Inspection·February 2, 2023

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to track the progression of a pressure ulcer for one resident (R6) of three residents reviewed for pressure ulcers in a sample of 15. Residents Affected - Few Findings include: The facility's Skin Assessment, Prevention and Care policy dated 5/2022 documents 2. Documentation including size, color, depth, tunneling present, exudates/drainage, pain association with the wound will be completed in the Electronic Health Record on the worklist. R6's medical record dated 8/25/22 documents Bottom wound pressure ulcer stage two. R6's medical record dated 9/7/22 documents Bottom wound pressure ulcer stage two R6's medical record does not document any measurements for her stage two pressure ulcer. R6's medical record documents R6 was discharged on 9/7/22 and returned 9/22/22. R6's re-admission skin assessment documents Left Upper buttocks shearing. On 02/01/23 at 2:20 PM, V3 (Minimum Data Set (MDS) Coordinator), stated The stage two pressure ulcer was found on 8/25/22 while she was here and still present when she was admitted downstairs on 9/7/22. It looks like she came back to us on 9/22/22 and at that time, the stage two had healed, and it was documented as shearing up until 11/27/22 when it is resolved. We didn't track (R6)'s wound measurements for her stage two pressure ulcer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145572 If continuation sheet Page 2 of 5 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 145572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Graham Hospital 210 West Walnut Street Canton, IL 61520 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview and record review, the facility failed to maintain the catheter drainage bag below the level of the bladder for one resident (R70) of five resident reviewed for catheters in a total sample of 15. Findings include: The facility's Indwelling Urinary Catheter policy dated 7/22 documents 8. When transporting patient, maintain position of drainage bag below the level of the patient's bladder. R70's physician order dated 2/2/23 documents Indwelling catheter for decubitus ulcer perineal area, incontinent patient. On 1/31/23 at 9:37 AM, V8 (Certified Nursing Assistant/CNA) stated I have to get (R70) ready for transportation to the wound clinic. On 1/31/23 at 9:39 AM, V2 (Director of Nursing/DON) entered the room and stated, I'll help you get (R70) ready. On 01/31/23 at 9:40 AM, V8 (CNA) observed preparing R70 for transportation to the wound clinic. V8 reached down, grabbed R70's catheter drainage bag and placed it on top of the resident's abdomen. V2 grabbed the catheter drainage bag and stated You can't do that. The bag has to be below the bladder. and hung the bag on the extension arm of the recliner where R70 is sitting. On 2/1/23 at 2:00 PM, V2 (DON) verified that the catheter drainage bag should not be raised above the level of the bladder and stated Yeah, I can't believe she did that. As soon as I saw her (V8 CNA) do that, I immediately grabbed it and placed it back down below the bladder. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145572 If continuation sheet Page 3 of 5 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 145572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Graham Hospital 210 West Walnut Street Canton, IL 61520 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on record and interview the facility failed to identify a specific diagnosis or behavior for psychotropic medication use for two residents (R2 and R10) and failed to limit an as needed psychotropic medication use to 14 days for one resident (R10) of 5 reviewed for unnecessary medication use in a total sample of 15. The Facility's Psychotropic Medication Use policy dated 4/2022 documents Residents of the facility who are prescribed a psychotropic medication will be monitored. The resident's need for the psychotropic medication will be monitored as wells as when the resident has received optional benefits from the medication and when the medication dose can be lowered or discontinued. The Facility's policy also documents Attending physicians must document that a psychotropic medication is necessary to treat a specific condition/behavior. Psychotropic medications include drugs from the following classes: hypnotics, antipsychotics, long and short-acting benzodiazepines, sedatives/anxiolytics and antidepressants. Behaviors for which these drugs are used must present a danger for others, interfere with staff's ability to provide care or cause the resident frightful distress due to paranoia, hallucinations or delusions. R2's Physician Order Sheet for January 2023 documents R2 takes Alprazolam 0.25 mg (Milligrams) twice daily for anxiety, Sertraline 100 mg daily for depression and Mirtazapine 7.5 mg daily for depression. R2's Medical Record does not include any listing of any identified behaviors for R2. On 2/1/23 at 11:00 AM V5 (Registered Nurse/RN) stated R2 did not have any behavior problems that she knew of. On 2/1/23 at 11:10 AM V6 (Certified Nurse Assistant/CNA) and V7 (CNA) both stated they were not aware of any behavior problems/behaviors to monitor with R2. On 2/2/23 at 8:00 A.M. V2 (Director of Nurses/DON) confirmed that R2 did not have any identified behaviors listed in her medical record for the use of the psychotropic medications. V2 stated (R2) shouldn't be on two antidepressants either. I don't know why she is. 2. The facility's Psychotropic Medication Use policy dated 4/22, documents 3. Both the medical staff and nursing shall evaluate the effectiveness of PRN (as needed) orders for psychotropic drugs within 14 days to manage behavior. R10's medication orders dated 1/16/23 documents Alprazolam (Xanax) 0.25 milligrams (mg) by mouth at bedtime PRN for anxiety and Alprazolam (Xanax) 0.25 mg by mouth every eight hours as needed for anxiety. R10's medication administration record documents R10 received Alprazolam 0.25 mg on 1/25/23 and 1/31/23. R10's medical record does not include a diagnosis of anxiety or rationale for the PRN Xanax 0.25 mg (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145572 If continuation sheet Page 4 of 5 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 145572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Graham Hospital 210 West Walnut Street Canton, IL 61520 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 0758 to extend beyond 14 days. Level of Harm - Minimal harm or potential for actual harm R10's medical record dated does not document an evaluation of the use of Xanax 0.25 mg for anxiety. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 02/01/23 at 01:12 PM, V2 (DON) stated (V9 Medical Director) won't write a stop date or rationale for the PRN psychotropics. The pharmacists has sent him notifications letting him know and I've sent him notification that we need a stop date or rationale for PRNs psychotropics, but he keeps putting indefinite on the orders without a rationale. He hasn't responded to any of my, or the pharmacists, notifications about it. This has been an ongoing issue with him. Event ID: Facility ID: 145572 If continuation sheet Page 5 of 5