Health inspection·December 12, 2023

F 0600 Level of Harm - Actual harm Residents Affected - Few in a rough manner and firmly grabbed R2's right hand. V8 stated Stop digging your nails into my skin now, let go! V8 walked away from R2's bed and left the bed in the high position. V8 retrieved the mechanical lift sling and placed it under R2 as R2 was lying on her left side. V8 turned R2 to her right side in a rough manner while bringing R2's left hand over on top of R2's right hand and then V8 used her left hand and arm to restrain R2's hands. V8 then shifted her body weight to increase pressure on top of R2's hands and wrists. R2 stated. Ow! V8 then turned R2 onto her back. V8 stated to R2, You're terrible! R2 stated, What? and V8 replied You are terrible, why do you keep trying to hit me and pinch me? V8 then lowered the bed and left the room. On 12/4/23 at 12:10 PM V1, Administrator, stated We didn't report the video concerns because we cleared it on the spot when the sister (V14) brought it to me and our Social Worker. While we didn't like her behavior, we didn't feel like it rose to the level of abuse, so we didn't report it. On 12/4/23 at 12:30 PM, V7, Social Worker, stated, When the family showed me the video, I was adamant that we had to report it to the Administrator. V7 stated that V14, R2's sister/POA, said she didn't want to get anyone in trouble. V7 stated In my opinion, I think the CNA could have handled it differently, but we don't feel it was abuse. We didn't feel it was intentional. The CNA apologized the next day to (V14). On 12/5/23 at 4:40 AM V17, Registered Nurse (RN) stated that she feels that some of the staff speak to residents in a rough tone especially if it is a resident who was being resistive to care. V17 stated that she thinks that some of the staff need more education regarding dementia care. She continued to state that she would report them to (V1, Administrator) or to (V23, ADON) who was over the CNAs. On 12/5/23 at 1:20 PM V8, CNA, stated, On 11/26/23, I went to get (R2) dressed and I felt myself getting worked up, so I lowered her bed and walked out. V8 stated, I grabbed her wrist softly at times to redirect her and I did not see any bruises on her hands or wrists. V8 continued to state The ADON (Assistant Director of Nursing) came to me later that day and said (R2's) sister showed me the video. V8 stated (V23) knows how her sister is and (V23) didn't want me to get in to trouble. V8 stated, (V23) told me to talk to the sister, so I did, I apologized, and her sister hugged me and said I am a good CNA. V8 stated They did not send me home, they just put me on another hall. R2's Progress Note, dated 11/26/23 at 3:31 PM, documented, Bruise was noted to R (right) index finger. No s/s (signs or symptoms) of pain noted when assessing finger. ROM (range of motion) WNL (within normal limits). POA (power of attorney) notified. Will monitor. R2's Facility's incident report form, dated 11/26/23, documented, Resident frequently combative with staff. Resident noted to have hands folded on lap frequently. Likely bumped on table at meal or over bed table. Nurse and CNAs interviewed, and no areas of concern noted. The facility could not provide documentation of investigation, including witness statements and root cause analysis. It also could not provide documentation that the state agency was notified. An electronic mail (email) dated 12/06/2023 at 11:23 AM, from V1, Administrator, documented, Our morning meeting ran over and then Wednesday Medicare Mtg, but I wanted to get you at least the Abuse Policy as it relates to investigations and procedures. Our employees are also given a copy of this entire policy at hire and sign a form they received it. (V2, DON, V23, ADON and V1, Administrator) reviewed it again this morning at 8am to make sure we felt we followed the policy. While hindsight is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145515 If continuation sheet Page 2 of 15 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 12/12/2023 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 0600 Level of Harm - Actual harm Residents Affected - Few always 20/20, we still don't believe the definition listed of verbals, physical or mental abuse in our policy was met by (V8, CNA) lack of warmth and patience with (R2). Harsh tone, yes. Abrupt care, yes. Willful disparaging and derogatory terms to the resident, threats of harm or isolation were not present. Harassment and threats of punishment, not present. Hitting, slapping, pinching, kicking and corporal behavior, not present. After further discussion, we all agree that (V14, R2's sister/POA) came to (V7, Social Service) saying she had a concern, but asked us not to report (V8, CNA) because she didn't want her to lose her job or get in trouble. Our conclusion was that this was not an allegation of abuse by the sister, but dissatisfaction with level/type of care/attitude/tone. In summary, it didn't meet our policy's definition of abuse as it's laid out. Going forward, we will err on the side of caution, take your advice, and over-report. We feel we followed our policy and did a best practice decision of removing (V8, CNA) from the hall, speaking to her about her tone and abruptness of care, and respecting the family's wishes that she will not be fired or be made to be in trouble. It was only after (R2) passed from an unrelated rapid onset medical condition that this concern resurfaced and was escalated beyond what the sister originally asked us to do. We still struggle with the position we were asked to be in, but next time, we will report despite family asking us to handle it internally, per again, erring on the side of caution. Thank you! The facility Abuse Prevention Program Policy and Procedure, dated 9/26/23, documented, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect, or abuse of its residents, and has attempted to establish a resident-sensitive and secure environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145515 If continuation sheet Page 3 of 15 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 12/12/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement a system in which staff immediately report allegations of abuse and injuries of unknown origin to the Administrator and State Agency. This has the potential to affect all 96 residents residing in the facility. Findings include: 1.R2's admission Record Form, dated 12/3/23, documented R2 was admitted to the facility on [DATE] with diagnosis of dementia, anxiety disorder, age-related nuclear cataract, essential hypertension, dissection of unspecified site of aorta, thoracic aortic aneurysm (without rupture), and fracture of unspecified part of neck of right femur. R2's admission record form documented a diagnosis (with an onset dated 8/9/23) of acute embolism and thrombosis of another specified deep vein of right lower. R2's admission record form documented diagnosis (with onset dates of 8/17/23) of unspecified fracture of lower end of right femur, subsequent encounter for closed fracture with routine healing, unspecified severe protein-calorie malnutrition, and unspecified fracture of unspecified femur, subsequent encounter for closed fracture with routine healing. R2's Minimum Data Set, MDS, dated [DATE], documented R2 as being severely cognitively impaired. R2's care plan, dated 6/8/23, documented R2 as requiring a mechanical lift and assist of 2 for all transfers. On 12/4/23 at 11:20 AM, V14, R2's sister/Power of Attorney (POA), stated that R2 was admitted with a broken hip that was not repaired because of an aneurysm she had. V14 stated that the facility used a mechanical lift to transfer her because she could not stand. V14 stated that the doctor at the hospital said the hip might heal on its own but it didn't. She continued to state that she was visiting R2 one day in August, that she visited every day, and one day noticed her (R2's) leg was swollen, that it was bruised so she told them she wanted something done. V14 stated that they did a doppler and it revealed blood clots. V14 stated they sent her to the local hospital, and the local hospital transferred her to the regional hospital for surgery. V14 stated that V26, R2's orthopedic surgeon, at the regional hospital said it was a new break and the leg was broken this time, not the hip. V14 stated that V26 said it was a twisted break and if they didn't operate it would come through the skin, so they did surgery. She continued to state that V26 told her that this fracture was not from the previous hip fracture and that this was a new fracture of the leg. V14 stated she went to the facility staff and management and told them something caused this and that she wanted to know what did. She continued to state that the facility said that they do not have any documentation and that this was not a new fracture, it was from the hip fracture. V14 stated she tried to explain it wasn't, but that they just kept saying it was the same fracture. On 12/4/23 at 11:30 AM, V14, R2's sister/ POA stated, some of these young kids do not have compassion and some of the (Certified Nurse Assistants (CNA) are rough. I have video of a CNA named, (V8), tossing my sister around back and forth, yanking on her hands, and being rude. V14 stated that it happened a week ago Saturday when the CNA was getting R2 ready for breakfast. V14 stated she went to the Social Worker, and she said she had to report it to the Administrator. V14 stated she showed them both the video and they said they would speak to V8 about it. V14 stated that when she visited R2 on 11/28/23 she observed a large bruise covering R2's right hand. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145515 If continuation sheet Page 4 of 15 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 12/12/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 12/4/23 at 12:10 PM, V1, Administrator, with V2, Director of Nurses (DON) who was on a speaker phone as she was home sick. V2 stated that they tried to explain to, V14, R2's sister/POA that the fracture in August was not a new fracture and that it was from the hip fracture that she was admitted with in January. V1 stated that V2 even tried to explain with anatomy pictures to V14 about the fracture being the same one R2 had when she was originally admitted and that V14 just wasn't comprehending it. V2 stated I attempted multiple times to explain to (V14) that it was a fragility fracture from the hip, and it wasn't new. When V1 was asked for their investigations and root cause analysis of the allegations of abuse and injury of unknown origin, V1 stated We didn't report or investigate the fracture from August because it wasn't a new fracture. V1 continued to state We didn't report the video concerns because we cleared it on the spot when the sister brought it to me and our Social Worker. While we didn't like her behavior, we didn't feel like it rose to the level of abuse, so we didn't report it. R2's Video and audio footage, dated 11/26/23 at 6:40 AM, was reviewed by the surveyor and showed R2 was nude and lying in bed. V8, CNA, turned R2 to her left side while placing a disposable undergarment on R2. V8 stated, Stop, let go before you rip it, let go of my finger, man! V8 abruptly pulled her hand away and stated, There's no reason for you to hold on to me and squeeze my fingers like that, that hurts! R2 stated I'm sure it does hurt. V8 replied Then stop! V8 then rolled R2 onto her left side in a rough manner. V8 stated to R2, Put your shirt on, come on put your sweater on, stop holding onto me! R2 continues to be resistant with dressing and V8 was observed tightly holding R2's right hand. R2's Video and audio footage dated 11/26/23 at 6:43 AM, documented, V8, CNA, pulling R2's pants up and R2's sweater down while R2 was lying in bed on her left side. V8 turned R2 onto her back in a rough manner and firmly grabbed R2's right hand, V8 stated Stop digging your nails into my skin now, let go! V8 walked away from R2's bed and left the bed in the high position. V8 retrieved the mechanical lift sling and placed it under R2 as R2 was lying on her left side. V8 turned R2 to her right side in a rough manner while bringing R2's left hand over on top of R2's right hand and then V8 used her left hand and arm to restrain R2's hands. V8 then shifted her body weight to increase pressure on top of R2's hands and wrists. R2 stated. Ow! V8 then turned R2 onto her back. V8 stated to R2, You're terrible! R2 stated, What? and V8 replied You are terrible, why do you keep trying to hit me and pinch me? V8 then lowered the bed and left the room. R2's Facility titled form, dated 11/26/23, documented, Resident wheeled to nurse's station and CNA reported bruise to (right) index finger. R2's Incident Report, dated 11/26/23, documented, Bruise found on right index finger. Area of concern: none. Resident frequently combative with staff. Resident noted to have hands folded on lap frequently. Likely bumped on table at meal or over bed table. Nurses and CNAs interviewed, and no areas of concern noted. The facility was unable to provide witness statements. On 12/5/23 at 2:35 PM V2, stated, We report any fractures, anyone that goes to the hospital from an incident, or burns that require outside treatment. V2 stated, I know in (R2's) case, she was combative, so we knew the bruise was from that. We did not do an investigation and I know we should have looked into that. V2 stated, I was not involved in the instance with the CNA on the camera. V2 continued to state, What I usually do is clear it with (V1, Administrator), and she usually says we know what happened, so we don't need to report it. On 12/5/23 at 3:08 PM, V1 stated We report to state if there is any kind of injury that requires anything beyond first aid, if they were sent to the hospital from an incident, founded abuse, and allegations of abuse if we know its legit. V1 stated We are not going to hot line until we know its (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145515 If continuation sheet Page 5 of 15 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 12/12/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many legit, like if the resident has a UTI (urinary tract infection), we will factor that into what they are saying. V1 stated that V2, DON, V23, Assistant Director of Nurses (ADON), and herself collaborate to decide if they need to report it. V1 stated that a serious injury or anything beyond first aid, they would report it. V1 continued to state that with unknown injuries they do a lot of interviewing and that they do not document the interviews with staff and residents. V1 stated that if there's a bruise like on R2, V2, DON, keeps a file on those. V1 continued to state that R2's was a tiny bruise on a finger. V1 stated Honest to God if I did an investigation on every single little bruise, well it's not going to happen. V1 continued to state, On abuse we decide if it is a reportable or not reportable. On 12/4/23 at 12:30 PM, V7, Social Worker, stated When (R2's) family showed me the video, I was adamant that we had to report it to the Administrator. V7 continued to state that V14, R2's sister/POA, said she didn't want to get anyone in trouble. V7 stated In my opinion, I think the CNA could have handled it differently, but we don't feel it was abuse. We didn't feel it was intentional. The CNA apologized the next day to V14. On 12/6/23 at 10:42 AM, V24, LPN stated that R2 had a fracture earlier this year and there was no surgical intervention. V24 stated there was a follow-up x-ray in March with no change, no healing. V24 stated R2 complained of leg pain in August. V24 stated she knew nothing caused a new injury because there were no incidents in the chart. V24 stated they did another x-ray in August and that is when R2 was sent out to the hospital. V24 stated she recalled the leg being swollen and the family would tell us when they thought she was having pain because R2 could not always tell you when she was hurting. On 12/5/23 at 1:20 PM, V8, Certified Nurse Assistant (CNA), stated, On 11/26/23, I went into (R2's) room to get her dressed for breakfast, she was combative as usual. V8, stated, I got her dressed and I felt myself getting worked up, so I lowered her bed and walked out. V8 continued to state, I grabbed her wrist softly at times to redirect her and I did not see any bruises on her hands or wrists. V8 stated (V23, Assistant Director of Nursing) came to me later that day and said R2's sister showed her the video. V8 stated, (V23) knows how (R2's) sister is and (V23) didn't want me to get in to trouble. (V23) told me to talk to the sister, so I did, I apologized, and her sister hugged me and said I am a good CNA. V8 stated that they did not send her home, they just put her on another hall. On 12/6/23 at 2:49 PM, V25, V26's Orthopedic Registered Nurse, stated that V26, R2's Orthopedic Surgeon, said the fracture in August was from a new injury and was not related to the past hip fracture. R2's x-ray results dated 8/8/23 from the x-ray that was completed in the facility documented there was an acute, displaced spiral fracture of the distal third of shaft of the femur with a conclusion of acute fracture distal femur. The facility failed to investigate the cause of the new fracture. R2's medical record dated 11/26/23 at 3:31 PM documented a bruise was noted to R (right) index finger. No s/s (signs or symptoms) of pain noted when assessing finger. ROM (range of motion) WNL (within normal limits). POA (power of attorney) notified. Will monitor. The facility's incident report form dated 11/26/23 documented resident frequently combative with staff. Resident noted to have hands folded on lap frequently. Likely bumped on table at meal or over bed table. Nurse and CNAs interviewed, and no areas of concern noted. The facility failed to provide documentation of investigation including witness statements. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145515 If continuation sheet Page 6 of 15 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 12/12/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 2. R16's admission record, dated 12/4/23, documented diagnoses of Encephalopathy, Major depressive disorder, and Dementia. R16's MDS, dated [DATE], documented that his cognition was severely impaired. R16's Progress note, dated 10/21/23, documented, CNA notified nurse res is bleeding. Nurse observes dried black blood with scant amount light red blood to R (right) hand. Resident unable to answer, how did this happen. On 12/5/23 at 10:55 AM, R16 was sitting in dining room in wheelchair, activity getting ready to start. Resident was unshaven with food on his face. Resident said hello but did not respond to questions by writer. No bruises were noted. On 12/5/23 at 3:08 PM, V1, Administrator, stated I was looking at (R16's) chart when I sent it to you and the nurse probably assumed it was from picking. The facility had no documentation that nurse reported this to V1 for investigation and was unable to provide an unknown injury investigation including witness statements into the cause of this injury. 3. On 12/05/2023 at 10:00 AM, R1 was sitting up in a high back reclining wheelchair in the hallway. R1 had a fading yellowish/green bruising below both of her eyes and a large, approximately 2 centimeters (cm), greenish/yellow raised area to the right side of the top of her head. R1's facility titled form, dated 10/29/2023, documented, CNA alerted this nurse that res had bump on forehead, purple bruise over bump noted to middle of resident's forehead. Measures 3.5 cm x 3.0 cm. Neuro assessment WNL (within normal limits). No (signs or symptoms) of pain or distress noted. It also documents, Was incident witnessed? No. R1's Progress Note, dated 10/29/2023 at 9:00 AM, documented, CNA, alerted this nurse that resident has bump on forehead. Purple bruise over bump noted to middle of resident's forehead. Measures 3.5 cm x 3.0 cm. Neuro assessment WNL. No s/s of pain or distress noted. There were not any investigative notes, root cause analysis or interviews in R1's progress notes or in R1's electronic medical record. R1's admission Record, dated 12/05/2023, documented diagnoses of Vascular Dementia, Chronic Obstructive Pulmonary Disease and Alzheimer's Disease. R1's, Minimum Data Set (MDS), dated [DATE], documented that R1 was rarely to never understood, that she had no impairment to her upper or lower extremities and that she was incontinent of bowel and bladder. On 12/05/2023 at 2:35 PM, V2, DON, stated that R1's bump on her head on 10//29/2023, was from the mechanical lift. When asked for investigation, root cause analysis and interviews of staff and residents, V2 stated, We only have what's in the chart. The facility was unable to provide documentation that this incident was reported to V1 for investigation and was reported to the state agency. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145515 If continuation sheet Page 7 of 15 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 12/12/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 4. On 12/05/2023 at 9:45 AM, R17 was sitting up in her wheelchair at the nurse's station. Staff was assisting with putting her hearing aid back in her right ear. R17 stated she was good and asked writers name but was unable to recall anything else regarding skin tears or bruising to her body or how it happened. R17's MDS dated [DATE] documented that her cognition was severely impaired, that she has no impairments to her upper or lower extremities and that she uses a wheelchair and a walker. It also documents that she requires substantial to maximal assistance for most activities of daily living and that she was frequently incontinent of bowel and bladder. R17's Care Plan dated 9/25/2023 documented, Educate resident/family/ caregivers of causative factors and measures to prevent skin injury. R17's Skin/Incident report dated 10/14/2023, documented, CNA alerted this nurse of resident skin tear. Skin tear noted to (right forearm) crescent shaped measuring 6.5cm x 1.0 cm. small amount of serous fluid noted. Cleansed ns. Unable to reapproximate. Xeroform, non-adherent pad and dry dressing applied. Denies pain. no (signs/symptoms) of distress. It continues, Was incident witnessed? No. and it did not document any actions taken. R17's Skin/Incident report, dated 11/6/2023, documented, After resident assisted into bed, noted a 7 x 2 cm skin tear to (left upper arm). Resident was combative when assisted to bed. Steri strips applied (and) a (dressing). (Complain of) pain and (vital signs) stable. It continues, Was incident witnessed? Yes, It continues, Action taken: Resident Education. The facility was unable to provide documentation that this incident was reported to the Administrator and state agency and investigated as an injury of unknown origin. An electronic mail dated 12/06/2023 at 11:23 AM, from V1 documented, Our morning meeting ran over and then Wednesday Medicare Mtg, but I wanted to get you at least the Abuse Policy as it relates to investigations and procedures. Our employees are also given a copy of this entire policy at hire and sign a form they received it. ( V2, DON, V23, ADON and V1, Administrator) reviewed it again this morning at 8am to make sure we felt we followed the policy. While hindsight is always 20/20, we still don't believe the definition listed of verbal, physical or mental abuse in our policy was met by (V8, CNA) lack of warmth and patience with (R2). Harsh tone, yes. Abrupt care, yes. Willful disparaging and derogatory terms to the resident, threats of harm or isolation were not present. Harassment and threats of punishment, not present. Hitting, slapping, pinching, kicking and corporal behavior, not present. After further discussion, we all agree that (V14, R2's sister/POA) came to (V7, Social Service) saying she had a concern, but asked us not to report (V8, CNA) because she didn't want her to lose her job or get in trouble. Our conclusion was that this was not an allegation of abuse by the sister, but dissatisfaction with level/type of care/attitude/tone. In summary, it didn't meet our policy's definition of abuse as it's laid out. Going forward, we will err on the side of caution, take your advice, and over-report. We feel we followed our policy and did a best practice decision of removing (V8, CNA) from the hall, speaking to her about her tone and abruptness of care, and respecting the family's wishes that she not be fired or be made to be in trouble. It was only after (R2) passed from an unrelated rapid onset medical condition that this concern resurfaced and was escalated beyond what the sister originally asked us to do. We still struggle with the position we were asked to be in, but next time, we will report despite family asking us to handle it internally, per again, erring on the side of caution. Thank you! (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145515 If continuation sheet Page 8 of 15 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 12/12/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many The facility's Accident/Incident Reporting dated 12/2023 documented, Purpose: All accidents or incidents that result in an injury or illness must be reported to the Administrator, DON, or ADON. Procedure:1. Any accident or incident that results in an injury or illness must be reported within twenty-four (24) hours of the accident or incident. Any incident involving abuse will be reported within 2 hours of first notification. The abuse policy will be followed. 2.The DON will make an initial report of the incident and report it to IDPH through Facility Reported Incident. The following data, as it may apply, must be included on the Accident/Incident Report form: a. Name and address of the facility. b.Date and time the accident/incident occurred. c. Circumstances surrounding the accident/incident. d.Where the accident/incident occurred. e. Name(s) of any witness(es) and his/her account of the accident or incident. f. Name of the injury or illness (e.g., cut, needlestick, bruise, etc.). g.Follow-up information. h.Other pertinent facts as appropriate. Signature and title of the person completing the report. 3. The five-day final investigation report will be submitted through Facility Reported Incidents with in five working days after the incident initial report, a complete written report of the conclusion of the investigation, includes steps the facility has taken in response to the accident/incident. For the protection of the individuals involved, copies of any internal reports, interviews and witness statements during the course of the investigation shall be released only with permission of the Administrator or the facility attorney. The facility's Abuse prevention policy and procedure, dated 9/26/23, documented, Upon learning of suspected mistreatment, the administrator or designee shall notify the Illinois Department of Public Health and initiate an investigation. The facilities policy does not address injuries caused by an unknown source. The facility's matrix, dated 12/4/23, documented that there were 96 residents living in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145515 If continuation sheet Page 9 of 15 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 12/12/2023 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 0610 Respond appropriately to all alleged violations. 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 properly investigate allegations of verbal and physical abuse and injuries of unknown origins for 4 of 4 (R1, R2, R16, R17) residents reviewed for accidents and abuse in a sample of 17. This failure has the potential to affect all 96 residents residing in the facility. Residents Affected - Many Findings include: 1. R2's admission record form, dated 12/3/23, documented R2 was admitted to the facility on [DATE] with diagnosis of dementia, anxiety disorder, age-related nuclear cataract, essential hypertension, dissection of unspecified site of aorta, thoracic aortic aneurysm (without rupture), and fracture of unspecified part of neck of right femur. R2's admission record form documented a diagnosis (with an onset dated 8/9/23) of acute embolism and thrombosis of other specified deep vein of right lower. R2's admission record form documented diagnosis (with onset dates of 8/17/23) of unspecified fracture of lower end of right femur, subsequent encounter for closed fracture with routine healing, unspecified severe protein-calorie malnutrition, and unspecified fracture of unspecified femur, subsequent encounter for closed fracture with routine healing. R2's MDS (Minimum Data Set), dated 11/6/23, documented R2 as being severely cognitively impaired. R2's care plan, dated, documented R2 as requiring a mechanical lift and assist of 2 for all transfers. On 12/4/23 at 11:20 AM, V14, R2's sister/Power of Attorney (POA), stated that R2 was admitted with a broken hip that was not repaired because of an aneurysm she had. V14 stated that the facility used a mechanical lift to transfer her because she could not stand. V14 stated that the doctor at the hospital said the hip might heal on its own but it didn't. She continued to state that she was visiting R2 one day in August, that she visited every day, and one day noticed her R2's leg was swollen, that it was bruised so she told them she wanted something done. V14 stated that they did a doppler and it revealed blood clots. V14 stated they sent her to the local hospital, and the local hospital transferred her to the regional hospital for surgery. V14 stated that V26, R2's orthopedic surgeon, at the regional hospital said it was a new break and the leg was broken this time, not the hip. V14 stated that V26 said it was a twisted break and if they didn't operate it would come through the skin, so they did surgery. She continued to state that V26 told her that this fracture was not from the previous hip fracture and that this was a new fracture of the leg. V14 stated she went to the facility staff and management and told them something caused this and that she wanted to know what did. She continued to state that the facility said that they do not have any documentation and that this was not a new fracture, it was from the hip fracture. V14 stated she tried to explain it wasn't, but that they just kept saying it was the same fracture. On 12/4/23 at 11:30 AM, V14, R2's sister/ POA stated, some of these young kids do not have compassion and some of the (Certified Nurse Assistants (CNA) are rough. I have video of a CNA named, (V8), tossing my sister around back and forth, yanking on her hands, and being rude. V14 stated that it happened a week ago Saturday when the CNA was getting R2 ready for breakfast. V14 stated she went to the Social Worker, and she said she had to report it to the Administrator. V14 stated she showed them both the video and they said they would speak to V8 about it. V14 stated that when she visited R2 on 11/28/23 she observed a large bruise covering R2's right hand. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145515 If continuation sheet Page 10 of 15 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 12/12/2023 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 12/4/23 at 12:10 PM, V1, Administrator, with V2, Director of Nurses (DON) who was on a speaker phone as she was home sick. V2 stated that they tried to explain to, V14, R2's sister/POA that the fracture in August was not a new fracture and that it was from the hip fracture that she was admitted with in January. V1 stated that V2 even tried to explain with anatomy pictures to V14 about the fracture being the same one R2 had when she was originally admitted and that V14 just wasn't comprehending it. V2 stated I attempted multiple times to explain to V14 that it was a fragility fracture from the hip, and it wasn't new. When V1 was asked for their investigations and root cause analysis of the allegations of abuse and injury of unknown origin, V1 stated We didn't report or investigate the fracture from August because it wasn't a new fracture.' V1 continued to state We didn't report the video concerns because we cleared it on the spot when the sister brought it to me and our Social Worker. While we didn't like her behavior, we didn't feel like it rose to the level of abuse, so we didn't report it. R2's Video and audio footage, dated 11/26/23 at 6:40 AM, documented, R2 was nude and lying in bed. V8, CNA, turned R2 to her left side while placing a disposable undergarment on R2. V8 stated, Stop, let go before you rip it, let go of my finger, man! V8 abruptly pulled her hand away and stated, There's no reason for you to hold on to me and squeeze my fingers like that, that hurts! R2 stated I'm sure it does hurt. V8 replied Then stop! V8 then rolled R2 onto her left side in a rough manner. V8 stated to R2, Put your shirt on, come on put your sweater on, stop holding onto me! R2 continues to be resistant with dressing and V8 was observed tightly holding R2's right hand. R2's Video and audio footage dated 11/26/23 at 6:43 AM, documented, V8, CNA, pulling R2's pants up and R2's sweater down while R2 was lying in bed on her left side. V8 turned R2 onto her back in a rough manner and firmly grabbed R2's right hand, V8 stated Stop digging your nails into my skin now, let go! V8 walked away from R2's bed and left the bed in the high position. V8 retrieved the mechanical lift sling and placed it under R2 as R2 was lying on her left side. V8 turned R2 to her right side in a rough manner while bringing R2's left hand over on top of R2's right hand and then V8 used her left hand and arm to restrain R2's hands. V8 then shifted her body weight to increase pressure on top of R2's hands and wrists. R2 stated. Ow! V8 then turned R2 onto her back. V8 stated to R2, You're terrible! R2 stated, What? and V8 replied You are terrible, why do you keep trying to hit me and pinch me? V8 then lowered the bed and left the room. R2's Facility titled form, dated 11/26/23, documented, Resident wheeled to nurse's station and CNA reported bruise to (right) index finger. R2's Incident Report, dated 11/26/23, documented, Bruise found on right index finger. Area of concern: none. Resident frequently combative with staff. Resident noted to have hands folded on lap frequently. Likely bumped on table at meal or over bed table. Nurses and CNAS interviewed, and no areas of concern noted. The facility was unable to provide witness statements. On 12/5/23 at 2:35 PM V2, DON, stated, We report any fractures, anyone that goes to the hospital from an incident, or burns that require outside treatment. V2 stated, I know in R2's case, she was combative, so we knew the bruise was from that. We did not do an investigation and I know we should have looked into that. V2 stated, I was not involved in the instance with the CNA on the camera. V2 continued to state, What I usually do is clear it with V1, Administrator, and she usually says we know what happened, so we don't need to report it. On 12/5/23 at 3:08 PM, V1, Administrator, stated We report to state if there is any kind of injury that requires anything beyond first aid, if they were sent to the hospital from an incident, founded (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145515 If continuation sheet Page 11 of 15 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 12/12/2023 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many abuse, and allegations of abuse if we know its legit. V1 stated We are not going to hot line until we know its legit, like if the resident has a UTI (urinary tract infection), we will factor that into what they are saying. V1 stated that V2, DON, V23, Assistant Director of Nurses (ADON), and herself collaborate to decide if they need to report it. V1 stated that a serious injury or anything beyond first aid, they would report it. V1 continued to state that with unknown injuries they do a lot of interviewing and that they do not document the interviews with staff and residents. V1 stated that if there's a bruise like on R2, V2, DON, keeps a file on those. V 1 continued to state that R2's was a tiny bruise on a finger. V1 stated Honest to God if I did an investigation on every single little bruise, well it's not going to happen. V 1 continued to state, On abuse we decide if it is a reportable or not a reportable. On 12/4/23 at 12:30 PM, V7, Social Worker, stated When (R2's) family showed me the video, I was adamant that we had to report it to the Administrator. V7 continued to state that V14, R2's sister/POA, said she didn't want to get anyone in trouble. V7 stated In my opinion, I think the CNA could have handled it differently, but we don't feel it was abuse. We didn't feel it was intentional. The CNA apologized the next day to V14. On 12/6/23 at 10:42 AM, V24 LPN stated that R2 had a fracture earlier this year and there was no surgical intervention. V24 stated there was a follow-up x-ray in March with no change, no healing. V24 stated R2 complained of leg pain in August. V24 stated she knew nothing caused a new injury because there were no incidents in the chart. V24 stated they did another x-ray in August and that is when R2 was sent out to the hospital. V24 stated she recalled the leg being swollen and the family would tell us when they thought she was having pain because R2 could not always tell you when she was hurting. On 12/11/23 at 2:04 PM, V29, CNA stated that at one point we when R2 was getting therapy we used a pivot disc and 2 CNAS to transfer. On 12/11/23 at 2:17 PM, V30, CNA, stated that he always used a hoyer lift when transferring R2. He continued to state that therapy mentioning the pivot disc but he never attempted it with R2. On 12/5/23 at 1:20 PM, V8, Certified Nurse Assistant (CNA), stated, On 11/26/23, I went into (R2's) room to get her dressed for breakfast, she was combative as usual. V8, stated, I got her dressed and I felt myself getting worked up, so I lowered her bed and walked out. V8 continued to state, I grabbed her wrist softly at times to redirect her and I did not see any bruises on her hands or wrists. V8 stated (V23, Assistant Director of Nursing) came to me later that day and said R2's sister showed her the video. V8 stated, (V23) knows how (R2's) sister is and (V23) didn't want me to get in to trouble. (V23) told me to talk to the sister, so I did, I apologized, and her sister hugged me and said I am a good CNA. V8 stated that they did not send her home, they just put her on another hall. On 12/6/23 at 2:49 PM, V25, V26's Orthopedic Registered Nurse, stated that V26, R2's Orthopedic Surgeon, said the fracture in August was from a new injury and was not related to the past hip fracture. R2's x-ray results dated 8/8/23 from the x-ray that was completed in the facility documented there was an acute, displaced spiral fracture of the distal third of shaft of the femur with a conclusion of acute fracture distal femur. The facility failed to investigate the cause of the new fracture. R2's medical record dated 11/26/23 at 3:31 PM documented a bruise was noted to R (right) index (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145515 If continuation sheet Page 12 of 15 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 12/12/2023 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 0610 Level of Harm - Minimal harm or potential for actual harm finger. No s/s (signs or symptoms) of pain noted when assessing finger. ROM (range of motion) WNL (within normal limits). POA (power of attorney) notified. Will monitor. The facility's incident report form dated 11/26/23 documented resident frequently combative with staff. Resident noted to have hands folded on lap frequently. Likely bumped on table at meal or over bed table. Nurse and CNAs interviewed, and no areas of concern noted. The facility failed to provide documentation of investigation including witness statements. Residents Affected - Many 2. R16's admission record, dated 12/4/23, documented diagnoses of Encephalopathy, Major depressive disorder and Dementia. R16's MDS, dated [DATE], documented that his cognition was severely impaired. R16's Progress note, dated 10/21/23, documented, CNA notified nurse res is bleeding. Nurse observes dried black blood with scant amount light red blood to R (right) hand. Resident unable to answer, how did this happen. On 12/5/23 at 10:55 AM, R16 was sitting in dining room in wheelchair, activity getting ready to start. Resident was unshaven with food on his face. Resident said hello but did not respond to questions by writer. No bruises were noted. On 12/5/23 at 3:08 PM, V1, Administrator, stated I was looking at R16's chart when I sent it to you and the nurse probably assumed it was from picking. The facility was unable to provide an unknown injury investigation including witness statements into the cause of this injury. 3. On 12/05/2023 at 10:00 AM, R1 was sitting up in a high back reclining wheelchair in the hallway. R1 had a fading yellowish/green bruising below both of her eyes and a large, approximately 2 centimeters (cm), greenish/yellow raised area to the right side of the top of her head. R1's facility titled form, dated 10/29/2023, documented, CNA alerted this nurse that res had bump on forehead purple bruise over bump noted to middle of resident's forehead. Measures 3.5 cm x 3.0 cm. Neuro assessment WNL. No (signs or symptoms) of pain or distress noted. It also documents, Was incident witnessed? No. R1's progress note, dated 10/29/2023 at 9:00 AM, documented, CNA, alerted this nurse that resident has bump on forehead. Purple bruise over bump noted to middle of resident's forehead. Measures 3.5 cm x 3.0 cm. Neuro assessment WNL. No s/s of pain or distress noted. There was not any investigative notes, root cause analysis or interviews in R1's progress notes or in R1's electronic medical record. R1's admission Record, dated 12/05/2023, documented diagnoses of Vascular Dementia, Chronic Obstructive Pulmonary Disease and Alzheimer's Disease. R1's, Minimum Data Set (MDS), dated [DATE], documented that R1 was rarely to never understood, that she had no impairment to her upper or lower extremities and that she was incontinent of bowel and bladder. R1's Care Plan, dated 11/25/2023, documented, Floor mat x2. Neuro checks, re arrange furniture. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145515 If continuation sheet Page 13 of 15 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 12/12/2023 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 12/05/2023 at 2:35 PM, V2, DON, stated that R1's bump on her head on 10//29/2023, was from the mechanical lift. When asked for investigation, root cause analysis and interviews of staff and residents, V2 stated, We only have what's in the chart. The facility was unable to provide documentation that this incident was investigated and was reported to the state agency. 4. On 12/05/2023 at 9:45 AM, R17 was sitting up in her wheelchair at the nurses station. Staff was assisting with putting her hearing aide back in her right ear. R17 stated she was good and asked writers name, but was unable to recall anything else regarding skin tears or bruising to her body or how it happened. R17's MDS dated [DATE] documented that her cognition was severely impaired, that she has no impairments to her upper or lower extremities and that she uses a wheelchair and a walker. It also documents that she requires substantial to maximal assistance for most activities of daily living and that she was frequently incontinent of bowel and bladder. R17's Care Plan dated 9/25/2023 documented, Educate resident/family/ caregivers of causative factors and measures to prevent skin injury. R17's Skin/Incident report dated 10/14/2023, documented, CNA alerted this nurse of resident skin tear. Skin tear noted to (right forearm) crescent shaped measuring 6.5cm x 1.0 cm. small amount of serous fluid noted. Cleansed ns. Unable to reapproximate. Xeroform, non adherent pad and dry dressing applied. Denies pain. no (signs/symptoms) of distress. It continues, Was incident witnessed? No. and it did not document any actions taken. R17's Skin/Incident report, dated 11/6/2023, documented, After resident assisted into bed, noted a 7 x 2 cm skin tear to (left upper arm). Resident was combative when assisted to bed. Steri strips applied (and) a (dressing). (Complain of) pain and (vital signs) stable. It continues, Was incident witnessed? Yes, It continues, Action taken: Resident Education. The facility was unable to provide documentation that this incident was investigated and was reported to the state agency. An electronic mail, dated 12/06/2023 at 11:23 AM, from V1, Administrator, documented, Our morning meeting ran over and then Wednesday Medicare Mtg, but I wanted to get you at least the Abuse Policy as it relates to investigations and procedures. Our employees are also given a copy of this entire policy at hire, and sign a form they received it. ( V2, DON, V23, ADON and V1, Administrator) reviewed it again this morning at 8am to make sure we felt we followed the policy. While hindsight is always 20/20, we still don't believe the definition listed of verbal, physical or mental abuse in our policy was met by (V8, CAN) lack of warmth and patience with (R2). Harsh tone, yes. Abrupt care, yes. Willful disparaging and derogatory terms to the resident, threats of harm or isolation were not present. Harassment and threats of punishment, not present. Hitting, slapping, pinching, kicking and corporal behavior, not present. After further discussion, we all agree that (V14, R2's sister/POA) came to (V7, Social Service) saying she had a concern, but asked us not to report (V8, CNA) because she didn't want her to lose her job or get in trouble. Our conclusion was that this was not an allegation of abuse by the sister, but dissatisfaction with level/type of care/attitude/tone. In summary, it didn't meet our policy's definition of abuse as it's laid out. Going forward, we will err on the side of caution, take your advice, and over-report. We feel we followed our policy and did a best (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145515 If continuation sheet Page 14 of 15 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 12/12/2023 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many practice decision of removing (V8, CNA) from the hall, speaking to her about her tone and abruptness of care, and respecting the family's wishes that she not be fired or be made to be in trouble. It was only after (R2) passed from an unrelated rapid onset medical condition that this concern resurfaced and was escalated beyond what the sister originally asked us to do. We still struggle with the position we were asked to be in, but next time, we will report despite family asking us to handle it internally, per again, erring on the side of caution. Thank you! The facility's Accident/Incident Reporting dated 12/2023 documented, Purpose: All accidents or incidents that result in an injury or illness must be reported to the Administrator, DON, or ADON. Procedure:1. Any accident or incident that results in an injury or illness must be reported within twenty-four (24) hours of the accident or incident. Any incident involving abuse will be reported within 2 hours of first notification. The abuse policy will be followed. 2.The DON will make an initial report of the incident and report it to IDPH through Facility Reported Incident. The following data, as it may apply, must be included on the Accident/Incident Report form: a. Name and address of the facility. b.Date and time the accident/incident occurred. c.Circumstances surrounding the accident/incident. d.Where the accident/incident occurred. e. Name(s) of any witness(es) and his/her account of the accident or incident. f. Name of the injury or illness (e.g., cut, needlestick, bruise, etc.). g.Follow-up information. h.Other pertinent facts as appropriatei. Signature and title of the person completing the report. 3. The five-day final investigation report will be submitted through Facility Reported Incidents with in five working days after the incident initial report, a complete written report of the conclusion of the investigation, includes steps the facility has taken in response to the accident/incident. For the protection of the individuals involved, copies of any internal reports, interviews and witness statements during the course of the investigation shall be released only with permission of the Administrator or the facility attorney. The facility's Abuse prevention policy and procedure, dated 9/26/23, documented, Upon learning of suspected mistreatment, the administrator or designee shall notify the Illinois Department of Public Health and initiate an investigation. The facilities policy does not address injuries caused by an unknown source. The facility's matrix, dated 12/4/23, documented that there were 96 residents living in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145515 If continuation sheet Page 15 of 15