Inspection·January 25, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Record/Phones) was down. I personally got ahold of (V14, Medical Director) and he wanted her sent out. A resident who was across the hall from Mom's old room told me about it the next day. V11continued to state that R1's eye had been red and looked like it was getting ready to bleed. V11, continued to state that she told the nurses about it for about a week before, but was ignored, until V9, Licensed Practical Nurse, (LPN) got ahold of the doctor and got an eye ointment. Residents Affected - Few On 1/23/24 at 11:30 AM, V3, RN (Registered Nurse), stated that on 1/14/24 she was working her first weekend on her own after completing new hire orientation and that towards the end of her 16 hour shift the CNAs(Certified Nursing Assistant) informed her that R1 was leaning in the bathroom and they had to lower her to the floor. V3 stated that she assessed R1 and did not find any injuries. V3 stated that she went to put the fall in the computer and that she had locked herself out of the electronic medical record. V3 stated, We didn't have a DON (Director of Nursing) so I called the new Administrator and she said she didn't have a way to reset me in the EMR (electronic medical record) so I didn't fill out an incident report. I hate it but I couldn't because I was locked out. V7, CNA and V8, CNA was with me. I didn't call the doctor or the family because I thought she was okay. On 1/24/24 at 10:30 AM, V8, CNA, stated I went in there after the family left and asked (R1) if she needed to use the restroom and she said yes. (V7, CNA) and I put her on toilet. (R1) said she wanted to sit awhile so I educated her on using the call light. When we came back into the bathroom a few minutes later she was laying on the floor. (V3, RN) assessed her and she did not have any injuries. On 1/24/24 at 3:20 PM, V7, CNA, stated On 1/14/24 around 7:00 PM, me and (V8, CNA) transferred (R1) onto the toilet. (R1) said she needed to sit for awhile. We came back and found her laying on the bathroom floor. The nurse assessed her and we didn't see any injuries. I don't remember if we put a gait belt on her or not. I am not sure how we determine who we are supposed to use gait belts on. The facility fall investigation for R1, dated 1/15/24, documented the root cause of R1's fall on 1/14/24 was R1 attempted to transfer self without activating her call light. New intervention was to trial with a chair alarm. On 1/24/24 at 2:04 PM, V2, Regional Nurse/DON, stated that she would expect CNA's and nurses to use a gait belt when transferring residents. V2 also stated that she would expect the facility nurses to complete incident/accident reports on the shift it occurred on and to notify the resident's physician and family of the incident/accident. The facilities Accidents and Incidents Policy, dated 7/1/23, documented, The purpose is to provide staff with guidelines for investigating, reporting, and recording accidents and incidents. The policy is all accidents/incidents involving a resident will be documented in Risk Management. The nursing team will complete an investigation with the root cause and new interventions. Definition: an accident/incident is any occurrence which is not consistent with the routine operation of the facility or the routine care of a particular resident. It may involve injury or damage to property. It may involve residents, visitors, or volunteers. Responsibility: It is the responsibility of the Charge Nurse to complete the accident and incident in the electronic medical record, notify attending physician and responsible parties and document information accordingly. It continues, Procedure: 1. Reporting an accident and incident: A. Accident and incidents, including injuries of an unknown origin, must be reported to the department supervisor, and an Accident/Incident Report should be completed on the shift that the accident or incident occurred. It continues, 3. Medical Attention: B. The Medical Director or the resident's personal physician shall be notified of Accident/Incident. It continues, 4. (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 01/25/2024 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 0580 Level of Harm - Minimal harm or potential for actual harm Investigate and follow up Action: A. The Charge Nurse must conduct an immediate investigation of the accident/incident and implement immediate appropriate interventions to affected parties. B. The Accident/Incident report must be completed. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 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 01/25/2024 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 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 observation, interview, and record review, the facility failed to follow their policy to ensure a safe transfer for one of three residents (R1) reviewed for accidents, in a sample of nine. The findings include: R1's face sheet, dated 1/25/24, documents resident was admitted to the facility on [DATE]. It also documents R1's medical diagnoses of Alzheimer's disease, dementia, chronic heart failure, type 2 diabetes, atrial fibrillation, atherosclerotic heart disease, hypertension, psychotic disorder with hallucinations, osteoarthritis, major depressive disorder, hypothyroidism, and anxiety disorder. R1's Care Plan, dated 11/24/23, documents that R1 is at risk for falls related to confusion, deconditioning, gait/balance problems, incontinence, and psychoactive drug use. It continues, Care Plan interventions: assistive device/reacher, tab alarm placed on 1/16/24, remind resident to ask for assist when she feels unable to complete a task, assist resident with keeping her reacher near her while in her room, be sure call light is within reach and encourage resident to use it for assistance as needed, ensure resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair and remind resident to ask for assistance when needed. R1's Minimum Data Set (MDS), dated [DATE], documents that R1 was moderately cognitively impaired and requires partial/moderate assistance with toilet transfers. On 1/24/24 at 9:15 am V4, CNA (Certified Nurse Assistant), transferred R1 from her wheelchair onto the toilet without the benefit of a gait belt. R1 progress note, dated 1/16/23 at 8:53 AM, documents that on 1/15/24, (R1's) daughter reported that (R1) told her she fell and hurt her head. It continues, Upon physical exam this writer noted that there was an approximately 2.5 by 2.5 cm (centimeter) red area to (R1's) forehead above her right eye at (R1's) hairline. (R1) unable to tell this writer what happened. She states she thinks she fell but is unsure if she was in her room, bathroom or hallway. Denied any pain or discomfort to her head. R1 progress note, dated 1/17/24 at 12:39 PM, documents late entry for 1/15/24 1 pm. Resident taken to ER (Emergency Room) accompanied by one staff member for evaluation, daughter notified and asks that resident be allowed to each lunch prior to taking her to the ED (Emergency Department). On 1/22/2024 V11, R1's daughter/POA stated, I left the facility just before 7:00 PM on 1/14/2024 and Mom had to use the bathroom before she did her therapy. The next day she was slouched down in her chair and had a great big knot on her forehead. She told me I fell. I never received a phone call about the fall and it was not charted. I was told the system (Electronic Medical Record/Phones) was down. I personally got a hold of (V14, Medical Director) and he wanted her sent out. A resident who was across the hall from Mom's old room told me about it the next day. It takes two people to transfer mom since she's so weak and incontinent. On 1/23/24 at 11:30 AM, V3, RN (Registered Nurse), stated that on 1/14/24 she was working her first weekend on her own after completing new hire orientation and that towards the end of her 16 hour (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 01/25/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few shift the CNAs informed her that R1 was leaning in the bathroom and they had to lower her to the floor. V3 continued to state that she assessed R1 and did not find any injuries. V3 stated that she went to put the fall in the computer and that she had locked herself out of the electronic medical record. V3 stated, We didn't have a DON (Director of Nursing) so I called the new Administrator and she said she didn't have a way to reset me in the EMR (electronic medical record) so I didn't fill out an incident report. I hate it but I couldn't because I was locked out. (V7, CNA and V8, CNA) was with me. I didn't call the doctor or the family because I thought she was okay. On 1/24/24 at 10:30 AM, V8, CNA, stated I went in there after the family left and asked (R1) if she needed to use the restroom and she said yes. (V7) and I put her on toilet. (R1) said she wanted to sit awhile so I educated her on using the call light. When we came back into the bathroom a few minutes later she was laying on the floor. (V3) assessed her and she did not have any injuries. On 1/24/24 at 3:20 PM, V7, CNA, stated, On 1/14/24 around 7:00 PM, me and (V8) transferred (R1) onto the toilet. (R1) said she needed to sit for awhile. We came back and found her lying on the bathroom floor. The nurse assessed her and we didn't see any injuries. I don't remember if we put a gait belt on her or not. I am not sure how we determine who we are supposed to use gait belts on. The facility fall investigation for R1, dated 1/15/24, documented the root cause of R1's fall on 1/14/24 was that R1 attempted to transfer self without activating her call light. New intervention was to trial with a chair alarm. On 1/24/24 at 2:04 PM V2, (Regional Nurse/DON), stated that she would expect CNAs and nurses to use a gait belt when transferring residents. V2 also stated that she would expect the facility nurses to complete incident/accident reports on the shift it occurred on and to notify the resident's physician and family of the incident/accident. The facilities Accidents and Incidents Policy, dated 7/1/23, documents, The purpose is to provide staff with guidelines for investigating, reporting, and recording accidents and incidents. The policy is all accidents/incidents involving a resident will be documented in Risk Management. The nursing team will complete an investigation with the root cause and new interventions. Definition: an accident/incident is any occurrence which is not consistent with the routine operation of the facility or the routine care of a particular resident. It may involve injury or damage to property. It may involve residents, visitors, or volunteers. Responsibility: It is the responsibility of the Charge Nurse to complete the accident and incident in the electronic medical record, notify attending physician and responsible parties and document information accordingly. It continues, Procedure: 1. Reporting an accident and incident: A. Accident and incidents, including injuries of an unknown origin, must be reported to the department supervisor, and an Accident/Incident Report should be completed on the shift that the accident or incident occurred. It continues, 3. Medical Attention: B. The Medical Director or the resident's personal physician shall be notified of Accident/Incident. It continues, 4. Investigate and follow up Action: A. The Charge Nurse must conduct an immediate investigation of the accident/incident and implement immediate appropriate interventions to affected parties. B. The Accident/Incident report must be completed. 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 01/25/2024 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 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/apply a pain patch as ordered for 1 of 3 residents reviewed for medications in a sample of 9. The findings include: R1's face sheet, dated 1/25/24, documents resident was admitted to the facility on [DATE]. R1's medical diagnosis includes Alzheimer's disease, dementia, chronic heart failure, type 2 diabetes, atrial fibrillation, atherosclerotic heart disease, hypertension, psychotic disorder with hallucinations, osteoarthritis, major depressive disorder, hypothyroidism, and anxiety disorder. R1's Care Plan, dated 11/24/23, documented that R1 has and is at risk for pain. The Care Plan goal is R1 will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. The Care Plan interventions are to evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. It continues, my pain is alleviated/relieved by medication and movement. R1's Minimum Data Set (MDS), dated [DATE], documented R1 is moderately cognitively impaired. On 1/22/2024, V11, R1's daughter/POA (Power of Attorney) stated, Mom's pain patch is supposed to be put on every morning. On her right shoulder for arthritis. There have been at least three to four times she didn't even have it on. For example, the day I found her with the big knot on her head I told the nurse she didn't have it on. (V3, LPN) said they ran out, so they just put (another arthritis ointment) on it. I then asked (V13,LPN) and she said they were not out of the patches. They were in the drawer (of the medication cart). On 1/24/24 at 9:12 AM, V6 CNA (Certified Nurse Assistant) lowered and raised R1's shirt to see if R1's pain patch had been applied to R1's right shoulder as ordered at 8:00 AM. The pain patch was not observed and V6 confirmed that the patch was not on R1. R1's medication administration record, dated 01/2024, documented that R1's pain patch was applied at 8:12 am by V10 RN (Registered Nurse). On 1/24/24 at 9:35 AM, V9 LPN (Licensed Practical Nurse) documented that R1's pain patch was put on late this am due to being in dining room at breakfast, MD (Medical Doctor) notified. On 1/24/24 at 3:08 PM, V10 RN stated that she had initially applied R1's pain patch when R1 was in bed before the CNAs got R1 up for breakfast but she could not recall what time that was. On 1/24/24 at 3:15 PM, V9 LPN stated that she applied R1's pain patch after breakfast and that she notified the doctor regarding the pain patch being applied late. V9 stated that the pain patch was only applied once today and that it wasn't applied earlier because R1 was already in the dining room when V10 was passing medications. (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 01/25/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 1/24/24 at 2:04 PM, V2, DON (Director of Nursing)/Regional Nurse, stated that she would expect the facility nurses to administer medications as ordered and sign the medication off on the MAR (Medication Administration Record) after it was administered. The facility Medication Administration Policy/Procedure, dated 7/1/23, does not address transdermal patch application/administration. The policy does document the purpose is to ensure proper administration of oral medication. Policy: 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 required. It continues, policy interpretation and implementation: 8. Follow the specific instructions listed for each type of medication to be given. It continues, 12. Chart the medication administered on the electronic medication record. Event ID: Facility ID: 145286 If continuation sheet Page 7 of 7