Health inspection·May 3, 2024

F 0689 conversation. Level of Harm - Minimal harm or potential for actual harm On 5/1/2024 at 2:38 PM, V11, Certified Nursing Assistant (CNA), stated, (R41) is on one on ones because he is a wanderer and likes to go into female residents' rooms. He has been on one on ones for almost two months now. He is a sundowner, and has behaviors. We are watching him to make sure he does not go into anyone's room or upset anyone. Residents Affected - Few R41's Progress Notes dated 1/1/2024 at 7:00 PM, documents, Resident went into another resident's room and was sitting on their bed. Resident was walked to his room at that time. Resident has been seen going in and out of other resident's room. (There was no incident report or any abuse allegations for this incident on 1/1/2024). R41's Progress Notes dated 1/1/2024 t 7:30 PM, documents, Resident went into a female resident's room and took some of her snacks. Female resident came and reported to nurse. Stated she would not tolerate this man coming into her room. R41's Progress Notes dated 1/3/2024 at 7:45AM documents, Ambulating in hallway at beginning of shift, easily redirected to own room and went to bed. No acute distress noted. Alert to self only. R41's Progress Notes dated 1/5/2024 at 7:25 AM, documents, Up all night, roaming hallways, easily redirected to room but ineffective, comes right back out into hallway. No acute distress noted. R41's Progress Notes dated 1/08/2024 at 8:15 PM documents, Resident went into females' room [ROOM NUMBER] and urinated in the floor. One of the ladies came out of the room to tell staff. Her socks were wet with urine. Male Resident was walked to his room and assisted into bed. R41's Progress Notes dated 01/11/2024 at 12:37 AM documents, Up ambulating independently, wandering went to exit door setting off alarm x1, redirected away from door and started going into other residents' rooms. Taken to BR (bathroom), snacks and fluids given then to his bed and slept. R41's Progress Notes dated 01/11/2024 at 7:16 PM documents, Resident went into female's room and shut the door and scared resident. R41's Progress Notes dated 02/09/2024 at 7:23 PM documents, Resident went into another resident's room and got into altercation with other resident. Resident spilled soda on both residents in their rooms. There was no incident report or abuse investigation for this incident on 2/9/2024. R41's Progress Notes dated 02/19/2024 7:53 PM documents, CNA reports that she went to change resident's undergarments, resident grabbed her wrists and blocked her in the bathroom. CNA states he let go of her wrists, and then went to leave bathroom. Resident then hit CNA in left arm with fist on her way out. CNA denied injury. R41's Progress Notes dated 03/10/2024 at 9:18 AM documents, Staff was cleaning dining room, when resident got up she tried to help get across the wet floor so he would not fall and he tried to smack the staff, she did explain to him that she just wanted to help him on the wet floor and he stated no you not wise up. R41's Progress Notes dated 03/15/2024 at 4:31AM documents, At 0035 staff making rounds and went into the resident's room and found him urinating on his roommate and a large puddle of urine on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145286 If continuation sheet Page 2 of 13 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 05/03/2024 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 floor. Resident assisted back to his bed and he laid down. Staff changed roommates linen and cleaned up floor. R41's Progress Notes dated 03/28/2024 at 3:25AM documents, Combative with staff, hitting, kicking and scratching, wandering in hallway at this time, redirection ineffective, continue 15 minute checks. Residents Affected - Few R41's Progress Notes dated 04/01/2024 at 2:12PM documents, resident walking in hall and urinated in hall. R41's Progress Notes dated 04/04/2024 at 4:40 PM documents, A resident wandering into rooms on the hall, resident is hitting staff. R41's Progress Notes dated 04/09/2024 at 4:38AM documents, Wandering, combative with staff, hitting, cursing, difficult to redirect. Interventions ineffective. R41's Progress Notes dated 04/18/2024 at 9:47AM documents, Notified POA of room move today. POA (Power of Attorney) agreeable. R41's Progress Notes dated 04/19/2024 at 2:35 AM documents, Wandering in hallway, redirected, taken to BR (bedroom), snacks and fluids given, Interventions ineffective. R41's Progress Notes dated 04/30/2024 at 10:14 AM documents, This am during med pass resident combative and punched this nurse in the stomach. Redirected to put his shirt on. Sitting on side of bed. With call light in reach. On 5/2/2024 at 4:02 PM, V1, Administrator stated, Nobody ever expressed to me or told me they were scared or any allegation of abuse regarding (R41). (R41) had behaviors and he had wandered into other residents' room, but it was more of a behavior. On 5/3/2024 at 12:36 PM, V1, Administrator stated there was no policy on Supervision. 2. R36's Face sheet documents an admission date of 9/29/2023 with diagnoses of Anxiety Disorder, Cerebral Palsy, Heart Failure. R36's Minimum Data Set, MDS, dated [DATE] documents R36 has no cognitive deficits. R36's Care Plan updated 4/22/2024 has no documentation for abuse. On 5/02/2024 at 8:39 AM R36 stated I do not know when it happened, but there is a predator here. It's (R41). He is an Alzheimer's patient, and he goes in women's rooms. He was pounding on my bathroom door and another time he walked in my doorway. I lunged at him, and he left. The facility put a banner up in my doorway, but (R41) walked right under it. My brother and I talked to the Administrator. I know he is on another hall right now and I haven't seen him. R36 stated I woke up one night and (R41) was sitting in a chair looking at me. I raised up and said 'You need to leave. This is not your room,' and he left.' R36 is unsure of when incident occurred. R36's progress notes dated 1/1/2024 at 1:15PM documents Power of Attorney, POA, wants hydroxyzine held until he talks to Nurse Practitioner on 1-2-24 also stated that R36 has been upset with a male (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145286 If continuation sheet Page 3 of 13 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 05/03/2024 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 resident yelling all night and her not being able to sleep. The resident has come into her room and (R36) is uncomfortable. On 5/2/2024 at 4:00PM V23, R36's Power of Attorney, POA, stated (R36) and I talked to (V1) about (R41) going into the women's rooms. (R36) told (V1) that she was afraid of (R41). I don't think (R41) ever touched (R36). For a while they put a Velcro banner on (R36)'s doorway. B. R29's Facesheet documents an admission date of 1/13/2023. Diagnosis include Nondisplaced Intertrochanteric Fracture of Left Femur, Chronic Pulmonary Edema, Spondylosis, Dementia. R29's Minimum Data Set, MDS, dated [DATE] documents R29 is moderately cognitively impaired, is dependent for sitting to standing, chair to bed transfers, and toilet transfers. R29's fall risk assessment dated [DATE] documents R29 is at high risk for falls. R29's Care Plan updated 4/22/2024 document R29 is risk for falls and injuries related to medications, decreased cognition, attempts to transfer/walk without assist. Interventions include assess toileting needs, bed in lowest position, orient to room, provide adequate lighting, provide/reinforce use of assistive devices. R29's Progress Notes dated 3/20/2024 at 9:40AM documents R29 observed on floor in room laying on left side. Roommate stated that R29 got her feet tangled up in blankets while getting up. Assessed R29. R29 complained of pain to left hip and left foot extended out. Called physician and Power of Attorney, POA, notified and agreed to send R29 out to hospital. R29's Progress Notes dated 3/23/2024 at 9:40PM R29 arrived from local hospital after hip pinning for fracture to left hip. R29 is weight bearing as tolerated. R29 was walking with a walker only with therapy at hospital. Recommendations were made for use of sit to stand or pivot transfer. R29 may shower and has 3 incisions with daily dressing to let hip. R29 complains of pain at times. R29 is alert and oriented times two with intermittent confusion. R29 is oriented to call light, bed in low position and call light in reach. R29's History and Physical dated 3/20/2024 documents Chief Complaint: hip pain. Assessment and Plan: Closed left hip fracture of unspecified part of neck of left femur. Initial encounter for closed hip fracture. Procedure notes dated 3/21/2024 procedure performed Open Reduction and Internal Fixation of left hip. Intertrochanteric fracture with cephalomedullary nail. R29's fall investigation dated 3/20/2024 documents R29 on floor in room laying on left side. Roommate stated she got her feet tangled up in blankets while getting up. Assessed R29. R29 complained of left hip pain. Left foot extended out. Called physician and ordered to sent to local hospital. R29 stated I fell and my hip hurts. Facility fall log documents R29 sustained falls on 3/20/2024, 3/7/2024 and 2/21/2024. On 5/1/2024 at 8:07AM R29 observed up in restroom unassisted. R29's pressure alarm sounding. No staff in room. V10, Certified Nursing Assistant, CNA, entered room and assisted R29 back to wheelchair and assisted to dining room. On 5/1/2024 at 9:25AM R29 observed up to restroom unassisted. Surveyor entered room. No staff in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145286 If continuation sheet Page 4 of 13 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 05/03/2024 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 room. R29's pressure alarm not sounding. Level of Harm - Minimal harm or potential for actual harm On 5/2/2024 at 2:30PM observed R29's pressure alarm sounding with door closed and no staff in room or entering room within 1 minute. Residents Affected - Few On 5/1/2024 at 9:25AM V10, CNA, stated The pressure alarms are pretty sensitive. Not sure why it did not go off. On 5/1/2024 at 9:40AM V2, Director of Nursing, DON, stated I put new batteries in (R29)'S alarm at 7:00AM this morning. Explained to V2 that R29 was observed by herself washing hands in restroom, and alarm did not sound. V2 stated We will have to test it and replace it. On 5/2/2024 at 1:50PM V2 stated If a resident's alarm is going off, I would expect any staff to check on the resident. It doesn't just have to be nursing. On 5/2/2024 at 2:00PM V21, Certified Nursing Assistant, CNA, stated We try to get in here as soon as we hear an alarm. (R29) likes to be very independent. On 5/3/2024 at 9:25AM V24, Physician, stated (R29) has been a challenge with getting up without assistance. If (R29) has an alarm, then I would expect the alarm to sound off if (R29) gets up. They should be checking the alarms. Facility fall policy dated 7/1/2023 states 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. 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145286 If continuation sheet Page 5 of 13 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 05/03/2024 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 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 timely incontinent care for 1 of 9 residents (R8) reviewed for Urinary Tract Infections (UTI) in the sample of 33. Findings include: On 4/30/24 at 11:35 AM V3 Certified Nursing Assistant (CNA) was observed transferring R8 with a sit to stand mechanical lift from her reclining wheel chair (w/c) to the toilet. The seat of R8's wheel chair was visibly wet and R8's pants were saturated with urine . V3 transferred R8 into the bathroom with the lift and pulled down her pants that were wet and removed her saturated adult incontinence brief. There was a strong foul urine odor in R8's room and the bathroom. V3 stated, That is probably from her wheel chair because it has urine on it too. V6, CNA, entered the room because V3 had put on R8's call light. V3 informed V6 she needed some towels and washcloths to clean R8 up. After V6 returned with towels, she stayed to assist V3. V3 cleansed R8's groin, thighs and vagina with soap and water, rinsed her with clean, wet wash cloths, and then dried all areas. V3 and V6 then used the mechanical lift to lift R8 off toilet and V3 cleansed her buttock and rectum with soap and water, rinsed and then dried her skin. V3 applied a new adult diaper and clean pants and then they transferred R8 back to her w/c after V3 wiped it off with a wash cloth. When asked when the last time R8 would have been checked and changed, V3 and V6 both stated she would have been changed before the night shift got her up before 7:00 AM this morning. R8's Face Sheet documents her diagnoses to include: Personal History of Urinary Tract Infections. R8's Minimum Data Set (MDS) dated [DATE] documents R3 is severely cognitively impaired and is always incontinent of bowel and bladder. R8's Care Plan, undated, documents, The resident is at risk dehydration or potential fluid deficit r/t history of chronic UTI and need for assist and encouragement for adequate fluid intake. The interventions for this care plan include, Report PRN (as needed) any s/sx (signs and symptoms) of dehydration: decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness on sitting/standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, dry/sunken eyes. R8's Care Plan, undated, documents, ADL (Activities of Daily Living) Self Care Performance Deficit r/t Dementia, Impaired balance. Interventions for this care plan include, Toilet Use: incontinent of bowel and bladder; assist of 2 with sit to stand lift for toileting transfer. On 5/03/24 at 8:25 AM V4, CNA stated they normally do rounds and check and change residents every two hours. She stated if they are able to do that with R8 she usually does pretty good with toileting. V4 stated on the day R8 was observed to be soaked, they had one CNA call off, and were late getting residents from the dining room and had to lay down the residents who use full body mechanical lifts first, so she was running late. V4 stated she was not trying to make excuses because R8 should never have been left wet that long and should have been checked and changed or toileted within two hours of the last time she was changed. V4 stated she did not know if R8 had had any recent UTIs. On 5/3/24 at 12:15 PM V2, Director of Nursing (DON) stated she expects staff to make rounds at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145286 If continuation sheet Page 6 of 13 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 05/03/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete least every 2 hours and should provide incontinent care as needed during rounds. She stated she would not expect an incontinent resident to not be checked for four and a half hours for any reason, even if CNAs are running a little behind. The facility's policy, Incontinence Care Policy issued 7/1/23 documents, Purpose: To provide guidelines to all nursing staff for providing proper incontinence care in order to keep skin clean, dry, free of irritation and odor. Policy: 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. Event ID: Facility ID: 145286 If continuation sheet Page 7 of 13 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 05/03/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interviews and record reviews, the facility failed to ensure there was an air gap in the ice machine between the floor sewage drain and the ice machine and there were no signs of water damage from sewage lines and or/pipelines. This has the potential to affect all 45 residents living in the facility. Findings include: On 5/1/2024 at 8:33 AM, the ice machine was in the dining area. Behind the ice machine there was water present on the floor. Behind the machine there were also 2 orange cones with the words wet floor that were placed behind the machine. On 5/1/2024 at 8:39 AM, Behind the ice machine there was a white pipe that went into another pipe into a drain. The pipe was going directly into the drain, and no air gap was observed. The air gap was not twice the diameter of the water outlet from the fixture and the fixture's flood-level rim and there was the potential for backflow or back siphonage. The white pipe was also covered with black spots covering the entire pipe, and was wet with moisture. On 5/1/2024 at 8:55 AM, on the walls behind the ice machine, the walls were protruding, and appears patchy clusters of raised areas on the drywall with black specks. The area affected was approximately five feet in length and four feet in width and covered the entire area behind the ice machine. The large pipes coming out of the back of the machine behind the ice machine were also covered with black spots with moisture present. The dry wall was not smooth, and was puffy in appearance. On 5/1/2024 at 9:00 AM, V28, Dietary Manager, stated, I am not sure why it is wet back there or why the area has the orange cones. I think it is from the ice melting. On 5/3/2024 at 9:19 AM, V22, Environmental Health Director, stated, Those orange cones behind the ice machine are put there by dietary staff not by me. They are always behind the ice machine. We use different cones for wet floors. I am not sure why the floor is wet but it has been like that for a while. I could not say exactly how long. It has been a few weeks. Again, I don't do anything with that area. On 5/3/2024 at 9:24 AM, V25, Cook, stated, Those cones have been there for awhile. We get water back there. I am not sure how long it has been like that. On 5/3/2024 at 9:45 AM, V25, [NAME] President of Operations Maintenance, stated, There was water behind the ice machine. I believe with the temperature of the outside wall and the temperature of the actual ice makes it is causing moisture to cling to the surface. I am going to have staff scrap the area, repair the walls from the moisture damage and hit it with some products to reduce the moisture and prevent future moisture. When I got back there and pulled things out the air gap was not to code, and I will address that as well. We will incorporate some new panes behind them as well so they can be wipes and are cleanable. On 5/3/2024 at 10:02 AM, V28, Dietary Manager, stated, The ice machine that is in the dining room is the only ice machine in the building. We use the ice for all meal preparations and meal services, passing out ice, and water coolers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145286 If continuation sheet Page 8 of 13 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 05/03/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm On 5/3/2024 at 10:31 AM, V1, Administrator, stated, We do not have a policy on air gaps but we follow all state and local ordinances. The Long -Term Care Facility Application for Medicare and Medicaid form, dated 4/30/2024, documented that the facility had a census of 45 residents. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145286 If continuation sheet Page 9 of 13 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 05/03/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to adequately develop an ongoing infection control program that adequately collected data to calculate and analyze infection rates and failed to operationalize infection control policies to adequately define infection control practice in the facility. This has the potential to affect all 45 residents living in the facility. Residents Affected - Many Findings Include: On 5/2/2024 at 10:22 AM, an infection control log was provided but did not have any dates or organisms listed or documented. On 5/2/2024 at 10:33 AM, V2, Director of Nursing (DON), stated, I was just hired and just finished taking the ICP (Infection Control Preventionist) course. I am new to this position, and this is the only surveillance I have. I will look and see what else I can find. I do not have a book, but I will call corporate and see what she has. A second list of Infection control log was provided and contained two and half pages. Not all urinary tract infections had organisms documented and were not provided when requested. There were 10 Urinary Tract Infections documented on the log but only two of ten had documented organisms. The Facility Infection Control Program Policy issue, dated 09/15/2020, documented, Purpose to provide guidelines and guidance for all staff regarding the facility established infection control program that investigates, controls and prevents infections. Surveillance for nosocomial infections will be done to provide a format for the surveillance of infections occurring within the facility. The facility will establish and maintain the program in order to provide a safe and sanitary environment, and to help prevent the development and transmission of disease and infection. Infections will be investigated, controlled, and prevented, and isolation precautions will be determined on an individual basis. The Infection Report Form will be kept on those residents who are receiving antibiotics or have an infection. Data will be compiled, and a report completed monthly. Data will be discussed during the QA Meeting. The Infection Control Coordinator will track and trend infections and ensure proper training of staff and ongoing interventions to prevent the spread of infections. Infection Surveillance: the collection of data on nosocomial infections that is used primarily to plan control activities, educational programs and to prevent epidemics. An important reason for collecting and analyzing data is for the early detection and prevention of infectious disease outbreaks. Procedure for infection surveillance: surveillance data will be collected on ongoing basis. Recording, reviewing, analyzing, and reporting of infection case data will be done monthly, quarterly, and annually to detect trends. Surveillance data shall be used for planning control efforts, detecting epidemics, directing in-service education, and identifying individual resident problems for intervention. Analysis of surveillance data will include at least the following elements on each infection to detect clusters and trends: date of onset, body site, geographic location, and appropriate culture information. Data collection: Continuous collection of data is necessary to determine what an infection is, when it is present, and whether it is nosocomial in origin. Data may incorporate the number of infections, type of infections, and related issues which may be present. Monthly reports will include: the incidence of all types of infections. The incidence of community acquired infections. Rates for various types of nosocomial infections. Predisposing infectious organisms in types of nosocomial infections. Any recommendations made regarding isolations or cross infections. The infection control log should be updated on an ongoing basis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145286 If continuation sheet Page 10 of 13 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 05/03/2024 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 0880 The Long -Term Care Facility Application for Medicare and Medicaid form, dated 4/30/2024, documented the facility had a census of 45 residents. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145286 If continuation sheet Page 11 of 13 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 05/03/2024 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm 3. R8's Physician Order Summary, dated 5/2/24, documented, 9/2/22: Keflex Capsule 250 MG (Cephalexin) Give 250 milligrams (mg) by mouth in the morning related to Personal History of Urinary Tract Infections. It also documented that this antibiotic was not discontinued until 3/21/24. Residents Affected - Some R8's Medication Administration Records, dated 5/2023 to 3/2024, documented that R8 received Keflex 250 mg every day while she was in the facility for past year. R8's Progress Notes and Lab results, dated 5/2023, were reviewed, and there was no documentation for a diagnosis of UTI nor was there any abnormal urinalysis found. 05/03/24 at 09:43 AM, V2, Director of Nursing, stated that she talked to the physician and got R8's Keflex order discontinued, and she was started on UTI-Stat pm 3/21/24 to help prevent UTIs. 4. R31's Physician Order Summary, dated 4/1/24 to 5/1/24, documented, 4/3/24: Acyclovir 400 mg by mouth every 12 hours for UTI for 5 days and Cefdinir 300 mg by mouth every 12 hours for UTI for 5 days. R31's MAR, dated 4/1/24 through 4/30/24, documented that R31 received all ordered doses of her Acyclovir and Cefdinir from 4/4/24 to 4/8/24. R31's Urinalysis Culture results, dated 4/2/24, documented, Urine Culture Final; Result: Mixed genital flora isolated. These superficial bacteria are not indicative of a urinary tract infection. No further organism identification is warranted on this specimen. The antibiotic Stewardship Policy, revision date of 12/13/2023, documented, Antibiotics are powerful tools for fighting and preventing infections. However, widespread use of antibiotics has resulted in an alarming increase in antibiotic resistant infections and a subsequent need to rely on broad-spectrum antibiotics that might be more toxic and expensive. In addition to the development of antibiotic resistance, antibiotic use is associated with an increased risk of Clostridium difficile infections and adverse drug reactions. Since antibiotics are frequently over or inappropriately prescribed, a concerted effort to decrease or eliminate inappropriate use can make a big impact on resident safety and the reduction of adverse events. Antibiotics stewardship consists of coordinated resident safety and the reduction of adverse events. First line treatment recommendations. There are no definitive practice guidelines that specifically address treatment of UTI in elderly patients in the LTCF (Long term care facility). Prescribers will base treatment recommendations on the following factors: facility specific culture and antibiotics sensitivity data. Based on interview and record review, the facility failed to ensure the residents were given the correct antibiotics for the organism causing infection for 4 of 4 residents (R8, R25, R31 and R150) reviewed for antibiotic stewardship, in the sample of 33. Findings include: 1. R25's Progress Notes, dated 03/28/2024 at 11:01 AM, documented, Received call from ER (Emergency Room), reports has UTI (urinary tract infection) starting on Macrobid at ER (emergency room) and script being sent to (Pharmacy). Placed call to family to update on results of ER visit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145286 If continuation sheet Page 12 of 13 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 05/03/2024 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R25's Progress Notes, dated 04/04/2024 at 9:55 PM, documented, ABT (antibiotic) completed this shift. No adverse reactions noted. Continue encouraging fluids. Denies any s/s (signs or symptoms) of UTI such as burning, pain, and frequency. R25's Physician Order Sheet (POS), dated 3/1/2024 to 4/30/2024, documented, Nitrofurantoin microcrystal capsule 100 milligrams (mg), give 1 capsule by mouth every 12 hours for UTI Prophylaxis for seven days. R25's Lab Report, collection date 3/28/2024 and verification date 3/29/2024, documented, Mixed genital flora isolated. These superficial bacteria are not indication of a urinary tract infection. R25's Medication Administration Record (MAR), dated April 2024, documented, Nitrofurantoin microcrystal capsule 100 milligrams (mg), give 1 capsule by mouth every 12 hours for UTI (urinary tract infection) for 7 days. Start date 3/28/2024. On 5/2/2024 at 10:00 AM, a Culture and Sensitivity Report (C&S) was requested, and no C&S was provided for R25. 2. R150's Progress Notes, dated 04/20/2024 at 10:49 AM, documented, Resident cont. (continues) ABT (antibiotic) for tx (treatment) of UTI (urinary tract infection), no adverse effects noted. R150's POS, dated 4/19/2024, documented an order for cefdinir oral capsule 300 mg, give 1 tablet by mouth two times a day for UTI for six days. R150's MAR for April 2024, documented that R150 received for cefdinir oral capsule 300 mg, give 1 tablet by mouth two times a day for UTI for six days. R150's Progress Notes, dated 04/28/2024 at 8:59 PM, documented, Remains on antibiotic for UTI. No adverse effects noted. Able to make needs known. Resident denies s/s of UTI this shift. Able to make needs known. R150's Lab results from local hospital, that was collected on 4/16/2024, documented that a urine culture was taken but did not document any culture or sensitivity for the use of cefdinir. The facility was unable to provide a culture and sensitivity (C&S: a lab test to attempt to grow bacteria, viruses, or fungi and then test which medications will effectively work to stop the infection) for R150 when requested. On 5/3/2024 at 9:32 PM, V2, Director of Nursing, stated, My expectations are that anytime any resident is started on antibiotics we have a culture and sensitivity for it and the organism was identified before any antibiotic was given. A lot of times, the hospitals will not send us the C & S and we will have to follow up. I just started this position in April. We also have some issues with the hospice too. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145286 If continuation sheet Page 13 of 13