Health inspection·June 20, 2023

F 0684 Level of Harm - Actual harm Residents Affected - Few shirt, socks, and no shoes. He didn't have on any oxygen. His daughter came to nurses' station. She asked me to go to her father's room and check on him. I went into his room to help her get him situated, although I was assigned to C hall. He was laying horizontal on his bed. His roommate R4 was screaming for Norco, but the nurse for that hall didn't show up. So, I told the Corporate Staff in the facility. V6 (former Director of Nursing), sent V7 (RN) over to give R4 his medications. V8 was the CNA on that hall. The rest of the patients on that hall did not get their medications either. V7 (RN) was over there around 3pm or 4pm because R4 had been putting on his call light since 2:30 PM for Norco. On [DATE] I went into R2's room he didn't have on oxygen, and the oxygen level was 74, and he had to be sent out to the hospital. On [DATE] at 11:15 AM V2 (Director of Nurses/DON) stated it depends on the resident and clinical condition. If the oxygen saturation is in the 80's, they should call the doctor, and if they are symptomatic, they should send them out right away. On [DATE] at 1:35 PM, V7 (RN) stated, I am familiar with (R2), but I do not normally work with him. On [DATE] I was working the C Hall, it was before 6:30 PM. Some of the nurse aids told me they found (R2) unconscious. We started CPR (cardiopulmonary resuscitation) and called all for initial support. We did not know that no nurse was working the A hall until this happened. There was no nurse working the A hall when (R2) coded. On [DATE] at 10:02 AM, staffing schedules for [DATE] was requested. There were two nurses on the A Hall and B hall that were crossed off and V14 was documented, as a call off. The only nurse not crossed off on the schedules was documented as V7 (Registered Nurse/RN). V13, V15, V7 were the nurses documented as working after the cross outs on the form. On [DATE] at 1:30 PM V8 (Human Resources/CNA) stated, there were three nurses in the building, and they were to split A-hall. I don't know what rooms they were assigned. Around dinner time which is between 5:45 to 6 PM R2 ate a little because V9 (CNA) fed him. Around 6:30 PM I was collecting trays, I looked into R2's room and say he was unresponsive. I went into R2's room and rubbed his chest twice and then called his name out twice. I went out and I called V7 that was the first nurse I saw. V7 walked up to R2 and started CPR. It was noted that there were no meds passed on this A-hall and the nurses did not divide the hall and care for the 23 residents, there was CNAs that were caring for residents. On [DATE] at 9:00 AM V11 (Medical Director) stated, he (R2) had just returned from the hospital, and he should have been checked on frequently. The vital signs are important, but checking on him was most important, and it could have contributed to him coding. On [DATE] at 1:54 PM the facility, only provided a notification of change of condition policy. Not a change of condition policy. The Facility Policy entitled notification of change of condition dated [DATE] documents, it is the responsibility of the charge nurse to notify the family, DON (Director of Nursing), and Physician of any change in resident condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145571 If continuation sheet Page 2 of 6 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 145571 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Ridge Health & Rehab Ctr One Perryman Street Lebanon, IL 62254 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure there were sufficient nursing staff for monitoring residents for one of three residents (R2) reviewed for monitoring in the sample of 17. This failure resulted in R2 being sent back to the hospital after being found unresponsive with no heartbeat, spontaneous respirations, and blood pressure. Findings include: On [DATE] at 10:02 AM, staffing schedules for [DATE] was requested. There were two nurses on the A Hall and B hall that were crossed off and V14 was documented, as a call off. The only nurse not crossed off on the schedules was documented as V7 (Registered Nurse/RN). V13, V15, V7 were the nurses documented, as working after the cross outs on the form. On [DATE] at 11:20 AM V4 (Certified Nursing Assistant/CNA) stated, On [DATE] (R2) was found on the bed with no shirt, socks and no shoes. He also didn't have on any oxygen on. His daughter came to nurses' station I was there charting. She asked me to go to her father's room. I went in to help her get him situated although I was assigned to C hall. He was also laying horizontal on his bed. His roommate (R4) was screaming for Norco, but the nurse for that hall (A Hall) didn't come, show up. So, I told the corporate person and V6 (former Director of Nursing) sent V7 (Registered Nurse/RN), over to give his medications. V8 was the CNA on the hall. The rest (of the patients) did not get medications. V7 was over there around 3 or 4 because (R4) had been putting on his call light since 2:30 PM for Norco. (R2) is not on a low air mattress so he should have had linen on his bed. On [DATE] I went into (R2's) room (R2) didn't have on oxygen, and the oxygen level was 74, and he had to be sent out to the hospital. (R2) has a history of taking off his oxygen. On [DATE] at 1:30 PM V8 (Human Resources/CNA) stated, there were three nurses in the building, and they were to split A-hall. I don't know what rooms they were assigned. Around dinner time which is between 5:45 to 6 PM R2 ate a little because V9 (CNA) fed him. Around 6:30 PM I, V8, was collecting trays, I looked into R2's room and say he was unresponsive. I went into R2's room and rubbed his chest twice and then called his name out twice. I went out and I called V7 that was the first nurse I saw. V7 walked up to R2 and started CPR. On [DATE] at 1:35 PM, V7 (RN) stated, I am familiar with (R2), but I do not normally work with him. On [DATE] I was working the C Hall, it was before 6:30 PM. Some of the nurse aids told me they found (R2) unconscious. We started CPR (cardiopulmonary resuscitation) and called all for initial support. We did not know that no nurse was working the A hall until this happened. There was no nurse working the A hall when (R2) coded. On [DATE] at 2:49 PM, V2 (Director of Nursing) stated, (R2's) family was upset because, they felt he was not being taken care. I believe there was an issue with staffing that day when (R2) passed away, On [DATE] at 2:04 PM, V15 (Licensed Practical Nurse/LPN) stated, They called me in to work that day Sunday, [DATE], because they were short staffed. I worked the B hall that night. I am not sure how many other nurses were working that day we try and have four nurses. I cannot say for sure how many nurses were there that day. I did not work the A hall; I only worked the B hall. I do not go by the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145571 If continuation sheet Page 3 of 6 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 145571 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Ridge Health & Rehab Ctr One Perryman Street Lebanon, IL 62254 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 0725 name (V16) that is a different person. V15 was written in as working the B hall. Level of Harm - Minimal harm or potential for actual harm R2's Nurses Note dated [DATE] at 4:30 AM, documents received this resident back from the ER (emergency room). Accompanied by 2 EMTs transferred from wheelchair to bed with 2 assists. Resident A&O (alert and oriented) x1. 02 saturation at 89% on room air. R2's Nurse's notes does not document that Director of Nursing manager was alerted that R2's oxygen was only at 89%. Residents Affected - Some The Facility Assessment with a revision date of [DATE] documents, it is the facility practice to provide sufficient staff with the appropriate competencies and skill sets to provide care and service to attain or maintain the highest, practical physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnosis of the facility population. Daily staffing is determined by Nursing Administration and Administrative leadership utilizing various reports to analyze the number of patients, velocity of expected of expected admissions and discharges, diagnosis, the types of tasks and serviced required of nursing, nursing assistants, and other ancillary personnel. On [DATE] at 1:10 PM, V1 (Administrator) stated, We do not have a policy on staffing. The Facility's Resident Census and Conditions of Residents form, CMS 672, dated [DATE] documented the facility had a census of 98 residents. Facility Matrix shows 23 residents residing on A-hall. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145571 If continuation sheet Page 4 of 6 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 145571 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Ridge Health & Rehab Ctr One Perryman Street Lebanon, IL 62254 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 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review the facility failed to provide medications in a timely manner for 3 of 3 residents (R1, R2, R3) reviewed for medication administration in the sample of 16. Residents Affected - Few Finding Include: R1's Medication Administration Record (MAR) for the month of June documents that on 6/4/23 R1 did not receive Ferrous Sulfate 325mg (milligrams) Three Times a Day (TID) in the evening, Omeprazole 20mg twice daily (BID), and Gabapentin 100mg every evening at 5:00PM. R2's MAR for the month of June documents that R2 did not receive his Doxycycline 100mg at 5:00 PM on 6/4/23. R3's MAR for the month of June documents, R3 did not receive Duloxetine 30mg at 5:00 PM and Gabapentin 100mg at 5:00PM. On 6/16/23 at 1:00 PM R1 stated on 6/4/23 she did not receive her medications until 10:30 PM. On 6/15/23 at 2:15 PM R3 stated, on 6/4/23 they were very late getting their evening medications, and there was only one CNA on their hallway. The facility policy entitled Medication Administration Policy/Procedure dated 9/27/22 documents medications will be administered safely to residents within the facility by licensed nurses at the specified time/time frame. Following the recommended administration method and will be documented as required. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145571 If continuation sheet Page 5 of 6 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 145571 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Ridge Health & Rehab Ctr One Perryman Street Lebanon, IL 62254 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to administer significant medications in a timely manner for 2 of 3 (R1, R3) residents reviewed for significant medications in the sample 16. Residents Affected - Few Findings Include: R1's Medication Administration Record (MAR) for the month of June documents, that R1 didn't receive her 5:00 PM and her evening medications on 6/4/23. R1's 5:00 PM and evening medications were Carvedilol 6.25mg twice daily (BID) and Metformin 500mg at 5:00 PM. R3's MAR documents R3 receives Carvedilol 12.5mg at 5:00 PM, Klor-Con 10 Milliequivalents every evening, and Furosemide 20 MG BID in the evening. On 6/16/23 at 1:00 PM R1 stated, on 6/4/23 she did not receive her medications until 10:30 PM. On 6/15/23 at 2:15 PM R3 stated, on 6/4/23 they were very late getting their evening medications, and there was only one CNA on their hallway. On 6/20/23 at 1:00 PM (V19) Consulting Pharmacist stated the Metformin, Carvedilol, Klor-Con and Furosemide would all be significant. They should be given as ordered so the blood levels of the medication would not drop. The facility policy entitled Medication Administration Policy/Procedure dated 9/27/22 documents medications will be administered safely to residents within the facility by licensed nurses at the specified time/time frame. Following the recommended administration method and will be documented as required. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145571 If continuation sheet Page 6 of 6