Inspection·February 28, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to ensure residents were free from abuse for 2 of 2 residents (R15, R4) reviewed for abuse in the sample of 21. Findings include: 1. R42's Face Sheet documents R42 was admitted to the facility on [DATE] with diagnoses including dementia, depression, and anxiety. R42's Minimum Data Set (MDS) dated [DATE] documented R42 was severely cognitively impaired, ambulated via wheelchair, and had behaviors including wandering and physical verbal behaviors directed toward others. R42's Care Plan with start date of 7/23/24 documents R42 exhibited problems as seen by cursing, hitting, grabbing others, rummaging, making disruptive sounds, screaming at others, wandering and looking for a boyfriend. R15's Face Sheet documents R15 was admitted to the facility on [DATE] with diagnoses including failure to thrive, protein calorie malnutrition, and major depressive disorder. R15's MDS dated [DATE] documented R15 was cognitively intact and ambulated via wheelchair. R15's Care Plan dated 10/9/24 documents R15 is at risk for abuse and neglect. R15's Progress Note dated 10/11/24 by V22, Licensed Practical Nurse (LPN) documents, Was on 200 hall passing medicine, and heard (R15) calling out. Went in room and (R42) was standing beside (R15)'s bed hitting her and telling her to get out of her room. R42's Progress Note dated 10/11/24 by V22 documents, Was passing medicine on 200 hall and heard (R15) calling out for help, and went in and found (R42) standing by (R15)'s bed. She was hitting (R15) and telling her to get out of the room. On 2/27/25 at 12:42 PM, V22 stated, (R15) was crying out and (R42) was standing beside her bed. (R15) said, Get me out; she is hitting me! (R15) said (R42) hit her. I think (R42) thought it was her room and was trying to get (R15) out of the bed. 02/27/25 01:30 PM, R15 stated she woke up to R42 hitting her. She stated, She hit me in the face, chest, breasts she is brutal. She wanted to ruin me. I avoid her with everything I have. I don't go to the dining room. Nobody is going to hurt me in here. 2. R4's Face Sheet documents R4 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, atherosclerotic heart disease, and depression. R4's MDS dated [DATE] documented R4 was cognitively intact and ambulated via wheelchair. R4's Progress Note dated 11/24/24 documents, Patient was in the dining room eating lunch when he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145465 If continuation sheet Page 2 of 16 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 145465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerseyville Nsg & Rehab Center 1001 South State Street Jerseyville, IL 62052 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 was approached by another female resident and hit in the right upper back from behind. Level of Harm - Minimal harm or potential for actual harm R42's Progress Note dated 11/24/24 by V12, LPN, documents, Writer was called into dining room from CNA (Certified Nursing Assistant). CNA has stated that patient had got up from wheelchair and walked to another male patient and hit patient in right side of upper back closed handed. When asked why patient hit him, she stated, Because he brought another woman in here and was pointing to another female. Writer explained the other female was in the dining room to eat as the rest of them were. Patient then replied, shes just a wh***, that is why she is in here. Residents Affected - Few On 2/28/25 at 8:20 AM, V12 stated she remembers a CNA coming to tell her R42 rolled up in her wheelchair in the dining room and hit R4 in the back of the head with a closed fist. She was unable to remember which CNA alerted her. On 2/27/25 at 3:16 PM, V1, Administrator, stated he expects the Facility to follow its abuse policy. The Facility's Abuse Prevention Program Policy revised 9/29/22 documents, Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145465 If continuation sheet Page 3 of 16 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 145465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerseyville Nsg & Rehab Center 1001 South State Street Jerseyville, IL 62052 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 Based on interview and record review, the Facility failed to investigate allegations of abuse for 2 (R15, R42) of 2 residents reviewed for abuse, neglect and exploitation in the sample of 21. Residents Affected - Few Findings include: 1. R15's Progress Note dated 10/11/24 by V22, Licensed Practical Nurse (LPN) documents, Was on 200 hall passing medicine, and heard (R15) calling out. Went in room and (R42) was standing beside (R15)'s bed hitting her and telling her to get out of her room. R42's Progress Note dated 10/11/24 by V22 documents, Was passing medicine on 200 hall and heard (R15) calling out for help, and went in and found (R42) standing by (R15)'s bed. She was hitting (R15) and telling her to get out of the room. On 2/27/25 at 11:24 AM, V1, Administrator, stated he does not have an abuse investigations for this allegation. 2. R42's Progress Note dated 11/24/24 by V12, LPN, documents, Writer was called into dining room from CNA (Certified Nursing Assistant). CNA has stated that patient had got up from wheelchair and walked to another male patient and hit patient in right side of upper back closed handed. When asked why patient hit him, she stated, Because he brought another woman in here and was pointing to another female. Writer explained the other female was in the dining room to eat as the rest of them were. Patient then replied, shes just a wh***, that is why she is in here. On 2/27/25 at 11:24 AM, V1 stated he does not have an abuse investigation for this allegation. On 2/27/25 at 3:16 PM, V1 stated he expects the Facility to follow its abuse policy. The Facility's Abuse Prevention Program Policy revised 9/29/22 documents, All incidents will be documented, whether or not abuse occurred, was alleged or suspected. Any incident or allegation involving abuse, neglect, or misappropriation will result in an abuse investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145465 If continuation sheet Page 4 of 16 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 145465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerseyville Nsg & Rehab Center 1001 South State Street Jerseyville, IL 62052 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Interview, and Record Review, the facility failed to provide progressive fall interventions and to complete a fall investigation for 1(R28) of 2 residents in the sample of 21.This failure resulted in R28 sustaining a displaced fracture of greater trochanter of left femur. Findings include: R28 documents an admission date of 10/28/2022. Diagnosis include Displaced fracture of greater trochanter of left femur, subsequent encounter for closed fracture with routine healing, Emphysema, Aneurysm of the Descending Thoracic Aorta, Dementia, Tremors. R28's Minimum Data Set, MDS, dated [DATE] documents R28 is severely cognitively impaired. R28 requires maximum/substantial assist for activities of daily living, (ADLs) and mobility. R28's Care Plan updated 1/1/2025 documents Problem: R28 is at risk for falls due to diagnosis of tremors, vertigo, dementia, arthritis of left hip, pain in left and right knee, history of falling, iron deficiency anemia, and poor safety awareness, up ad lib in facility with walker. Falls 7/20/23, 09/27/2023, 12/1/23, 12/8/23 atb initiated fall 2/10/24 fall 3/6.24. Interventions include: Staff to toilet resident every 2 hours and as needed. R28 to wear no skid socks to bed to prevent sliding on the mat when getting out of bed. Encourage R28 to take frequent rest periods and staff to provide stand by assist when ambulating with walker. Encourage R28 to utilize walker when ambulating. R28 struggles with her sleep pattern, medication review for any changes. Attempt to keep bathroom light on and leave bathroom door open. Place R28 in common areas for increased supervision. Therapy to evaluate and treat for strengthening and balance. Approach: engage in activities when noted wandering to prevent further falls. Approach: educate staff on R28's need for increased assistance at times. Place on Walk to Dine program. Approach: Clock place in R28's room to show the R28 what time it is. Approach: Staff to have a discussion with daughter regarding hip protectors and a helmet. Approach: Night light placed in resident's room to assist with vision during night hours. R28's Care Plan updated 1/1/2025 documents Problem: [NAME] is cognitively impaired related to unspecified dementia, mild, with anxiety, unspecified abnormalities of gait and mobility, Muscle weakness (generalized). Interventions include Approach: Simple YES/NO questions and commands Approach: Allow ample time for resident to respond. R28's fall risk assessment dated [DATE] documents R28 is at high risk for falls. R28's progress notes dated 12/19/2024 at 11:00AM documents POA (Power of Attorney) had R28 ambulate to nurses' station and brought to this writer's attention that R28 has abrasion/bruised area to left forehead and an area into left hairline and that R28 complains of pain to head and to left upper hip down into left upper thigh and left foot slightly rotated inwards. States R28 was sitting on toilet when she first got here and when she went to assist R28 up, R28 started complaining of pain left hip and had a difficult time getting up. V2, Director of Nusing/DON, made aware and assessed R28 also. Origin/time of fall unknown at this time. R28 unable to say when or how she fell due to mental status. Will send R28 to local hospital evaluation. R28's progress notes dated 12/19/2024 at 1:07PM documents Received call from staff nurse at local (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145465 If continuation sheet Page 5 of 16 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 145465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerseyville Nsg & Rehab Center 1001 South State Street Jerseyville, IL 62052 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 - Actual harm Residents Affected - Few hospital and she states that R28 will be returning to facility. She states everything was negative and they did the following: Cat Scan of head and cervical spine without contrast; Xray of the chest, left femur, pelvis and left shoulder. R28's fall report conclusion with root cause dated 12/19/2024 documents R28 coming out of restroom tripped over her walker and fell into roommate's wardrobe. R28 sent to local hospital for evaluation and treatment. R28 given pain medications for hip pain. R28's care plan does not document new interventions for falls occurring on 12/19/2024, 12/23/2024, and 12/27/2024. R28's progress notes dated 12/20/2024 at 2:36PM documents R28 is resting in low bed with eyes closed. No signs of pain or discomfort noted. Bruising/abrasion remains to L forehead/hairline. Staff assist with toileting during night. R28 does get up without assist at times and walks around room without walker. Reminders to use call light for assistance. Staff checking on R28 frequently during night and every 2hrs. Call light in reach. R28's progress notes dated 12/23/2024 at 2:26AM CNA (Certified Nursing Assistant) called this writer to R28's room she was s found lying on the bathroom floor on her back with her hands behind her head, no new injury bruising continues to right arm and some areas on forehead. No new injury noted. Lifting R28 off floor she begins to yell and resist care. While sitting on bed resident begins to shake all over will not respond to questions when asked by nurse. R28 transported to local hospital by ambulance. Parties notified. R28's fall event conclusions with root cause dated 12/23/2024 documents R28 attempting to take self to restroom. Sent to local hospital for evaluation and treatment. Staff requests urinalysis order. R28's progress notes dated 12/23/2024 at 3:16PM documents follow up from fall 12/23/2024. No injuries and range of motion within normal limits. No complaints of pain, discomfort or facial expressions. R28's progress notes dated 12/26/2024 at 8:42PM R28 displaying difficulty with ambulation and transfer this shift as well as bruising to the left hip and thigh area and complaints of pain. Daughter expressed concerns to this writer that no x-rays were completed when R28 was sent to the local hospital on [DATE]. Call placed to on call physician. This writer expressed family concerns to Physician. Orders to X-ray left hip leg and ankle. Order placed with bio tech x-ray. R28's progress notes dated 12/27/2024 at 5:22PM documents R28 found sitting on wheelchair pedals. Roommate stated she sat on her pedals hanging onto the arms of the wheelchair. No new bruises noted at this time. R28 offer any complaints of pain, discomfort, or facial expressions. Parties notified. R28's fall event does not documents fall on 12/27/2024. R28's progress notes dated 12/28/2024 at 10:41PM documents R28 has a broken Trochanter left hip. Daughter wants her to see Physician who will not be available until after New Year according to daughter. Suggested she see local physician and she states she wants her to wait and see her Physician delaying treatment. In the meantime, resident is getting worse, and having more pain. R28's progress notes dated 12/28/2024 at 11:35PM documents R28 noted with increased pain to left (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145465 If continuation sheet Page 6 of 16 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 145465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerseyville Nsg & Rehab Center 1001 South State Street Jerseyville, IL 62052 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 hip. R28 guarding L leg. On call Physician notified of L hip xray results. New order noted to send R28 to local hospital for evaluation and treatment. POA notified. V2 notified. 911 called for transport. Level of Harm - Actual harm Residents Affected - Few On 2/26/25 at 10:12 AM, V2, DON, stated she does not think the hip fracture was attributed to the 12/23 fall and thinks they have an investigation on the unknown injury and will try to locate it. On 2/26/25 at 10:53 AM, V2, DON, stated she fell on 12/23 and they did not Xray her at the hospital. We had been trying to keep her in her chair because she was getting some medication for pain but her daughter kept walking her and would complain of pain so that is why we ordered the x-ray on 12/27. There were no falls in between those days. Any change of plane would be a fall. There should be an intervention after every fall or incident, and they should be on the care plan. On 2/26/25 at 11:08 AM, V2 provided pain evaluation. No pain documented from 12/23/25 until 12/27/25. Unsure whether there were staff interviews to determine what happened but will look for them. On 2/27/2025 at 3:10PM V18, Regional Director, stated Any change of plane should be considered a fall. Facility fall policy with a revision date of 7/2017 states It is the policy of (Facility) to assess and manage resident falls through prevention, investigation, and implementation, and evaluation of intervention. The definition of a fall refers to unintentionally coming to rest on the found, floor, and other lower level, but not as a result of an overwhelming external force (e.g., resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall. A fall without injury is still a fall. Unless there is evident suggesting otherwise, when a resident is observed on the floor, a fall is considered to have occurred. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145465 If continuation sheet Page 7 of 16 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 145465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerseyville Nsg & Rehab Center 1001 South State Street Jerseyville, IL 62052 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to obtain monthly weights on 2 of 3 residents (R13, R41), reviewed for nutrition in the sample of 21.This failure resulted in R13 having a significant weight loss of 15.6% from 11/8/24 to 2/26/25. Residents Affected - Few Findings include: 1. On 2/26/25 at 8:43 AM, R13 was sitting in a specialty chair in the dining room. She appeared thin with observable temporal wasting and did not respond when spoken to. V10, Certified Nursing Assistant (CNA), stated R13 has to be fed by staff. R13's Face Sheet documents R13 was admitted to the facility on [DATE] with diagnoses including cerebrovascular disease, depression, and pain. R13's Minimum Data Set (MDS) dated [DATE] documented R13 was severely cognitively impaired, ambulated via wheelchair, required substantial assistance with eating, was on mechanically altered diet, and had no or unknown weight loss. R13's Care Plan revised 2/11/24 documents R13 is at risk for hydration problems, dehydration, constipation, and urinary tract infection related to communication deficit, poor intakes, diagnoses of heart disease and hypothyroidism, and vitamin deficiency. The goal was for R13 to remain free of malnutrition as evidenced by labs, weight monitoring and intake monitoring through review date. The approach was weigh monthly and as needed and record. If weight changes 5% in one month, 7.5% in three months, or 10% in six months, notify provider and family. R13's Physician Order dated 7/25/24 documents mechanical soft diet with pureed meat. R13's Physician Order dated 5/2/23 documents nutritional supplement twice daily due to weight loss history. R13's 11/8/24 weight measured 153.2 pounds (lbs). R13's 2/26/25 weight measured 129.0 lbs. A 15.6% weight loss from 11/8/24. R13 had no recorded weights for December 2024 or January 2025. 2. On 2/25/25 at 1:50 PM, R41 appeared thin and stated since he has been on isolation for COVID-19, he doesn't get his meals until later than normal, it is cold by the time it gets to him and the meat tastes horrible. R41 stated he isn't sure if he has lost any weight but has been trying to gain weight. R41 stated he has not been weighed recently. R41's Face Sheet, undated, documents R41 has a diagnosis of Moderate Protein Calorie Malnutrition. R41's Minimum Data Set (MDS), dated [DATE], documents R41 has a BIMS (Brief Interview for Mental Status) score of 14, indicating R41 is cognitively intact and requires set up with eating. R41's Care Plan, dated 11/7/24, documents R41 is at risk for weight loss with an intervention to monitor and record weight. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145465 If continuation sheet Page 8 of 16 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 145465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerseyville Nsg & Rehab Center 1001 South State Street Jerseyville, IL 62052 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 0692 R41's Physician Order Sheet (POS), documents an order, dated 11/6/24, to weigh R41 monthly. Level of Harm - Actual harm R41's Weight Records, document the last recorded weight was on 12/14/24 and R41 weighed 160.8 lbs (pounds). R41's weight on 11/6/24 was 160.8 lbs. R41's weight on 10/14/24 was 168.6 lbs. Residents Affected - Few R41's Progress Note, dated 11/6/24 at 11:49 AM, documents the following: IDT (Interdisciplinary Team) met regarding resident weights. Resident is noted to have a significant weight change of 10% in 180 days. Resident had medication changes in September which could have contributed to weight loss. Resident tis stable at this time. Chart review completed, medications reviewed, diet and intakes reviewed. Will continue to monitor with monthly weights. MD (Medical Doctor) and family notified. R41's Progress Note, dated 11/12/24 at 3:14 PM, documents the following: Quarterly dietary progress note, resident has had some weight loss, not significant. Has a past history of not coming to the dining room and eating. Currently comes to the dining room and consumes 75-100% of all meals. Feeds himself in the dining room. Non-diabetic. On 2/26/25 at 1:20 PM, V5, Certified Nursing Assistant (CNA), stated the Facility's scale was broken for about six weeks, and the replacement did not arrive until a few days ago. On 2/26/25 at 1:44 PM, V19, Registered Dietitian (RD), stated she uses the Electronic Health Record (EHR) to obtain resident weights and monitors residents monthly for weight loss. She stated, There were no weights done for January, and that is a problem. People might already be losing weight, and we don't know it, and they could be malnourished. Last time I was there, some residents had not been weighed in December either. I would expect weights to be done monthly unless they have CHF (Congestive Heart Failure). I don't see any documentation that residents have been refusing (weights). If I had seen (R13)'s weight loss, I would have first requested a reweight (to ensure accuracy), and then I would have seen what I could do for her. If (R13) went from 153.2 lbs to 129.2 lbs, that is 15.6% weight loss, and that's a problem. On 2/26/25 at 1:44 PM, V19, Registered Dietician, stated she visits the facility once per month, she runs a report that shows her any new admits, weight loss, and other concerns like skin. V19 stated there were no weights done for January 2025 and that is a problem. V19 stated she has contacted the facility about it. V19 stated people might already be losing weight and they don't know it and they could be malnourished. V19 stated the last time she at the facility, there were some residents that had not been weighed in December either. V19 stated she would expect weights to be done monthly. V19 stated the facility is supposedly getting a new scale. On 2/27/25 at 3:16 PM, V1, Administrator, stated, Residents are always weighed upon admission, and then monthly unless other factors and requirements that necessitate them to be weighed daily or weekly. The Facility's Weighing and Measuring the Resident Policy revised 8/2014 documents, The purposes of this procedure are to determine the resident's weight and height, to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident, and to provide a baseline height in order to determine the ideal weight of the resident. Monthly weights are to be obtained by the 8th of the month. Weight is usually measured upon admission and readmission weekly x 4 weeks and then monthly during the resident's stay. The Facility's Nutritional Assessments Policy revised 1/2012 documents, All residents who (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145465 If continuation sheet Page 9 of 16 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 145465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerseyville Nsg & Rehab Center 1001 South State Street Jerseyville, IL 62052 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 0692 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete experience significant or undesirable weight loss shall be assessed for nutritional status and required intervention by the registered, licensed dietitian. A course of action increasing calories shall be implemented unless the weight loss is deemed desirable and necessary for improvement of medical status. Weights shall be reported to the RDLD (Registered Dietitian, Licensed Dietitian) for review and assessment. Residents shall be weighed and weights reported monthly to RDLD. Event ID: Facility ID: 145465 If continuation sheet Page 10 of 16 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 145465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerseyville Nsg & Rehab Center 1001 South State Street Jerseyville, IL 62052 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview and record review, the facility failed to post it's licensed and unlicensed staffing that are responsible for resident care when reviewed for posted nurse staffing. This failure has the potential to affect all 48 residents residing in the facility. Residents Affected - Many Findings include: On 2/25/25 at 1:05 PM, the facility was toured and the staffing for resident care was not posted. On 2/25/25 at 1:05 PM, V2, Director of Nursing, stated the daily staffing was posted in the employee break room, however the only staff posted in the break room was the daily assignment sheets for the Certified Nurses Assistants and Nurses. The assignment sheets were reviewed and did not list the census or total number and actual hours worked per shift for licensed and unlicensed staff responsible for resident care. On 2/28/25 at 8:58 AM V18, Regional Director of Clinical Operations, stated I'm sure we have a policy on daily staff posting, we would follow the regulations, but we haven't been doing it, this is something that we will be implementing. The CMS (Centers for Medicare & Medicaid Services) - 671, dated 02/25/2025, documents there are 48 residents residing in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145465 If continuation sheet Page 11 of 16 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 145465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerseyville Nsg & Rehab Center 1001 South State Street Jerseyville, IL 62052 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to serve meals at a desirable temperature to 2 of 2 residents (R14, R41), reviewed for preferred temperature in the sample of 21. Residents Affected - Few Findings include: On 2/25/25 at 1:03 PM, the food temperatures were checked with a metal calibrated thermometer after the last resident tray was served with the following noted: Hamburger: 169 degrees, Ground hamburger 156 degrees, French fries 107 degrees and vegetable medley 123 degrees. 1 On 2/25/25 at 11:28 AM, R14 stated the food is horrible, tastes bad, is cold and never on time. R14 stated there are times when lunch isn't served until 2:00 PM. R14's Minimum Data Set (MDS), dated [DATE], documents R14 has a BIMS (Brief Interview for Mental Status) score of 15, indicating R14 is cognitively intact. 2. On 2/25/25 at 1:50 PM, R41 stated since he has been in isolation for COVID-19, he doesn't get his food until later than normal, it is cold by the time it gets to him and the meat tastes horrible. R41's Face Sheet, undated, documents R41 has a diagnosis of Moderate Protein Calorie Malnutrition. R41's MDS, dated [DATE], documents R41 has a BIMS score of 14, indicating R41 is cognitively intact. On 2/26/25 at 10:20 AM, V1, Administrator, stated residents in the dining room are served first beginning at noon and then they serve the hall trays. V1 stated food temps have been a problem because of the heating elements, the meal cart is insulated but not heated. V1 stated they are working on getting new carts, but it is a process. The Resident Council Minutes, dated 2/11/25, documents the food is not real hot. The Meal Services Temperatures Policy, dated 1/2012, documents meal temperatures shall be monitored by the Dietary Manager and the Cooks on a daily basis. Hot food shall be cooked or heated to a temperature above 165 degrees. Food which does not meet the appropriate temperatures shall be removed and reheated or re-chilled prior to service. The purpose of the policy is to ensure appropriate food temperatures during the meal service and to ensure appropriate food holding temperatures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145465 If continuation sheet Page 12 of 16 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 145465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerseyville Nsg & Rehab Center 1001 South State Street Jerseyville, IL 62052 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on observation, interview, and record review, the Facility failed to serve meals in a timely manner for 4 of 4 residents (R14, R29, R19, R32) reviewed for nutritional services in the sample of 21. Findings include: The Facility's Meal Times List documents Lunch is served at 12:00 PM daily. On 2/25/25 at 12:13 PM, V7, Cook, began plating food from the steam table for residents in the dining room. On 2/25/25 at 12:54 PM, V7 continued making plates of food and stated, Today is just an off day (regarding the timing of meal). On 2/25 25 at 1:03 PM, V7 finished making plates and took a cart of trays to the nurse's station. She stated she would watch the food until Certified Nursing Assistants (CNAs) were available to pass the trays to the rooms. On 2/25/25 at 1:08 PM, V9, Certified Nursing Assistant (CNA), pushed the cart down the 100 Hallway and stated the meals are always late. On 2/25/25 at 1:19 PM, V8, Dietary Manager, took a meal tray from the cart and delivered it to R14's room. On 2/25/25 at 1:20 PM, V9 took a meal tray from the cart and delivered it to R29's room. On 2/25/25 at 1:23 PM, V9 took a meal tray from the cart and delivered it to R19's room. On 2/25/25 at 1:25 PM, V9 took a meal tray from the cart and delivered it to R32's room. On 2/26/25 at 10:20 AM, V1, Administrator, stated residents in the dining room are served first, but the hall trays should not be that late. He stated the Facility does not have a policy regarding timeliness of meal service. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145465 If continuation sheet Page 13 of 16 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 145465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerseyville Nsg & Rehab Center 1001 South State Street Jerseyville, IL 62052 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, interview, and record review, the Facility failed to ensure food was prepared, stored and distributed in a manner that prevents foodborne illness. This has the potential to affect all 48 residents living in the Facility. Findings include: On 2/25/25 at 8:45 AM, V6, Dietary Aid, placed a tray of pans in the dish machine and began the cycle. She stated she has never checked the dish machine sanitizer level. On 2/25/25 at 8:47 AM, the refrigerator labeled Fridge 2 contained a cardboard box of lettuce with sticky, red spatters on top of it. There was an opened container of whipped cream that was not dated upon opening. On 2/25/25 at 8:50 AM, the air conditioner above the toaster was covered in dust. On 2/25/25 at 8:52 AM, there was a rack of pots and pans next to the stovetop with crumbs on one of the pans. On 2/25/25 at 8:54 AM, the refrigerator labeled Fridge 1 contained a package of sliced deli meat that was opened, but was not dated or resealed after opening, leaving the contents open to air. V7, [NAME] stated, I'm not sure what that is. I think it's turkey .I think. There was a stainless steel bin containing a yellow liquid that was not labeled or dated. There were two sandwiches wrapped in plastic wrap that were not labeled or dated. There was a plastic container of sliced cheese that was not labeled or dated. There was a container labeled gravy with use by date of 2/24/25. There was a container with a label that was difficult to read with use by date of 2/24/25. V7 clarified the contents were chicken pot pie and placed the container back into the refrigerator. On 2/25/25 at 8:58 AM, the wall next to the stove top was spattered with a brown substance. On 2/25/25 at 9:01 AM, on the shelf in the dry storage room there were multiple dented cans of vegetable broth. V7 stated she stores dented cans on the shelf with all the other cans of the same product. On 2/25/25 at 9:03 AM, in the freezer labeled Freezer 3 there were three breaded meat patties in a plastic bag that were not labeled or dated. There was a bag of pancakes that was not labeled or dated. On 2/25/25 at 9:05 AM, in the freezer labeled Freezer 4 there was a bag of crinkle cut French fries that were opened, but were not dated or resealed upon opening, leaving the contents open to air. There was an opened bag of garlic bread that was not labeled or dated. On 2/25/25 at 9:06 AM, in the dry storage room there was a container of barbecue sauce that was opened and approximately half empty. The back of the container stated Refrigerate after opening. On 2/26/25 at 8:37 AM, the resident refrigerator in the room next to the nurse's station contained two boxes of fast food chicken that were not labeled or dated and a fast food milkshake that was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145465 If continuation sheet Page 14 of 16 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 145465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerseyville Nsg & Rehab Center 1001 South State Street Jerseyville, IL 62052 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 covered, labeled or dated. Level of Harm - Minimal harm or potential for actual harm On 2/27/25 at 10:14 AM, V1, Administrator, stated he expects staff to follow food service policies to include labeling, dating, and discarding outdated food. Residents Affected - Many The Facility's Food and Supply Storage Policy dated 1/2012 documents, Food and supply storage areas shall be maintained in a clean, safe, and sanitary manner. Food services will maintain clean food storage areas. Prepared foods stored in the refrigerator until service will be covered, labeled, and dated with an expiration date. All foods will be covered, labeled, and dated. The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 2/25/25 documents there are 48 residents living in the Facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145465 If continuation sheet Page 15 of 16 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 145465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerseyville Nsg & Rehab Center 1001 South State Street Jerseyville, IL 62052 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the Facility failed to ensure use of proper PPE (Personal Protective Equipment) for 2 of 3 isolated residents (R39, R42) reviewed for infection control in the sample of 21. Residents Affected - Few Findings include: 1. R39's Face Sheet documents R39 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus and chronic obstructive pulmonary disease (COPD). R39's Progress Note dated 2/23/25 documents R39 did not feel well and requested a Covid test which resulted positive. R39's Progress Note dated 2/24/25 documents R39 had a sore throat and remained on isolation for Covid. R39's Progress Notes dated 2/25/25 and 2/26/25 document R39 remained on isolation for Covid. On 2/25/25 at 4:08 PM, V13, Certified Nursing Assistant (CNA) was in R39's room passing water with the door open. She was not wearing a gown or gloves, and her mask was down below her nose. She stated she was not wearing a gown or gloves because she was just passing water. On 2/26/25 at 7:45 AM, R39 was lying in bed in her room. The door to her room was open. 2. R42's Face Sheet documents R42 was admitted to the facility on [DATE] with diagnoses including dementia, depression, and anxiety. R42's Progress Note dated 2/22/25 documents R42 reported having a sore throat and tested positive for Covid. R42's Progress Note dated 2/23/25 documents R42 remains on droplet isolation precautions related to Covid. R42's Progress Notes dated 2/24/25-2/26/24 document R42 remained on isolation for Covid. On 2/26/25 at 11:50 AM, R42 was sitting in her wheelchair in the hallway outside her room. She was wearing a mask that was pulled down below her chin. On 2/27/25 at 10:14 AM, V1, Administrator, stated he expects staff to ensure proper isolation precautions are followed which includes the use of a mask, gown and gloves, in rooms with droplet precautions for Covid. The Facility's Isolation Precautions Policy revised 4/2019 documents, A Transmission-Based Precautions category was assigned if there was strong evidence for person-to-person transmission via droplet, contact, or airborne routes in healthcare or non-healthcare settings and/or if patient factors increased the risk of transmission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145465 If continuation sheet Page 16 of 16