Health inspection·January 26, 2025

F 0584 services 3x/week for 4 weeks to target memory and problem solving / insight. Level of Harm - Minimal harm or potential for actual harm On 1/22/25 at 12:10 PM, V1, Administrator, stated There is a guy fixing the heaters in the building now and you should be feeling more heat in the dining room and other areas. When asked about the Therapy room, V1 stated I had to get that approved by Corporate and they just approved that for the guy fixing the other heaters, and he will be working on the therapy room next. That room heater has been broken since 1/1/25, almost a month now. Residents Affected - Some On 1/23/25 at 12:00 PM, V9, Maintenance Director, stated I have been fighting with the heat in this building since I turned it on in October 2024. The Therapy Department's heat never did come on. It was mid-October of 2024 when I told the previous Administrator that it needed fixed. I had to get a bid and then send it to Corporate to approve, which I did. I waited weeks for an answer and heard nothing. Then they said I had to get three different bids and forward to them. I finally did that and now apparently, they approved one. Unfortunately, I have no idea when it will be fixed or how long we have to wait for that company to get it fixed. The local weather on 1/20/25, documented the high temperature was 19 degrees Farenheight (F.). On 1/21/25 the high temperature was 10 degrees F., and on 1/22/25, the high temperature was 37 degrees F. The Local Weather was obtained from the website https://www.timeanddate.com/weather. The Facility provided a list of residents receiving therapy at the facility. This list consisted of nine Residents receiving either PT, OT, or ST. The Facility's Resident Rights Policy, dated 12/2016, documents Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property, and exploitation; g. exercise his or her rights as a resident of the facility and as a resident or citizen of the United States; h. be supported by the facility in exercising his or her rights; jj. equal access to quality care, regardless of source of payment. The Facility's Resident Rights for People in Long-Term Care Facilities from the State of Illinois Department of Aging, dated 3/2017, documents You have the right to Safety and Good Care: Your facility must provide services to keep your physical and mental health, and sense of satisfaction. You must not be abused by anyone - physically, verbally, mentally, financially, or sexually. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145518 If continuation sheet Page 2 of 7 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 145518 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mascoutah Rehab and Nursing 201 South 10th Street Mascoutah, IL 62258 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 - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Interview, Observation, and Record Review, the facility failed to secure cigarettes and lighters; failed to reassess resident's smoking risk; and failed to provide appropriate supervision for residents while smoking for 4 of 5 residents (R1, R2, R5, R6)) reviewed for resident safety while smoking in the sample of 9. The Findings Include: 1. R1's Facesheet, dated 1/22/25, documents R1 was originally admitted to the facility on [DATE], with a most recent admission of 3/31/24 with diagnosis of Hydronephrosis, Emphysema, Extended-Spectrum Beta-Lactamases (ESBL), Cirrhosis of Liver, Malnutrition, Peripheral Vascular Disease (PVD), Thrombocythemia, Methicillin-Resistant Staphylococcus Aureus (MRSA), Neuromuscular dysfunction of bladder, Bilateral Above Knee Amputation (AKA), COVID, Arteriosclerotic Heart Disease (ASHD), Hypertension (HTN), Benign Prostatic Hyperplasia (BPH), Depressive Disorder, Anemia, Generalized Anxiety disorder, Falls, and Hepatitis C. R1's Care Plan, dated 11/28/24, documents R1 is a smoker. Interventions: R1 is encouraged to wear smoking apron, but resident refuses most of the time. Smoking apron is located right on the inside of the front entrance door. Smoking materials are kept secured by staff. Smoking per facility protocol. This Care Plan was changed just prior to facility providing a copy of it - as of 1/23/25, the Smoking materials are kept secured by staff was removed (see R1 Care Plan prior to change attachment). R1's Minimum Data Set (MDS), dated [DATE], documents R1 has a moderate cognitive impairment and requires partial/moderate assistance from staff for Activities of Daily Living (ADLs). R1's Smoking Assessments were documented as completed on 7/15/21 (non-smoker), 10/4/21 (non-smoker), 1/3/22 (non-smoker), 2/8/22 (non-smoker), 4/4/22 (non-smoker), 7/15/22 (smoker), 10/14/22, 1/10/23 (Does the resident only smoke in designated areas at designated times - No), 3/21/24 (Res clothing free from ashes or burn marks - No), 3/31/24, and 10/18/24 (Smoking Plan: Smoking materials are kept secured by staff, smoking per facility protocol. On 1/22/25 at 9:55 AM, R1 stated that he is a smoker and the only thing staff told him was that he needed to stay at least 15-feet away from the building. R1 stated he keeps his cigarettes with him and has a Cigarette pack (green pack) with five cigarettes and a lighter inside his pack laying on the bed next to him. R1 stated the staff are usually so busy, they don't ask for them back, so he just keeps them with him. R1 stated there is no smoking times and they can go out anytime they want to. R1 stated he is usually outside by himself, with no staff member out there with him. R1 stated at first, they gave him a cover for his clothes, but normally he does not wear one, and the staff never say anything to him. R1 stated he has burnt his clothes before, all the time. 2. R2's Facesheet, dated 1/22/25, documents R2 was admitted to the facility on [DATE] with diagnosis of Chronic Obstructive Pulmonary Disease (COPD), Major Depressive Disorder, and Insomnia. R2's Care Plan, dated 11/15/24, documents R2 is a smoker. Interventions: Smoking per facility protocol. R2's MDS, dated [DATE], documents R2 is cognitively intact and is independent on ADLs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145518 If continuation sheet Page 3 of 7 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 145518 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mascoutah Rehab and Nursing 201 South 10th Street Mascoutah, IL 62258 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 - Minimal harm or potential for actual harm Residents Affected - Some R2's Smoking Assessments were completed on 5/1/23 (non-smoker), 3/21/24 (smoker), 6/20/24, 8/6/24, and 11/5/24 (Smoking Plan: Smoking per facility protocol.) On 1/22/25 at 10:10 AM, R2 was seen sitting in a recliner with his walker next to him. R2 stated he is a smoker and keeps his cigarettes with him under his rolling walker seat. R2 showed a pack of cigarettes (white pack) and stated he keeps his lighter in his pocket all the time. R2 stated he does not wear any clothing protector and has no problems with burns. R2 stated he can go outside whenever he wants to smoke and usually it is just the residents out there with no staff. 3. R5's Facesheet, dated 1/22/25, documents R5 was originally admitted to the facility on [DATE] with diagnosis of COPD, Schizophrenia, Asthma, Deep Vein Thrombosis (DVT), Encephalopathy, Pulmonary Hypertension (HTN), Acute Kidney Failure, Atheroembolism of lower extremities, Depression, HTN, Anemia, Bipolar disorder, Personality disorder, Dysthymic disorder, Psychosis. R5's Care Plan, dated 11/20/24, documents R5 is a smoker. Interventions: Assure smoking material is extinguished prior to leaving smoking area. R5 is supervised while smoking. Smoking materials are kept secured by staff. Smoking per facility protocol. R5's MDS, dated [DATE], documents R5 has a moderate cognitive impairment and is independent for ADLs with substantial/maximal assistance from staff for bathing. R5's Smoking Assessments were completed on 2/7/22 (non-smoker), 4/9/22 (smoker: Can the resident light a cigarette independently - No, Smoking Care Plan: Resident is supervised while smoking. Smoking materials are kept secured by staff. Smoking per facility protocol), 5/10/22 (smoker - Does the resident only smoke in designated areas at designated times - No), 8/10/22, 11/9/22, 2/19/24, and 4/15/24 (smoker Does the resident only smoke in designated areas at designated times - No). No Smoking Assessments have been completed since 4/15/24. On 1/22/25 at 11:45 AM, R5 stated he was a smoker and can go outside the front door whenever he wants to and usually about every two hours. R5 stated the staff usually keeps his cigarettes, but he keeps his lighter with him because after nurse gives him a cigarette, he goes out by himself and uses his lighter to light his cigarette. R5 stated no staff ever goes out with him. R5 stated he does not use a clothing protector. On 1/22/25 at 12:00 PM, R5 was seen going outside the front door, he lit up a cigarette, and sat in his wheelchair with a coat on smoking the cigarette. At 12:08, R5 was seen using the door combination to get himself back inside the facility and back to dining table for lunch. On 1/22/25 at 3:55 PM, R5 was seen sitting in his wheelchair, smoking by himself, outside the front door. 4. R6's Facesheet, dated 1/22/25, documents R6 was originally admitted to the facility on [DATE] with diagnosis of Malnutrition, Phantom limb syndrome, Bursopathy, Gout, Congestive Heart Failure, Osteomyelitis, Paraplegia, Hypothyroid, Vascular implants, Suprapubic catheter, Colostomy, Nicotine dependence, Peripheral Neuropathy, Right Above the Knee Amputation (AKA), Anxiety disorder, HTN, and Major Depressive disorder. R6's Care Plan, dated 10/8/24, documents R6 is a smoker and has been educated about the rules of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145518 If continuation sheet Page 4 of 7 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 145518 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mascoutah Rehab and Nursing 201 South 10th Street Mascoutah, IL 62258 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 - Minimal harm or potential for actual harm Residents Affected - Some smoking and verbalizes understanding. Interventions: R6 will be supervised while smoking, Nursing staff to store cigarettes and lighters in a secure location, Smoking assessment to be completed on admission and quarterly. R6's MDS, dated [DATE], documents R6 is cognitively intact and requires partial/moderate assistance from staff for ADLs. R6's Smoking Assessments were completed on 6/5/20, 1/17/21, 5/7/21, 6/6/21, 9/10/21, 10/8/21, 12/17/21, 3/9/22, 4/16/22, 6/1/22, 8/12/22, 9/1/22, 10/3/22, 10/21/22, 1/2/23, 2/2/23, 3/16/23, 2/3/24, 4/15/23, 5/31/24, 7/7/24, 10/11/24, 10/18/24, 12/18/24, and 1/11/25 (smoker - Smoking Care Plan: R6 will be supervised while smoking, Nursing staff to store cigarettes and lighters in a secure location, Smoking assessment to be completed on admission and quarterly) On 1/22/25 at 11:45 AM, R6 was seen outside front doors smoking by herself, R6 was seen pushing codes to get back in door. R6 had her smoking supplies with her in her purse. On 1/22/25 at 11:50 AM, R6 stated she is a smoker and can smoke whenever she wants to. R6 stated she always carries her cigarettes and lighter with her in her purse and her purse is always on her. R6 stated she goes out by herself with no staff present. R6 stated she does not have to wear a clothing protector. On 1/22/25 at 10:30 AM, V6, Licensed Practical Nurse (LPN), stated There really is no set times for smoke breaks. The residents can go outside anytime they want to smoke. They usually go out the front door and sit on the benches by themselves. On 1/22/25 at 4:00 PM, V1, Administrator stated that any resident who is alert and oriented can go outside and smoke whenever they want. V1 stated they all have the code to go in and out the door. V1 stated if they are alert and oriented, they can hold their own cigarettes but should not have their lighters with them. The Facility's Smoking Policy, dated 2/2021, documents 1. Any resident that expresses an interest to smoke will be assessed at the time of admission and at least quarterly or with any significant change to determine the level of assistance that will be needed to ensure the resident's safety. 2. Based on the assessment findings the resident's plan of care will be revised to reflect the level of assistance and any assistive devices that will be needed by the resident to enable the resident's safety. 3. Residents or their representative must provide all smoking materials (cigarettes, pipes, cigars, lighters etc.). Smoking materials must be secured at the nurse's station when not in use. 4. All residents will be supervised when they smoke. Residents must smoke in designated smoking area. 5. Residents may not use vaping devices or e-cigarettes in the building. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145518 If continuation sheet Page 5 of 7 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 145518 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mascoutah Rehab and Nursing 201 South 10th Street Mascoutah, IL 62258 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record reviews the facility failed to keep daily temperature logs for refrigerators/freezers, wear hairnets covering all hair, dispose of and store food according to policy and hold food temperatures according to policy. This failure has the potential to affect all 38 residents in the facility. Findings include: 1. On 1/22/25 at 8:52 AM, both V3(kitchen manager) and V10(dietary aide) had their hair outside of their hair nets in the kitchen while handling food. On 1/22/25 at 12:00 PM, V10, dietary aide, had hair outside of her net from her ponytail and bangs. V3 told V10 to put all her hair back in the net. V10 put her ponytail in the hair net but her bangs remained outside. V3 did not correct her. V10 picked up her personal cell phone with her left hand's fingers, ungloved, while preparing beverages for the residents, put the cell phone back down on the counter, and then used those same fingers to hold beverages to be served inside the cups with no hand hygiene. V12, dietary staff, did not have any hair net covering on his head or facial hair while working with food. V11, cook in training, did not have his facial hair net over his beard covering his facial hair. V3 did not correct V1 or V12 about their hair net use while preparing lunch in the kitchen. On 1/23/25 at 8:00 AM, V3, V11, and V12 were not wearing hair nets in the kitchen preparing breakfast. Biscuits were at 109.2 degrees Fahrenheit, and when gravy was placed on top of them, the biscuit and gravy were at 109 degrees Fahrenheit on the plate to be served. V12 stated the key will be to get the food out to the residents as fast as possible since they are losing heat fast. The food was placed on a tray and prepared to be served to the residents. R1's MDS dated [DATE] documented R1 to be moderately cognitively impaired. On 1/22/25 at 9:55 AM, R1 stated the food is not good and usually cold; eats in dining room and food is still cold. R2's MDS dated [DATE] documented R2 to be cognitively intact. On 1/22/25 at 10:10 AM, R2 stated the food is terrible and sometimes cannot identify what it is and is usually cold. R4's MDS dated [DATE] documented R4 to be cognitively intact. On 1/22/25 at 10:25 AM, R4 stated the food is typical Institutional Food and it has improved the past month but still needs a lot of work. R4 stated he eats in dining room and in his room and food is usually cold, even in the dining room. R4 stated he used to be a Federal Consumer Safety Officer and he is well aware of how to store and cook food. R4 stated they need to watch the temperatures of the food and no one in the kitchen monitors the food temps like they are supposed to. R7's Minimum Data Set (MDS) dated [DATE] documented him to be cognitively intact. On 1/22/25 at 2:48 PM, R7 stated the food varies in temperature, it is sometimes served warm but sometimes cold you just never know what you're going to get. R7 stated he would like the kitchen staff to wear their hair nets, proper fitted clothing, and use proper hand hygiene before working with the food also. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145518 If continuation sheet Page 6 of 7 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 145518 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mascoutah Rehab and Nursing 201 South 10th Street Mascoutah, IL 62258 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 R9's MDS dated [DATE] documented him to be cognitively intact. On 1/22/25 at 2:45 PM, R9 stated the food is not cold but could be warmer, it varies every day. On 1/23/25 at 9:10 AM, R9 stated the biscuits and gravy for breakfast was not hot, it was room temperature, and he only ate two bites of it; it wasn't good. Resident Council Meeting Minutes dated 12/30/24 documented the food comes out cold at dinner and food was not good quality. 2. On 1/22/25 at 8:45 AM, the kitchen freezer has 5 bags of frozen breaded chicken labeled Don't cook use for activity with no date. The beverage refrigerator has a gallon of two percent milk 2/3's the way used with a expiration date of 1/17/25. On 1/22/25 at 8:49 AM, V3, stated the 5 bags of frozen breaded chicken are for the Certified Nursing Assistants (CNA's) to use for activities, they like to have food for the residents sometimes. On 1/22/25 at 8:50 AM, V3 and V10 stated the beverages in the refrigerator (containing the expired milk) is what they serve the residents. 3. On 1/22/25 at 12:15 PM, no active temperature logs in facility binder since December of 2024 for freezers and refrigerators. On 1/22/25 at 12:15 PM, V3 stated he was not aware that the freezers and refrigerators needed to having daily temperature checks. On 1/23/25 at 8:15AM, V1, Administrator, stated she expects the kitchen staff to be wearing hair nets properly, we just got in a whole order of nets for their beards in fact, they should know better. V1 stated we will have to provide more education to the kitchen staff on proper procedures. The Facility's Food Labeling and Storage Policy dated 3/29/21 documented all foods must be labeled and dated right away when going into the cooler, the expiration date is the most important. The facility's Storeroom/Freezer Food Storage Policy dated 6/22/21 documented all open food items in the freezer must be labeled and dated. The facility's Food Safety Policy undated documented foods or beverages that are past the manufacturer's expiration date should be discarded, foods should be stored at the appropriate temperature to maintain safety: hot foods should be held at 135 degrees or higher. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145518 If continuation sheet Page 7 of 7