Inspection·June 10, 2025

F 0684 Level of Harm - Actual harm Residents Affected - Few res stood up on own and immediately fell. Res landed on right side. Fall was witnessed by staff member who was down the hall and tried to get to resident but could not reach her in time. Staff member states res did not hit her head. Res denies pain with ROM to all extremities. Res assisted into wheelchair with assist of gait belt and two CNA's. Res has a small laceration to top and towards medial aspect of left fifth finger. It measures 1.8 cm l x 0.2 cm w. Area cleansed, steri-stripped and dry dressing applied. Res states finger hurts. VSS (vital signs). R3's progress Notes, dated 03/13/2025 at 11:46 AM, documents (V8), Physician, informed of res fall landing on right side; sustained a laceration to top left fifth finger which was cleansed, steri-stripped and covered with a dry dressing. VSS. 1226: New orders received for x-ray of left hand and wrist. Daughter (V9) called and informed of new orders. R3's Progress Note, dated 3/13/2025 at 11:12 PM Resident receiving therapy services for generalized weakness and fatigue following L (left) hip fx (fracture). Resident afebrile and has c/o pain or discomfort this shift. Resident is TTWB (toe touch weight bearing) and noncompliant due to dementia. All meds taken whole. Fluids offered and encouraged. Resident transfers with a 1 assist and requires assistance with ADLs. On f/u (follow up) post fall today. No changes in LOC. Family notified of x-ray results. Asked to see report tomorrow. Hearing aides are locked in top of nurse cart. Resident lying in bed asleep at this time with bed lowest position and call light in reach. R3's Progress Note, dated 03/18/2025 at 10:01 PM Resident's daughter states that since the last fall, her mother has c/o right hip pain when she transfers, sits, or stands. I told her we could order a right hip x-ray, and she states she wants to wait another night to see if it improves. She also states resident has an ortho appointment about the left hip fracture, and maybe she can get them to x-ray her right hip as well. R3's Progress Notes, dated 03/21/2025 at 4:04 PM Patient returned from appointment with (V15), daughter here reporting to this nurse that patient has right hip fracture. DON and admin made aware. Dr office is faxing paperwork from visit. R3's Orthopedic Office Clinical Notes, dated 3/21/2025, documents that Chief Complaint: 3-month status post left hip fracture, daughter with patient today and states she is having pain in right side today and not showing signs of left side being painful anymore. fell on right side 8 days ago. History of present Illness: 8 days ago, she had a fall, falling backward landing on buttock and right hip. Since then, she complains of pain along the lateral aspect of the right hip as well as in the gluteal fold of the right buttock. She has discomfort with lowering down to a seated position and has increased pain especially when seated on a firm surface such as a toilet seat. She denies any increased groin or anterior thigh discomfort but does not lateral hip pain. Physical Exam: She has stiffness with passive internal and external rotation. There is lateral hip soreness to palpation and stiffness to passive range of motion of the right knee. She is neurovascularly intact in the right lower extremity. There is some discomfort with resisted hip extension and some mild discomfort with passive hip flexion. Assessment/Plan: 1 Inferior pubic ramus fracture. Xray of the right hip may indicated nondisplaced inferior pubic ramus fracture. We would like her to be protective weight bearing that she does. She may require an additional person for assist to minimize fall risk and she would be at risk for worsening fracture position if she has another trauma. May benefit from use of donut type cushion to offload some weight from the ischial tuberosity when seated. Avoidance of low chairs can be helpful to can be helpful to minimize stress to this area and the use of a high-rise commode may be a benefit to her to minimize symptoms as well. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145465 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 145465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2025 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 0684 Level of Harm - Actual harm R3's Progress Notes, dated 03/22/2025 at 9:51 PM Resident was up before dinner, and then family here and took resident to her room after dinner. She did try to stand a few times but was redirected. She has a left hip fracture and a right hip fracture. No c/o pain as long as she is sitting. She receives scheduled Tylenol for pain at 4PM. Residents Affected - Few R3's Progress Note, dated 03/24/2025 at 7:45 AM, documents that Report received of results of right and left hip x-ray done while at (V15) on 3/21/25 which shows no new fracture of either hip. Also states on right hip x-ray-status post right hip intramedullary rod and dynamic hip screw fixation across the intertrochanteric femur fracture-hardware appears well positioned without failure or complications. On left hip x-ray also states unchanged position of a mildly displaced greater trochanter fracture. R3's Progress Note, 03/27/2025 at 4:55 AM, documents that resident has been up all night sitting at the nurse's station with her chair alarm in place. Continues to try to stand up and self-transfer. PRN Tylenol given as resident seems uncomfortable. Staff with multiple attempts to redirect. Currently sitting in w/c at nurse's station. R3's 03/31/2025 at 2:53 AM At 0000, after hearing a noise down the hall, staff found resident sitting on her bottom on the floor between her bed and the wall with her back and head resting against the wall and her legs up on the bed. She was moaning saying her head was hurting and rubbing her right thigh with her hand. There was a little redness to the back of her head, but no open skin noted. Writer attempted to complete neuro assessments, but resident wouldn't open eyes and is HO so unable to respond to verbal commands. Initial BP was 154/86. Pulse 63. Temp 97.7.96% on RA. Resp (respirations) 20. Resident assisted back into bed. For approximately 5-10 seconds, resident's whole body started shaking. Staff continued obtaining vitals and stayed by resident's side while writer called daughter/POA (0020) and 911 (0026). Resident left via EMS at approximately 0045. Face sheet, POLST, and bed hold policy sent with. Report called to nurse at (Local Hospital) ED. Daughter to meet resident at (local hospital). (V18), FNP-BC, notified. R3's Orthopedic Clinical Note, dated 3/31/2025, documents that Chief Complaint: Right Pubic Ramus Fracture Follow up. Returns in regard to her inferior pubic ramus fracture on the right side. She was seen on March 21 and diagnosed at that time with the inferior pubic ramus fracture as she had previously had a fall at her facility. She sustained another fall around March 30 that was not witnessed. seen at emergency room with x-rays of the right hip that showed no acute changes. Her family stated that she complains of pain in the lateral aspect of the hip and rubs that area. They are concerned about her decline due to lack of activity secondary to her fractures she has been contending with. Physical Exam: There is some tenderness with palpation of the lateral aspect of the hip overlying the greater trochanter. She has tightness to passive hip internal and external rotation. On 6/2/2025 at 2:15 PM V9, R3's daughter, stated that her mother has had about 11 falls within the last 6 months. R3 stated that the staff do not listen when she voices concerns or observations she has for her mother. V9 stated that she is at the facility at least daily but mostly twice a day. V9 stated that on March 13th her mother had a fall. V9 stated that she was informed that her mother stood up and then fell to the ground hard. V9 stated that her mother complained of pain to her hand and an Xray was performed. V9 stated that she helps with her mother's care which consists of eating, transfers, walking, and toileting. V9 stated that after the fall she reported to the nurse that her mother was having pain when she sits on the toilet and when she gets off. V9 stated that she was disregarded and told that her mother had a recent fall and that R3 would have pain. V9 stated that she was aware that her mother would have pain, but this was different. V9 stated that she told the nurses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145465 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 145465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2025 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 0684 Level of Harm - Actual harm Residents Affected - Few and the CNAs. V9 stated that this went on for several days. V9 stated that she spoke to a nurse not sure her name about this and finally someone listened. V9 stated that they talked about R3's upcoming ortho appointment and getting them to do the xray. V9 stated that she never refused an xray. V9 stated that no one was doing anything so I thought the orthopedic would. V9 stated that they went to the appointment on March 1st and xrays were done. V9 stated that the doctor came in and showed her the film and pointed out the fracture to R3's pelvis. V9 stated that she notified the facility about the fracture and they were not surprised. V9 stated that he mother experienced increased pain during this time. V9 stated that her mother's cognition is poor and she can't always say that she is in pain but she stands up and she grabs you and hits at you when trying to put her on and take her off the toilet. On 6/4/2025 at 11:37 AM V7, CNA, stated that she takes care of R3 frequently. V7 stated that R3 has had multiple falls. V7 stated that they all run together. V7 stated that R3 does not voice pain but does winces and is more agitated and combative when sitting on and standing up from toilet. V7 stated but when standing up from the chair she will stand straight up and does not appear to be in pain, but you can't really tell. V7 stated that V9 would voice that she notices R3 was having pain. V7 stated that R3 has had a lot of fall she would be having pain. On 6/4/2025 at 12:10 PM V11, RN, stated that V9 did voice that R3 was having pain. V11 stated that she told V9 that R3 had just had a fall and would have pain. V11 stated that R3 was receiving Tylenol routinely. V11 stated that she informed V9 that she could get a xray but didn't think that it would show anything and that the pain was related to the fall. V11 stated that V9 would continue to talk about R3 having pain. V11 stated that V9 informed her that R3 had a follow up appointment with the ortho for her left hip fracture and would have them do the xray. V11 stated that she agreed, and this became the plan. V11 stated that R3 did have pain. V11 stated that R3 had a fall and with her age this would cause her to have pain. V11 stated that she did not notify the physician. On 6/4/2025 at approximately 3:00 PM V8 stated that he was not notified of R3's increase pain or pubis fracture. V8 stated that the facility is usually pretty good about notifying him of changes of condition. On 6/4/2025 at 3:35 PM V17, CNA, stated that R3 is confused and it is hard to tell if she is having pain. V17 stated that she will pop up out of a chair and does not appear to have pain but will be combative when trying to sit her on or the toilet or down in her chair. V17 stated that she feels R3 is in pain when being combative. On 6/10/2025 at 1:43 PM V2, Director of Nursing, stated that R3 is challenging and that they are trying to keep R3 safe. V2 stated that there has been some resistance with interventions. V2 stated that they were not initially aware of the pelvic fracture. V2 stated that the information was not given in report and the documents didn't come with R3. V2 stated that they requested the documents. V2 stated that in that time frame R3 fell again. V2 stated that she would expect her nurses to notify the physician of changes in conditions. Facility did not provide change in condition policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145465 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 145465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2025 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 - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on Interview, and Record Review the facility failed to assure fall interventions were in place for 1 (R3) of 3 residents reviewed for falls in the sample of 5. Residents Affected - Few Findings include: R3's admission Record, not dated, 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. R3's Minimum Data Set,, dated 2/19/2025, documents R3 is severely cognitively impaired. R3 requires maximum/substantial assist for activities of daily living, (ADLs) and mobility. R3's Care Plan updated 5/8/2025, documents Problem: R3 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 related to a BIMS of 8, up ad lib in facility with walker. Falls 7/20/23, 09/27/2023, 12/1/23, 12/19/24, 12/23/24,1/3/25, 2/18/25, 3/13/25 and 3/31/25. Interventions include: Staff to toilet resident every 2 hours and as needed. (R3) has an alarm which sounds reminding resident not to stand without assist and staff aware (R3) is standing and to provide assistance. R3 to wear no skid socks to bed to prevent sliding on the mat when getting out of bed. Encourage R3 to take frequent rest periods and staff to provide stand by assist when ambulating with walker. Encourage R3 to utilize walker when ambulating. R3 struggles with her sleep pattern, medication review for any changes. Attempt to keep bathroom light on and leave bathroom door open. Place R3 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 R3's need for increased assistance at times. Place on Walk to Dine program. Approach: Clock place in R3's room to show the R3 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. It also documents Problem: R3 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. R3's Incident Report, dated 4/17/2025, documents that R3 had an unwitnessed fall in her room. Root Cause and Conclusion Resident woke up and attempted to get out of bed without assistance and fell to floor. Staff reeducated on putting the chair alarm under resident when she gets in the bed. R3's Physician Order Sheet, documents 1/3/2025 bed/chair alarm at all times. R3's Progress Notes, dated 04/17/2025 8:45 PM, [Recorded as Late Entry on 04/18/20250 12:25 AM] , documents Resident had an unwitnessed fall at approximately 2045 in bedroom. Appeared resident attempted to get out of bed and fell to the floor. Roommate heard her fall and told the CNA who then came and got the nurse. Resident was found sitting onfall mat with legs straight out in front of her. Upon initial assessment, resident had a laceration to R pinky finger that was bleeding. No other injuries observed. VS were WNL (within normal limits) for resident. Resident was incontinent of urine at time of fall. Grips equal bialt (bilateral). Pupils equal and reactive. Transferred to w/c (wheelchair) with a 2 assist and reassessed. changes in LOC. Resident brought out to nurse's station for close (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145465 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 145465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2025 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 - Minimal harm or potential for actual harm Residents Affected - Few monitoring. Cleansed and bandaged laceration to R pinky finger. C/o (complains of)) pain in R hand. PRN (as needed) pain meds (medication) given. On 6/4/2025 at 11:37 AM V7 stated that R3 has a bed and chair alarm. V7 stated that there has been times that she has had to go put in on her because it was not there. V7 stated that the alarm is supposed to be on her when she is in the chair and the bed. On 6/4/2025 at approximately 2:50 PM V1, Administrator, stated that V2 is on vacation, and he is not aware of what staff member it was. V1 stated that he expects the interventions to be in place. On 6/4/2025 at 3:35 PM V17 stated that R3 always has an alarm in place. V17 stated that the alarm is to be in place in the chair and bed. On 6/10/2024 at 1:43 PM V2, Director of Nursing, stated that the bed alarm was not in place at the time of the fall and the CNA was reeducated. The facility did not provide fall pevention policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145465 If continuation sheet Page 6 of 6