Health inspection·May 25, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 5/25/23 at 9:45 AM, V15 CNA (Certified Nursing Assistant) stated (R31) used to smoke but hasn't for a few months. V15 CNA stated R31 now uses nicotine lozenges. On 5/25/23 at 10:09 AM, V14 MDS Coordinator stated Activities or Social Services update the smoking Care Plans. V14 MDS Coordinator stated R31 hasn't smoked for a couple months that I know of and her Care Plan should have been updated when she quit smoking. On 5/25/23 at 10:11 AM, V4 SSD (Social Service Director) stated she is responsible for updating the resident smoking care plans. V4 SSD stated R31 quit a while ago and (V4) should have updated R31's current Care Plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145488 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 145488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rushville Nursing & Rehab Ctr 135 South Morgan Street Rushville, IL 62681 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to implement pressure relieving interventions and perform daily Diabetic foot skin assessments for one of two residents (R47) reviewed for impaired skin integrity, in a sample of 27. These failures resulted in R47 developing unstageable pressure ulcers to the right and left heel after being admitted to the facility, which lead to osteomyelitis of the left heel and a delay in his discharge back to home. Residents Affected - Few Findings include: The facility policy, titled Pressure Ulcer and Wound Prevention/Management Program (updated 12/05/2006) documents, Purpose: To identify residents who are at risk for pressure ulcers and skin breakdown. To prevent pressure ulcers and skin breakdown. To provide a guideline for the appropriate nursing management of skin breakdown when it occurs. Responsibility: Director of Nursing, Licensed Nurses, Certified Nursing Assistants, Restorative Nursing, Care Plan Coordinator, Dietitian, Physician and Medical Director. Policy: It is the policy of this facility to ensure that residents who enter the facility without pressure ulcers do not develop pressure ulcers unless the individual's clinical condition demonstrates that the pressure ulcers were unavoidable; ensure a resident who has been admitted with pressure ulcers or develops pressure ulcers in-house receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing, when possible. The policy further documents, 3. Residents' skin will be inspected during daily bathing, dressing, showering, and incontinence care with special attention to bony prominences by CNAs (Certified Nursing Assistants) and staff nurses. Bony prominences include: Occipital, chin, scapula, elbow, sacrum, ischium, iliac crest, trochanter, knee, malleolus, and heel. Other common areas of breakdown include lower extremities and toes. 4. Weekly skin assessments will be completed for residents who are mild and moderate risk for breakdown. Daily skin assessments will be completed for residents who are high and severe risk for breakdown. Facility will determine where documentation of skin assessments will be completed. The Electronic Medical Record documents R47 was admitted to the facility on [DATE] for aftercare following a left total hip replacement, with the goal of returning to his home after completing Physical and Occupational Therapy. R47's admitting diagnoses include: Type 2 Diabetes Mellitus, Long Term (current) use of Insulin, Left Femur Fracture, Osteoarthritis and Anemia. An Initial/Baseline Care Plan dated 1/10/23 documents R47 required extensive assistance for bed mobility, was at risk for pressure sore/ulcer/skin injury and needed Positioning-turn and reposition every two hours and as needed. R47's Comprehensive Plan of Care, with a start date of 1/10/23, documents R47 is at risk for pressure ulcers (related to) weakness, related to (Diabetes Mellitus Type II), Folate Anemia, Primary Osteoarthritis, with a short term goal of (R47's) skin will remain intact. The Comprehensive Plan of Care instructs staff to do the following to prevent R46 from experiencing skin breakdown: Avoid shearing skin during positioning, transferring and turning; Keep clean and dry as possible, Keep linens clean, dry and wrinkle free, Pressure relieving device to chair and bed, Provide incontinence care after each incontinent episode, Report any signs of skin breakdown, Use absorbent, skin-friendly pads/briefs, Use moisture barrier product to perineal area. The Comprehensive Plan of Care failed to include instruction to staff for turning and repositioning R47 or frequency of R47's skin assessments. A Minimum Data Set assessment, dated 1/16/23, documents R47 as having a BIMS (Brief Interview of Mental Status) of 15, which indicates R47 is cognitively intact, requires the extensive assistance of 2+ staff members for bed mobility (turning/repositioning), and as at risk for developing pressure ulcers/injuries. The 1/16/23 Minimum Data Set assessments documents, under M1200. Skin and Ulcer/Injury (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145488 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 145488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rushville Nursing & Rehab Ctr 135 South Morgan Street Rushville, IL 62681 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 0686 Level of Harm - Actual harm Residents Affected - Few Treatments the following marked as implemented: Pressure reducing device for chair and bed; however, Turning/repositioning program and Nutritional or hydration intervention were not marked as implemented at that time. A Braden Scale assessment (scores risk of pressure ulcer development), dated 1/25/23, documents R47 is at Moderate Risk for the development of pressure ulcers, based on his ability to respond meaningfully to pressure related discomfort, level of physical activity, limited ability to make changes in body position independently, inadequate oral/nutritional intake, and requiring moderate to maximum assistance to move his body. The 1/25/23 Braden Scale assessment checks off the following interventions as being implemented: Pressure relieving device for chair and bed and other preventative or protective skin care; again, turning/repositioning program and nutrition or hydration intervention was not checked off as being implemented by staff. Nursing Progress notes, dated 1/27/23, document R47 continues to require extensive staff assistance with bed mobility. On 2/01/23, R47 experienced weight loss when his weight decreased from 176.8 pounds (1/11/23) to 169.8 pounds in three weeks. A Nursing Progress note dated 2/06/2023 at 5:58 AM, documents (R47) noted to have (two) areas to right heel and one area to left heel. No (sign/symptoms) of infection noted. Heels offloaded. (Physician) notified via fax and will have wound doctor evaluate today. Skin Integrity Conditions reports, dated 2/06/23, documents R47 was found to have the following wounds: 1.) Right heel, facility acquired, unstageable wound measuring 1.0 cm (centimeters) x 0.5 cm; 2.) Right heel, facility acquired, unstageable Deep Tissue Injury, measuring 4.5 cm x 2.5 cm, with a black and purple wound bed; and 3.) Left heel, facility acquired, unstageable Deep Tissue Injury, measuring 5.0 cm x 4.0 cm, with a black and purple wound bed, and serosanguineous exudate. The 2/06/23 Skin Integrity Conditions report documents staff then implemented a turning and repositioning program, ulcer/wound care and treatment and a nutrition/hydration intervention for R47. On 2/06/2023, a Daily Diabetic foot inspection was initiated for R47 as well according to the documented Daily Skin Checks. On 2/09/23, Nursing Progress notes document, Resident was seen by wound physician via telehealth this afternoon for evaluation of bilateral heels. Left heel: diabetic wound. 3.4 (cm) x 5.0 (cm) Wound is closed. Cleansed and betadine applied and left (open to air). Placed off-loading boot on. Right heel: diabetic wound 4.0 (cm) x 4.0 (cm). Wound is closed. Cleansed and betadine applied and left (open to air). Placed off-loading boot on. Resident was having poor blood sugar control which contributed to the development of these wounds. He states that he rubs his heels on his sheets at night when he is trying to sleep. Wound doctor suggests to continue painting heels with betadine and leaving (open to air) and to continue with off-loading boots at all times except when bathing, transferring, ambulating, etc. Physician did order the following labs to be performed: CBC (Complete Blood Count), CMP (Complete Metabolic Pane), A1C (Hemoglobin A1C), pre-albumin. He also ordered a multivitamin daily, Vitamin C 500 mg (twice per day), and zinc sulfate 220 mg (orally for) 14 days as well as a protein supplement with meals or per dietary. Will have dietary manager ask dietician. Resident did state during rounds that he is not going to be taking any extra medications to help the healing process. Education provided. On 2/15/23, Nursing Progress notes document the following, This RN (Registered Nurse) sent fax to (Primary Care Physician) updating her on (R47's) wounds. She replies back: CBC, CMP, Sedimentation Rate, CRP (C-Reactive Protein) STAT (as soon as possible), MRI (Magnetic Resonance Imaging) bilateral heels- (to rule out) Osteomyelitis, -Schedule with (Wound Clinic as soon as possible) for debridement, (discontinue) Betadine to heels. (Begin treatment of) Calcium Alginate to bilateral heels and cover with ABD pad and kling/kerlix daily and (as needed), (start antibiotic) Augmentin 875 mg (orally every 12 hours for 14 days). On 2/16/23, Nursing Progress notes document R47's heel wounds had increased in size, with the left heel measuring 4.0 (cm) x 7.0 (cm) x 0.0 (cm) and the right heel (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145488 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 145488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rushville Nursing & Rehab Ctr 135 South Morgan Street Rushville, IL 62681 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 0686 measuring 8.5 (cm) x 11.0 (cm) x 0.0 (cm) and R47 was referred to the local Wound Clinic due to the facility's Wound Doctor only being able to do telehealth. Level of Harm - Actual harm Residents Affected - Few A Wound Clinic Note, dated 2/20/23 by V10 (Wound Doctor), documents (R47) has a large wound of the right heel that measures 2.8 cm by 3.8 cm circumferentially, by 0.1 cm deep. A black eschar that is adherent occupies nearly the entire surface of the wound. No discharge. No surrounding Heat, erythema or fluctuance. There is a similar wound of the left posterior heel that measures 4.8 cm by 7.5 cm circumferentially, by 0.1 cm deep. It has the same characteristics as the wound about the right posterior heel. The Wound Clinic Note later documents, Assessment: 1. Large multifactorial unstageable pressure wounds of both heels. 2. Contributions from immobility, pressure, diabetes, diabetic neuropathy and arterial insufficiency. A 5/16/23 MRI of R47's lower extremities documents R47 had developed acute Osteomyelitis of the left heel. Wound Management Notes, dated 5/18/23, document R47's Left Heel wound as measuring 4.0 cm x 6.0 cm and Right Heel wound as measuring 2.5 cm x 5.5 cm. On 5/23/23 at 2:08 PM, V16 (Registered Nurse/Wound Nurse) and V17 (Licensed Practical Nurse) provided wound care to R47. At that time, R47 had a left heel wound, slightly larger than a golf ball, with a black center and a right heel wound, approximately the size of a quarter, with a black center. On 5/24/23 at 11:20 AM, R47 stated he needed the help of staff to turn over and change positions in bed when he was admitted to the facility from the hospital, and R47 indicated he still needs assistance to do so. R47 stated, When I came (to the facility), my heels would just lay flat on the bed, not up and off like now. When R47 was asked if staff would routinely help him turn and reposition on a scheduled or regular basis after he was admitted , R47 stated No, but they do more so now that I have sores on my feet. R47 stated, I want to go home, but now I can't because I have these (pointing to his feet) that need taken care of. On 5/24/23 at 11:27 AM, V2 (Director of Nursing) stated, facility protocol is for all residents that have Diabetes to be placed on a nightly foot skin check upon admission. V2 confirmed that R47's daily foot skin assessments were not implemented until his heel wounds were found on 2/06/23. On 5/25/23 at 12:29 PM, V16 stated she determines if a resident needs to be on a turning and repositioning program, based on their assessed risk for pressure ulcer development based and if they are able to turn and reposition themselves. V16 concluded that R47 was not able to turn and reposition himself independently when he was admitted to the facility and R47 did have multiple factors that put him at risk for skin breakdown. V16 stated it was unknown why R47 was not placed on a turning and repositioning program at the time of admission. On 5/25/23 at 8:41 AM, V10 (Wound Doctor) stated he saw R47 in his outpatient wound clinic about two weeks after R47's wounds initially developed. V10 stated R47's wounds are as a result of pressure to his heels, over a boney prominence, along with multifactorial contributions, such as his immobility, Diabetes Mellitus, nutrition, and arterial insufficiency. V10 stated, given R47's immobility and risk factors for pressure ulcer development at the time of his admission to the facility, nursing staff should have implemented basic interventions, like scheduled turning and repositioning and daily skin assessments. V10 stated The key to daily skin assessments is to identify skin breakdown early, as a Stage I, and to prevent progression. Routine skin checks would prevent wounds, like (R47's) from being first identified at the size and progression his were. V10 stated, resident wounds that are found to be necrotic on the initial assessment, indicate a lack of ongoing skin assessments by staff. V10 stated R47's left heel now has Osteomyelitis which could very likely lead to amputation of the left foot. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145488 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 145488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rushville Nursing & Rehab Ctr 135 South Morgan Street Rushville, IL 62681 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to perform a GDR (Gradual Dose Reduction) for one resident (R1), document a diagnosis and clinical indication to warrant the use of an antipsychotic and comprehensively evaluate and assess for underlying conditions or stressors, non-pharmacological behavioral interventions, and psychotropic drug use prior to administering a PRN (as needed) antipsychotic for one resident (R26), and document clinical indications to justify the increase of an antipsychotic for one resident (R39), of four residents reviewed for anti-psychotic medication use in the sample of 27. Findings include: The Psychotropic Medication Policy dated 5/2017, documents This facility shall ensure that residents do not receive psychotropic drugs unless such therapy is necessary to treat a specific condition diagnosed by the attending physician or psychiatric consultant. Attempts will be made to reduce or discontinue use of such medications whenever possible without compromising resident's health and safety, ability to function appropriately, or the safety of other. Gradual Dose Reduction - The tapering of a daily medication dosage to determine if the medication can be eliminated altogether As needed or PRN psychotropic drugs shall be used only when the resident has a specific condition to which the medication is indicated in one of the following conditions exists: b. Drug is being used to manage unexpected harmful behaviors that failed to respond to interventions other than psychotropic drugs. 1. On 05/24/23 11:25 AM, V1 (Administrator) stated that on 1/23/20 R1's Seroquel (antipsychotic)was decreased from 600 milligrams/mg to 400 mg. R1 has not had any other Seroquel reduction attempts since then. On 5/24/23 at 12:02 PM, V1 (Administrator) stated that she has discussed the need for medication reductions with V8 (R1's Primary Care Physician). V8 does not like to do medication reductions for psychotropic medication. V1 also stated that she understands psychotropic medication needs to be reduced to the lowest dose possible. Behavior Tracking needs to be documented along with the attempts to lower psychotropic medication. On 5/24/23 at 3:40 PM, V1 stated that none of the behaviors that are being tracked for R1 requires the use of a psychotropic medication. On 5/24/23 at 1:57 PM, V4 (Social Service Director) stated that the only behavior R1 has is she does some hoarding of small salt and pepper packets. R1 gives them to her family when they come in to visit. Sometimes R1 is noncompliant with care but does not bother the residents and gets along with the staff. On 5/23/23 at 8:15 AM, R1 was sitting in her wheelchair at the breakfast table eating breakfast. R1 was alert, oriented, calm, quiet and did not display any behaviors. R1 stated that she takes a lot of medication, and she is not sure what they all are. On 5/25/23 at 8:20 AM, R1 was sitting in her wheelchair in the dining room eating breakfast. R1 was at a table with one other resident. R1 was alert, oriented, calm, and answered questions in a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145488 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 145488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rushville Nursing & Rehab Ctr 135 South Morgan Street Rushville, IL 62681 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 0758 pleasant calm manner. Level of Harm - Minimal harm or potential for actual harm R1's Face Sheet documents R1 was admitted to the facility with Major Depressive Disorder, Recurrent Severe Without Psychotic Features, Anxiety Disorder, Obsessive- Compulsive Disorder, and Persistent Mood (Affective) Disorder. Residents Affected - Few R1's Physician Order Sheet dated 5/24/23, documents that R1 has an order to receive Seroquel 400 mg (milligrams) tablet by mouth at bedtime for persistent mood (affective) disorder. R1's MDS (Minimum Data Set), dated 3/27/23, documents that R1 is cognitively intact, has no behaviors, and receives an antipsychotic medication daily. The MDS also documents that R1 has not had a GDR. R1's Care Plan 5/24/23, documents that R1 uses psychotropic medication. (R1) is at risk for adverse consequences related to receiving antipsychotic medication for treatment of her major depression disorder with psychotic features. R1's care plan does not document R1's target behaviors for the use of the psychotropic medication. The last Gradual Dose Reduction for R1 was done on 1/23/20. R1's Care Plan also documents the following approach: Attempt to give the lowest dose possible. R1's Behavior/Intervention Record for 3/1/23 - 5/24/23, documents the behaviors being tracked are noncompliant refusal of cares, irritability/agitation, hoarding items, and cursing staff/or peers. The Consultant Pharmacist Communication to Physician Report documents that V9 (Pharmacy Consultant) recommended a gradual dose reduction for R1's psychotropic medication, Seroquel 400 mg, by mouth at bedtime on 10/3/20, 4/6/21, 9/2/21, 2/4/22, 12/2/22, and 5/5/23. The recommendations were sent to V8 (R1's Primary Care Physician). V8 marked all the requests as GDR (Gradual Dose Reduction) not possible clinically without a negative effect on the underlying psychiatric illness or An attempted GDR is likely to result in impairment of function or increased distressed behavior. (There were no GDR attempts made since 1/23/20.) 2. On 05/22/23 at 10:10 AM, R26 was sitting up in her wheelchair in her room sleeping. On 05/23/23 at 03:03 PM, R26 was sitting up sleeping in her wheelchair in her room. R26's Physician order report, dated 3/14-5/23/23, documents that R26 has orders to receive Risperidone (antipsychotic) 2 mg (milligrams) by mouth twice a day (5/16/23) and that R26 was admitted to the facility on [DATE]. R26's Psychotropic Drug Use Care plan, dated 4/13/23, documents that R26 is at risk for adverse consequences related to receiving antipsychotic medication for the treatment of her Vascular Dementia with behavioral disturbance. R26's Physician order report, dated 3/14-5/23/23, documents that R26 was admitted on [DATE] with the orders to receive Seroquel (antipsychotic) 50 mg (milligrams) by mouth daily for the diagnosis of Major Depressive Disorder. The report also documents that on 3/15/23 an order was received to administer Haldol (antipsychotic) 0.5 mg intramuscularly (IM) now and again in one hour if no improvement in behaviors. Then, on 3/16/23 Haldol 1 mg intramuscularly was ordered again, but at a higher dose, to be given immediately and again one hour later if first dose was ineffective as well as adding Risperidone (antipsychotic) 2 mg by mouth twice a day to R26's scheduled medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145488 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 145488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rushville Nursing & Rehab Ctr 135 South Morgan Street Rushville, IL 62681 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 0758 Level of Harm - Minimal harm or potential for actual harm R26's Nurses' notes, dated 03/15/2023 at 04:29 PM, document, R26 continues to be disruptive to others. She is yelling and saying hateful things in a hateful tone. When redirection is attempted, she just starts to laugh. At this time, was taken out of dining room due to behaviors. (Physician) notified of behaviors and orders received for Haldol 0.5 mg IM now and if no improvement in one hour, may repeat Haldol 0.5 mg IM. Also wants a straight catheter UA (urinalysis) with culture when resident calms down. Residents Affected - Few R26's Nurses' notes, dated 3/15/2023 at 04:29 PM, document, IM Haldol administered as ordered. R26's Nurses' notes, dated 03/15/2023 at 05:30 PM, document, Resident remains hyper alert and disruptive. Sitting at CNA (Certified Nursing Assistant) desk with staff and is speaking in slang associations. Continues to cuss and be hateful to others. Second dose of Haldol IM given as ordered. R26's Phone consent, dated 3/15/23, documents that verbal consent was given for R26 to receive PRN Haldol. The consent has no behaviors, or a diagnosis documented to warrant the administration of the Haldol. R26's Nurse's notes, dated 3/16/23 at 12:50 a.m., document, R26 disruptive and waking others up. CNA reports R26 cursing saying, 'shut the f*** up' to roommate who is snoring loudly. CNA says R26 has taken incontinent brief off multiple times and urinated on floor/bed even after offering to toilet just prior. CNA says resident threw pitcher of water onto floor. Staff ask R26 to lower her voice and R26 yells, I don't give a s*** if people hear me. They need to get the h*** up.' R26 asking to be covered up then throws linens on floor. R26 having full conversations with people not there and thinks people are out to get her. R26 wanting hair and nails done because she thinks she is moving in with maintenance man and wants to leave now. R26 yelling, 'All these a******* need to get up now. If I can't sleep nobody needs to'. CNA reports resident bit her when trying to perform incontinent cares. R26 has been calling this nurse as well as other staff fat a** and asking our weight. R26 laughs at staff hysterically when trying to redirect. R26's Nurses' notes, dated 03/16/2023 at 01:15 AM, document, Physician returned call and updated on behaviors. Order for 1 mg Haldol IM stat then may give 2nd dose of 1 mg IM in 1 hour if first dose ineffective. R26's Nurses' notes, dated 03/16/2023 at 03:04 AM, document, First dose Haldol given at 01:20 (AM) and R26 is calm at this time. Will continue to monitor. R26's Nurses' notes, dated 03/16/2023 at 10:19 AM, document, Physician called to check status of R26 behaviors. R26 is being verbally aggressive to staff and residents. Per physician ok to give R26 1 mg IM Haldol. Haldol given as ordered. R26's Nurses' notes, dated 3/16/23 at 11:43 a.m., document that orders were received to change the time of administration for R26's Seroquel and add Risperidone (antipsychotic) 2 mg by mouth twice a day for the diagnosis of Dementia with behavioral disturbances. R26's Nurses' notes, dated 03/16/2023 at 03:20 PM, document, Dx (diagnosis): Depression. R26 to continue antipsychotic medications and antidepressants as ordered by physician. R26's Nurses' notes, dated 03/17/2023 at 02:20 PM, document, R26 has been less verbally inappropriate this shift. She has yelled out a couple of times but significantly less than yesterday. Mood (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145488 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 145488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rushville Nursing & Rehab Ctr 135 South Morgan Street Rushville, IL 62681 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 0758 Level of Harm - Minimal harm or potential for actual harm appears calm except the couple of episodes earlier, but they were not at another, the yelling was in general in the dining room. R26's Urinalysis results, dated 3/19/23, document that R26's urine cultured to have growth of morganella morganii. Residents Affected - Few R26's Nurses notes, dated 03/19/2023 01:32 PM, document, Physician ordered Keflex (antibiotic) 500 mg PO (by mouth) BID (twice a day) for 7 days for UTI (Urinary Tract Infection). R26's Physician note, dated 3/21/23, documents, Assessed: Dementia with behavioral disturbance. Since returning to facility, R26 initially had significant outburst and was not easily redirected. Today at time noted heightened conversation but was redirectable. 3/14/23: was started on Risperidone 2 mg BID continue medication as R26 reaccumulates back to facility hoping the behaviors will resolve and baseline will re-develop. R26 sitting in wheelchair in no acute distress and pleasant to visit with. Reports no concerns today, did have heightened conversation about, 'Let me tell you living through mums is hard and I will get the hell out of here.' When talked about facility she did not report being in one and could not understand why she was home and now here. R26's Nurses' notes, dated 3/26/23 at 12:50 p.m., document, Depression is managed with antidepressant and antipsychotic medications. These appear to be effective. R26 has been more relaxed and quieter with no behaviors observed or reported as of this time. R26's Nurses' notes, dated 03/26/2023 at 11:00 PM, document, No behaviors this shift. ABT (antibiotic) for UTI completed this AM. R26's Nurses' notes, dated 03/28/2023 at 01:44 PM, document, Physician here to see R26. Due risk of heart irregularity R26 will not stay on two antipsychotics. Increase Risperdal to 2 mg by mouth in the morning and 3 mg by mouth at bedtime. Decrease Seroquel to 25 mg by mouth at 5pm for one week then every other day for one week then discontinue. R26's Physician note, dated 3/28/23, documents, Dementia with behavioral disturbance. R26 had significant behaviors when returned. Has appeared to become more stable since readmission. Initially Haldol was used with starting of Risperidone. Given R26 was already on Seroquel with risk heart irregularities will start taper of Seroquel. Will increase Risperidone to 2 mg in am and 3 mg at bedtime. Since readmission significant behaviors have occurred and following use of Haldol, Seroquel was initiated which overall has benefited R26. Staff reports at times remains with time of short answer and redirectable agitation. R26 sitting in wheelchair in no acute distress and pleasant to visit with. R26's Behavior/Intervention Monthly Flow Records, dated 3/23, document that R26 was monitored for the following behaviors: irritability/agitation, restless/anxious, difficulty falling/staying asleep, rude to staff and others. R26's Physician note, dated 5/15/23, documents, Assessed: Dementia with behavior disturbance. Today R26 appears to be fatigued. No behaviors per staff. R26 sitting in wheelchair in no acute distress and pleasant to visit with. Appears very tired today. Visited with staff and report overall has been more fatigued lately. R26's Nurses' notes, dated 05/19/2023 08:44 PM, document, R26 in bed and drowsy at this time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145488 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 145488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rushville Nursing & Rehab Ctr 135 South Morgan Street Rushville, IL 62681 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R26's Behavior/Intervention Monthly Flow Record, dated 5/2023 and as 5/23/23, documents that R26 continues to be monitored for the following behaviors: irritability, restless/anxious, rude to staff and/or peers, and difficulty falling/staying asleep. The record has no documentation of any behavioral episodes occurring from 5/1-5/23/23. On 05/24/23 at 12:12 PM, V1 (Administrator) stated, (R26's) diagnosis for the use of her Risperdal is Vascular dementia with behavioral disturbance. The behaviors we are treating are irritability, agitation, restless, anxious, difficulty in falling/staying asleep, being rude to staff and others. The behaviors do not put her or others at risk for harm. The behaviors she exhibited when they gave her the PRN Haldol was yelling at others, cussing, calling staff names, disruptive behaviors, and yelling saying hateful things. Non-pharmacological staff interventions I see are we redirected her to remove from the dining room due to her disruptive behaviors. (R26) was here before and had a time where she had lots of behaviors. Her medications needed adjusted then, so I think the staff assumed that's what was going on. They did a UA (urinalysis) and determined that she had a UTI (Urinary Tract Infection) during this time as well. 3. R39's Physician Order Report, dated 5/23/23, documents that R39 has an order to receive Zyprexa (antipsychotic) 5 mg (milligrams) by mouth at bedtime that was ordered on 2/22/23. R39's Psychotropic Drug Use care plan, dated 7/7/22, documents, R39 receives antipsychotic medication related to her diagnosis of Dementia with behavioral disturbance and unspecified Psychosis. R39's Mood Care plan, dated 5/22/23, documents, R39 is displaying signs and symptoms of mood distress as evidenced by finding little interest or pleasure in doing things secondary to the diagnosis of MDD (Major Depressive Disorder). R39's Behavior care plan, dated 5/23/23, documents, R39 has physical behavioral symptoms directed toward staff (hitting). R39's Consultant Pharmacist Communication to Physician, dated 2/1/23, documents a recommendation to decrease R39's Zyprexa 5 mg by mouth at bedtime. The recommendation also documents, This medication includes a black box warning regarding the increased risk of mortality in elderly dementia patients. The recommendation was accepted, and the physician ordered to decrease the Zyprexa to 2.5 mg by mouth at bedtime. R39's Psychotropic Medication Monitoring, most recent date 2/22/23, documents that R39's Zyprexa is prescribed for the diagnosis of Dementia with behaviors, and the most recent GDR (Gradual Dose Reduction) was on 2/17/23 when the Zyprexa was decreased to 2.5 mg daily. However, the monitoring documents that this reduction failed, and it was increased back to 5 mg daily on 2/22/23. R39's Nurses' notes, dated 2/21/23 at 6:30 p.m., document, R39 sitting in recliner in another resident's room. Refused to leave when other resident suggest she do so. Became verbally abusive to staff and attempts to hit staff. Eventually redirected R39 and she went to sit by CNA (Certified Nursing Assistant) desk. R39's Nurses' notes, dated 2/21/23 at 6:49 p.m., document, R39 has been fixated on exit doors this afternoon and wandering in and out of other resident rooms and being verbally aggressive as well as hitting staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145488 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 145488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rushville Nursing & Rehab Ctr 135 South Morgan Street Rushville, IL 62681 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R39's Nurses' notes, dated 2/22/23 at 1:38 p.m., document, R39 continues on a decreased dose of Zyprexa with continued behaviors observed. Resistive to cares this AM, refused AM medications and yells at staff when assist attempted. R39's Nurses' notes, dated 2/22/23 at 2:08 p.m., document, N.O (new order): Increase Zyprexa back to 5 mg PO (by mouth) QHS (every day at bedtime). Failed dose reduction. R39's Nurses' notes, dated 2/23/23 at 11:52 p.m., document, R39 to start an increased dose of Zyprexa 5 mg on 02/23/23. R39 was very agitated this evening. Attempts to redirect by staff were not successful. R39 left alone for a few minutes then staff would reattempt cares then R39 was more cooperative. R39's Nurses' notes, dated 2/23/23 at 1:44 p.m., document, R39 to start an increased dose of Zyprexa 5 mg on 2/23/23. R39 was very agitated this morning as she was very compacted and needed to have a BM (Bowel Movement). Staff did help assist with this and R39 is better. R39's Nurses' notes, dated 2/23/23 at 8:46 p.m., document, Zyprexa increase starting tonight. She has been restless. Has required increased supervision due to opening exit doors and setting alarms off. She has been easily re-directed. She did not have any behaviors when staff provided incontinent cares. Currently resting quietly in bed. R39's Behavior/Intervention Monthly Flow Record, dated 2/1/23, documents that R39 was being monitored for verbal aggression towards staff, physical aggression towards staff, difficulty falling/staying asleep, and restless. The record also documents from 2/17/23 (decrease) to 2/22/23 (increase) that R39 had one episode of verbal aggression towards staff on 2/19/23 day shift and three episodes on 2/20/23 day shift as well as three episodes of physical aggression towards staff on that same date/shift. On 05/23/23 at 10:52 AM, V4 (Social Services Director) stated, (R39's) behaviors are physical aggression towards staff, irritability, restless/anxious, and difficulty falling/staying asleep. She doesn't put herself or others at risk for harm. On 05/24/23 at 12:06 PM, V1 (Administrator) stated, The behaviors that caused (R39's) increase in Zyprexa were wandering, agitation, restlessness, and difficulty falling asleep. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145488 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 145488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rushville Nursing & Rehab Ctr 135 South Morgan Street Rushville, IL 62681 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. On 05/22/23 at 10:45 AM, R7 was alert sitting up in bed. R7 stated, This menu is meant to make people gain weight. Not all of us want to gain weight. We've requested lighter options and just different options in general. We've requested this at resident council minutes, but (V5 Dietary Manager) isn't very receptive. We are told they aren't able to get the things we are requesting, even just salad. There are no substitutes outside of what's on the menu except for lunch meat and peanut butter and jelly sandwiches. On 05/22/23 at 10:55 AM, V11 (Dietary Aide) came into R7's room to take R7's lunch order. R7 ordered the rotini with meat sauce and the peach crisp. R7 declined the sweet potatoes and the capri vegetable. V11 stated, We don't have a substitute for the potatoes or the vegetables today. Sometimes we have mashed potatoes but that is only offered to the residents who are lactose intolerant. We sometimes have another vegetable as well but not today. On 05/22/23 at 12:08 PM, R7 was served rotini with meat sauce, applesauce, cottage cheese and peach cobbler. On 5/23/23 at 11:15 AM V7 (Cook) stated We make deli meat sandwiches and peanut butter and jelly sandwiches ahead of time so that residents can have that if they do not like what is being served. On 5/23/23 at 2:00 PM V5 (Dietary Manager) stated The way residents can know what is available for substitutes is to ask a dietary staff member. I don't post the menu ahead of time, and the substitute list isn't posted either. If we have it in the kitchen to make, the dietary staff should always cook what a resident is requesting. The Resident Census and Condition Report dated 5/21/23 documents 56 residents currently reside in the facility. Based on observation, record review and interview the facility failed to consistently offer substitutes at mealtimes. This failure has the potential to affect all 56 residents who reside in the facility. Findings Include: The Facility's undated Food Substitution Policy documents Resident may be offered a planned substitute entrée if desired. An alternate menu will be posted in addition to the planned menu. On 5/22/23 at 11:00 AM after V6 (Dietary Aide) listed the lunch options R208 stated he did not like either option. V6 stated I need you tell me which one you would rather. On 5/22/23 at 11:05 AM V6 (Dietary Aide) stated Sometimes we have mashed potatoes as a substitute but not today, and those are usually only offered to the lactose intolerant residents. On 5/23/23 at 10:00 AM during resident group meeting R26, R34, R35, R37, R38, R40 and R108 all stated it can be difficult to get a substitute. On 5/23/23 during group R40 stated The food is gross; you get a choice of two things. If you don't (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145488 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 145488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rushville Nursing & Rehab Ctr 135 South Morgan Street Rushville, IL 62681 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 0806 like one of the two things, you just eat the sides. Level of Harm - Minimal harm or potential for actual harm On 5/23/23 during group R180 stated I have asked for a grilled cheese before, and they (dietary staff) told me they simply don't have the time. So, I could have lunch meat sandwich that was already made. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145488 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 145488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rushville Nursing & Rehab Ctr 135 South Morgan Street Rushville, IL 62681 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 0808 Level of Harm - Minimal harm or potential for actual harm Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on observation, interview, and record review, the facility failed to serve physician ordered supplements for three of six residents (R3, R12, R39) reviewed for nutrition in the sample of 27. Residents Affected - Few Findings include: The facility's Therapeutic Diets policy, dated 4/2007, documents, Therapeutic diets shall be prescribed by the attending physician. A therapeutic diet must be prescribed by the resident's attending physician. The physician's diet order should match the terminology used by Food services. The Food Services Manager will establish and use a tray identification system to ensure that each resident receives his or her diet as ordered. Residents on therapeutic diets will not receive extra or reduced portions or modifications that are not part of the diet, unless approved by the attending physician in conjunction with the clinical dietitian. 1. On 05/22/23 at 12:44 PM, R3 was served turkey salad, capri vegetables, and peach cobbler. R3 was not served a high protein high calorie frozen supplement. R3 stated, I don't get an ice cream cup with my lunch. R3's Physician Orders, dated 5/24/23, document that R3 has an order to receive a Magic Cup (high calorie high protein frozen supplement) twice a day with lunch and dinner dated 4/29/22. R3's Nutritional care plan, dated 5/5/23, documents, (R3) is on a General diet, thin liquids, magic cup (high protein high calorie frozen supplement) at lunch and supper, health shakes TID (three times a day) and this may put her at nutritional risk if she does not follow proper diet regimen. The care plan also documents the intervention of: R3 will receive magic cup (high protein high calorie frozen supplement) at lunch and supper and health shakes TID from dietary. R3's RD (Registered Dietician) Annual Review, dated 5/11/23, documents, Occasional poor appetite reported per progress noted. At increased risk of malnutrition. General diet, mechanical soft texture, thin liquids. Magic cup (high protein high calorie frozen supplement) BID (twice a day) with lunch and supper meal. Estimated daily nutrition needs: 1500-1800 kcals/day (25-30kcals/kg-kilograms), 60g-grams protein/day (1g/kg), 1500mL (milliliters) fluid minimum for maintenance. Current diet with supplements BID exceed daily nutrition needs. Continue current diet, which is supportive of nutrition needs. 2. On 05/22/23 at 12:41 PM, R12 was served a lunch meat sandwich, Jell-O, and peach crisp by V11 (Dietary Aide). R12 was not served a high calorie high protein frozen supplement. R12 stated, I don't get one of those things. V11 confirmed that R12 was not served a high calorie high protein frozen supplement. R12's Physician Order Report, dated 5/1-5/25/23, documents that R12 received an order on 5/19/23 to receive a frozen nutritional treat/Magic cup (high calorie high protein frozen supplement) at lunch and dinner. R12's Care plan, dated 4/7/23, documents, R12 is at a potential for malnutrition risk due to having osteoarthritis, heart disease and other medical conditions and scoring a 15 on the nutritional risk scale. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145488 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 145488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rushville Nursing & Rehab Ctr 135 South Morgan Street Rushville, IL 62681 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R12's RD (Registered Dietician) note, dated 05/18/2023 at 10:03 PM, documents, Weight change note: Height 64 Weight 5/17-95.2# (pounds) BMI (Body Mass Index)-16.34, underweight. Significant weight loss over past 6 months; trending weight loss since then. 5/1/23-96.6#, 3/1/23-101#, indicating a 5.7% loss; 12/2/22-103.4#, 11/3/22-107.8#, indicating 12.6# (11.6%) significant loss over past 6 months. Diet-NAS (no added sodium), regular, thin liquids with nutritional health shake at breakfast. NKFA (No known food allergies) or chewing/swallowing issues noted. Intakes per Dietary Manager~75%. Diet remains appropriate for diagnosis HTN, but intakes may not be consistent and meeting estimated needs as evidenced by weight loss. Recommend starting frozen nutritional treat (high calorie high protein frozen supplement)/Magic Cup at lunch and dinner. Continue health shake at breakfast. 3. R39's Physician Order Report, dated 5/23/23, documents an order for R39 to receive a frozen nutritional treat (high calorie high protein frozen supplement) one time a day at lunch. R39's Nutritional Status care plan, dated 4/22/23, documents, R39 requires a mechanical soft diet, health shake at breakfast, nutritional treat at lunch, but due to Dementia and other medical conditions this may lead to nutritional risk if proper diet regimen isn't followed. On 05/22/23 at 12:11 PM, R39 alert, sitting up in her wheelchair at the dining room table. R39 was served rotini and meat sauce, sweet potatoes, capri vegetables, 2% milk, coffee and pink lemonade. R39 was not served a high calorie high protein frozen supplement. On 05/22/23 at 12:33 PM, V13 (CNA-Certified Nursing Assistant) was assisting R39. V13 stated if a resident is supposed to have a magic cup (high protein high calorie frozen supplement) it is on their card. V13 confirmed that R39 had Magic cup on her card that was lying on the table, and that R39 was not served one. On 05/24/23 at 12:45 PM, V5 (Dietary Manager) stated, We are not serving the Magic cups (high protein high calorie frozen supplement) or the 2 cal (high protein high calorie supplement) supplements. I haven't been able to order magic cups or 2cal for over a year now. My dietician is aware of this. If a resident has those ordered than we serve them mighty (supplement) shakes instead. On 5/25/23 at 9:55 a.m., V12 (Registered Dietician) stated, A few months ago, (V5 Dietary Manager) told me that they were having issues with receiving the 2 cal (high protein high calorie supplement) and the magic cup (high protein high calorie frozen supplement). As far as I knew they had resolved that issue and they were able to receive. I know I just recommended some this month. I recommend these supplements when residents are losing weight and not eating much so they can get the needed protein and increase in calories. The magic cup (high protein high calorie frozen supplement) has more protein in it than the mighty (supplement) shakes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145488 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 145488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rushville Nursing & Rehab Ctr 135 South Morgan Street Rushville, IL 62681 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 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 store dry goods in a clean and sanitary manner. This failure has the potential to affect all 56 residents who currently reside in the facility. Residents Affected - Many Findings Include: The Facility's undated Storage of Dry Goods/Foods Policy documents non-refrigerated foods, disposable dishware and other dry goods are stored in a clean, dry area which is free from contaminants. The Storage of Dry Goods/Foods Policy documents Plastic containers with tight-fitting lids will be used for storing flour, sugar, bulk cereal, dried vegetables, etc. Opened products are labeled, dated with the use by date and tightly covered to protect against contamination including from insects and rodents. On 5/22/23 at 9:10 AM, In the kitchen dry storage room there were 8 boxes full of various dry food stuffs sitting directly on the floor and two paper bags full of loaves of bread sitting directly on the floor. V5 (Dietary Manager) stated We got our delivery on Friday (5/19/23) and we are still working on getting it put away. On 5/22/23 at 9:20 AM in the kitchen dry storage room there was a big bag of flour that was sitting directly on the concrete floor and was opened on the top. V5 (Dietary Manager) stated That should have been dumped into the proper container and dated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145488 If continuation sheet Page 16 of 16