Inspection·December 18, 2024

F 0646 Level of Harm - Minimal harm or potential for actual harm R2's Progress Notes dated 12-12-24 and 12-13-24 document R2 was complaining of having dust in her eyes. R2's Physician's Order dated 12-11-24 and signed by V7 (Physician) documents, Zyprexa (anti-psychotic medication) 2.5 mg (milligrams) daily for the diagnosis of Refractory Depression with Psychotic Symptoms. Residents Affected - Few R2's Medical Record documents the most recent PASRR Level I screen was obtained on 2-2-23. R2's Medical Record does not include evidence of the facility referring R2 to the PASRR State Agency to obtain a Level II PASRR once R2 started exhibiting new behavioral symptoms on 11-30-24 and was ordered Zyprexa to treat the new diagnosis of Refractory Depression with Psychotic Symptoms on 12-11-24. On 12-16-24 at 2:30 PM V1 (Administrator) stated, I am responsible for requesting PASRR screenings. I have not requested a level II PASARR to be done for (R2) since (R2) started exhibiting new behaviors and was started on Zyprexa. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145572 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 145572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R9's current medical record documents R9's Diagnoses to include: Generalized Weakness, Gait Instability, Fall, Urinary Tract Infection and Osteoporosis. R9's Minimum Data Set Assessment (dated 11/13/24) documents the following: R9 requires substantial/maximal assistance putting on/taking off footwear; and requires partial/moderate assistance with shower/bathing, upper body dressing and lower body dressing. On 12/16/24 at 01:45 PM, V15 (R9's daughter) stated, They talked about starting some type of exercise program to maintain her mobility. I am not sure if they have started anything yet, but it has been discussed. R9's current Impaired Mobility care plan documents the following restorative programs in place: Walking and Dressing. R9's Restorative Program Logs for Dressing and Walking (dated 11/01/24 - 12/18/24) contain 42 days with no documentation of completion during this time frame. On 12/18/24 at 08:45 AM, V2 (Director of Nursing) stated that the facility currently has no restorative aide and confirmed R9's restorative programs have not been getting completed. 5. R13's medical record document R13's Diagnoses to include: History of CVA (Cerebrovascular Accident) with residual defect, Right Hemiplegia, Generalized Weakness, Vertigo and Balance Disorder. R13's Minimum Data Set Assessment (dated 10/16/24) documents the following: R13 has impairment on one side of her upper extremities and utilizes a walker. This same assessment documents R13 is dependent with toileting hygiene, lower body dressing and putting on/taking off footwear; and R13 requires substantial/maximal assistance with shower/bathing, upper body dressing and personal hygiene. On 12/16/24 at 09:40 AM, R13 was sitting upright in her recliner and stated she has weakness in her right arm after having a stroke. R13 stated, I have my good days and my bad days. I wish they would exercise me more. I was receiving therapy and after they said I was finished; I haven't done anything since. R13 stated staff does not assist her to complete any type of daily range of motion/restorative exercises. On 12/16/24 at 03:15 PM, V6 (Registered Nurse) stated R13 is not on any type of range of motion/restorative program, I think she was given exercises to do, and she does not do them. R9's current Impaired Mobility care plan documents the following restorative programs in place: Walking and Hygiene. R9's Restorative Program Logs for Personal Hygiene and Walking (dated 11/01/24 - 12/18/24) contain 42 days with no documentation of completion during this time frame. On 12/18/24 at 11:30 AM, V2 (Director of Nursing) stated R13's restorative exercises have not been getting completed, and V2 verified that R13 does not have any type of range of motion programming in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145572 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 145572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2024 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 0688 place. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to develop and implement restorative programming for five of six residents (R5, R9, R11, R13, and R15) reviewed for limitations in range of motion in the sample of 21. Residents Affected - Some Findings include: The facility's Restorative Activity Aide Job Description (undated) documents, The restorative aide will perform specialized restorative nursing and activities of daily living activities for residents, assess and documents the resident's response and assist the nursing staff as directed. Primary Duties and Responsibilities: 1. Is responsible to perform specific restorative nursing procedures. (Example: Exercises, ambulation, and assistance with ADLs (Activities of Daily Living), to residents as directed by the MDS (Minimum Data Set) Coordinator. 2. Is responsible to keep daily performance records on residents receiving restorative nursing procedures. Reporting to MDS Coordinator daily refused treatments, omitted treatments, or other adverse observations. 3. Is responsible to document weekly progress notes and present them to the MDS Coordinator for review. 9. Assists residents with range of motion exercises, walking, and other therapies as ordered. 1. R5's MDS (Minimum Data Set) Assessments dated 11-6-24 and 8-6-24 documents R5 is severely cognitively impaired, has an impairment in range of motion to one side of the lower extremity, and does not receive passive or active range of motion restorative programs or therapy. R5's current Impaired Mobility Care Plan documents, Outcome: (R5) will improve right knee range of motion through the next review date. Approach: (R5): Actively assist (R5) to perform ten repetitions of range of motion to both knees at least twice daily while sitting in wheelchair. R5's Restorative Active Range of Motion Program logs dated 10-1-24 through 12-18-24 documents, Problem: Impaired mobility due to Parkinsonism and past right hip fracture as evidenced by weakness, stiffness, and limited mobility. Approach: Actively assist (R5) to perform ten repetitions of range of motion to both knees at least twice daily while sitting in wheelchair. Stretch his right leg after range of motion by placing right heel on chair in front of him for five minutes. These same logs document R5 has not received range of motion as directed for 53 days between 10-1-24 through 12-18-24. On 12/16/24 at 11:03 AM V8 (R5's Family Member) stated, I visit (R5) every other day. I have never witnessed the staff do range of motion with (R5). (R5) fell and broke his femur in the past. I would like the staff to do range of motion with (R5) to help (R5) gain strength. 2. R11's MDS assessment dated [DATE] documents R11 is cognitively intact, has impairments in range of motion of both sides of the lower extremities, and does not receive passive or active range of motion restorative programs or therapy. R11's current Impaired Mobility Care Plan documents, Outcome: (R11) will maintain lower extremity range of motion to prevent hip and knee contractures through the next review date. Intervention: Perform range of motion to exercises eight to ten repetitions of range of motion to both shoulders, elbows, wrists, hips, knees, and ankles at least twice daily. R11's Restorative Active Range of Motion Program logs dated 10-1-24 through 12-18-24 documents, Problem: Impaired mobility due to arthritis, diabetes and neuropathy as evidenced by weakness, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145572 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 145572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some inability to stand, and limited mobility. Approach: Actively assist (R11) to perform eight to ten repetitions of range of motion to both shoulders, elbows, wrists, hips, knees, and ankles at least twice daily. These same program logs document R11 has not received range of motion as directed from 10-25-24 to 12-18-24. On 12/26/24 at 10:45 AM R11 was sitting in a high back padded wheelchair in the dining room. R11 stated, I do not get exercises daily. I cannot move my legs that well and cannot walk. 3. R15's current Diagnosis Report documents R15 has the diagnoses of abnormalities of gait and mobility, presence of a right artificial knee joint, and a fracture of the shaft of the humerus, left arm, and sequela. R15's MDS Assessments dated 7-9-24 and 10-8-24 document R15 is cognitively intact, has impairments in range of motion to one side of the upper extremity and to both sides of the lower extremities, and does not receive passive or active range of motion restorative programs or therapy. R15's current Care Plan does not include interventions to address R15's limitations in range of motion. On 12/17/24 at 08:35 AM R15 was sitting in a recliner in her room with a right sided walker at her right side and her left arm lying next to her left side. R15's left arm was flaccid. R15 stated, I had breast cancer and had my left breast and left lymph nodes in my left arm removed. I cannot lift my left arm. Staff do not do any exercises (range of motion) with me. On 12/17/24 at 2:00 PM V2 (Director of Nursing) stated, (R15) does not have a restorative range of motion plan or program to address her limitations in range of motion. (R5 and R11) are not receiving their range of motion programs twice daily. We (the facility) have not had a restorative aide to do restorative programs for quite some time. I hired a restorative aide (V14) and she quit while still in orientation. Restorative programs are lacking here (the facility). On 12/18/24 at 9:00 AM V1 (Administrator) stated, We (the facility) use the restorative aide job description as the policy for performing restorative programs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145572 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 145572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2024 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 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. Based on observation, interview and record review, the facility failed to use temperature testing strips to ensure dishes reach the required surface temperature during the rinse cycle in the dish machine, failed to ensure hanging light covers over the kitchen's fryer baskets were clean and free of debris and grime, and failed to complete and record cool down temperatures for prepared meats and leftover items that were prepared ahead and stored in the facility's refrigerator and freezer for future use. These failures have the potential to affect all 22 residents residing in the facility. Findings include: 1.) The facility's Washing and Storage of Dishes and Utensils policy, dated 4/2024, documents The dish machine water temperatures are as follows: Wash cycle: 150 to 165 degrees. Rinse cycle: 160 to 180 degrees. Final Rinse cycle: 180 to 195 degrees. If the proper temperatures are not met, the management team is notified. On 12/16/24 at 10:20 AM V5 (Dietary Manager) ran a temperature test cycle on the facility's dish machine. V5 stated the facility's dishwasher is a high temperature machine and has to reach a temperature of 185-200 degrees. V5 stated the kitchen staff check the temperature on this machine everyday by the gauge on the outside of the machine. V5 stated They record the temperature on the outside to ensure its correct. We do not use the test strips anymore or run anything through the cycle to check the surface temperature. We used to do that but have not used those in a while. I have a few strips, but staff do not use them. On 12/18/24 at 8:58 AM V11 (Director of Plant Operations) provided the facility's dishwasher manual. V11 stated They (dietary staff) should be checking the water cycle temperature with the strips they can run through the machine every day. The strips turn black when the water gets to the correct temperature. They should be checking that daily and I am not sure why they would've stopped. 2.) The facility's Patient [NAME] Cleaning Checklist dated 12/15/24-12/28/24, documents multiple areas in the kitchen that are to be cleaned by kitchen staff but does not include a cleaning schedule for lights located above the kitchen's fryer baskets. On 12/16/24 at 10:15 AM, two hanging lights with black metal grids over the bulbs, located under the kitchen's fryer hood, both were coated with grease and caked on grime containing small fuzzy hair like fibers and debris. Both lights hang directly over the fryer baskets used to prepare food. At this time V5 (Dietary Manager) stated the stove hood and fryer hood are cleaned by an outside cleaning company. On 12/17/24 at 11:20 AM, both lights above the kitchen's fryer baskets were noted to still contain caked on debris and hair like fuzz. On 12/17/24 at 11:25 AM, V5 confirmed the lights above fryer baskets are caked with debris and stated I am not sure who cleans the lights over the fryer. We (kitchen staff) usually come in and those things are just clean. On 12/18/24 at 8:58 AM V11 (Director of Plant Operations) stated The hood above the stove and the fryer are cleaned every four months by (a contracted cleaning company). The lights above the fryers (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145572 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 145572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many are not a part of that cleaning process so I would say those would need cleaned by the (facility's) kitchen staff. 3.) The facility's Patient Food Services policy, dated 7/2024, documents Purpose: To assure proper and safe food handling, storage, delivery and preparation. This same policy documents Proper heating and cooling temperatures are followed using the HACCP (Hazard Analysis and Critical Control Point) procedure on the recipe. The facility's (undated) HACCP Cooling log documents Daily cooling log for hot potentially hazardous foods. From 135 degrees to 70 degrees within two hours and 70 degrees to 40 degrees or below in an additional four hours. Take corrective action immediately if food is not chilled from 135 degrees to 70 degrees within two hours. Take immediate corrective action if food is not chilled from 135 degrees to 40 degrees within the six-hour cooling process. This log documents blank areas for facility kitchen staff to record the date, time, food item, starting temperature, first reading (temperature) within two hours and second reading less than four hours from the first reading. On 12/16/24 at 10:10 AM, the facility's walk-in refrigerator and freezer contained several metal pans covered with aluminum foil and food labels including but not limited to Beef tamale pie, Taco meat, Chicken and wild rice soup, Meatloaf, Turkey, and Roast Beef. At this time V5 (Dietary Manager) stated they do not keep a cool down log for hot foods when placing them in a cooler or freezer. V5 stated The freezer food is mostly leftovers that we can make into pureed foods. When we cook a turkey, it will be cooked, placed in the cooler to cool down then sliced and placed in the freezer. We do not have any cool down logs to show the temperatures of these foods in the cooling process. I think we did that at one time, and it's been something that we went away from or stopped for some reason. Any leftovers or cooked items that are placed in the fridge or freezer do not have cool down logs. We don't do those and haven't for a while. The facility's Long Term Care Application for Medicare and Medicaid dated 12/16/24 and signed by V1 (Administrator) documents 22 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145572 If continuation sheet Page 7 of 7