9:50AM, V1, Administrator stated the bolsters were loose and laying on the bed. The facility policy Accidents and Incidents dated revised 9/7/2023 documents the interdisciplinary team (IDT) will complete an investigation to determine root cause and implement appropriate interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145273 If continuation sheet Page 5 of 15 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 145273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jacksonville Skld Nur & Rehab 1517 West Walnut Street Jacksonville, IL 62650 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 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 and catheter care for 2 of 5 residents (R44, R58) reviewed for incontinence and catheter care in the sample of 41. Findings include: 1. R58's admission Record, dated 6/5/25, documents R58 was admitted to the facility on [DATE] with Diagnoses of Polyneuropathy, Morbid Obesity, Buerger's Disease, Myiasis, Major Depressive Disorder, and Arthropathy. R58's Care Plan, dated 4/2/25, documents R58's Self-Care Deficit as Evidenced by: Needs assistance with ADLs (Activities of Daily Living). Interventions: Toilet Use: Two-person physical assistance required. R58's Minimum Data Set (MDS), dated [DATE], documents R58 is cognitively intact and is dependent on staff for toileting. R58 is always incontinent of both bowel and bladder. On 6/4/25 at 12:50 PM, V13, Certified Nursing Assistant (CNA), and V10, CNA, provided incontinent care on R58. All supplies were on the bedside table, with a large pile of wash cloths that were wet from the restroom sink, and then placed on top of the bedside table. V10 sprayed a wet washcloth with peri-wash, wiped R58's right and left groins from top going down through R58's inner thigh, spread R58's labia and wiped downward front to back three times, then dried R58's groins and vaginal area. There was no wiping of R58's abdominal fold as she has Morbid Obesity. R58 was turned to her right side with V13 holding her while V10 sprayed a wet washcloth with peri-wash and wiped R58's left buttock down her posterior thigh, then dried. R58 rolled to her left side and V10 wiped R58's right buttock down her posterior thigh. V10 did not clean R58's anal area or between her buttocks. V10 applied cream to R58's right hip per R58's request, but there was no cream or moisture barrier applied to R58's groin, buttocks, peri-area, or skin folds. R58's Physician Order (PO), dated 11/5/24, documents Triad cream to buttocks and thighs. three times a day for MASD (moisture associated skin damage). R58's PO, dated 1/9/24, documents Skin Inspection / Nursing Weekly Assessment Thursday days. Every day shift every Thu (Thursday). R58's PO, dated 10/4/23, documents Interdry to breast and abdominal folds daily and PRN (as needed). Every day shift for rash and as needed daily PRN (as needed). 2. R44's admission Record, dated 6/5/25, documents R44 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Hypertension (HTN), Dementia, Major Depressive Disorder, Benign Prostatic Hyperplasia (BPH), Uropathy, Malignant Neoplasm of Bladder, Wedge fracture of lumbar vertebra, and Malnutrition. R44's Care Plan, dated 5/26/25, documents R44 has impaired urinary elimination. Intervention: Supra pubic catheter as ordered. It continues R44 has a Self-Care Deficit. Interventions: Toilet Use- Requires one-person physical assistance with catheter care. It continues R44 is at High Risk for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145273 If continuation sheet Page 6 of 15 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 145273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jacksonville Skld Nur & Rehab 1517 West Walnut Street Jacksonville, IL 62650 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 Urinary Tract Infection due to: Suprapubic Catheter. Interventions: Change catheter and drainage bag per MD (medical doctor) orders, empty catheter drainage collection bag QS (every shift), Enhanced Barrier Precautions, ensure catheter tubing and drainage bag are properly positioned to prevent urinary backflow or contamination, minimize catheter related injury, provide catheter / peri care QS, provide catheter irrigation as ordered, provide thorough perineal hygiene daily. Residents Affected - Few R44's MDS, dated [DATE], documents R44 has a moderate cognitive impairment, requires substantial/maximal assistance for toileting. R44 has urinary catheter and is frequently incontinent of bowel. On 6/2/25 at 10:40 AM, R44 was lying in bed, suprapubic catheter in place, bag covered and hanging on his walker on the side of bed, dated 5/25/25. On 6/5/25 at 10:17 AM, R44 stated No one does any sort of catheter care on me. They change my bag and that is it. R44 showed his supra-pubic catheter coming out of his supra-pubic area, which appears dirty, and is draining a white substance into his incontinence brief and down his penis and scrotum. R44's PO, dated 11/1/24, documents Cleanse supra-pubic catheter site with Normal saline, apply TAO (topical antibiotic ointment) and T-drain sponge daily and PRN (as needed) until healed. Every day shift for drainage/redness at supra-pubic catheter site. This is documented as completed each day in the Treatment Administration Record (TAR). R44's PO, dated 9/18/24, documents Foley: Change Catheter Bag every 7 days and as needed when bag is soiled or Catheter Dislodged, and every night shift every 7 day(s) for catheter use. R44's PO, dated 9/18/24, documents Change Bag every 7 days and as needed every night shift every 7 day(s) for catheter use. R44's PO, dated 5/4/25, documents Suprapubic Cath care every shift. On 6/5/25 at 10:25 AM, R44's Catheter bag was seen dated 5/25/25. R44's Treatment Administration Record (TAR), dated June 2025, documents R44's catheter bag was changed on 5/28/25. The bag was due to be changed on 6/1/25 (every 7 days). On 6/5/25 at 10:30 AM, V22, CNA, brought in supplies to do catheter care on R44. V22 stated I have been here about a year, and I have never done catheter care on (R44), but I don't usually take care of (R44). V22 wet wash cloths in the sink and sprayed them with peri cleaner. V22 took R44's pants and incontinence brief off and stated His catheter does look dirty. It looks like it has been draining into his (incontinence brief). V22 provided incontinent care including wiping R44's penis and scrotum which had dried drainage from his supra-pubic site. R44 stated This was the first time that someone has cleaned my catheter like that. I used to have a leg strap to hold the catheter in place, but a nurse took it off and told me that I didn't need it. R44's catheter care was done with no TAO or T-drain sponge applied to his supra-pubic site. There was no securing of his catheter as it was fed through his pants leg. On 6/5/25 at 3:20 PM, V1, Administrator, stated I would expect the staff to perform complete incontinent care, including the cleaning of all areas. I would expect the staff to provide complete and timely catheter care, including site care, and bag changes as ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145273 If continuation sheet Page 7 of 15 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 145273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jacksonville Skld Nur & Rehab 1517 West Walnut Street Jacksonville, IL 62650 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm The Facility's Incontinence Care Policy, dated 5/1/22, documents in part All incontinent residents will receive incontinence care in order to keep skin clean, dry and free of irritation and/or odor. Incontinence care will be provided as required. Procedure: 8. Wash all soiled skin areas and dry very well, especially between skin folds; changing gloves and performing hand hygiene as required to prevent cross-contamination. 9. Apply protective skin lubricant and rub well into skin. Residents Affected - Few The Facility's Indwelling Catheter Care Policy, dated 10/7/22, documents in part The facility shall maintain and care for foley catheters per the facility, following physician orders and adhering to facility infection control and best nursing practice standards. d. Empty the collection bag and perform indwelling catheter care at least every shift. Steps in the Procedure: 3. Fill the wash basin one-half (1/2) full of warm water. Place the wash basin on the bedside on the bedside stand within easy reach. 12. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward. 13. Secure catheter utilizing a leg band. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145273 If continuation sheet Page 8 of 15 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 145273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jacksonville Skld Nur & Rehab 1517 West Walnut Street Jacksonville, IL 62650 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to administer resident medications at the correct time as ordered for 2 of 6 residents (R44, R39), reviewed for pharmacy services in the sample of 41. The Findings Include: 1. R44's admission Record, dated 6/5/25, documents R44 was admitted to the facility on [DATE] with Diagnosis of Cerebral Infarction, Hypertension (HTN), Dementia, Major Depressive Disorder, Benign Prostatic Hyperplasia (BPH), Uropathy, Malignant Neoplasm of Bladder, Wedge fracture of lumbar vertebra, and Malnutrition. R44's Care Plan, dated 5/26/25, documents R44 has a diagnosis of hypertension. Interventions: Give antihypertensive medications as ordered, Obtain blood pressure readings per orders. It continues R44 is receiving medications with a black box warning. Medication type: antidepressant, antianxiety agent, nonopioid/opioid analgesic. Interventions: Administer medication as directed (correct time, dose, route, duration). It continues R44 is at risk for altered nutrition and hydration related to recent illness, bladder cancer diagnosis. Interventions: Medication per MD (medical doctor) order. R44's Minimum Data Set (MDS), dated [DATE], documents R44 has a moderate cognitive impairment. R44's Physician Order (PO), dated 2/25/25, documents Amlodipine Besylate Tablet 10 MG (milligram), Give 0.5 tablet by mouth one time a day for HTN. R44's PO, dated 2/14/25, documents D-Mannose Oral Capsule 500 MG. Give 1 capsule by mouth one time a day for supplementation. R44's PO, dated 1/17/25, documents Lactobacillus Capsule, Give 1 capsule by mouth in the morning for supplementation. R44's PO, dated 1/17/25, documents Cranberry Oral Tablet 500 MG, Give 500 MG by mouth one time a day for supplementation. On 6/4/25 at 11:05 AM, R44 seen sitting at nurse's desk waiting for lunch. R44 has a medicine cup of medications (4 pills) sitting on his bedside table with a cup of water. On 6/4/25 at 11:18 AM, V12, Licensed Practical Nurse (LPN), stated Some residents have an order for Self-Administration of a medication and we leave that medication in their room. When advised of R44's meds still sitting in a cup in his room, V12 stated I put (R44's) medications on his table and he leaned over to take them, I thought that he took them. That was totally my fault. On 6/4/25 at 11:45 AM, V12, LPN, seen giving R44 his medications that he did not take earlier. Amlodipine 0.5 MG scheduled and was signed off as given at 6:00 AM, Cranberry tablet 500 MG scheduled and was signed off as given at 6:00 AM, D-Mannose 500 MG scheduled and was signed off as given at 6:00 AM, and Lactobacillus 1 capsule scheduled and was signed off as given at 6:00 AM. R44's General Note, dated 6/4/25 at 11:49 AM, documents Resident took morning meds at 11:45 today, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145273 If continuation sheet Page 9 of 15 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 145273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jacksonville Skld Nur & Rehab 1517 West Walnut Street Jacksonville, IL 62650 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 0755 MD (Medical Doctor) is aware. Level of Harm - Minimal harm or potential for actual harm On 6/5/25 at 10:17 AM, R44 seen lying in bed, a medicine cup of medications (4 pills) sitting on his bedside table with a cup of water. R44 stated The nurse brought them in and set them on my table this morning and I have not taken them yet. Residents Affected - Few On 6/5/25 at 10:25 AM, R44 was seen taking his cup of medications left at his bedside. 2. R39's admission Record, dated 6/5/25, documents R39 was admitted to the facility on [DATE] with Brown-Sequard Syndrome, Morbid Obesity, Cerebrovascular Disease affecting left non-dominant side, Hemiplegia/Hemiparesis, Arthropathy, HTN, Congestive Heart Failure (CHF), Cardiomegaly, Pulmonary Embolism (PE), BPH, and Gastro-Esophageal Reflux Disease (GERD). R39's Care Plan, dated 3/19/25, documents R39 has shortness of breath at times related to chronic bronchitis. R39 has asthma. Interventions: Inhalers as per MD order. It continues R39 is receiving medications with a black box warning. Medication type: Anticoagulant, Antihypertensive. Interventions: Administer medication as directed (correct time, dose, route, duration). It continues R39 has dx of GERD. Interventions: Give medications as ordered. R39's MDS, dated [DATE], documents R39 is cognitively intact. On 6/2/25 at 10:53 AM, R39 has a medicine cup with an orange pill in it (stated for his constipation), Fluticasone inhaler, Generic Afrin Nasal Spray on his bedside table, R39 stated The nurse always comes in and leaves my medications in a cup on my table, and I take them on my own, she never stays and watches me take them. On 6/4/25 at 11:20 AM, R39 has his Fluticasone Inhaler and a medicine cup with 3 large round pills sitting on his bedside table. R39 stated These are my Tums; they give me some in a cup for when I need them. R39's PO, dated 10/28/24, documents Advair Diskus Aerosol Powder Breath Activated 100-50 MCG (microgram)/Dose, 1 inhalation inhale orally every 12 hours for COPD (chronic obstructive pulmonary disease) related to other Pulmonary Embolism without Acute Cor pulmonale. Rinse mouth with water after use. Do not swallow the water. This order was updated on 6/4/25 as 1 inhalation inhale orally every 12 hours for COPD related to other Pulmonary Embolism without Acute Cor pulmonale. Unsupervised self-administration Rinse mouth with water after use. Do not swallow the water. R39's PO, dated 10/2/24, documents Senna-Plus Oral Tablet 8.6-50 MG, Give 1 tablet by mouth two times a day for Constipation. There was no order for the Generic Afrin Nasal Spray or Tums seen in R39's Physician Orders. On 6/5/25 at 3:20 PM, V1, Administrator, stated I would expect the nurses to watch the residents take their medications and not to leave them with the resident to take on their own. They all know they are not supposed to do that. The Facility's Medication Administration Policy/Procedure, dated 9/27/22, documents in part Medications will be administered safely to residents within the facility by Licensed Nurses at the specified time/timeframe, following the recommended administration method and will be documented as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145273 If continuation sheet Page 10 of 15 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 145273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jacksonville Skld Nur & Rehab 1517 West Walnut Street Jacksonville, IL 62650 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 0755 required. 9. Ensure medication has been swallowed before leaving. 10. Throw away used disposable supplies. 12. Chart the medication administered on the electronic medication administration record. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145273 If continuation sheet Page 11 of 15 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 145273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jacksonville Skld Nur & Rehab 1517 West Walnut Street Jacksonville, IL 62650 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. R39's admission Record, dated 6/5/25, documents R39 was admitted to the facility on [DATE] with Brown-Sequard Syndrome, Morbid Obesity, Cerebrovascular Disease affecting left non-dominant side, Hemiplegia/Hemiparesis, Arthropathy, Hypertension (HTN), Congestive Heart Failure (CHF), Cardiomegaly, Pulmonary Embolism (PE), Benign Prostatic Hyperplasia (BPH), and Gastro-Esophageal Reflux Disease (GERD). R39's Care Plan, dated 3/19/25, documents R39 has shortness of breath at times related to chronic bronchitis. R39 has asthma. Interventions: Inhalers as per MD order. It continues R39 is receiving medications with a black box warning. Medication type: Anticoagulant, Antihypertensive. Interventions: Administer medication as directed (correct time, dose, route, duration). It continues R39 has dx of GERD. Interventions: Give medications as ordered. R39's Minimum Data Set (MDS), dated [DATE], documents R39 is cognitively intact. On 6/2/25 at 10:53 AM, R39 has a medicine cup with an orange pill in it (stated for his constipation), Fluticasone inhaler, Generic Afrin Nasal Spray on his bedside table, R39 stated The nurse always comes in and leaves my medications in a cup on my table, and I take them on my own, she never stays and watches me take them. On 6/4/25 at 11:20 AM, R39 has his Fluticasone Inhaler and a medicine cup with 3 large round pills sitting on his bedside table. R39 stated These are my Tums; they give me some in a cup for when I need them. R39's Physician Order (PO), dated 10/28/24, documents Advair Diskus Aerosol Powder Breath Activated 100-50 MCG (microgram)/Dose, 1 inhalation inhale orally every 12-hours for COPD (chronic obstructive pulmonary disease) related to other Pulmonary Embolism without Acute Cor pulmonale. Rinse mouth with water after use. Do not swallow the water. This order was updated on 6/4/25 as 1 inhalation inhale orally every 12 hours for COPD (chronic obstructive pulmonary disease) related to other Pulmonary Embolism without Acute Cor pulmonale. Unsupervised self-administration Rinse mouth with water after use. Do not swallow the water. R39's PO, dated 10/2/24, documents Senna-Plus Oral Tablet 8.6-50 MG, Give 1 tablet by mouth two times a day for Constipation. 5. R44's admission Record, dated 6/5/25, documents R44 was admitted to the facility on [DATE] with Diagnosis of Cerebral Infarction, HTN, Dementia, Major Depressive Disorder, BPH, Uropathy, Malignant Neoplasm of Bladder, Wedge fracture of lumbar vertebra, and Malnutrition. R44's Care Plan, dated 5/26/25, documents R44 has a diagnosis of hypertension. Interventions: Give antihypertensive medications as ordered, Obtain blood pressure readings per orders. It continues R44 is receiving medications with a black box warning. Medication type: antidepressant, antianxiety agent, nonopioid/opioid analgesic. Interventions: Administer medication as directed (correct time, dose, route, duration). It continues R44 is at risk for altered nutrition and hydration r/t recent illness, bladder cancer dx. Interventions: Medication per MD order. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145273 If continuation sheet Page 12 of 15 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 145273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jacksonville Skld Nur & Rehab 1517 West Walnut Street Jacksonville, IL 62650 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 R44's MDS, dated [DATE], documents R44 has a moderate cognitive impairment. Level of Harm - Minimal harm or potential for actual harm R44's PO, dated 2/25/25, documents Amlodipine Besylate Tablet 10 MG, Give 0.5 tablet by mouth one time a day for HTN. Residents Affected - Many R44's PO, dated 2/14/25, documents D-Mannose Oral Capsule 500 MG. Give 1 capsule by mouth one time a day for supplementation. R44's PO, dated 1/17/25, documents Lactobacillus Capsule, Give 1 capsule by mouth in the morning for supplementation. R44's PO, dated 1/17/25, documents Cranberry Oral Tablet 500 MG, Give 500 mg by mouth one time a day for supplementation. On 6/4/25 at 11:05 AM, R44 seen sitting at nurse's desk waiting for lunch. R44 has a medicine cup of medications (4 pills) sitting on his bedside table with a cup of water. On 6/4/25 at 11:18 AM, V12, Licensed Practical Nurse (LPN), stated Some residents have an order for Self-Administration of a medication and we leave that medication in their room. When advised of R44's meds still sitting in a cup in his room, V12 stated I put (R44's) medications on his table and he leaned over to take them, I thought that he took them. That was totally my fault. On 6/4/25 at 11:45 AM, V12, LPN, seen giving R44 his medications that he did not take earlier. Amlodipine 0.5mg scheduled and was signed off as given at 6:00 AM, Cranberry tablet 500mg scheduled and was signed off as given at 6:00 AM, D-Mannose 500mg scheduled and was signed off as given at 6:00 AM, and Lactobacillus 1 capsule scheduled and was signed off as given at 6:00 AM. R44's General Note, dated 6/4/25 at 11:49 AM, documents Resident took morning meds at 11:45 today, MD (Medical Doctor) is aware. On 6/5/25 at 10:17 AM, R44 seen lying in bed, a medicine cup of medications (4 pills) sitting on his bedside table with a cup of water. R44 stated The nurse brought them in and set them on my table around 10:00 AM this morning and I have not taken them yet. On 6/5/25 at 10:25 AM, R44 was seen taking his cup of medications left at his bedside. 6. On 6/4/25 at 11:00 AM, R58 stated usually the nurse will bring in her medications and put them on her table and walk away, the only time they stay and watch her take it is if it is a controlled medication. R58's MDS, dated [DATE], documents R58 is cognitively intact. 7. On 6/4/25 at 11:15 AM, R70 stated some nurses do bring his meds in and will leave them on the bedside table for him to take and they don't watch to see if he takes them. R70 stated they are supposed to stay and watch me swallow them, but they don't. R70 stated this morning's meds were brought in and left on his table. R70's MDS, dated [DATE], documents R70 was cognitively intact. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145273 If continuation sheet Page 13 of 15 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 145273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jacksonville Skld Nur & Rehab 1517 West Walnut Street Jacksonville, IL 62650 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 6/5/25 at 3:20 PM, V1, Administrator, stated I would expect the nurses to watch the residents take their medications and not to leave them with the resident to take on their own. They all know they are not supposed to do that. The facility's Medication Storage policy, dated 8/23/22, documented Purpose: To provide guidance to facility nursing staff on the proper storage of medication. Policy: The facility stores all drugs and biologicals in a safe, secure, and orderly manner and in accordance with state and federal regulations. Policy Interpretation and Implementation: 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. Only persons authorized to prepare and administer medications may have access to locked medications. 2. Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals shall be returned to the dispensing pharmacy or destroyed. 5. Medications shall be administered prior to the manufacturer's expiration date. 6. Hazardous drugs shall be clearly marked and stored separately from other medications. 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use. Unlocked medication carts are not left unattended. 8. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications shall be stored separately from food and are labeled accordingly. 9. Over-the-counter medications shall be dated when opened, prior to use. 10. Schedule 11-V controlled medications are stored in separately locked, permanently affixed compartments. Access to controlled medication is separate from access to non-controlled medications. 8. The Facility's Long-Term Care Facilities Application for Medicare and Medicaid, CMS 671, dated 6/2/25, documented there were 75 residing in the facility. Based on interview, observation, and record review the facility failed to date an open vial of Tuberculin that is used for all staff and residents, failed to date opened insulin administration pens, failed to date an open bottle of eye drops, failed to date an open bottle of liquid acetaminophen, failed to date an open vial of multi-dose insulin, and failed to properly dispense medications to residents by leaving them at the resident's bedside. This failure has the potential to affect all 75 residents in the facility. Findings include: 1. On 6/2/25 at 10:15 AM the facility's South unit medication room was checked with V21, Registered Nurse (RN). There was one medication refrigerator checked, and it contained an open tuberculin (TB) vial with no open date documented. The medication refrigerator contained 2 opened prefilled insulin pens with no open date or labeled with patient/resident name and 1 opened prefilled insulin pen with R9's name but no open date was documented on the insulin pen. R60's azelastine .05% eye drop bottle was open, approximately half full, and no open dated was documented on the bottle. V21 stated the TB vial and eye drop bottle should have been dated when it was opened. V21 also stated the insulin pens should have been stored in a bag labeled with the resident's name and dated when they were first used. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145273 If continuation sheet Page 14 of 15 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 145273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jacksonville Skld Nur & Rehab 1517 West Walnut Street Jacksonville, IL 62650 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 2. On 6/2/25 at 10:32 AM medication cart #1 on the Medicare unit was observed and it contained an undated open bottle of ciprofloxacin-dexamethasone 0.3-0.1% ear drops for R333 and 1 undated open bottle of liquid acetaminophen 160 mg/5ml. V21 stated both should have been dated when they were first opened, and that the acetaminophen is floor stock and used for all residents if they have an order for it. 3. On 6/2/25 at 10:40 AM medication cart#2 on the Medicare unit was inspected and it contained R77's undated opened multi-dose vial of Lantus insulin 100 units/ml. V12 LPN (Licensed Practical Nurse) stated the vial should be labeled with the date it was opened. On 6/5/25 at 9:35 AM V2, Director of Nursing, DON, stated the TB solution is used for all staff and residents to complete TB testing. V2 stated the TB vial should have been dated when it was opened and that all insulin medications and floor stock medications should be dated when they are opened. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145273 If continuation sheet Page 15 of 15