Health inspection·April 17, 2025

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. On 4/15/2025 at 7:30 AM, R37 was taking a nebulizer treatment of Albuterol Sulfate. R37's nebulizer treatment mouthpiece, medication cup dispenser and tubing had a date on it of 3/8/2025. Residents Affected - Some On 04/15/2025 at 10:32 AM, R37 had oxygen flowing at 3 liters per minute via nasal canula but there was no date on the oxygen tubing or humidifier bottle. R37 then stated that her oxygen tubing was changed on 3/30/2025. R37's MDS, dated [DATE], documented that her cognition was intact and that she receives oxygen therapy. R37's Physicians Order Sheet, dated 4/15/2025, documented diagnoses of Chronic Obstructive Pulmonary Disease. It continued to document, Change (nebulizer) tubing weekly every night shift, every 7 day(s). It also documented, Change oxygen tubing every week at bedtime every 7 day(s). It continued to document an order for Albuterol Sulfate Inhalation Nebulization Solution (2.5 (milligrams)/3 (milliliters) 0.083% (Albuterol Sulfate) 2.5 (milligrams) inhale orally every 4 hours as needed. For inhale of 2.5 milligrams (every 4-6 hours PRN for bronchospasm rinse mouth out with water after each use. R37's physician order sheet continued to document an order for Oxygen at 3 (liters per minute) via (nasal canula) continuous. R37's April 2025 treatment administration record did not document that her oxygen tubing was changed on 4/12/2025. R37's Care Plan, undated, documented, Give medications as ordered by physician. Monitor/document side effects and effectiveness. It continued, OXYGEN SETTINGS: (oxygen) via (nasal canula) (at) 3 (liters) continuously. Humidified. On 4/15/25 at 3:41 PM, V6, licensed practical nurse (LPN) stated she thinks the oxygen tubing, humidification and nebulizer equipment should be changed out weekly or monthly, but midnights complete that task so she's not sure; they should all be labeled. On 4/16/25 at 8:59 AM, V15 (LPN) stated the NC tubing, oxygen humidification containers and nebulizer equipment should all be changed out and dated weekly. On 4/16/25 at 9:34 AM, V9, registered nurse (RN) stated the NC tubing, oxygen humidification containers and nebulizer equipment are supposed to be labeled and dated so we know when it was changed; night shift is supposed to be doing that once a week. On 4/15/25 at 3:40 PM V2, director of nursing (DON), stated R19's oxygen humidification container was dated 4/3/25 and R24's oxygen tubing, humidification container and nebulizer equipment do not have dates either. V2 stated the oxygen tubing, humidification container and nebulizer administration equipment should be dated and changed weekly. The facility's Oxygen Administration Policy dated 7/1/23 documented the procedure for oxygen administration included to care plan oxygen use, label humidifier with date opened, and tubing will be changed and dated weekly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145286 If continuation sheet Page 2 of 6 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 04/17/2025 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 0695 Level of Harm - Minimal harm or potential for actual harm Based on interviews, observations, and record reviews the facility failed to date nasal cannulas, oxygen humidification containers and nebulizer administration equipment for 5 out of 5 residents (R24, R19, R30, R7, R37); reviewed for respiratory care in a sample of 41. Findings include: Residents Affected - Some 1.R24's face sheet documented she was admitted to the facility on [DATE] with diagnosis of, in part, fracture of the lumbar vertebra, pulmonary hypertension, heart failure and chronic kidney disease. R24's Minimum Data Set (MDS) dated [DATE], documented she was moderately cognitively impaired and at the time did not require oxygen. R24's Care Plan last updated 4/15/25 documented no care plan for oxygen use. R24's orders dated 4/14/25 at 2:00 PM, documented oxygen at 4 LPM (liters Per Minute). R24's orders dated 1/17/25 at 10:00 PM, documented change oxygen tubing every week, every night shift, every 7 days. R24's orders dated 4/13/2025 at 12:46 PM, documented 3 ml(milliliters) inhale orally every 6 hours as needed for shortness of breath or wheezing. On 4/14/25 at 9:46 AM and 11:54 AM as well as on 4/15/25 at 10:44 AM, R24's oxygen NC (nasal cannula) tubing with humidification container and nebulizer equipment was not dated. 2.R19's face sheet dated she was admitted to the facility on [DATE] with diagnosis of, in part, polyneuropathy, acute respiratory failure with hypoxia, and chronic obstructive pulmonary disease. R19's MDS dated [DATE] documented she is cognitively intact and requires oxygen therapy. R19's Care Plan last revised 4/16/25, documented no care plan for oxygen use. R19's orders dated 1/23/2025 at 6:00 PM documented oxygen at 4 LPM via NC continuous. R19's orders dated 1/23/2025 at 8:00 PM documented change oxygen tubing every week. On 4/14/25 at 9:46 AM and 11:54 AM and 4/15/25 at 10:44 AM, R19's oxygen humidification bottle was dated 4/3/25 with no date on her NC tubing. 3.R7's face sheet documented she was admitted to the facility on [DATE] with diagnosis of, in part, chronic obstructive pulmonary disease, type two diabetes mellitus, and congestive heart failure. R7's MDS dated [DATE] documented she was cognitively intact and required oxygen therapy. R7's Care Plan dated 3/12/24 documented she has oxygen therapy. R7's orders dated 10/28/2024 at 6:00 PM documented oxygen at 2 LPM via NC continuous. R7's orders dated 3/4/2024 at 8:00 PM documented change oxygen tubing every week. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145286 If continuation sheet Page 3 of 6 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 04/17/2025 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 0695 On 4/15/25 at 8:00 AM, R7's oxygen humidification was dated 4/7/25 with no date on her NC tubing. Level of Harm - Minimal harm or potential for actual harm 4.R30's face sheet documented she was admitted on [DATE] with diagnosis of, in part, type two diabetes mellitus, heart failure and hypertension. Residents Affected - Some R30's Care Plan last revised 2/24/25, documented no care plan for oxygen use. R30's MDS dated [DATE] documented she was cognitively intact and did not require oxygen use at that time. R30's orders dated 4/8/2025 at 3:30 AM documented oxygen at 2L(liters)/NC to keep saturations above 90. On 4/14/25 at 9:52 AM, R30's oxygen NC tubing did not have a date labeled. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145286 If continuation sheet Page 4 of 6 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 04/17/2025 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 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** Based on observation, interview,and record review, the facility failed to properly store and discard expired medication. This failure has the potential to effect all 48 residents residing in the facility. Findings include: On [DATE] at 9:40 AM the facility's 100 Hall Medication Cart was inspected. The medication cart contained the following: R19's opened and labeled multi dose Aspart insulin Pen. The multi-dose vial was labeled with open date of [DATE]. R19's open and labeled multi dose Glargine insulin pen. The multi-dose vial was labeled with open date of [DATE]. On [DATE] at 9:45 AM V5, Licensed Practical Nurse, verified that the multi dose vials were open and in use. V5 stated that when opening an insulin pen the resident's last name and open date is placed on the multi dose pen. V5 stated that they only 30 days to use the insulin when opened. V5 stated that R19's Aspart and Glargine was discontinued in January and the insulins should have been removed from the cart and destroyed. On [DATE] at 9:50 AM the facility 200 hall medication room was inspected. The refrigerator located in the medication room contained the following: An opened box of Bisacodyl 10mg Suppository, with expiration date, 1/2025. R199's bottle of Glycerin suppositories with expiration date 3/2025. On [DATE] at 9:50 AM V5, LPN, stated that the Bisacodyl are stock medication and are used for everyone as long as they don't have an allergy. V5 stated tht R199 died in January and this medication should have been removed from the refrigerator and destroyed. On [DATE] at 3:15 PM V2, Director of Nursing, stated that she would expect that expired medication be destroyed. V2 stated that she would expect that any discontinued medication and medication of a deceased resident would be taken out of circulation and destroyed. The Resident's Census and Conditions of Resident, CMS 671, dated 4/14//2025, documents that the facility has 48 residents living in the facility. The facility's Medication Storage policy, dated [DATE], documents PURPOSE: To provide guidance to facility nursing staff on the proper storage of medication. POLICY INTERPRETATION AND IMPLEMENTATION 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145286 If continuation sheet Page 5 of 6 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 04/17/2025 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 observation, interview and record review, the facility failed to perform hand hygiene after touching clothing, hair and cellular phone during meal service for 18 of 18 (R1, R3, R4, R5, R10, R11, R12, R13, R16, R22, R26, R27, R29, R32, R34, R36, R38, R40) residents reviewed for infection control in a sample of 41. Residents Affected - Some Findings include: On 04/14/2025 at 12:40 PM, V8, Certified Nurse Assistant (CNA), was in the dining room, was touching hair and face, with her bare hands. Then without performing hand hygiene, V8 was pouring cups of coffee for the residents. V8 then served the coffee to R34 then to R10 and then to R40. Then the meal service began, and V8 touched her glasses and rubbed her nose, and then without benefit of hand hygiene, passed meal trays to R32 and R29. V8 was waiting on the meal trays from the kitchen, she touched her glasses and nose again, and retrieved the meal trays for R4 and R12, and without benefit of hand hygiene, distributed those meal trays. She then cut R12's meat. V8 returned to the kitchen and did not perform hand hygiene, took lunch trays to R3 and then to R34. V8, without benefit of hand hygiene, carried a bowl of mashed potatoes, by the rim with her fingers to R10. V8, without the benefit of hand hygiene, made a cup of coffee for R12 and took it to him. V8 then returned to the kitchen opening, where the ABHR dispenser was, did not use it or perform hand hygiene any other way and retrieved meal trays for R26 and R13 and passed out those meal trays and cut up R13's meal. V8 did not perform hand hygiene and retrieved the meal trays for R1 and R11, passed their meal trays to them and then went and got a cup of coffee and gave it to R1. V8 returned to the kitchen opening, waiting for more meal trays, took her cellular phone out of her pocket, and was touching her screen of her cellular phone. Then the kitchen had 2 more meal trays ready for her to pass and without benefit of hand hygiene, she took R5's meal to him and assisted him with set up and then took R40's meal tray to her. V8 returned to the kitchen opening and retrieved R38's and R36's meal trays and delivered those to the residents without benefit of hand hygiene. She then went back to the kitchen opening and while waiting on more meal trays, she was touching her scrub shirt. She was given R27's meal to take to him and without benefit of hand hygiene passed R27's meal to him. V8 severed R22's meal tray to her and then sat down and assisted R16, with his meal. V8, CNA did not perform hand hygiene during the whole meal service. On 4/24/2025 at 1:30 PM, the alcohol based hand rub dispenser at the kitchen opening was operational with product. On 04/16/2025 at 09:20 AM, V19, Certified Nurse Assistant, (CNA) stated that she would wash her hands using the Alcohol Based Hand Rub available at the kitchen door in between passing trays to residents if she touches her hair or clothes during meal tray pass. On 04/16/2025 at 09:25 AM, V11, CNA, stated that he washes his hands in between passing meal trays to the residents and if he touches his clothes, hair or cell phone he will wash his hands. On 04/16/2025 at 09:30 AM, V3, CNA, stated that she washes her hands when passing meal trays to each resident and that she doesn't carry her cellular phone when at work. The facility's policy, Hand Hygiene, Hand Washing, undated, documented, K. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident . It continues, O. Before and after assisting a resident with meals . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145286 If continuation sheet Page 6 of 6