Inspection·December 19, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few V4's statement as, Staff told me that (V9) was a little rough with (R3). (V9) was in a bad mood all night, just frustrated and she was saying, I'm over this. I just want to go home. The next day I spoke to (V9) concerning the issue. I asked her if she was rough with (R3). (V9) told me I was short with her. I counseled her on the behavior, telling her that it was unacceptable and how she can't take it out on a resident. I told her if she gets frustrated to walk away and get another staff. There was a hand-written question on V4's typed statement that documented question/answer: Did she describe what she meant by short? No, she didn't. I didn't ask all the details. I checked on (R3) to check her blood sugars and she was fine. The blood sugars were a normal check. At the bottom of the statement another handwritten statement documented, If (V9) raised her voice, sometimes (R3) just looks past you and won't acknowledge you. She might have been trying to get her attention. I believe that whole heartedly. This document had V4's name on it and was signed by V1, Administrator and labeled as phone interview 7/21/23. V16, CNA's written statement, dated 7/17/23 documents, As we were serving supper (R3) started getting agitated and trying to get up, wanting to leave. I told (V4) that it might be a good idea to give (R3) something to calm her down as the day before she had done something to the point she was going after other residents. I assumed she did and the next thing I know she was at the nurse's desk, and the chair alarm was going off. I came down the hall and (V9) was going on about she wasn't dealing with it. I told her to let her go that I would take care of her. I walked down one hall with her, and she turned to go to employee entrance exit so I walked with her not really letting her get around me. We were about to room (xxx) when (V9) approached with (R3's) wheelchair (w/c). As (R3) had her back to (V9), with (V9) behind the chair, she grabbed her waist and forcefully put her in the chair. As she did, she said, Sit the f*** down. (R3's) eyes got big and she became more agitated and started swinging her hands. I again stated to (V9) that I had (R3) and to walk away. Within an hour of this, as (R3) and I was down the hall further by room (xxx) (V9) stood in front of the exit door telling me to let her (R3) go. By this point I had (R3) calmer and it was almost as if (V9) was trying to provoke her (R3). At around 6:15 PM (V9) and (unknown CNA) came out of the breakroom and one of them had made the comment they were getting her chair and she WILL sit down. At this point I almost lost it and told them no one was getting the chair and I had her calmed down and to leave her alone. I told the nurse about the incident. She asked where (V9) was, but by then she was off, and she said she'd let (V2) know. I contacted the administrator the next day, but I was unable to reach her. This handwritten statement was signed by V16. On 12/14/23 at 3:33 PM V1 stated the abuse report regarding V9 and R3 does not say whether the abuse allegation was substantiated or not, but stated it was not substantiated because it was on person's word against another's and there was no proof that it happened. V1 stated she did interviews with staff and residents and the allegation was unfounded due to lack of evidence. The facility's policy, Abuse Policy revised 9/15/23 documents, Purpose: To provide guidance and procedures to the facility and staff to assure residents remain to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Responsibility: The administrator and /or designee is the facility abuse coordinator for the facility. It is the responsibility of all facility staff to assure that all residents remain to be free from abuse, including injuries of unknown origin, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. It is all staff responsibility report any allegation or witnessed abuse immediately to the administrator (Abuse Coordinator). Procedure: Establishing an environment that promotes resident sensitivity, resident security, and prevention of mistreatment; immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145286 If continuation sheet Page 2 of 7 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 145286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Staunton Health and Rehab Ctr 215 West Pennsylvania Avenue Staunton, IL 62088 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete misappropriation of property; implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent further occurrences; and filing accurate and timely investigative reports. This policy further documents: Any staff member or person suspected of abuse will be escorted by staff out of the facility and will be notified that they are not permitted back into the facility until the investigation has been complete. The facility will report all allegations of abuse immediately to the Administrator and timely to the proper authorities to include IDPH, Ombudsman, Local Police Department, POA, and MD in a timely manner. Event ID: Facility ID: 145286 If continuation sheet Page 3 of 7 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 145286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Staunton Health and Rehab Ctr 215 West Pennsylvania Avenue Staunton, IL 62088 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 0609 Level of Harm - Minimal harm or potential for actual harm Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to immediately report abuse for 1 of 3 residents (R3) reviewed for reporting of abuse allegations in the sample of 8. Residents Affected - Few Findings include: The facility's document, Report Form-IDPH (Illinois Department of Public Health) Notification, documents: Date of incident: 7/17/23, not reported until 7/21/23. R3 was identified as the resident involved. The report documents the type of incident as alleged abuse, verbal. Per the report, Another staff member reported inappropriate verbal interaction between a staff member and a resident. Staff member immediately suspended pending investigation. Resident assessed; no physical or psychosocial injury noted. Final to follow. Per the report, R3's Power of Attorney (POA), Medical Doctor (MD) and the police were notified on 7/21/23. Under Verification of Incident Investigation/Administrative Summary the report documents the type of incident as allegation of verbal/physical abuse. A brief description of the incident/event is documented as, A C.N.A. (Certified Nursing Assistant) of the facility reports that another C.N.A. used inappropriate language and attempted to make a resident sit down in her wheelchair. At the time of the event, the resident was having behaviors of exit seeking and walking without an assistive device unsafely. Under Immediate Actions Taken (assessments, reporting, suspensions, etc.) it documents Verification of Incident Investigation/Administrative Summary dated 7/26/23 documents, Follow-up Actions taken: in servicing the LPN on duty regarding abuse/neglect, in servicing certified nursing staff on abuse/neglect and resident rights, trauma assessment, updated care plan, and social service director to meet with resident x 2 weeks to assure no psychosocial issues. A staff interview with V4, LPN dated 7/21/23 was included in the abuse investigation and documented V4's statement as, Staff told me that (V9) was a little rough with (R3). (V9) was in a bad mood all night, just frustrated and she was saying, I'm over this. I just want to go home. The next day I spoke to (V9) concerning the issue. I asked her if she was rough with (R3). (V9) told me I was short with her. I counseled her on the behavior, telling her that it was unacceptable and how she can't take it out on a resident. I told her if she gets frustrated to walk away and get another staff. V16, CNA's written statement, dated 7/17/23 documents, As we were serving supper (R3) started getting agitated and trying to get up, wanting to leave. I told (V4) that it might be a good idea to give (R3) something to calm her down as the day before she had done something to the point she was going after other residents. I assumed she did and the next thing I know she was at the nurse's desk and the chair alarm was going off. I came down the hall and (V9) was going on about she wasn't dealing with it. I told her to let her go that I would take care of her. I walked down one hall with her, and she turned to go to employee entrance exit so I walked with her not really letting her get around me. We were about to room (xxx) when (V9) approached with (R3's) wheelchair (w/c). As (R3) had her back to (V9), with (V9) behind the chair, she grabbed her waist and forcefully put her in the chair. As she did, she said, Sit the f*** down. (R3's) eyes got big and she became more agitated and started swinging her hands. I again stated to (V9) that I had (R3) and to walk away. Within an hour of this, as (R3) and I was down the hall further by room (xxx) (V9) stood in front of the exit door telling me to let her go. By this point I had (R3) calmer and it was almost as if (V9) was trying to provoke her. At around 6:15 PM (V9) and (unknown CNA) came out of the breakroom and one of them had made the comment they were getting her chair and she WILL sit down. At this point I almost lost it and told them no one was getting the chair and I had her calmed down and to leave her alone. I told the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145286 If continuation sheet Page 4 of 7 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 145286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Staunton Health and Rehab Ctr 215 West Pennsylvania Avenue Staunton, IL 62088 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nurse about the incident. She asked where (V9) was, but by then she was off, and she said she'd let (V2) know. I contacted the administrator the next day, but I was unable to reach her. On 12/14/23 at 3:33 PM V1 stated she would expect to be notified immediately if abuse is suspected and stated she should have been notified on 7/17/23 when the alleged abuse occurred but she was not notified until 7/21/23. V1 stated V16, CNA told her she tried to call the next day after the alleged abuse occurred but V1 was in a meeting so V16 was unable to get in touch with her. V1 stated V4, LPN, did not notify her of the alleged abuse after V16 informed V4 on 7/17/23. V1 stated there should have been no delay in contacting her to report the alleged abuse. She stated she suspended V9 as soon as she was aware of the allegation of abuse on 7/21/23 but stated V9 did continue to work for the next 3 days after the abuse allegedly occurred. The facility's policy, Abuse Policy revised 9/15/23 documents, Purpose: To provide guidance and procedures to the facility and staff to assure residents remain to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Responsibility: The administrator and /or designee is the facility abuse coordinator for the facility. It is the responsibility of all facility staff to assure that all residents remain to be free from abuse, including injuries of unknown origin, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. It is all staff responsibility report any allegation or witnessed abuse immediately to the administrator (Abuse Coordinator). Procedure: Establishing an environment that promotes resident sensitivity, resident security, and prevention of mistreatment; immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property; implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent further occurrences; and filing accurate and timely investigative reports. This policy further documents: Any staff member or person suspected of abuse will be escorted by staff out of the facility and will be notified that they are not permitted back into the facility until the investigation has been complete. The facility will report all allegations of abuse immediately to the Administrator and timely to the proper authorities to include IDPH, Ombudsman, Local Police Department, POA, and MD in a timely manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145286 If continuation sheet Page 5 of 7 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 145286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Staunton Health and Rehab Ctr 215 West Pennsylvania Avenue Staunton, IL 62088 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an allegation of abuse was thoroughly investigated timely and the alleged perpetrator of abuse was removed from direct patient contact while the allegation was investigated for 1 of 3 residents (R3) reviewed for abuse in the sample of 8. Residents Affected - Few Findings include: R3's Face Sheet documents her diagnoses to include: Vascular Dementia, Mild, With Other Behavioral Disturbance; Major Depressive Disorder, Recurrent, Unspecified, Unspecified Hearing Loss and Encounter for Palliative Care. R3's Minimum Data Set (MDS) dated [DATE] documents R3 is severely cognitively impaired and requires assist from staff for Activities of Daily Living (ADLs). The facility's document, Report Form-IDPH (Illinois Department of Public Health) Notification, documents: Date of incident: 7/17/23, not reported until 7/21/23. R3 was identified as the resident involved. The report documents the type of incident as alleged abuse, verbal. Per the report, Another staff member reported inappropriate verbal interaction between a staff member and a resident. Staff member immediately suspended pending investigation. Resident assessed; no physical or psychosocial injury noted. Final to follow. Per the report, R3's Power of Attorney (POA), Medical Doctor (MD) and the police were notified on 7/21/23. Under Verification of Incident Investigation/Administrative Summary the report documents the type of incident as allegation of verbal/physical abuse. A brief description of the incident/event is documented as, A C.N.A. (Certified Nursing Assistant) of the facility reports that another C.N.A. used inappropriate language and attempted to make a resident sit down in her wheelchair. At the time of the event, the resident was having behaviors of exit seeking and walking without an assistive device unsafely. Individuals with direct knowledge of incident/event and/or those interviewed were identified as (V16) CNA, (V9) CNA and (V4) Licensed Practical Nurse (LPN). Per the report, V4, V9 and V16 were interviewed on 7/21/23. Under Immediate Actions Taken (assessments, reporting, suspensions, etc.) it documents R3's Primary Care Physician and family/POA (Power of Attorney), local police, Medical Director and IDPH were notified, and incident was reported to the administrator on 7/21/23, and V9 was suspended pending the investigation. The report does not document whether the allegation of abuse was substantiated or not after investigation completed. A staff interview with V4, LPN dated 7/21/23 was included in the abuse investigation and documented V4's statement as, Staff told me that (V9) was a little rough with (R3). (V9) was in a bad mood all night, just frustrated and she was saying, I'm over this. I just want to go home. The next day I spoke to (V9) concerning the issue. I asked her if she was rough with (R3). (V9) told me I was short with her. I counseled her on the behavior, telling her that it was unacceptable and how she can't take it out on a resident. I told her if she gets frustrated to walk away and get another staff. V16, CNA's written statement, dated 7/17/23 documents, As we were serving supper (R3) started getting agitated and trying to get up, wanting to leave. I told (V4) that it might be a good idea to give (R3) something to calm her down as the day before she had done something to the point she was going after other residents. I assumed she did and the next thing I know she was at the nurse's desk and the chair alarm was going off. I came down the hall and (V9) was going on about she wasn't dealing with it. I told her to let her go that I would take care of her. I walked down one hall with her, and she turned to go to employee entrance exit so I walked with her not really letting her get around (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145286 If continuation sheet Page 6 of 7 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 145286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Staunton Health and Rehab Ctr 215 West Pennsylvania Avenue Staunton, IL 62088 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few me. We were about to room (xxx) when (V9) approached with (R3's) wheelchair (w/c). As (R3) had her back to (V9), with (V9) behind the chair, she grabbed her waist and forcefully put her in the chair. As she did, she said, Sit the f*** down. (R3's) eyes got big and she became more agitated and started swinging her hands. I again stated to (V9) that I had (R3) and to walk away. Within an hour of this, as (R3) and I was down the hall further by room (xxx) (V9) stood in front of the exit door telling me to let her go. By this point I had (R3) calmer and it was almost as if (V9) was trying to provoke her. At around 6:15 PM (V9) and (unknown CNA) came out of the breakroom and one of them had made the comment they were getting her chair and she WILL sit down. At this point I almost lost it and told them no one was getting the chair and I had her calmed down and to leave her alone. I told the nurse about the incident. She asked where (V9) was, but by then she was off, and she said she'd let (V2) know. I contacted the administrator the next day, but I was unable to reach her. This handwritten statement was signed by V16. V9's Time Sheet documents she continued to work every day after alleged abuse occurred including 7/18/23, 7/19/23, and 7/20/23. On 12/14/23 at 3:33 PM V1, Administrator, stated the abuse report regarding V9 and R3 does not say whether the abuse allegation was substantiated or not, but stated it was not substantiated because it was on person's word against another's and there was no proof that it happened. V1 stated she did interviews with staff and residents and the allegation was unfounded due to lack of evidence. V1 stated she would expect to be notified immediately if abuse is suspected and stated she should have been notified on 7/17/23 when the alleged abuse occurred but she was not notified until 7/21/23. V1 stated V16, CNA told her she tried to call the next day after the alleged abuse occurred but V1 was in a meeting so V16 was unable to get in touch with her. V1 stated V4, LPN, did not notify her of the alleged abuse when V16 informed V4 on 7/17/23. V1 stated there should have been no delay in contacting her to report the alleged abuse. She stated she suspended V9 as soon as she was aware of the allegation of abuse on 7/21/23 but stated V9 did continue to work for the next 3 days after the abuse allegedly occurred. The facility's policy, Abuse Policy revised 9/15/23 documents, Purpose: To provide guidance and procedures to the facility and staff to assure residents remain to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Responsibility: The administrator and /or designee is the facility abuse coordinator for the facility. It is the responsibility of all facility staff to assure that all residents remain to be free from abuse, including injuries of unknown origin, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. It is all staff responsibility report any allegation or witnessed abuse immediately to the administrator (Abuse Coordinator). Procedure: Establishing an environment that promotes resident sensitivity, resident security, and prevention of mistreatment; immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property; implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent further occurrences; and filing accurate and timely investigative reports. This policy further documents: Any staff member or person suspected of abuse will be escorted by staff out of the facility and will be notified that they are not permitted back into the facility until the investigation has been complete. The facility will report all allegations of abuse immediately to the Administrator and timely to the proper authorities to include IDPH, Ombudsman, Local Police Department, POA, and MD in a timely manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145286 If continuation sheet Page 7 of 7