Inspection·April 9, 2025

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure chemical restraints were not utilized for one resident (R12) of five residents reviewed for psychotropic medication in a total sample of 33. This failure resulted in over sedation and physical functioning for R12. Findings Include: The Facility's Abuse Prevention Policy and Procedure, dated 2/2020, documents Chemical Restraint is any drug that is used for discipline or convenience and is not required to treat medical symptoms or behavior manifestations of mental illness. The Facility's undated Psychopharmacological Drug Use Procedure documents the procedure is to assure the appropriate monitoring is provided to residents receiving psychopharmacological drugs, that the lowest possible dose necessary for the benefit of the resident to improve or control mood, mental status and/or behavior is utilized, and to reduce or eliminate the usage of these medications. The Facility's undated Psychopharmacological Drug Use Procedure documents Antipsychotic medications in persons with dementia should not be used if one or more of the following is/are the only indication: 1. Wandering 2. Poor self-care 3. Restlessness 4. Impaired memory 5. Mild anxiety 6. Sadness or crying alone that is not related to depression or other psychiatric disorders,7. Insomnia 8. Inattention or indifference to surroundings 9. Fidgeting 10. Nervousness 11. Uncooperativeness (e.g. refusal of or difficulty receiving care). R12's Medical Record documents that she was admitted on [DATE] with diagnosis to include Conversion disorder with seizures or convulsions, generalized anxiety and unspecified dementia, unspecified severity, with other behavioral disturbance. R12's Physician Order Sheet dated March 2024 documents that R12 was admitted on Risperdal 2 mg (milligrams) every night for unspecified Dementia, unspecified severity, with other behavioral disturbance. R12's Medical Record documents that on 11/15/24 she was sent to a hospital for an increase in behaviors. R12's Psychiatric Evaluation from the hospital documented by V22 (Nurse Practitioner) dated 11/22/24 documents (R12)'s aggressive behavior has also continued to get worse, and she would have temper tantrums that would last one to three days with a daughter she was living with. She was continually aggressive with staff at the facility she was residing in. She does have severe Dementia. She also was continually refusing meds, and she was psychiatrically admitted on [DATE]. R12's Medical Record documents that she was readmitted to the facility after hospitalization on 12/9/2024 with a new diagnosis of Bipolar Disorder and her Risperidone had been changed from 2 mg (milligrams) by mouth to Risperidone 125 mg subcutaneous once a month. R12's Behavior/Intervention Monthly Flow Record identified the following behaviors to be monitored (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145488 If continuation sheet Page 2 of 17 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 04/09/2025 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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for R12: easily agitated, cursing staff, restlessness, non-compliant/getting up by herself, insomnia, false allegations, yelling/screaming at others, crying/tearful, depressed/withdrawn, hallucinations and delusions. R12's Admission MDS (Minimum Data Set) dated 3/31/24 documents that R12 had no hallucinations, or delusions, no physical behavioral symptoms directed towards others (e.g. hitting, kicking, pushing, scratching, grabbing, abusing others sexually), no verbal behavioral symptoms directed toward others (e.g. threatening others, screaming at others, cursing others), no other behavioral symptoms not directed towards others (e.g. physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds), no rejection of care (e.g. blood work, taking medications, ADL (Activities of Daily Living) that is necessary to achieve the resident's goals for health and well-being. R12's MDS (Minimum Data Set) dated 12/25/2024 documents R12 had no hallucinations or delusions, No physical behavioral symptoms directed towards others (e.g. hitting, kicking, pushing, scratching, grabbing, abusing others sexually), no other behavioral symptoms not directed towards others (e.g. physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds. R12's MDS dated [DATE] also documents had no instances of rejection care (e.g. bloodwork, taking medications, ADL (Activities of Daily Living) assistance) that is necessary to achieves resident's goals for health and well-being. R12's MDS documents that she had Verbal behavioral symptoms directed toward others (e.g. threatening others, screaming at others, cursing others) 1 to 3 days out of 7 days. R12's MDS dated [DATE] documents R12 had hallucinations and delusions. R12's MDS documents that R12 had no physical behavioral symptoms directed toward others (e.g. hitting, kicking, pushing, scratching, grabbing abusing others sexually), no verbal behavioral symptoms directed toward others (e.g. threatening others, screaming at others, cursing at others), no other behavioral symptoms not directed toward others (e.g. physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) and no instances of rejection of care (e.g. blood work, taking medications, ADL assistance)that is necessary to achieves resident's goals for health and well-being. On 4/7/25 at 11:30 AM V21 (Social Services) confirmed the behaviors listed on R12's Behavior/Intervention Monthly Flow Record. V21 stated that the false allegations being monitored for R12 is related to R12 stating that staff members are sleeping with her husband. V21 stated that R12 very easily agitated and can get very nasty when (staff) attempt to do anything (give cares). V21 stated that the yelling/screaming at others behavior can be described as R12 yelling when cares are being done or attempted and that R12 sometimes just yells for nothing. On 4/8/25 at 1:00 PM V7 (Registered Nurse) confirmed that after R12 was admitted in March 2024 she had an increase in aggression and agitation. V7 described the aggression and agitation displayed by R12 to be refusing cares, yelling out, cursing staff and hallucinations/delusions. V7 stated R12's hallucinations/delusions behaviors could be described as speaking in 3rd person, speaking as if she actually is her husband, believing that staff are sleeping with her husband who has been dead for years. V7 stated that R12 can be combative with cares also, but she is very hard of hearing and can't see very well, so that may be some of that. V7 denied any self-harming behavior by R12 stated I know (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145488 If continuation sheet Page 3 of 17 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 04/09/2025 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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she was putting herself on the floor sometimes, but from what I understood she would just lay on the ground, she did not throw herself on the floor. V7 denied any aggression or violence towards any other residents by R12. V7 stated R12's Risperidone was changed from pill form to shot form because R12 was refusing the pill. R12's Nurse's Note dated 4/2/2025 documents (R12) sleeping in recliner all this morning, was cleaned up and dressed by staff.(R12) would not rouse enough to take oral meds, scheduled insulin given. (R12) typically sleeps for a day or 2 post (Antipsychotic) injection. On 04/08/25 at 1:00 PM V7 (Registered Nurse) stated that R12 is very tired for a couple of days after her antipsychotic medication is administered via injection. V7 reported that R12 has had a significant decline in her physical condition related to her not being able to do as much for herself physically. R12's Admission MDS dated [DATE] documents that R12 used a cane previously, no wheelchair use. R12's MDS indicates that R12 required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided through the activity or intermittently) for oral hygiene and toileting hygiene. R12's MDS documents that she required partial moderate assistance (Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort) for eating, shower/bathe self, dressing upper body and personal hygiene. R12's MDS documents that she required substantial/maximum assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for lower body dressing and putting on footwear. R12's MDS dated [DATE] documents that R12 used a wheelchair. R12's MDS documented that R12 required partial moderate assistance (Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort) for eating, upper and lower body dressing, putting on footwear and personal hygiene. R12's MDS documents that she required Substantial/maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for oral hygiene, toileting hygiene and shower/bathe self. R12's MDS dated [DATE] documents that R12 used a wheelchair. R12 required partial/moderate assistance (helper does less than half the effort. helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for eating and upper body dressing. R12's MDS documents that she required substantial/maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for oral hygiene and personal hygiene. R12's MDS documents that R12 was dependent (helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) for toileting hygiene, shower/bathe self, lower body dressing and putting on footwear. On 4/9/25 at 11:00 AM V16 (Nurse Practitioner) stated that R12 was admitted on Risperidone 2 mg (milligrams) in pill form and has had increasing behaviors and has since been admitted to the hospital and her Risperidone was changed from pill form to shot form due to R12 refusing to take the medicine. V16 stated that R12 had many harmful behaviors which have led to V16 declining to reduce her antipsychotic medication. V16 described these behaviors as easily agitated and refusing cares. V16 confirmed that staff from the facility have informed her that R12 sleeps and refuses to participate in any cares for a couple days after she is given the antipsychotic injection. But she comes right back around in a couple of days and begins with the harmful behaviors again. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145488 If continuation sheet Page 4 of 17 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 04/09/2025 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on record review and interview the facility failed to obtain a Preadmission Screening and Resident Review (PASRR) after a significant change in condition for one resident (R12) of one reviewed for PASRRs in a total sample of 33. Findings Include: The Facility Admission policy dated November 2016 documents PASSR screens must be valid and reviewed on admission, annually and upon any significant change. All residents with a newly evident or possible serious mental disorder, intellectual disability, or a related condition should be referred for a level II resident review upon a significant change in status admission. R12's admission Physician Order Sheet dated March 2024 documents R12 was admitted with diagnoses that include but were not limited to conversion disorder with seizures, dementia and anxiety. R12's admission Physician Order Sheet did not include any serious mental illness diagnosis. R12's PASSR Level I dated 3/26/2024 did not document any serious mental illness diagnosis. R12's Nurse's Note dated 11/15/2024 document that R12 was sent to the hospital due to increased behaviors. R12's Nurse's Note dated 11/21/24 documents that R12 was transferred from the area hospital to an inpatient psychiatric hospital related to behaviors. R12's Nurse's Note dated 12/9/24 document that R12 returned to the facility from an inpatient psychiatric hospital stay. R12's readmission Physician Order Sheet dated December 2024 documents that R12 was on subcutaneous Risperidone 125 mg (milligrams) every month for bipolar disorder. On 4/7/25 at 11:00 AM V21 (Social Service Director) confirmed that R12's bipolar diagnosis was new from her hospitalization in November/December 2024. V21 confirmed that no repeat PASSR had been done. On 4/9/25 at 2:00 PM V1 (Administrator) confirmed that no level II PASSR had been done after R12's significant change in mental health diagnosis and that it should have been done. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145488 If continuation sheet Page 5 of 17 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 04/09/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review the facility failed to ensure indwelling urinary catheters were placed securely off the floor in a sanitary manner for two (R41 and R119) of six residents reviewed for indwelling urinary catheters in the sample of 33. Findings include: The facility Urinary Catheter Care policy and procedure, dated September 2005, documents The purpose of this procedure is to prevent infection of the resident's urinary tract. Be sure the catheter tubing and drainage bag are kept off the floor. 1. The current Physician Orders for R41 documents a 7/29/24 physician order for R41 to use a 16 FR (french)/10cc (cubic centimeter) balloon indwelling urinary catheter for the diagnosis of Urinary Retention. The current Care Plan for R41 documents R41 requires an indwelling urinary catheter for a diagnosis of Urinary Retention and requires Enhanced Barrier Precautions due to placement of indwelling urinary catheter. The documented goals as follows: R41 will have catheter care managed appropriately with no signs of infection and to reduce the spread of infectious agents, minimize the transmission of infection, and reduce the risk of colonization. The interventions include Do not allow tubing or any part of the drainage system to touch the floor; Follow facility's Infection Control and Enhanced Barrier Precautions policies/procedures; Use principles of infection control and enhanced barrier precautions; and Teach resident/caregiver the chain of infection/methods of transmission. On 4/6/25 at 9:36 AM R41 was sitting in his wheelchair in the hallway with an indwelling urinary catheter bag hanging from underneath his wheelchair. The catheter was not in a protective dignity bag, urine visible in the catheter tubing, and the catheter tubing was dragging the floor. 2. The current Physician Orders for R119 documents a 4/2/25 physician order for R119 to use a 16 FR/10cc balloon indwelling urinary catheter for the diagnosis of Urinary Retention. The current Care Plan for R119 documents R119 requires an indwelling urinary catheter for diagnosis of Urinary Retention and requires Enhanced Barrier Precautions due to placement of indwelling urinary catheter. The documented goals as follows: R119 will have catheter care managed appropriately with no signs of infection and to reduce the spread of infectious agents, minimize the transmission of infection, and reduce the risk of colonization. The interventions include: Teach resident/caregiver the chain of infection/methods of transmission and Use principles of infection control and enhanced barrier precautions. On 4/6/25 at 7:30 AM R119 was lying in bed with an indwelling urinary catheter. The indwelling urinary catheter drainage bag was not in a protective dignity bag, urine visible in the catheter tubing and both the drainage bag and tubing were resting on the floor. On 4/9/25 at 2:30 PM, V1 Administrator and V2 DON (Director of Nursing) confirmed indwelling urinary catheter bags should be in protective dignity bags and catheter bags and catheter tubing should not be on the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145488 If continuation sheet Page 6 of 17 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 04/09/2025 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure oxygen tubing is changed weekly and ear pads are used for residents wearing oxygen for two (R25 and R119) of two residents reviewed for respiratory care in the sample of 33. Residents Affected - Few Findings include: The facility Oxygen Administration policy and procedure, dated March 2004, documents The purpose of this procedure is to provide guidelines for safe oxygen administration. Securely anchor the tubing so that it does not rub or irritate the resident's nose, behind the resident's ears, etc. Place ear protectors as needed for residents utilizing oxygen more than 8 hours a day. Observe the resident upon set up and periodically thereafter to be sure oxygen is being tolerated. If the resident refused the procedure, the reasons(s) why and the interventions taken are to be documented in resident medical record. Notify the supervisor if the resident refuses the procedure. 1. The Progress Note for R119, dated 4/2/25, documents R119 readmitted to the facility from the local hospital on 4/1/25 with diagnoses: Adult Failure to Thrive related to Influenza A, pneumonia, dehydration with renal failure and was having hypoxia with oxygen saturations in the 80's requiring supplemental oxygen to keep blood oxygen saturations between 88-94%. Staff will administer oxygen and assist with head of bed elevation to prevent shortness of breath. The current Physician Order Report for R119 documents the following orders dated 4/1/25: Oxygen via nasal cannula, titrate oxygen to keep blood oxygen saturations between 88-94% every shift; Use ear pads for continuous oxygen; Check oxygen saturation every shift; Change and label oxygen tubing and mask weekly and change as needed. The current Care Plan for R119 documents (R119) has a dx (diagnosis) of chronic lung disease and exhibits the following symptoms: easily fatigued, shortness of breath placing resident at risk for death. This plan of care does not address or list interventions regarding R119's use of oxygen or R119's behavior of removing his oxygen. On 4/6/25 at 7:20 AM, R119 was lying in bed on his left side without ear pads or nasal cannula in his nares and with a pillow partially covering R119's head. The oxygen concentrator next to R119's bed was running at 3.5 liters and R119's undated nasal cannula was resting on R119's bed under a blanket. On 4/7/25 at 10:13 AM, R119 was lying in bed without ear pads or oxygen on and nasal cannula oxygen tubing was resting across R119's overbed table. On 4/8/25 at 10:21 AM, R119 is lying in bed without oxygen in place with the nasal cannula resting next to R119, on the bed. There were no ear pads in place for the oxygen tubing and the oxygen concentrator was on and blowing three liters of oxygen into the air. On 4/8/25 at 10:53 AM, V17 LPN (Licensed Practical Nurse) and V18 CNA (Certified Nursing Assistant) entered R119's room to provide care. V18 CNA performed cares for R119 and at no time did V17 LPN or V18 CNA attempt to put R119's nasal oxygen cannula back in place and no education given to R119 regarding R119s' need for the oxygen. After the completion of R119's care, V18 CNA retrieved the nasal cannula from R119's bed and placed it on R119 without ear pads. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145488 If continuation sheet Page 7 of 17 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 04/09/2025 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 4/8/25 at 10:53 AM, V17 LPN confirmed R119 did not have oxygen on, and oxygen tubing should not be on the floor. V17 LPN stated R119 is non-compliant with his oxygen and frequently takes it off and staff have to put it back on. V17 confirmed R119 has had oxygen since returning from the hospital on 4/1/25 for pneumonia, influenza A, and chronic lung conditions. 2. R25's Treatment Administration Record dated March 2025 documents Oxygen: Change tubing and mask weekly and PRN (As Needed) once a week on Sunday. On 04/07/25 at 12:06 PM R25's Oxygen tubing and humidifier both had labels dated 3/23/25 and there was no ear pads placed on the tubing. On 4/7/25 at 2:00 PM V9 (Registered Nurse) confirmed that R25's oxygen tubing and humidifier was dated 3/23/25. V9 stated that the tubing and humidifier were overdue for change. On 4/9/25 at 2:30 PM, V1 Administrator and V2 DON (Director of Nursing) were unaware to confirm the facility oxygen policy and procedure documented residents with continuous oxygen are to have ear pads placed when used. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145488 If continuation sheet Page 8 of 17 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 04/09/2025 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** 2. The current Physician Order Sheet for R119, documents a 4/1/25 physician order for Risperdal 0.25 mg (milligrams) daily at 8:00 AM for Vascular dementia with psychotic disturbance ordered by V16 NP (Nurse Practitioner). The Behavior/Intervention Monthly Flow Records for R119, dated March 13th through March 27th, 2025, and April 1st through April 8th, 2025, a total of 24 days, documents R119's targeted behaviors warranting the use of an antipsychotic as easily agitated and throwing food. These reports document R119 was easily agitated 13 of 24 days and throwing food on one of 24 days on 3/13/25. There are no other targeted behaviors listed for the use of R119's antipsychotic use. The Quarterly MDS (minimum data set) Assessment for R119, dated 3/25/25, documents R119 with moderately impaired cognition, moderate depression, and verbal behavioral symptoms occurring four to six times weekly. The facility facsimile communication form for R119, dated 3/19/25 was sent to V19 NP requesting diagnosis as: Antipsychotic Risperdal prescribed 3/19/25 for (R119) violent behavior. May we have dx (diagnosis) of (one) of the following: Brief psychotic disorder or Dementia with psychotic disturbance or Dementia with behavioral disturbance by V7 MDS (minimum data set) Nurse/Psychotropic Nurse. This form is signed and dated by V19 NP on 3/19/25 and documents Moderate vascular dementia with psychotic disturbance. On 4/6/25 from 6:30 am through 11:00 AM and on 4/7/25 and 4/8/25 from 9:00 AM through 3:00 PM R119 was lying in bed with no behaviors. R119's room was located across from the Nurses Station and R119 was lying in bed with no behaviors. On 4/8/25 at 10:20 AM, V17 LPN (Licensed Practical Nurse) stated R119 is extremely hard of hearing, does not see very well, so staff use a dry erase board to help communicate with R119. On 4/9/25 at 2:30 PM, V1 Administrator and V2 DON (Director of Nursing) confirmed R119 targeted behaviors for the use of Risperdal was easily agitated and throwing food. V1 and V2 stated R119 has been resistive to cares, yells at staff, and hit a therapy staff with his cane. The Quarterly Psychoactive Medication Evaluation for R119, dated 4/3/25, documents R119 continues to receive Risperdal and behaviors controlled. Based on observation, interview, and record review the facility failed to attempt gradual dose reduction for one resident (R12) and failed to have clinical indication for the use of an antipsychotic medication for one resident (R119) of five residents reviewed for psychotropic medications in the sample of 33. Findings include: The facility's Psychotropic Medication Policy and Procedure, dated February 2014, documents Policy: To establish the process for monitoring the use of and the reduction of doses of psychotropic medications without compromising the president's health and safety, ability to function appropriately, or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145488 If continuation sheet Page 9 of 17 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 04/09/2025 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 the safety of others. 2. Residents shall not be given antipsychotic drugs unless antipsychotic drug therapy is necessary to treat a specific or suspected condition as diagnosed and documented in the clinical record or to rule out the possibility of one of the conditions listed in guidelines of recognized external review agencies. 3. Residents who receive antipsychotic drugs shall receive gradual dose reductions and behavior interventions, unless clinically contraindicated. Residents Affected - Few The facility's undated Psychopharmacologic Drug Use Procedure, documents Documentation of behaviors and conditions requiring the use of these medications must be done on a routine basis including resident response to the medication. The following examples of antipsychotic drugs should not be used in excess of the listed doses for resident with organic mental syndromes unless higher doses (as evidenced by the resident's response or the resident's clinical record) are necessary to maintain or improve the resident's functional status. Risperidone is listed on the facility list as maximum dose of 4 mg (milligrams) in divided dose of 2 mg doses. When antipsychotic drugs are used outside these Guidelines, they may be deemed unnecessary drugs as a result of excessive dose. Antipsychotic medications may be considered for elderly residents with dementia but only after medical, physical, functional, psychiatric, social and environmental causes have been identified and addressed. Antipsychotic medications must be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and review. Antipsychotic medications in persons with dementia should not be used if one or more of the following is/are the only indication: 1. Wandering, 2. Poor self-care, 3. Restlessness, 4. Impaired memory, 5. Mild Anxiety, 6. Sadness or crying alone that is not related to depression or other psychiatric disorders, 7. Insomnia, 8. Inattention or indifference to surroundings, 9. Fidgeting, 10. Nervousness, 11. Uncooperativeness (e.g. refusal of or difficulty receiving care. This policy and procedure also documents that diagnoses alone do not warrant the use of an antipsychotic unless: The behavioral symptoms present a danger to the resident or others; and one or both of the following: The symptoms are identified as being due to mania or psychosis (such as: auditory, visual, or other hallucinations; delusions, paranoid or grandiosity); or Behavioral interventions have been attempted and included in the plan of care, except in an emergency. 1. R12's Physician Order Sheet dated March 2025 documents that R12 receives the antipsychotic medication Risperidone 150 mg (milligrams) every month for bipolar disorder. R12's Medical Record documents that R12 was readmitted to the facility on [DATE] after a hospitalization with order for Risperidone 125 mg. R12's Behavior/Intervention Monthly Flow Record dated January, February and March 2025 documents the following identified behaviors being monitored for R12: Hallucinations, Delusions, crying/tearful, depressed/withdrawn, false accusations, yelling and screaming at others, restless, noncompliance by getting up by herself, easily agitated, cursing staff and difficulty falling and staying asleep. On 4/7/25 at 11:30 AM V21 (Social Services) confirmed the behaviors listed on R12's Behavior/Intervention Monthly Flow Record. V21 stated that the false allegations being monitored for R12 is related to R12 stating that staff members are sleeping with her husband. V21 stated that R12 very easily agitated and can get very nasty when (staff) attempt to do anything (give cares). V21 stated that the yelling/screaming at others behavior can be described as R12 yelling when cares are being done or attempted and that R12 sometimes just yells for nothing. V21 confirmed R12 had not had any attempts or documentation of any failed gradual dose reductions of R12's antipsychotic medications at any time. On 4/8/25 at 1:00 PM V7 (Registered Nurse) described the aggression and agitation displayed by R12 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145488 If continuation sheet Page 10 of 17 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 04/09/2025 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 to be refusing cares, yelling out, cursing staff and hallucinations/delusions. V7 stated R12's hallucinations/delusions behaviors could be described as speaking in 3rd person, speaking as if she actually is her husband, believing that staff are sleeping with her husband who has been dead for years. V7 stated that R12 can be combative with cares also, but she is very hard of hearing and can't see very well, so that may be some of that. V7 denied any self-harming behavior by R12 stated I know she was putting herself on the floor sometimes, but from what I understood she would just lay on the ground, she did not throw herself on the floor. V7 denied any aggression or violence towards any other residents by R12. confirmed R12 had not had any attempts or documentation of any failed gradual dose reductions of R12's antipsychotic medications at any time. R12's Nurse's Note dated 3/27/25 at 4:08 PM documents response on res (resident) behaviors per (V16/Nurse Practitioner) increase (Risperdal) to 150 mg injection SQ (Subcutaneous). R12's Pharmacy Recommendation dated 3/11/25 documents a request to gradually reduce R12's antipsychotic medication Risperidone. V16 (Nurse Practitioner) marked patient is currently stable. Dose reduction is contraindicated because benefits outweigh risks, and a reduction is likely to impair the resident's function and/or cause psychiatric instability. On 4/9/25 at 11:00 AM V16 (Nurse Practitioner) stated that R12 had many harmful behaviors which have led to V16 declining to reduce her antipsychotic medication. V16 described these behaviors as easily agitated and refusing cares. V16 reported that she regularly meets with (V11/R12's Health Care Power of Attorney) when V16 comes to the facility to see R12. V16 reported that V11 is very supportive of R12 being on antipsychotic medications related to her behaviors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145488 If continuation sheet Page 11 of 17 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 04/09/2025 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 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 Based on observation, interview and record review the facility failed to ensure food stays warm for six residents (R11, R12, R26, R47, R50, and R119) of six residents reviewed in a total sample of 33. Residents Affected - Some Findings Include: The Facility's undated Hot Food Service Temperatures policy documents foods will be served to the residents at a temperature that is palatable to prevent injury such as burned mouth or lips. Food will be offered to be reheated if it is not within resident's preferred food temperatures or another tray will be offered. On 4/8/25 at 8:30 AM R11, R12, R26, R47, R50, and R119's breakfast trays were sitting out on the dining room tables with either a lid or other plates on top of the dishes. R11, R12, R26, R47, R50, and R119 were not in the dining room at this time. On 4/8/25 at 8:35 AM V4 (Certified Nurse Aid/Transportation) stated that these residents had not come out to the dining room yet and she wasn't sure how long the trays had been sitting at the tables without residents present. V4 stated that staff routinely deliver trays to the resident's regular spot whether the resident is present or not. V4 stated I told them (R26) was in the shower. She is going to be a while. The food back here (assisted area of dining room) is not always hot when I feed it to the residents because people put it on the table whether or not the person is here. On 4/8/25 at 8:40 AM V6 (Dietary Manager) entered the dining room and asked V4 (Certified Nurse Aid/Transportation) where R11, R12, R26, R47, R50, and R119 were. V4 stated she did not know. V6 picked up R47's tray and walked it to R47's room. R47 was sitting in her recliner with her eyes closed. V4 (Dietary Manager) sat meal tray on R47's bedside table and left the room. Food temperatures at that time were scrambled eggs 89 degrees Fahrenheit and sausage 88 degrees Fahrenheit. R47 was pleasantly confused and did not answer any questions in a sensical manner. On 4/8/25 at 8:50 AM R11, R12, R26, R50, and R119's trays were no longer in the dining room. V4 (Certified Nurse Aid/Transportation) stated she didn't know where the trays went. On 4/8/25 at 9:30 AM V6 (Dietary Manager) stated that food should only be served if the residents are present. We have a lot of food temperature complaints because once the food leaves the steam table it automatically starts to lose temperature. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145488 If continuation sheet Page 12 of 17 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 04/09/2025 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Hospice's coordinated communication and required documents were available and accessible to the facility staff. This deficiency affects one of one resident (R11) reviewed for Hospice care management in a sample of 33 residents. Findings include: The Hospice Services Policy not dated documented Hospice service will conduct assessments and develop a hospice plan of care which will be integrated with the resident's overall plan of care and maintained in the medical record or other location with the interdisciplinary care plan. All hospice service staff will write a progress note for each resident visit indicating treatment provided and pertinent information related to the resident's condition which is available in the medical record for all interdisciplinary staff to access. Hospice service staff will attend care plan conferences and participate in the resident's care planning process. The Long Term Care Hospice Service Agreement dated 5/19/2019 documented responsibilities of facility were to obtain the Hospice's Plan of Care, Medications, Orders, Election Form and the Certification of Terminal Illness. R11's Face Sheet documented R11 was admitted on [DATE] and elected Hospice benefits on 11/13/24 with a terminal diagnosis of Dementia, age-related Osteoarthritis with pathological fracture of Femur. R11's current Care Plan lacked specific Hospice responsibilities/interventions. R11's medical record lacked a Hospice Plan of Care, Election forms, Physician certification of terminal illness and/or copies of clinical notes. On 4/7/25 at 11:05 AM, V19 (Licensed Practical Nurse) stated the nurses assess on each resident at shift change and this is how staff know if a resident is on Hospice or not. V19 stated R11's Hospice Nurse Aide calls the day before they come to the facility and give a time. V19 stated The nurses don't call. We don't know when they (nurses) are coming. Sometimes they (Hospice nurses) come and go, and we don't even know they have been here. V19 stated there was not a Hospice binder for R11. On 4/7/25 at 11:15 AM, V21 (Social Services) stated there is a general Hospice binder with contact information located on each wing but not a specific one for R11. At 11:45 AM, V21 stated I found out that if hospice has a change (in cares/medications), they (Hospice staff) write on the POS (Physician's Order Sheet) and it should be scanned into the record. V21 reviewed R11's record and agreed there were no Hospice documents scanned into the computer. On 4/9/25 at 1:00 PM, V19 (Hospice Nurse) stated she does not leave R11's plan of care or visit notes at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145488 If continuation sheet Page 13 of 17 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 04/09/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 2. The current Care Plan for R41 documents R41 requires Enhanced Barrier Precautions due to indwelling urinary catheter and interventions including: Follow facility's Infection Control and Enhanced Barrier Precautions policies/procedures; Use Principles of infection control and enhanced barrier precautions; Teach resident/caregiver the chain of infection/methods of transmission; and Practice good handwashing. Residents Affected - Many On 4/8/25 at 11:15 AM V18 CNA (Certified Nursing Assistant) performed indwelling urinary catheter care for R41. After completing care, with same soiled gloves on, V18 CNA assisted R41 with pulling up his pants, and threw garbage into R41's garbage can. V18 CNA then removed her gloves and applied a new set of gloves without performing hand hygiene, covered and positioned R41 with a bed sheet, moved R41's overbed table next to R41's bed, opened the window blinds, pulled back the privacy curtain, got into R41's nightstand retrieving a chocolate candy bar and handed it to R41. 3. The current Care Plan for R119 documents R119 requires Enhanced Barrier Precautions due to indwelling urinary catheter and interventions including: Follow facility's Infection Control and Enhanced Barrier Precautions policies/procedures; Use Principles of infection control and enhanced barrier precautions; Teach resident/caregiver the chain of infection/methods of transmission; and Practice good handwashing. On 4/8/25 at 10:52 am, V18 CNA (Certified Nursing Assistant) performed indwelling urinary catheter care for R119. After completing care, with same soiled gloves on, V18 CNA applied R119's clean brief and pulled up R119's pants. V18 CNA removed her soiled gloves and applied a new set of gloves without performing hand hygiene, placed call light in R119's hand, picked up R119's oxygen nasal cannula from the bed and placed it to R119's nares and wrapped around R119's ears. On 4/8/25 at 11: 35 AM, V17 LPN (Licensed Practical Nurse) and V18 CNA confirmed V18 CNA did not perform hand hygiene after removing her soiled gloves and should have. V17 LPN and V18 CNA confirmed V18 CNA should not have touched anything prior to washing her hands. V17 LPN stated she provided V18 CNA with hand sanitizer and V18 CNA stated she had hand sanitizer in her pocket. Based on observation, interview and record review the facility failed to perform hand hygiene after glove removal for two (R41 and R119) of 18 reviewed for infection control and failed to adhere to masking during an influenza outbreak. The failure of non-masking has the potential to affect all 71 residents currently residing in the facility. Findings Include: The Facility's undated Preventing and Controlling ARI (Acute Respiratory Illness) in Skilled Nursing Facilities and Other Facilities Providing Nursing Care documents Ensure everyone, including residents, visitors, and HCP (Health Care Providers) are aware of recommended Infection Prevention and Control (IPC) practices in the facility, including when specific IPC actions are being implemented in response to new infections in the facility or increases in respiratory virus levels in the community. Source control is recommended for individuals in health care settings who have suspected or confirmed respiratory infection or respiratory trends or observed trends). The facility Urinary Catheter Care policy and procedure, dated September 2005, documents The purpose of this procedure is to prevent infection of the resident's urinary tract. Staff are to wash and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145488 If continuation sheet Page 14 of 17 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 04/09/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many dry hands thoroughly, put on gloves, provide catheter care, discard disposable items, remove gloves, discard gloves, wash and dry hands thoroughly, reposition bed coverings, make resident comfortable, place call light, clean wash basin and bedside table, and to then wash and dry hands thoroughly again. The facility Hand-Washing/Hand Hygiene Policy, dated March 2020, documents It is he policy of the facility to assure staff practice recognized hand-washing/hand hygiene procedures as a primary means to prevent the spread of infections among residents, personnel, and visitors. alcohol based hand rubs (ABHR) can be used for hand hygiene when hands are not visibly soiled or contaminated with blood or bodily fluids. When hands are not visibly soiled, employees may use an alcohol-based hand rub (foam, gel, liquid) containing at least 60% alcohol in all of the foolwing situations: a. before direct contact with residents; b. after direct contact with a resident but prior to direct contact with another resident; c. before donning gloves; g. before moving from a contaminated body site to a clean body site during resident care; h. before and after putting on and upon removeal of PPE (personal protective equipment), including gloves; i. after contact with a resident's intact skin; j. after handling used dressings, potentially contaminated equipment; l. after contact with potentially infectious material; m. after removing gloves. The use of gloves does not replace compliance with hand-washing/hand hygiene procedures. If soap and water are not available, use an alcohol-based hand sanitizer that contains at least 60% alcohol, and wash with soap and water as soon as possible. The facility Personal Protective Equipment - Using Gloves policy and procedure, dated June 2005, documents Wash hands after removing gloves. (Note: Gloves do not replace handwashing.) 1. On 4/6/25 at 6:00 AM a sign indicating the facility was in Flu (Influenza) Outbreak Status and Masking beyond this point is recommended, please see nurse with questions was on the entry doorway to the facility. On 4/6/25 at 8:00 AM V14 (Infection Preventionist) stated that the facility was in flu outbreak status due to a resident testing positive. We put all the residents on TamiFlu and are masking. On 4/8/25 at 10:30 AM V5 (Hairdresser) standing in the North hallway speaking with another staff member. V5 did not have a mask on. V5 stated No one told me we were wearing masks. All staff, including the staff member V5 was speaking to had masks on. V5 continued to walk from North Hall to South Hall with no mask on. On 4/8/25 at 10:35 AM V14 (Infection Preventionist) stated that anyone who walked through the entire building without a mask on during a flu outbreak status would be putting all residents at risk of getting the flu. Why do you ask? We do not have any families or visitors that I know of that refuse to mask when we ask them to. On 4/9/25 at 2:20 PM, V1 Administrator stated the facility recommends all staff, contracted staff, and visitors to wear masks during the facility flu outbreak. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145488 If continuation sheet Page 15 of 17 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 04/09/2025 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to identify, monitor, and review prophylactic antibiotic use for four of four residents (R17, R21, R38, R49) for antibiotic stewardship in the sample of 33. Residents Affected - Some Findings include: The Infection Prevention and Control Program dated 2019 documented an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. Antibiotic Stewardship and review including reviewing data to monitor the appropriate use of antibiotics in the resident population. The Infection Preventionist will oversee the facility Antibiotic Stewardship Program. review of the use of antibiotics is a vital aspect of the infection prevention and control program. Involve the consultant pharmacist with the oversight by identifying antibiotics prescribed for resistant organisms. Track antibiotic use monthly and completes an antibiogram yearly or as directed by the Medical Director and the Quality Assurance Committee. The Antibiotic Stewardship Policy dated 11/28/17 documented the physician, nursing and pharmacy are the leads responsible for promoting and overseeing antibiotic stewardship activities. The facility maintains a consultant pharmacist with antibiotic stewardship-specific drug expertise. The facility will utilize the McGeer's criteria when considering initiation of antibiotics. The Infection Control Log documented R17, R21, R8 and R49 had no signs or symptoms and received prophylactic antibiotics for urinary tract infections which were ordered by V13 (Urologist). 1. R17's Face Sheet indicated R17 was admitted on [DATE] with diagnoses of Chronic Respiratory Failure, Tubulo-Interstitial Nephritis and Personal history of Urinary (Tract) Infections. R17's Physician Order dated 4/4/25 and has no end date documented to administer an Antibiotic for Urinary Tract Infection Prophylaxis. 2. R21's Face Sheet documented R21 was admitted on [DATE] with diagnoses of Adjustment Disorder with Mixed Anxiety and Depressed Mood, Neuromuscular Dysfunction of Bladder, Infection and Inflammatory Reaction due to Indwelling Urethral Catheter, Stress Incontinence and Personal history of Urinary (Tract) Infections. R21's Physician's Order dated 11/27/24 through 2/27/25 for an Antibiotic medication was for a Personal History of Urinary Tract Infection. 3. R38's Face Sheet indicated R38 was admitted on [DATE] with diagnoses of Osteoarthritis, Major Depressive Disorder and Interstitial Cystitis. R38's Physician's Order dated 10/15/24 and had no end date documented to administer an Antibiotic and did not indicate a diagnosis/reason for the medication. 4. R49's Face Sheet indicated R49 was admitted on [DATE] with diagnoses of Polyosteoarthritis, Schizoaffective Disorder and Urge Incontinence. R49's Physician's Order dated 1/24/25 through 4/24/25 documented to administer an Antibiotic and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145488 If continuation sheet Page 16 of 17 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 04/09/2025 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 0881 did not indicate a diagnosis/reason for the medication. Level of Harm - Minimal harm or potential for actual harm R49's Physician's Order dated 2/28/25 through 4/16/25 documented to administer an Antibiotic for Urge Incontinence. Residents Affected - Some The QA (Quality Assurance) Committee meeting minutes for each quarter of 2024 were reviewed. The attendance sheets documented V15 (Pharmacist) attended the QA meetings on 2/6/25 and 8/6/24. The Consultant Pharmacist's Medication Regimen Review reports included psychotropic medications and did not include antibiotic usage. The Infection Report Summary did not include prophylactic antibiotic use surveillance data. On 4/8/25 at 2:00 PM, V14 (Infection Preventionist) stated Urge Incontinence was not a diagnosis that required an Antibiotic. V14 stated V13 (Urologist) was the only physician that ordered prophylactic antibiotics for urinary tract infections. On 4/9/25 at 2:30 PM, V1 (Administrator) and V2 (Director of Nursing) stated the Antibiotic Stewardship program was not all inclusice and needed improvement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145488 If continuation sheet Page 17 of 17