Inspection·May 30, 2025

F 0552 require any outside intervention. Level of Harm - Actual harm On 5/27/2025 at 1:42 PM V18 Licensed Practical Nurse (LPN) stated she would transfer a hospice resident to the hospital depending on family and hospice. V18 states she would not transfer a hospice resident unless it was medically necessary and would do a head-to-toe assessment prior to calling doctor and obtain an order to transfer. Residents Affected - Few R2's medical records dated 5/10/25 documents R2 was seen in an area hospital for a complaint of Shortness of breath (SOB). Diagnostic testing was initiated before discovering (R2) was not the intended resident. The facility policy Resident Rights undated documents the facility must provide services to keep your physical and mental health and sense of satisfaction. The resident roster provided by the facility on 5/27/25 documented 100 residents currently resided in the facility. Prior to survey date, the facility took the following actions to correct the non-compliance: All facility nurses and Certified Nurse Assistants were in-serviced between 5/12/25 and 5/23/25 on the vital importance of resident identification, including Certified Nursing Assistants and/or nurse presence in room with Emergency Medical Service before transporting/transferring resident to the hospital. Additionally, Medical provider or Nurse Practitioner and Hospice company (if applicable) should be notified before any transfers or discharges. The Director of Nursing will Audit all hospital transfers for the next 4 weeks and then monthly for a period of 6 months. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145515 If continuation sheet Page 2 of 8 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 05/30/2025 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify 1 (R2) of 5 resident representatives of significant changes in status which were reviewed for change in status in the sample of 8. This past non-compliance occurred 5/10/25 to 5/23/25. Findings include: R2's undated Face Sheet documents an admission date of 12/31/24 with pertinent diagnosis of Cerebral Infarction due to Unspecified Occlusion or Stenosis of left Posterior Cerebral Artery and Facial Weakness. R2's Minimum Data Set (MDS) dated [DATE] that R2 is severely cognitively impaired. R2's Practitioner's Order for Life Sustaining Treatment (POLST) dated 12/31/2024 documents that V9 daughter of R2 is designated as agent of power of attorney for healthcare, R2's Nurse's Progress notes dated 5/10/25 documents a late entry: (R2) mistakenly sent to emergency room (ER) due to low blood pressure and low O2 sats. (V25) Medical Director (MD) and (V9) Power of Attorney (POA) were notified. On 5/27/25 at 11:46 AM V9, R2's daughter and power of attorney stated she was unaware of her mother being sent to the hospital until 5/12/25. V9 stated she was informed by the hospice nurse (V27). On 5/27/25 at 3:24 PM V25 medical director stated he had not been notified that (R2) had been sent out mistakenly to the hospital. On 5/28/25 at 10:12 AM V27 Hospice nurse stated she had not been notified until 5/12/25 that R2 had mistakenly been sent to the hospital. On 5/27/25 at 12:37 PM V1 Administrator stated that she was led to believe the assigned nurse (V19) had contacted R2's family. (V19) left things in a mess and we dodged a bullet, we followed policy and it was human error. On 5/28/25 at 11:14 AM V2 Director of Nursing stated she entered the documentation that R2's family had been notified because she thought the nurse (V19) had done so but had not completed her documentation before leaving the facility. R3's undated Face Sheet documents R3 was admitted [DATE] with pertinent medical diagnoses of Human Metapneumovirus as the causes of diseases classified elsewhere, Systemic Inflammatory of Response Syndrome (SIRS) of Non-infectious origin without Acute Organ Dysfunction. R3's Minimum Data Set, dated [DATE] documents she is cognitively intact. On 5/29/25 at 9:35 AM V28 R3's daughter stated she had not been notified on 5/10/25 by the facility that her mother was being transferred to the hospital for further evaluation. According to V28 she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145515 If continuation sheet Page 3 of 8 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 05/30/2025 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was contacted by the hospital for insurance information and during that conversation she discovered that it was not her mother (R3) in the hospital. The facility did not notify her that (R3) did not go to the hospital. On 5/28/25 at 3:24 PM V25 Medical Director stated he was not informed that the resident (R3) had not been sent out. He discovered 5/12/25 when he arrived at the facility for regular visits with residents that (R3) had not been sent out as ordered. V25 stated his expectations are that his orders are carried out and he be notified of any changes that warrant intervention. The facility policy Resident Rights undated documents the facility must provide services to keep your physical and mental health and sense of satisfaction. The facility policy on Transfers and Discharges undated documents A thorough assessment by the attending physician or healthcare provider will determine whether a transfer is medically necessary. This assessment will be documented in the resident's care plan. Notification: The resident and their family (or legal representative) will be notified of the transfer, including the reasons for the transfer and the expected timeline. The family will be given sufficient notice to make appropriate arrangements. Physician will be involved in and informed of resident's transfer. Detailed documentation of the transfer request, reasons, and any family discussions or approvals must be kept in the resident's record. The transfer process will be documented, including the physician's assessment, transfer arrangements, and communication with the resident and family. Prior to survey date, the facility took the following actions to correct the non-compliance: All facility nurses and Certified Nurse Assistants were in-serviced between 5/12/25 and 5/23/25 on the vital importance of resident identification, including Certified Nursing Assistants and/or nurse presence in room with Emergency Medical Service before transporting/transferring resident to the hospital. Additionally, Medical provider or Nurse Practitioner and Hospice company (if applicable) should be notified before any transfers or discharges. The Director of Nursing will Audit all hospital transfers for the next 4 weeks and then monthly for a period of 6 months. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145515 If continuation sheet Page 4 of 8 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 05/30/2025 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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based interview and record review the facility failed to ensure that 1 of 3 (R2) residents or their representative reviewed for hospital transfer received sufficient preparation for transfer to the hospital in the sample of 8. This past non-compliance occurred 5/10/25 to 5/23/25. Findings include: R2's undated Face Sheet documents an admission date of 12/31/24 with pertinent diagnosis of Cerebral Infarction due to Unspecified Occlusion or Stenosis of left Posterior Cerebral Artery and Facial Weakness. R2's Minimum Data Set (MDS) dated [DATE] that R2 is severely impaired. R2's Practitioner's Order for Life Sustaining Treatment (POLST) dated 12/31/2024 documents that V9 daughter of R2 is designated as agent of power of attorney for healthcare. On 5/27/25 at 11:46 AM V9, daughter of R2 stated she was not made aware her mother (R2) had mistakenly been sent to the hospital. (R2) cannot speak for herself and is not cognizant, therefore the facility did not have (R2's) or her (V9) consent to send (R2) to the hospital. R2's Nurse Progress notes dated 5/10/25 do not provide documentation the neither (R2) or (V9) received preparation for the transfer to the hospital. The active facility policy on Transfers, Discharges All discharge decisions, including reasons for discharge, discussions with the resident and family, and discharge plans, will be documented in the resident's record. The facility will ensure that all discharge paperwork, including any required notices and appeals information, is provided to the resident and their family. Prior to survey date, the facility took the following actions to correct the non-compliance: All facility nurses and Certified Nurse Assistants were in-serviced between 5/12/25 and 5/23/25 on the vital importance of resident identification, including Certified Nursing Assistants and/or nurse presence in room with Emergency Medical Service before transporting/transferring resident to the hospital. Additionally, Medical provider or Nurse Practitioner and Hospice company (if applicable) should be notified before any transfers or discharges. The Director of Nursing will Audit all hospital transfers for the next 4 weeks and then monthly for a period of 6 months. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145515 If continuation sheet Page 5 of 8 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 05/30/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow physician orders to send a resident (R3) to the emergency room for further evaluation and failed to follow hospice agreements that a resident (R2) is not to be transferred to the hospital for treatment without first notifying hospice for 2 of 4 residents (R2, R3) reviewed for quality of care in the sample of 8. This failure resulted in R2 being sent out to the hospital and having unnecessary diagnostic testing initiated before discovering (R2) was not the intended resident and R3 not being sent out to the hospital as ordered. This failure also puts R2 at risk to incur unnecessary medical bills. Residents Affected - Few This past non-compliance occurred 5/10/25 to 5/23/25. Findings include: 1. R2's Face sheet undated documents that resident was admitted to the facility on [DATE]. R2's Physician Order Summary (POS) dated 12/31/2024 documents diagnosis of Cerebral infarction, unspecified and Facial weakness following cerebral infarction. R2's MDS (Minimum Data Set) dated 4/7/2025 documents a BIMS (Brief Interview for Mental Status) score of 3 out of 15. R2's MDS dated [DATE] documents that resident is dependent with toileting hygiene, putting on/taking off footwear and lower body dressing and needs substantial/maximal assistance with shower/bathe self and upper body dressing. R2's MDS dated [DATE] document resident needs substantial/maximal assistance with mobility. R2's Nurse Progress Note dated 5/10/2025 at 11:47 PM documents resident mistakenly sent to ER for eval and treat of low BP and low 02 sats. When the hospital noticed the mistake, POA and MD made aware. Resident returned to facility with no further incident. R2's Hospital medical records dated 5/10/25 documents Patient arrives per EMS, wrong patient sent from facility. Pt being sent back to nursing home, emergency room Charge RN attempted to call pt family with no answer. emergency room Physician notes dated 5/11/24 at 12:26 AM documents Wrong patient sent by nursing home, patient is hospice, Do Not Resuscitate (DNR), Do Not Intubate (DNI), comfort care, and family did not want this patient seen. I did (?) evaluate or treat the patient. No facility physician order documented for R2 to be sent to hospital as of 5/27/2025. On 5/28/2025 at 11:22 AM, V1 Administrator states we dodged a whole lot of bullets with this one, so many things could have gone wrong. V1 states V19, Licensed Practical Nurse (LPN) was terminated the following Monday after incident. On 5/27/2025 at 1:46 AM V9, daughter of (R2), stated the emergency medical technicians (EMT's) went to the wrong room. She states her mother (R2) was in room [ROOM NUMBER] and the other resident was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145515 If continuation sheet Page 6 of 8 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 05/30/2025 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 0684 Level of Harm - Actual harm Residents Affected - Few 06. She states the EMT's took the patient in room [ROOM NUMBER] as the patient needing to be transported to the hospital. She states no one notified the family that (R2) had been taken to the hospital and they had no idea that it had happened. She states the hospital called at 11:58 PM to advise that our mother (R2) was at the hospital. She states (R2) had a series of strokes and was not alert. She states (R2) was receiving hospice services and had only been with hospice for 1 week. She states she did speak with a nurse and [NAME] in admissions who admitted that her mother (R2) had been sent to the hospital by mistake and the nurse had been fired. She states she has hospital records but not the ambulance records, mother (R2) did not receive any treatment but if they had provided treatment, it would have been for the wrong person. She states the patient they were supposed to transfer to the hospital had diabetes and questions what if they would have given (R2) insulin. She states anything that the hospital would have done would been unnecessary treatment and that her mother was not supposed to be transported. R2's medical records dated 5/10/25 documents R2 was seen in an area hospital for a complaint of Shortness of breath (SOB). Diagnostic testing was initiated before discovering (R2) was not the intended resident. On 5/28/2025 at 10:12 AM, V27, Hospice Nurse, states she was notified on 5/12/2025 at 9:00 am by V19, Licensed Practical Nurse (LPN), (R2) was having difficulties that day. V19 mentioned to V27 that (R2) had been sent to the ER on [DATE] by ambulance and they had taken the wrong resident. V27 states V19 told her emergency medical service (EMS) grabbed the wrong resident and not sure how this happened. V27 notified Hospice both clinical coordinator and medical director. V27 states she did not receive medical records from the hospital and had prepared a report of the incident. V27 states the Case Manager followed up with (R2's) family. V27 states she has not filed a report but would do so today. V27 states the nursing home told her that no care was provided at the hospital. V27 states her expectation is the facility will call before sending (R2) out to hospital. On 5/28/2028 at 4:48 AM, V15, certified nurse assistant, (CNA) stated she works nights but was not here at that time of the incident. V15 states she has been trained to accompany EMT's to the resident's room, stay with the resident and get the resident ready for transport. V15 states the nurse provides the information to the Emergency Medical Technicians (EMT). On 5/28/2025 at 5:00 AM, V16, CNA, states she work both evening and night shifts and has received in-service training on transferring a resident to the hospital and to notify the family representative. V16 states the CNA's duties are to stay with the resident and get the resident ready for transport. On 5/28/2025 at 4:00 AM, V10, Registered Nurse (RN) stated she works the evening and night shift and did relieve the evening shift nurse. V10 does not recall the events surrounding the wrong resident being sent out. V10 states CNAs that worked that evening were all agency CNA's and did not know names. Have no idea how the wrong person was sent out. Hospice organization dated December 1, 2008, documents regarding Patient Transfer. The Nursing Facility agrees not to transfer any Residential Hospice Patient to another care setting without the prior approval of Hospice. If the Nursing Facility fails to obtain the necessary prior approval, Hospice bears no financial responsibility for the costs of transfer and the costs of care provided in another setting. Facility Policy for Hospice Services undated documents Purpose: Provide and promote collaboration (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145515 If continuation sheet Page 7 of 8 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 05/30/2025 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 0684 Level of Harm - Actual harm and coordination of care and services for the resident receiving hospice care. This facility will immediately notify the hospice provider of the following: Significant change in resident's physical, mental, social, or emotional status; Clinical complications that suggest a need to alter the plan of care; Need to transfer the resident from this facility for any condition and the resident's death. Residents Affected - Few 2. R3's Face Sheet undated documents R3 was admitted [DATE] with pertinent medical diagnoses of Human Metapneumovirus as the causes of diseases classified elsewhere, Systemic Inflammatory of Response Syndrome (SIRS) of Non-infectious origin without Acute Organ Dysfunction. R3's Nurse's Progress notes dated 5/10/25 documents R3 was experiencing a temperature of 100.2 degrees, abnormal lung sounds and a decrease in blood pressure of 102/64 to 88/46. R3's Nurse Progress notes dated 5/10/25 documents R3 was experiencing a temperature of 100.2 degrees. The Medical Director ordered (R3) to be transferred to area hospital for further evaluation. R3's Nurse's Progress notes dated 5/10/25 documents by error resident was not sent to hospital. MD was made aware when error was noticed. Resident re assessed and not sent out to ER and resident family made aware. On 5/27/25 at 4:00 AM V10 Registered Nurse stated she work nights and was the on-coming nurse and was made aware that R3 had not been sent out to the hospital. V10 was familiar with R3, re-assessed her and believed her symptoms could be addressed at the facility. V10 did not contact the medial director with that information and did not send R3 as ordered. Prior to survey date, the facility took the following actions to correct the non-compliance: All facility nurses and Certified Nurse Assistants were in-serviced between 5/12/25 and 5/23/25 on the vital importance of resident identification, including Certified Nursing Assistants and/or nurse presence in room with Emergency Medical Service before transporting/transferring resident to the hospital. Additionally, Medical provider or Nurse Practitioner and Hospice company (if applicable) should be notified before any transfers or discharges. The Director of Nursing will Audit all hospital transfers for the next 4 weeks and then monthly for a period of 6 months. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145515 If continuation sheet Page 8 of 8