Inspection·July 8, 2022

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 7/7/22 at 1:27 PM, V13, Certified Nursing Assistant (CNA) stated, I changed (R26) this morning. I'm not sure what time, but I would guess around 9:45 AM. On 7/7/22 at 1:30 PM, V18, CNA, stated, I have not changed (R26) today. On 7/7/22 at 4:00 PM, V2, Director of Nursing, stated, I would expect staff to reposition residents and provide incontinence care every two hours. On 7/8/22 at 8:11 AM, V21, (Wound Consultant Company) Nurse Practitioner, stated, Typically we expect our patients to be turned and repositioned every two hours. Incontinence care should also be provided every 2 hours. Incontinence is the bigger factor for (R26) because she is always wet. If staff does not provide incontinence care as prescribed, that could definitely impact (R26's) healing. On 7/8/2022 at 9:00 AM, R26's pressure ulcer treatment was observed. V22 and V23, CNAs, positioned the resident on her right side. V12, Licensed Practical Nurse (LPN), removed the old dressing, applied skin prep to the peri wound area, applied wound cream to the wound bed, and then applied a dressing. In between removing the old dressing, applying skin prep, applying wound cream to the wound bed, and applying the clean dressing, V12 removed her gloves and sanitized her hands. Each time V12 sanitized her hands and changed gloves, V22 and V23 positioned the resident to lay directly on the incontinence pad, with no barrier between the pressure ulcer and the pad. On 7/8/2022 at 10:22 AM, V3, Assistant Director of Nursing (ADON) and Infection Control Preventionist (ICP), stated, I would not expect staff to leave residents with wound on incontinence pad for any length of time, but during dressing changes, as long as the pad is clean and the resident remains dry, it would be acceptable for a short period of time. On 7/8/22 at 12:45 PM, V3, ADON and ICP, stated, We do not have a policy on turning and repositioning. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145515 If continuation sheet Page 2 of 18 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 145515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freeburg Care Center 746 Urbanna Drive Freeburg, IL 62243 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to implement progressive interventions and provide supervision to prevent falls for 3 of 7 residents (R34, R55, R138) reviewed for accidents/supervision in the sample of 39. This failure resulted in R138 falling, hitting his head, and being sent to the emergency room (ER). R138 sustained multiple intracranial hemorrhages including intraparenchymal hemorrhage in the left temporal region with subarachnoid blood that caused death. Findings include: 1. On 4/17/2020, R138 was admitted to the facility with the following diagnoses: hypothyroidism, COVID-19, hypertension, dementia without behavioral disturbance and major depressive disorder. R138's Morse Fall Scale, dated 7/20/2021 documents he was high risk for falls. R138's Minimum Data Set (MDS), dated [DATE], documented R138 had severely cognitive impairment. R138's MDS documented his balance was not steady, only able to stabilize with staff assistance when walking, moving from seated to standing position and turning around. The MDS documented R138 required limited assistance of one person for transfers and ambulation. The MDS documented R138 utilized a walker and had no falls. R138's Late Entry Incident Note, dated 8/8/2021 at 9:23 AM documents res (resident) was agitated this morning before breakfast. Res pacing with walker up and down C Hall. Res redirected several times and unwilling to sit down or go back to bedroom. Res was standing against the wall at the top of C Hall. This nurse heard a loud noise and noted that res was laying on the left side on the floor where res had been standing. Assessed res and no injuries noted. Vitals stable at 110/58; P60; R 16; T 96.7; O2 100%. Res denies pain and denies hitting head, but this nurse started neuro checks because fall was not witnessed and unsure if resident actually hit head. Called and left message for POA (Power of Attorney) to call facility. Res resting in bed at this time. R138's Care Plan, dated 9/1/2021 documents he was at risk for falls/contractures R/T (related to) decreased mobility, weakness, hypothyroidism. The Care Plan documented that On 1/21/21, Certified Nurse's Aide (CNA) noted res (resident) up in BR (Bathroom) prior to going to next room. When CNA walked out into hall, res laying on back in BR. The Care Plan documented that on 8/8/21, R138 was agitated this am pacing C hall-redirection unsuccessful-had a fall in hallway. The Care Plan Goal documented (R138) placed in fall management, free of signs/symptoms pain. The Care Plan Intervention, dated 8/8/21 documented 1 on 1 spent with resident. R138's Care Plan Interventions, dated 9/1/21, documented Maintain safe environment to room/facility to prevent injuries, well-lit environment. Observe res (resident) for any unassisted transfers/ambulation status. Remind to wait assist and assist res PRN. B & B (Bowel and bladder) before meals/after and PRN (as needed). Instruct/remind resident to use of call lights when assist needed. Report any unsteady balance/gait to Nurse/ Phys (physician) PRN. Report any decline in safety awareness to Nurse PRN. Change of position every two hours and PRN. Non skin pad in chair as needed. Bed to low position and locked. Monitor use of eyeglasses, hearing aids. Reinforce assistive devices. Evaluate need for an adjustment in Resident's daily activity schedule. Observe res for restlessness. Assist resident to bathroom. This Care Plan did not address R138's need for increased supervision when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145515 If continuation sheet Page 3 of 18 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 145515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freeburg Care Center 746 Urbanna Drive Freeburg, IL 62243 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 ambulating. Level of Harm - Actual harm R138's Health Status Note, dated 9/27/21 at 10:16 AM documents Resident was taken to restroom had a large BM (bowel movement) because weak, and staring off. This nurse assessed resident elevated HOB (head of bed) and elevated feet. Resident able to grasp with upper extremities without difficulty. Able to smile without difficulty. Pushed PO (by mouth) fluids, answered questions without difficulty. Stated he felt better. V/S (vital signs) 100/60 (blood pressure), 97.3 (temperature), 88 (pulse), 20(respirations), SPO2 (oxygen saturation levels) 98% RA (room air). Placed on Mxxxxxxxxxx (secure clinical communication tool). Will monitor. Residents Affected - Few R138's Incident Note dated, 9/27/2021 at 11:04 PM documents Resident leaning against dining room wall. Resident had a fainting episode and fell onto the floor at 5:30 PM. Resident drooling, not responsive at first. Resident became more and more responsive after about 10 minutes. Vitals 97.1,68,20,118/88,98%. POA notified and agreed resident should be sent to ER (emergency room) for evaluation and treat. Doctor also notified. Resident left by ambulance without any resistance at 6:28 p.m. Nurse called at 10:00 PM to check on the status of resident and was informed resident is being admitted with GI bleed. R138's Fall Information Form, dated 9/27/2021 written by V14, Licensed Practical Nurse (LPN) documented at 5:30 PM Resident was standing in dining room against the wall. Resident then fainted and fell to the floor. Resident sent to ER for evaluation. The form documented that the incident was no witnessed. The form documented R138's family was notified at 5:45 PM and his physician was notified at 6:00 PM. R138's Electronic Medical Record, dated 9/27/2022 documents no further assessment of the R38 after he fell at 5:30 PM. There were no documented neurological checks after this incident occurred. R138's Communication - with Family/NOK (Next of Kin/POA (Power of Attorney) Note dated 9/28/2022 at 3:52 PM documents Call received from POA. She states resident has been placed on hospice care for brain bleed that the hospital medical team has been unable to control. She states family wishes to have any photos or cards of resident's but donates all clothing at this time. The Facility's Final Report of Serious Incident dated 10/1/2021 documents (R138) is a [AGE] year old resident with a diagnosis of hypothyroidism, history of COVID-19, essential hypertension, unspecified dementia without behavioral disturbance and major depressive disorder. (R138) is alert and oriented x 2, able to make all needs known, his primary mode of transportation is wheeled walker which he can ambulate without assistance. At approximately 5:30 PM on 9/27/2021 (R138) was ambulating in the dining room when he stopped and rested against the wall. (V15. Licensed Practical Nurse/LPN) noted his appearance changed with him staring straight ahead and appeared to faint and fell to the floor landing on his right side before any staff could get to him. (V15) and (V14, LPN) responded immediately and performed assessment, neurological assessment was abnormal due to loss of consciousness, vital signs were normal for (R138.) Upper and lower extremities showed no signs of injury. Nurse noted hematoma to right forehead starting to form. (R138) became alert and more responsive after approximately 10 minutes. (V15) stayed with (R138) while (V14) contacted the medical director, his physician and received orders to transfer to hospital of choice for further evaluation and treatment. Medical director, Illinois Department of Public Health (IDPH), Administrator, DON and POA notified in timely manner. Conclusion: no abuse was suspected. (R138) was sent to a local hospital for further evaluation and treatment. Immediate intervention was staff stayed with (R138) until ambulance arrived. (R138) was admitted with a diagnosis of intracranial bleed with midline shift. CT (Computerized (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145515 If continuation sheet Page 4 of 18 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 145515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freeburg Care Center 746 Urbanna Drive Freeburg, IL 62243 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 tomography) scan showed multiple intracranial hemorrhages. He was admitted to general in patient and POA wanted comfort measures only. (R138) passed away the next day at the hospital. Level of Harm - Actual harm Residents Affected - Few R138's Hospital Paperwork, dated 9/27/22, documents diagnosis of fall with head trauma and multiple intracranial hemorrhages including intraparenchymal hemorrhage in left temporal region with subarachnoid blood. The Hospital Report documents The resident is a [AGE] year old male with past medical history significant for hypertension (high blood pressure) hypothyroidism, dementia, depression, mitral valve insufficiency and COVID-19 infection December 2020. Patient presented to our ED (emergency department) via EMS (emergency medical services) from the nursing home secondary to a fall, patient was witnessed falling from a chair and struck his head on the tile floor, no loss of consciousness, patient unable to provide history information obtained from records, in the ED patient was evaluated CT (cat scan) showed multiple intracranial hemorrhages including intraparenchymal hemorrhage in the left temporal region with subarachnoid blood and parenchymal contusions, neurosurgery were consulted. There was a 3 to 4 centimeter hematoma to left parietal scalp. Patient was given IV (intravenous) Keppra, IV tranexamic acid, intensivist was consulted, and patient get admitted for further evaluation and treatment. Patient was admitted to ICU (intensive care unit.) Discharge condition: poor, discharged to inpatient Hospice. Hospice note: patient was recently admitted after a fall and was diagnosed with intracranial bleed with midline shift and is requiring total care of activities of daily living (ADLs.) The patient is lethargic, requiring IV gtt (drop) Morphine (narcotic pain medication) at 2 milligrams (mg)/hr (hour.) On 7/6/2022 at 12:21 PM V28, LPN stated she was the restorative nurse and remembered R138. V28 stated He walked with a walker and was supposed to only walk with staff assistance because he had unsteady gait, but he would often walk by himself. He was a high fall risk and staff had to remind him often not to walk alone. On 7/7/2022 at 11:00 AM V13, Certified Nurse's Aide, CNA stated he works day shift and recalled R138. V13 stated R138 was a walk to dine resident. V13 stated R138 walked unsteady on his feet so staff were supposed to walk with him. On 7/7/2022 at 11:14 AM V12, LPN stated she remembered R138 and stated he walked with a walker but only with staff assistance because he was unsteady on his feet. On 7/7/2022 at 11:20 AM V14, LPN remembered R138. She stated R138 walked with a walker with staff assistance. V14 stated she didn't see R138 fall on 9/27/21, staff alerted her he fell in the dining room and her and another nurse (name unknown) assessed R138. V14 stated she didn't recall if he hit his head or not, he didn't have any injuries from the fall that she could see. V14 stated after R138 fell he initially wasn't responsive but then he opened his eyes. V14 stated she called the family and physician and got an order to send him to the hospital for further evaluation and treatment. R138 stated she called the ambulance company directly, she did not call 911 because it wasn't a medical emergency. On 7/7/2022 at 11:28 AM V15, LPN stated she works evening shift and was familiar with the resident. He was confused and ambulated with a walker with staff assistance. He was unsteady on his feet to ambulate alone. She assessed him when he fell in the dining room on 9/27/21 but wasn't assigned to her. She didn't recall a head injury. V15 stated after R138 fell he was more confused than usual and was no longer communicating verbally. She felt this was a medical emergency after he fell because he had an altered mental status. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145515 If continuation sheet Page 5 of 18 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 145515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freeburg Care Center 746 Urbanna Drive Freeburg, IL 62243 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few On 7/7/2022 at 2:30 PM the Director of Nurses (DON) stated when a resident falls staff are expected to document everything from what they saw and what the assessment was and to be as descriptive as possible in the nurses note. She spoke to staff after the fall and V15, LPN reported the resident had a hematoma forming on the side of his head and V14, LPN reported the resident was unresponsive for a bit after the fall which means he lost consciousness and that is considered a medical emergency and 911 should have been called. She expected staff to call the resident's family and physician immediately after a fall. She also expected staff to get neuro checks when a resident has a head injury and to apply ice to the area. On 7/7/2022 at 2:00 PM V19, R138's Physician, stated he didn't recall the specifics of R138 falling in September 2021. V19 stated he has no notes on the fall the nurse must have called after the doctor's office closed for the day because if it was during office hours, he would have notes about the fall. V19 stated when a resident falls and loses consciousness it is considered a medical emergency and 911 should be called. He also expected staff to document what occurred with the fall in the resident's medical record especially document when a resident has a head injury. If the resident fell and hit his head that could cause a brain bleed and could have been a factor in his death. The facility's undated Neurological Assessment - Head Treatment policy documents the neurological assessment form is initiated by the nurse immediately upon noting any trauma to a resident's head. The assessment lists various items that are used to indicate presence of intracranial pressure. It is important to note the resident's normal neurological signs to accurately judge changes that are noted during the use of this assessment. A weak hand clasp is not a significant if it was noted to be present before initiation of the forms for example. A 72-hour assessment is done in full according to this time scheduled: every 15 minutes x 4, every half hour x 2, every four hours x 4, then every 8 hours for the last 48 hours. Levels of consciousness nurses noted by checking whether resident is oriented, disoriented, restless or drowsy. Any change in the level of consciousness is one of the earliest and most sensitive indicators or increased intracranial pressure. Summary: altercations in consciousness provide the best guide for the nurse to estimate intracranial pressure. 2. R55's Health Status Note, dated 5/22/2022 10:09 PM documents: Res (resident) across hall put her light on. She heard resident (R55) saying help. CNA entered room and found res lying on l (left) side in front of w/c (wheelchair). ROM (range of motion) WNL (within normal limits). Not witnessed so neuros started. WNL. Res was making voluntary movement with arms. Assist x 3 to get off floor. Res body was flaccid. She refused to assist. 0 inj (injury) noted. POA, DON and Dr (doctor) aware. Res remains on ABT (antibiotic) R/T (related to) UTI (urinary tract infection.) 0 ASE (adverse side effects) noted. Refused fluids. 0 signs or symptoms of pain noted. Will continue to monitor. R55's Significant Change MDS, 6/14/2022 documents wheelchair, walker, one fall since admission no injury and she was moderately cognitively impaired. R55's Late Entry Incident Note, dated 6/16/2022 at 10:46 documents Resident yelling out for help. Resident on buttocks leaned against side of bed. Resident could not explain what she was doing. states I slid down denies pain. ROM to all ext's (extremities) wnl. x 2 staff and gait belt resident back into center of low bed. call light in reach. will do 72-hour f/u per fall protocol. received order for floor mat at side of bed and initiated. 97.9-100-20-118/62-93%. R55's Health Status Note, dated 6/18/2022 at 7:05 AM documents CNA notifies nurse 'Can you come help me?' Nurse observes res r (right) side lying on floor mat, bed low position. Res Denies pain. No injury. 2 staff assist res to bed, low position. Res education provided r/t calling for help before (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145515 If continuation sheet Page 6 of 18 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 145515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freeburg Care Center 746 Urbanna Drive Freeburg, IL 62243 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 self-transfer attempts. Level of Harm - Actual harm R55's Care Plan dated 6/20/2022 documents problem: resident is at risk for falls. Goal: free from falls. Interventions: 2/5/21 staff reeducation on proper transfer resident out of shower chair and staff to ensure shower chair is locked when transferring. Dysom placed in wc to prevent sliding from cushion. 6/20/2022: floor matt x 1 door side due to resident throwing legs out of bed. Residents Affected - Few On 7/6/2022 at 10:58 AM, there was no floor mat on floor in R55's room. 3. R34's MDS date 05/04/22 documents a BIMS score of 9 out of 15. Resident is moderately impaired. R34's MDS dated [DATE] documents that resident requires extensive assistance of one-person for bed mobility. Resident requires limited assistance of one-person for transfer, walk in room, walk in corridor, locomotion on unit, locomotion off unit, dressing, toilet use, and personal hygiene. Resident is independent with setup help only for eating. Resident requires physical help limited to transfer only of one-person for bathing. Resident is not steady, only able to stabilize with staff assistance. Resident uses walker and wheelchair for mobility. R34's Care Plan dated 01/19/22 documents (R34) is at risk for falls /contractures R/T muscle weakness and poor safety awareness d/t recent hospitalization for infection in blood stream. R34's Care Plan documents the following incidents: 11/7/21 self-transferred self from w/c and slipped onto floor; 11/22/21 ambulating in room alone, slipped and fell. 1/19/21 out of bed and scooting on floor; 4/15/22 observed laying on floor near bed. 4/18/22 sitting on buttock in front of wc. R34's Care Plan Interventions are as follows: 01/19/22 - Maintain safe environment to room/facility to prevent injuries, well lite environment. Observe Res. for any unassisted transfers/ambulation status. Remind to wait assist and assist Res. PRN. B & B before meals/after and PRN. Keep Res Clean and dry. Instruct/remind Resident to use of call lights when assist needed. Report any unsteady balance/gait to Nurse/Phys PRN. Report any decline in safety awareness to Nurse PRN. Use of side rails times ____ checked every two hours and PRN; 04/18/22 - UA (Urinalysis) with C/S (Culture and Sensitivity); 04/15/22 - 2 Re-educated staff to organize and declutter the room; 02/24/22 - wheelchair alarm changed to alert one; 01/19/22 - bed pad alarm; 01/22/21 - reeducated CNA to toilet resident Q 2 hours at night; 01/07/21 - chair pad alarm. R34's Incident Note dated 05/31/22 at 10:05 AM documents This nurse notified that resident had fallen in assigned bedroom during a self-transfer. CNA responded to resident's alarm and witnessed resident fall onto back in front of nightstand while attempting to self-transfer from wheelchair onto bed. Area of impact back/head. No apparent injuries noted. Neuro checks initiated and WNL. PERRLA - brisk 3mm bilaterally. Hand grips strong bilaterally, while legs are weak bilaterally, which has been baseline for resident for a little while now. NP/DON/POA made aware of incident. Denies any pain at present time. Resident placed at nurses' station with this nurse for close monitoring. R34's Care Plan was not revised after this incident with progressive interventions to prevent her from future fall. R34's Incident Note dated 07/05/22 at 10:40 AM documents This nurse called to restorative room; resident noted to be lying on her back, legs outstretched with her head towards her wheelchair. alert one intact. Assessment done by this nurse- no injuries noted at present time. resident had no c/o pain or discomfort. resident unsure if she had hit her head, fall not witnessed. neuro checks initiated. POA AWARE, DON AWARE, (family) AWARE. will continue to monitor resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145515 If continuation sheet Page 7 of 18 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 145515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freeburg Care Center 746 Urbanna Drive Freeburg, IL 62243 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 R34's Care Plan was not revised after this incident with progressive interventions to prevent her from future falls. Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The facility's undated Fall Policy & Procedure, documents policy: All residents have a right to be cared for within a safe environment. Each resident should be considered part of our fall prevention plan, which includes assessment of risk and initiation of appropriate interventions. All residents are assessed for their risk of falls on admission and ongoing assessment continue on a regular basis depending on the resident status. All injuries will be promptly addressed, and post-fall interventions will be implemented. Perform verbal assessment to the cause of the fall and potential for injury. Perform physical assessment including vital signs, neurological assessments, range of motion and pain. Identify any environmental risks contributing to fall. Fall incident report filled out. Notify provider, DON, Administrator and POA. Document the fall in EMR (Electronic Medical Record). If transfer complete transfer/discharge summary. Event ID: Facility ID: 145515 If continuation sheet Page 8 of 18 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 145515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freeburg Care Center 746 Urbanna Drive Freeburg, IL 62243 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 - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to treat urinary tract infections timely with the appropriate antibiotics and perform thorough incontinent care for 4 of 10 residents (R34, R37, R52, R77) reviewed for incontinent care and Urinary Tract Infections in the sample of 39. Findings include: 1.R34's Communication with Physician dated 04/18/22 at 3:58 PM documents Labs and UA (urinalysis) reported to NP (Nurse Practitioner) - N.O. (new order) rec'd for Rocephin (antibiotic) 1gm IM X1 - then Macrobid (antibiotic) 100mg PO BID X 7 days - Watch for UA CX (culture) and report to NP ASAP (as soon as possible) to assure ABT (antibiotic) is sensitive to bacteria in urine. R34's Antibiotic was started prior to receiving urine culture results. R34's Lab Report dated 04/18/22 documents Specimen: Escherichia coli. Macrobid (Nitrofurantoin) is Sensitivity<=32. R34's Care Plan dated 01/19/22 documents (R34) is incontinent of bladder. R34's Care Plan documents ADL self-care needs limited to extensive assist of 1 for dressing, toileting, transfers. independent with bed mobility and needs encouragement for eating independent. R34's Minimum Data Set (MDS) dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 9 out of 15. Resident is moderately impaired. R34's MDS dated [DATE] documents resident requires extensive assistance of one-person for bed mobility. Resident requires limited assistance of one-person for transfer, walk in room, walk in corridor, locomotion on unit, locomotion off unit, dressing, toilet use, and personal hygiene. Resident is independent with setup help only for eating. Resident requires physical help limited to transfer only with one-person for bathing. Resident is not steady, only able to stabilize with staff assistance. Resident uses wheelchair and walker for mobility. R34's MDS documents resident is always incontinent of bladder and bowel. 2. R37's Health Status Note dated 07/02/22 at 8:15 PM documents REPORTED UA TO ON CALL DR. N.O. BACTRIM DS (antibiotic) BID X 7DAYS R/T (related to) UTI (urinary tract infection). NP MADE AWARE ON MP. PO (oral) FLUIDS ENC (encouraged) AND TAKEN FAIR. PERI CARE GIVEN Q (every) 2HRS AND PRN (as needed). DENIES ANY PAIN OR DISCOMFORT. WILL MX (monitor). R37's Lab Report dated 07/02/22 documents Detected Pathogen Results Summary: Escherichia Coli. Suggested Antibiotics: Fosfomycin po, Gentamicin, Plazomicin, Tobramycin. E. Coli is Resistive>2/38 to Bactrim (Trimethoprim/Sulfamethoxazole) antibiotic. R37's Physician Order dated 07/03/22 documents Bactrim DS tablet 800-160 mg (Sulfamethoxazole-Trimethoprim); Give 1 tablet by mouth two times a day for UTI for 7 Days until finished R37's Order Note dated 07/05/22 at 3:05 PM documents Resident has a new order to d/c (discontinue) Bactrim order and to start Fosfomycin (antibiotic) 3gm (gram) packet PO x1 dose, A1C (glycated hemoglobin) CMP (complete metabolic panel) CBC (complete blood count) TSH (thyroid stimulating hormone) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145515 If continuation sheet Page 9 of 18 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 145515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freeburg Care Center 746 Urbanna Drive Freeburg, IL 62243 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 Vit. D Vit. B12 and lipid to be drawn on 7/11/22. POA (Power of Attorney) NOT AWARE. Level of Harm - Minimal harm or potential for actual harm R37 was started on Bactrim and then had to being started on a Fosfomycin after the results of the urine culture showed that Bactrim was resistant to the bacteria. Residents Affected - Some R37's Physician Order dated 07/06/22 documents Fosfomycin Tromethamine Packet 3 gm; Give 1 packet by mouth one time a day for UTI for 1 day. R37's Physician Order dated 07/07/22 documents Fosfomycin Tromethamine packet 3 gm; give 1 packet by mouth one time a day for UTI for 1 day. On 07/08/22 at 9:25 AM, V13 Certified Nurse's Aide (CNA) and V24, Licensed Practical Nurse (LPN) assisted R37 with incontinent care. No hand hygiene was performed prior to starting. V24 spray wash clothes with Peri Fresh spray. She then handed the washcloth to V13, who wiped R37's right side of leg crease and right side of peri-area. V13 placed the washcloth in the dirty linen bag. V24 handed V13 another wash cloth sprayed with peri fresh. V13 then wiped the center of R37's peri-area and placed the washcloth in the dirty linen bag. V24 handed V13 another wash cloth sprayed with peri fresh. V13 wiped the left leg crease and left side of peri-area. He placed the washcloth in the dirty linen bag and removed his gloves. V13 then donned a new pair of gloves without washing hands or using hand sanitizer. V24 then handed V13 a washcloth with peri fresh to wipe her back side. After wiping her back side, V13 announced that they should change their gloves. Both staff changed their gloves without washing their hands or using hand sanitizer. V24 proceeded to dry R37's back side and peri-area using the same towel. V13 changed gloves 3 times without any hand hygiene. V24 change gloves 4 times without hand hygiene. R37's MDS dated [DATE] documents that resident requires extensive assistance of one-person for bed mobility, transfer, walk in room, walk in corridor, dressing, toilet use, and personal hygiene. Resident requires limited assistance of one-person for locomotion on unit and locomotion off unit. Resident is independent with setup help only for eating. R37's MDS documents resident is always incontinent of bladder and bowel. 3. R52's Communication with Physician dated 04/18/22 at 3:58 PM documents Labs and UA reported to NP - N.O. rec'd for Rocephin 1gm IM X1 - then Macrobid 100mg PO BID X 7 days - Watch for UA CX and report to NP ASAP to assure ABT is sensitive to bacteria in urine. R52 was started on 2 antibiotics before the knowing the results of the urine culture. R52's Communication with Physician dated 05/16/22 at 11:45 AM documents UA reported to NP - N.O. for Macrobid 100mg PO BID X 7 days. POA NN. R52's Physician Order dated 05/16/22 documents Macrobid 100 mg (Nitrofurantoin); Give 1 capsule by mouth two times a day for UTI for 7 days x 7 days. R52's Urine Culture & Sensitivity Reports dated 05/16/22 documents Organism: E. coli (ESBL producer). Sensitivity<=32 for Nitrofurantoin (Macrobid). R52's Physician Order dated 05/27/22 documents resident on contact isolation r/t ESBL. R52's Urine Culture Report dated 06/29/22 documents Pathogen: Klebsiella pneumoniae. Suggested (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145515 If continuation sheet Page 10 of 18 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 145515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freeburg Care Center 746 Urbanna Drive Freeburg, IL 62243 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 Antibiotic: Plazomicin, TMP-SMX. Level of Harm - Minimal harm or potential for actual harm R52's Physician Order dated 06/30/22 documents Bactrim DS tablet 800-160 mg (Sulfamethoxazole-Trimethoprim); Give 1 tablet by mouth two times a day for UTI for 7 days. Residents Affected - Some R52's MDS dated [DATE] documents that resident requires extensive assistance of one-person for bed mobility, transfer, walk in room, walk in corridor, dressing, toilet use, personal hygiene. Resident requires limited assistance of one-person for locomotion on unit, locomotion off unit, and eating. Resident is always incontinent of bladder and bowel. On 07/08/22 at 10:30 AM, observation of incontinent care with V25 and V26, CNAs. V25 and V26 transferred R52 from the wheelchair to the bed using a gait belt. V26 washed her hands in bathroom. V25 applied a gown over R52's clothes. V26 donned gloves. V25 washed her hands in the bathroom and donned gloves. V25 pulled down R52's pants and removed depends. V25 removed gloves and donned new gloves with hand hygiene. V25 spray peri-wash to wet wash cloth and wiped the right leg crease and right side of peri-area. V25 placed wash cloth in linen bag. V25 sprayed a new wet washcloth and proceeded to wipe the center of R52's peri-area. V25 placed wash cloth in linen bag. V25 sprayed a new wet wash clothes and wiped R52's back side. V25 placed wash cloth in linen bag. V25 sprayed a new wet cloth and wiped her buttocks. V25 then took a towel and dry her backside. V25 placed the towel in the linen bag. V25 took another towel and dried R52's peri-area. V26 applied a new depends on R52. V25 removed gloves and washed her hands in the bathroom. V26 applied R52's pants. V26 removed gloves and washed hands in bathroom. 4. R77's Order Note dated 10/19/21 at 12:56 PM documents Urine culture and sensitivity returned. Resident currently taking Macrobid 100mg PO BID - antibiotic noted to be resistant to bacteria present in urine. Urine C&S (culture and sensitivity) reported to NP - awaiting updated orders. R77's Order Note dated 10/19/21 at 1:15 PM documents N.O. rec'd from NP R/T urine culture and sensitivity - D/C Macrobid and start Ciprofloxacin (antibiotic)500mg PO BID (twice a day) X 7 days. R77's Physician Order dated 10/15/21 documents Macrobid capsule 100 mg (Nitrofurantoin Monohydrate); Give 1 tablet by mouth two times a day for UTI for 7 days. R77's Physician Order dated 10/19/21 documents Ciprofloxacin HCL tablet 500 mg; Give 1 tablet by mouth two times a day related to Urinary Tract Infection, Site Not Specified. R77's MDS dated [DATE] documents that resident requires extensive assistance of one-person for bed mobility, dressing, toilet use, and personal hygiene. Resident is total dependence of two plus persons for transfer. Resident is total dependence of one-person for locomotion on unit, locomotion off unit, and bathing. Resident requires limited assistance of one-person for eating. On 07/8/22 at 12:45 PM, V3, Assistant Director of Nursing (ADON)) stated, I expect my staff to wash their hands in between glove changes if the resident has a bowel movement and they get it on their gloves. Otherwise, I expect them to be using hand sanitizer in between glove changes. On 07/08/22 at 1:00 PM, V3, stated, We don't have a policy specific to UTIs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145515 If continuation sheet Page 11 of 18 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 145515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freeburg Care Center 746 Urbanna Drive Freeburg, IL 62243 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight hours daily which has the potential to affect all 83 residents living in the facility. Residents Affected - Many Findings include: The Facility's Nurse Schedule documents the facility did not have a RN scheduled for eight hours on June 25, 2022, or June 26, 2022. On 7/6/22 at 12:39 PM, V2, Director of Nursing (DON), stated, It looks like there was no RN coverage on that Saturday and Sunday (June 25, 2022, and June 26, 2022). On 7/6/22 at 1:32 PM, V1, Administrator, stated, We just follow the regulation for staffing. The Facility's Resident Census and Conditions of Residents form, (CMS 672), dated 7/5/2022 documents there are 83 residents living in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145515 If continuation sheet Page 12 of 18 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 145515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freeburg Care Center 746 Urbanna Drive Freeburg, IL 62243 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared in a manner which prevents potential contamination. This has the potential to affect all 83 residents living in the facility. Findings include: On 7/5/22 at 8:28 AM, there was a bag of cheddar Monterey shredded cheese in the walk in cooler that was opened, but not dated. There was a clear plastic tub containing a yellow colored product on third shelf which was not labeled or dated. On 7/5/22 at 8:45 AM, V4, Dietary Manager, stated, What is that? Maybe pureed egg salad? V7, Dietary Supervisor, stated, It's egg salad. It's from Sunday. It was labeled. It must have fallen off. On 7/5/22 at 8:38 AM in the standing freezer there was a five pound bag of blackberries that had been opened, but not dated. There was a clear plastic bag of biscuits that was tied up, but not labeled or dated. There was a clear plastic bag of diced chicken that was tied up, but not labeled or dated. On 7/5/22 at 8:40 AM in the standing freezer there was a box of fully cooked hamburgers that had been opened, but not dated. The inner plastic bag was not sealed, and the hamburgers were open to air. There was an opened 32 ounce bag of whole pearl onions that was not resealed or dated. There was a bag of meat in a sealed plastic bag that was not labeled or dated. V4, Dietary Manager, stated, That's pepper steak. There was a sealed bag of red and yellow peppers that appeared freezer burned and was not labeled or dated. There was a plastic bag of chocolate chip cookies that was tied up, but not labeled or dated. On 7/5/22 at 8:42 AM in the beverage refrigerator, there were two pitchers full of a yellow liquid and one pitcher full of a brown liquid. All were covered with plastic wrap, but none were labeled or dated. On 7/5/22 at 8:50 AM, V4, Dietary Manager, stated, I would expect all items to be labeled and dated after opening. On 7/8/22 at 10:22 AM, V3, Assistant Director of Nursing and Infection Control Preventionist, stated, I would expect the dietary department to follow their policies to the best of their abilities. The Facility's Food Storage (Dry, Refrigerated, and Frozen) Policy dated 2020 documents, All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. Leftover contents of cans and prepared food will be stored in covered, labeled and dated containers in refrigerators and/or freezers. The Resident Census and Condition of Residents Form, (CMS 672), dated 7/5/2022 documents there are 83 residents living in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145515 If continuation sheet Page 13 of 18 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 145515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freeburg Care Center 746 Urbanna Drive Freeburg, IL 62243 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview, observation, and record review the facility failed perform hand hygiene to prevent the spread of infection for 4 of 4 residents' (R37, R52, R71, R74) reviewed for infection control in the sample of 39. Residents Affected - Some Findings include: 1. R37's Health Status note dated 07/02/22 at 8:15 PM documents REPORTED UA (urinalysis) TO ON CALL DR. N.O. (new order) BACTRIM DS (antibiotic) BID (twice a day) X 7DAYS R/T (related to) UTI (urinary tract infection). NP (Nurse Practitioner) MADE AWARE ON MP. POANN. PO FLUIDS ENC AND TAKEN FAIR. PERI CARE GIVEN Q 2HRS AND PRN. DENIES ANY PAIN OR DISCOMFORT. WILL MX (monitor). On 07/08/22 at 9:25 AM, observation of incontinent care performed by V13, CNA (Certified Nursing Aid) and V24, LPN (Licensed Practical Nurse) on R37. No hand hygiene was performed prior to starting. V24 sprayed a washcloth with Peri Fresh spray. She then handed the washcloth to V13, who wiped R37 the right side of leg crease and right side of peri-area. V13 placed the washcloth in the dirty linen bag. V24 handed V13 another washcloth sprayed with peri fresh. V13 then wiped the center of R37's peri-area and placed the washcloth in the dirty linen bag. V24 handed V13 another washcloth sprayed with peri fresh. V13 wiped the left leg crease and left side of peri-area. He placed the washcloth in the dirty linen bag and removed his gloves. V13 then donned a new pair of gloves without washing hands or using hand sanitizer. V24 then handed V13 a washcloth with peri fresh to wipe her back side. After wiping her back side, V13 announced that they should change their gloves. Both staff changed their gloves without washing their hands or using hand sanitizer. V24 proceeded to dry R37's back side and peri-area using the same towel. V13 changed gloves 3 times without any hand hygiene. V24 change gloves 4 times without hand hygiene. 2. R52's Order Note dated 06/30/22 at 11:48 AM documents resident has new order for Bactrim DS (antibiotic) 1 tab PO BID x7 days r/t UTI, POA AWARE. On 07/08/22 at 10:30 AM, observation of incontinent care with V25 and V26. V25 and V26 transferred R52 from the wheelchair to the bed using a gait belt. V26 washed her hands in bathroom. V25 applied a gown over R52's clothes. V26 donned gloves. V25 washed her hands in the bathroom and donned gloves. V25 pulled down R52's pants and removed depends. V25 removed gloves and donned new gloves with hand hygiene. V25 sprayed peri-wash to wet washcloth and wiped the right leg crease and right side of peri-area. V25 placed washcloth in linen bag. V25 sprayed a new wet washcloth and proceeded to wipe the center of R52's peri-area. V25 placed washcloth in linen bag. V25 sprayed a new wet washcloth and wiped R52's back side. V25 placed washcloth in linen bag. V25 sprayed a new wet cloth and wiped her buttocks. V25 then took a towel and dried her backside. V25 placed the towel in the linen bag. V25 took another towel and dried R52's peri-area. V26 applied a new depends on R52. V25 removed gloves and washed her hands in the bathroom. V26 applied R52's pants. V26 removed gloves and washed hands in bathroom. 3. R71's Health Status Note dated 07/02/22 at 10:45 PM documents Spoke with Nurse at (local hospital). Resident has UTI and they are starting her on Macrobid. Will be sending back to facility tonight. Updated DON (Director of Nursing) and POA (Power of Attorney). Sent message on Mxxxxxxxxxx (secure clinical communication tool.) On 7/08/22 at 10:20 AM, observation of incontinent care with V13 and V24. No hand hygiene prior to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145515 If continuation sheet Page 14 of 18 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 145515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freeburg Care Center 746 Urbanna Drive Freeburg, IL 62243 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 donning gloves. Assisted R71 to restroom with walker. V13 assisted to pull pants and depends. V13 changed gloves with hand hygiene. V24 wiped R71's peri-area after toileting. V24 removed gloves and assisted R71's to stand. V13 wiped R71's backside. V24 donned gloves with no hand hygiene and assisted R71's with pulling up her depends and pants. V13 changes his gloves with no hand hygiene. V24 washed her hands. V13 flushed the toilet, removed his gloves and washed hands. Residents Affected - Some 4. R74's Order Note dated 10/19/21 at 12:56 PM documents Urine culture and sensitivity returned. Resident currently taking Macrobid 100mg PO BID - antibiotic noted to be resistant to bacteria present in urine. Urine C&S reported to NP - awaiting updated orders. On 07/08/22 at 10:49 AM, observation of incontinent care with V13 and V26. V26 washed her hands in the bathroom and applied gloves. V26 wiped the right leg crease and right side of peri-area with a wet washcloth. V26 placed washcloth in linen bag and grabbed a new wet washcloth. V26 wiped the left leg crease, left side of peri-area, and down the center of peri-area. V13 and V26 both changed gloves with hand hygiene. V26 wiped back side with wet washcloth then dried backside with a towel. V26 changed gloves with hand hygiene. V26 applied a new depend on R74. V13 removed gloves and wash hands in the bathroom. V26 applied R74's pants. V13 donned gloves and assisted V26 with pulling up R74's depends and pants. V13 changed gloves with no hand hygiene. V26 removed gloves and starting untying R74's shoes. V26 washed hands. V13 applied R74's shoes. V13 removed gloves. No hand hygiene. Attached legs to wheelchair. V13 applied new gloves with hand hygiene. Assisted R74 to transferred from the bed to the wheelchair using a gait belt. On 07/08/22 at 12:45 PM, V3, Assistant Director of Nursing stated, I expect my staff to wash their hands in between glove changes if the resident has a bowel movement and they get it on their gloves. Otherwise, I expect them to be using hand sanitizer in between glove changes. Facility's policy Standard Precautions for Infection Control undated documents Wash immediately after gloves are removed and between patient contacts. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145515 If continuation sheet Page 15 of 18 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 145515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freeburg Care Center 746 Urbanna Drive Freeburg, IL 62243 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 ensure antibiotics are effective in treating the infections they are prescribed to treat for 4 of 10 residents (R34, R37, R52, R77) reviewed for antibiotic stewardship in the sample of 39. Residents Affected - Some Findings include: 1.R34's Communication with Physician dated 04/18/22 at 3:58 PM documents Labs and UA (urinalysis) reported to NP (Nurse Practitioner) - N.O. (new order) rec'd for Rocephin (antibiotic) 1gm IM X1 - then Macrobid (antibiotic) 100mg PO BID X 7 days - Watch for UA CX (culture) and report to NP ASAP (as soon as possible) to assure ABT (antibiotic) is sensitive to bacteria in urine. R34's Antibiotic was started prior to receiving urine culture results. R34's Lab Report dated 04/18/22 documents Specimen: Escherichia coli. Macrobid (Nitrofurantoin) is Sensitivity<=32. R34's Care Plan dated 01/19/22 documents (R34) is incontinent of bladder. R34's Care Plan documents ADL self-care needs limited to extensive assist of 1 for dressing, toileting, transfers. independent with bed mobility and needs encouragement for eating independent. R34's Minimum Data Set (MDS) dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 9 out of 15. Resident is moderately impaired. R34's MDS dated [DATE] documents resident requires extensive assistance of one-person for bed mobility. Resident requires limited assistance of one-person for transfer, walk in room, walk in corridor, locomotion on unit, locomotion off unit, dressing, toilet use, and personal hygiene. Resident is independent with setup help only for eating. Resident requires physical help limited to transfer only with one-person for bathing. Resident is not steady, only able to stabilize with staff assistance. Resident uses wheelchair and walker for mobility. R34's MDS documents resident is always incontinent of bladder and bowel. 2. R37's Health Status Note dated 07/02/22 at 8:15 PM documents REPORTED UA TO ON CALL DR. N.O. BACTRIM DS (antibiotic) BID X 7DAYS R/T (related to) UTI (urinary tract infection). NP MADE AWARE ON MP. PO (oral) FLUIDS ENC (encouraged) AND TAKEN FAIR. PERI CARE GIVEN Q (every) 2HRS AND PRN (as needed). DENIES ANY PAIN OR DISCOMFORT. WILL MX (monitor). R37's Lab Report dated 07/02/22 documents Detected Pathogen Results Summary: Escherichia Coli. Suggested Antibiotics: Fosfomycin po, Gentamicin, Plazomicin, Tobramycin. E. Coli is Resistive>2/38 to Bactrim (Trimethoprim/Sulfamethoxazole) antibiotic. R37's Physician Order dated 07/03/22 documents Bactrim DS tablet 800-160 mg (Sulfamethoxazole-Trimethoprim); Give 1 tablet by mouth two times a day for UTI for 7 Days until finished R37's Order Note dated 07/05/22 at 3:05 PM documents Resident has a new order to d/c (discontinue) Bactrim order and to start Fosfomycin (antibiotic) 3gm (gram) packet PO x1 dose, A1C (glycated hemoglobin) CMP (complete metabolic panel) CBC (complete blood count) TSH (thyroid stimulating hormone) Vit. D Vit. B12 and lipid to be drawn on 7/11/22. POA (Power of Attorney) NOT AWARE. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145515 If continuation sheet Page 16 of 18 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 145515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freeburg Care Center 746 Urbanna Drive Freeburg, IL 62243 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 Level of Harm - Minimal harm or potential for actual harm R37 was started on Bactrim and then had to being started on a Fosfomycin after the results of the urine culture showed that Bactrim was resistant to the bacteria. R37's Physician Order dated 07/06/22 documents Fosfomycin Tromethamine Packet 3 gm; Give 1 packet by mouth one time a day for UTI for 1 day. Residents Affected - Some R37's Physician Order dated 07/07/22 documents Fosfomycin Tromethamine packet 3 gm; give 1 packet by mouth one time a day for UTI for 1 day. 3. R52's Communication with Physician dated 04/18/22 at 3:58 PM documents Labs and UA reported to NP - N.O. rec'd for Rocephin 1gm IM X1 - then Macrobid 100mg PO BID X 7 days - Watch for UA CX and report to NP ASAP to assure ABT is sensitive to bacteria in urine. R52 was started on 2 antibiotics before knowing the results of the urine culture. R52's Communication with Physician dated 05/16/22 at 11:45 AM documents UA reported to NP - N.O. for Macrobid 100mg PO BID X 7 days. POA NN. R52's Physician Order dated 05/16/22 documents Macrobid 100 mg (Nitrofurantoin); Give 1 capsule by mouth two times a day for UTI for 7 days x 7 days. R52's Urine Culture & Sensitivity Reports dated 05/16/22 documents Organism: E. coli (ESBL producer). Sensitivity<=32 for Nitrofurantoin (Macrobid). R52's Physician Order dated 05/27/22 documents resident on contact isolation r/t ESBL. R52's Urine Culture Report dated 06/29/22 documents Pathogen: Klebsiella pneumoniae. Suggested Antibiotic: Plazomicin, TMP-SMX. R52's Physician Order dated 06/30/22 documents Bactrim DS tablet 800-160 mg (Sulfamethoxazole-Trimethoprim); Give 1 tablet by mouth two times a day for UTI for 7 days. R52's MDS dated [DATE] documents that resident requires extensive assistance of one-person for bed mobility, transfer, walk in room, walk in corridor, dressing, toilet use, personal hygiene. Resident requires limited assistance of one-person for locomotion on unit, locomotion off unit, and eating. Resident is always incontinent of bladder and bowel. 4. R77's Order Note dated 10/19/21 at 12:56 PM documents Urine culture and sensitivity returned. Resident currently taking Macrobid 100mg PO BID - antibiotic noted to be resistant to bacteria present in urine. Urine C&S (culture and sensitivity) reported to NP - awaiting updated orders. R77's Order Note dated 10/19/21 at 1:15 PM documents N.O. rec'd from NP R/T urine culture and sensitivity - D/C Macrobid and start Ciprofloxacin (antibiotic)500mg PO BID (twice a day) X 7 days. R77's Physician Order dated 10/15/21 documents Macrobid capsule 100 mg (Nitrofurantoin Monohydrate); Give 1 tablet by mouth two times a day for UTI for 7 days. R77's Physician Order dated 10/19/21 documents Ciprofloxacin HCL tablet 500 mg; Give 1 tablet by mouth two times a day related to Urinary Tract Infection, Site Not Specified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145515 If continuation sheet Page 17 of 18 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 145515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freeburg Care Center 746 Urbanna Drive Freeburg, IL 62243 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 Level of Harm - Minimal harm or potential for actual harm R77's MDS dated [DATE] documents that resident requires extensive assistance of one-person for bed mobility, dressing, toilet use, and personal hygiene. Resident is total dependence of two plus persons for transfer. Resident is total dependence of one-person for locomotion on unit, locomotion off unit, and bathing. Resident requires limited assistance of one-person for eating. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145515 If continuation sheet Page 18 of 18