Inspection·August 20, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete as a resident-to-resident altercation, he viewed it more as an incidental contact between R7 and R8. The Facility's Resident Right to Freedom of Abuse, Neglect and Exploitation policy, initiated 10/16/2023, documents the facility's residents have the right to be free from abuse, neglect, misappropriation of their property and exploitation as defined in this policy. The facility shall review altercations from resident to resident as a potential situation of abuse. Staff shall monitor for any behaviors that may provoke a reaction by residents or others, which include physically aggressive behavior, such as grabbing and verbally aggressive behavior such as intimidating. 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 08/20/2025 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 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 investigate a resident-to-resident abuse for 1 (R7) of 3 residents reviewed for abuse in the sample of 11. Findings include: 1. R7's Undated Face Sheet, documents she was initially admitted to the facility on [DATE] with diagnoses including major depression disorder, anxiety disorder, chronic pain syndrome, paraplegia, anemia, heart failure, high blood pressure, osteoarthritis and neuropathy. R7's Quarterly Minimum Data Set (MDS), dated [DATE], documents BIMS 14 and no behaviors. R7's Nursing Progress Note, dated 7/29/2025 at 10:08 PM documented, res sustained skin tear to left forearm by another res holding her arm. Skin tear measures 0.4 centimeters (cm) x 0.3 cm. Area cleansed with NS (normal saline), steri strips applied. All parties notified. No documentation of a bruise on R7's left forearm. 2. R8's Undated Face Sheet, documents she was initially admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and mood disorder. R8's Quarterly MDS, dated [DATE], documents R8 is severely cognitively impaired, wanders daily, has disorganized thinking, inattention, altered level of consciousness, physical and verbal behaviors towards others occurred 4-6 days, other behaviors not directed towards others occurred 4-6 days and rejects care 1-3 days.R8's Nursing Progress Note, dated 7/29/2025 at 9:42 PM documented, res noted in another res room. Res confused and disoriented. When res asked him to leave out of room, he grabbed her left arm and held on to it causing a skin tear. Res requested assistance from staff to have him assisted out of room. Res taken to room & placed in bed. All parties have been notified.On 8/12/2025 at 1:35 PM, R7 sat up in her wheelchair in her room and stated a few weeks ago at around 9:30 PM R8 was in her room, when she told R8 to get out of her room he walked up to her grabbed both her forearms, and he squeezed them to death, and it hurt bad. R7 stated she had a large bruise to her left forearm and a skin tear. R7 stated the skin tear bled down her arm. Resident pulled left sleeve up and noted steri- strips on her left forearm, no bruising noted. R7 stated it scared the h*** out of her, but she didn't cry. R7 stated when she sees R8 down her hall now, she has staff redirect him because she doesn't want to get hurt again. R7 stated she knows R8 has Alzheimer's disease but that she wishes staff would redirect him more often because he really scared her that day.On 8/19/2025 at 12:30 R8 was observed sitting in the dining room at the facility. R8 didn't respond to any of the IDPH surveyor's question, R8 just starred straight ahead. On 8/19/2025 at 1:00 PM V20, LPN stated R8 is not alert and has Alzheimer's disease. Staff try to keep an eye on R8 because he often goes in other residents' rooms and lays in empty beds. R7 reported to her one night that while attempting to redirect R8 out of her room, R8 grabbed R7's left forearm which caused a skin tear. V20 stated she reported the incident to V8, Regional Administrator but that she didn't think it was a resident-to-resident altercation, V20 thought it was just a skin incident. V20 didn't ask R7 if she was scared of R8 and didn't note her left forearm was bruised. On 8/12/2025 at 2:15 PM V1 Administrator, V8 Regional Administrator and V2 Interim DON stated they were not aware of any resident-to-resident altercations on 7/29/2025. V1 stated she would have expected staff to report what occurred so she can start an investigation as soon as possible and put an intervention in place to prevent it from occurring again. V8 stated he didn't view the incident as a resident-to-resident altercation, he viewed it more as an incidental contact between R7 and R8. V1, V2 and V8 stated they started a resident to resident abuse investigation when it was brought to their attention on 8/12/2025. The Facility's Elder Justice Act and Reporting Suspected Crimes Against Residents Policy & Procedure, initiated 10/1/2023, documents it is the policy of the facility to empower and enable all owners, operators, employees, agents or contractors of the facility to make reports to the relevant authorities pursuant to the provision of the Elder Justice Act (EJA) and CMS Residents Affected - Few (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 08/20/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm regulations. Within five working days of the incident, the facility will provide in a follow-up investigation report. This report will contain information from the resident's record, summary of other documents obtained, sufficient information to describe the results of the investigation, and indicate any corrective actions taken, if the allegation was verified, who investigated the incident, and who is submitting the report. Residents Affected - Few 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 08/20/2025 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 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 observation, interview and record review, the facility failed to order a abdominal ultrasound, urinalysis/culture and sensitivity in a timely manner for 1 (R4) of 3 residents reviewed for timeliness of care in the sample of 3. This failure resulted in a nonverbal resident (R4) being transferred to the emergency room and diagnosed with a impacted stool in the intestine that was digitally removed from her rectum, enema, IV hydration and intramuscular shot for the urinary tract infection and put on oral antibiotics. Using the reasonable person approach, this failure caused pain, discomfort and invasive interventions during a hospital visit. Findings include: R4's Undated Face Sheet documents she was initially admitted to the facility on [DATE] with diagnoses including cerebral palsy, constipation and GERD.R4's Care Plan, dated 3/31/2025 documents focus bowel and bladder incontinence. Interventions: record bowel movements, frequency, and consistency. Assess any signs of discomfort, burning or itching around anus, loss of appetite, etc. No documentation of R4's diagnosis of constipation was addressed/documented on her care plan. Another focus: R4 has a communication problem, she is nonverbal. Goal: R4 will feel heard and understood, as reflected in her body language and facial expressions. Interventions: encourage resident to continue stating thoughts even if resident is having difficulty. Focus on a word or phrase that makes sense or respond to the feeling resident is trying to express. Monitor/document for physical/nonverbal indicators of discomfort or distress and follow-up as needed. R4's Annual Minimum Data Set, dated [DATE] documents she is severely cognitively impaired, no constipation present, both sides functional impairment in range of motion, wheelchair for mobility device, doesn't ambulate, dependent on staff for toileting, incontinent of bowel and bladder. R4's Physician's Order Sheet (POS), dated 12/2/2021 MiraLAX 17 grams by mouth every day for constipation. 12/2/2021 Senokot S 8.6 milligrams/50 mg two times a day for constipation and 1/27/2025 Bisacodyl 1 suppository rectally at bedtime every other night for constipation. R4's Medication Administration Record (MAR) dated 8/2025 staff documented physician prescribed medications to treat constipation were administered as ordered. R4's POS, dated 8/4/2025, documents a urinalysis and reflex culture (no reason for order) and an ultrasound abdomen and pelvis indication: mass in lower left quadrant.R4's Bowel and Bladder document, dated 8/3/2025 through 8/14/2025 staff documented R4 had a small bowel movement on 8/3/2025, large bowel movement on 8/9/2025 and 8/11/2025 and a small bowel movement on 8/12/2025. R4's Nursing Progress dated 8/4/2025 through 8/7/2025 no documentation as to why a urinalysis and reflex culture was ordered and no documentation if either test was collected/completed. R4's Nursing Progress Note, dated 8/7/2025 at 1:33 AM, documents attempted to get urine per sterile technique without success. No documentation if the ultrasound abdomen and pelvis was completed. R4's Physician's Progress Note, dated 8/8/2025 at 7:00 AM documents urinalysis and reflex culture sent. R4's Medical Record dated 8/8/2025 through 8/11/2025 showed no urinalysis and reflex culture, or ultrasound abdomen and pelvis results were not uploaded in R4's Medical Record. R4's Physician's Progress Note, dated 8/11/2025 at 7:00 AM, documents the patient is a poor historian due to cerebral palsy and aphasia. The patient history is taken from her family and nursing staff. The patient has been restless and agitation for the past week. There was possible grimacing and complaint of pain witness by her family. Anxiety versus GI/GU (genitourinary/gastrointestinal) symptoms, continuing to await US (ultrasound) and UA (urinalysis)/UC (urine culture.) R4's Medical Record was reviewed for the UA/UC and abdominal/pelvic ultrasound on 8/12/2025 at 12:00 PM. The results were not uploaded in R4's electronic medical record at that time. On 8/12/2025 at 12:10 PM V1, Administrator and V2, Interim Director of Nursing stated he noted a day or so ago that R4's UA/UC was not collected yet and the abdominal/pelvic Residents Affected - Few (continued on next page) 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 08/20/2025 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 0684 Level of Harm - Actual harm Residents Affected - Few ultrasound was not completed yet and he had been on the phone with the ultrasound company all morning trying to figure out why it wasn't done yet. V2 stated the ultrasound company informed him that the physician's order verbiage was not correct, and it needed the word limited to be added to it so the ultrasound would be covered by insurance. V2 stated he didn't know why the physician ordered a UA/UC other than to rule out a UTI and the ultrasound abdomen/pelvis was ordered because R4's physician felt a mass in her abdomen. V2 wasn't aware the laboratory and ultrasound tests were not completed until the surveyor requested the test results, that's when he started making calls to see why the tests were not completed. V1 stated when a physician orders a lab test and/or an ultrasound she expects the UA to be collected and sent off to the lab the next day and if it was attempted to be collected and unsuccessful, the nurse should report that to the oncoming nurse and that nurse should attempt to collect the specimen. If there are any issues getting a specimen i.e. urine collected and/or issues with getting an ultrasound completed nurses should notify the resident's physician within 24 hours and update them on why the tests were not done. V1 stated it was a breakdown of communication between nurses as to why these tests were not completed in a timely manner. R4's Nursing Progress Note, dated 8/12/2025 at 2:16 PM staff documented company here to do abd (abdominal) x ray for a mass to left quad. At 2:50 PM, staff documented, attempted to obtain UA sample via straight cath per sterile technique. Attempt was unsuccessful. Evening shift nurse notified that sample is needing to be collected, verbally understood. At 9:21 PM, staff documented x ray results received and faxed to MD (physician.) At 9:34 PM staff documented, urine obtained & in fridge in med room. Lab req filled out & faxed to lab. Lab to p/u (pick up) urine in the AM (morning.)R4's Laboratory Report, dated 8/12/2025 documents urine specimen collected on 8/12/2025. UA results: pending. UC results: Escherichila Coli (E-Coli.) R4's Ultrasound Patient Report, dated 8/14/2025 documents pelvis ultrasound findings: images of the bladder are unremarkable. Left lower quadrant images are unremarkable as well. There is no evidence of mass, cyst or fluid collection. Impression: unremarkable examination. R4's Ultrasound Patient Report, dated 8/14/2025 documents abdomen ultrasound findings: trace amount of ascites is noted in the left lower abdomen/pelvis. Peristalsing bowel loops are noted in the left lower abdomen early in the exam, measuring up to 2.3 centimeters in diameter. No discrete mass is identified. Impression: slightly dilated peristalsing bowel loops in the lower left abdomen. Correlate for enteritis versus small bowel obstruction. R4's After Visit emergency room Summary, dated 8/15/2025 documents, reason for visit: abdominal pain. Diagnoses: impacted stool in intestine, UTI and constipation. Instructions: Evaluated in the emergency department today with primary concern of possible constipation. Your workup was concerning for UTI as well. Fecal disimpactation at bedside. Medications administered: Rocephin 1 gram injection (treatment of UTI), saline enema, sodium chloride 0.9% (intravenous fluid for hydration) and Iodamide. R4's POS, dated 8/15/2025, documents a new physician's order Cephalexin 500 mg twice a day for 7 days to treat UTI. On 8/19/2025 at 10:00 AM V1, Administrator and V2, DON stated R4 is a total care, she is incontinent of bowel and bladder and is dependent with all care and is nonverbal. V2 stated staff are expected to document when a resident has a bowel movement in the electronic medical record so they can ensure residents are not constipated. Staff documented R4 had a small bowel movement on 8/12/2025. R4 was transferred to the emergency room after R4's physician reviewed the abdominal ultrasound results on 8/15/2025 as she wanted to rule out a small bowel obstruction. The emergency room discharge paperwork documents she was impacted, and emergency room staff digitally removed the impaction at bedside. After an enema was administrated R4 had a large bowel movement, and she had another large bowel movement when she was readmitted to the facility. V2 stated R4 was also diagnosed a UTI and was administered an intramuscular shot of antibiotics in the (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 08/20/2025 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 0684 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete emergency room and is continuing by mouth antibiotics at the facility to treat the UTI. V2 stated R4 didn't have a bowel obstruction and the constipation was resolved immediately after the enema was administered in the emergency room. On 8/19/2025 at 10:40 AM V19, R4's physician stated she ordered the abdominal ultrasound on 8/42025 due to feeling a mass in her abdomen but she was more concerned with her having a UTI at that time. R4 is nonverbal and therefore she can't voice pain but when she assessed her on 8/42025 V19 felt R4 was either in pain or experiencing anxiety so she ordered a UA/C&S and an abdominal ultrasound for the mass felt in her abdomen that day. V19 stated the tests were not done in a timely fashion and stated she comes to the facility on Mondays and Fridays and she expected to have both test results back that Friday, 8/8/2025 but she spoke to the floor nurses who were agency staff and they told her the tests were completed but the results weren't in R4's electronic medical record and the medical records employee was on vacation at that time so she had issues getting the test results. After the abdominal ultrasound was completed, she reviewed the results the next day and stated she sent R4 to the emergency room to rule out a small bowel obstruction and stated she reviewed the emergency room records and it was determined R4 had impacted stool near the rectum which was digitally removed at bedside in the emergency room and R4 received an enema in the emergency room where she had 2 large stools right after. V19 stated it was determined that R4 has a UTI and she received an intramuscular shot of antibiotics in the emergency room and she is on a by mouth antibiotic at the facility to treat that. V19 stated she expected the facility to follow the policies and procedures to ensure physician ordered tests are completed in a timely fashion. On 8/19/2025 at 3:00 PM, V2 stated the facility doesn't have a policy or procedure that documents when a lab or ultrasound timeframe should be done. Event ID: Facility ID: 145518 If continuation sheet Page 7 of 7