Health inspection·January 2, 2024

F 0609 investigation of cause of these bruises or notification of Administrator, Family or Doctor. Level of Harm - Minimal harm or potential for actual harm R20's Progress Note dated 12/27/2023 at 12:21 PM documents, Skin/Wound Note (HC): resident has a discoloration line from her right groin around her right buttock from her brief. hospice notified and new orders to cleanse area with NS (normal saline) or WC (wound cleanser), apply Calmoseptine and leave open to air, do not strap on brief. Monitor for s/s (signs and symptoms) of infection and notify md (medical doctor) if present. POA (Power of Attorney) and physician notified. There was no documentation of the bruises to R20's left groin and left buttock. Residents Affected - Few 2. R21's Face Sheet documents her diagnoses to include Anemia, Hypertension, End Stage Renal Disease, Diabetes Mellitus, Hyperlipidemia, Alzheimer's Disease, Anxiety, and Depression. R21's MDS dated [DATE] documents she is severely cognitively impaired, dependent on staff for all Activities of Daily Living (ADLS). It documents staff propel her in her w/c and she is always incontinent of bowel and bladder. Per the assessment, R21 had no pressure ulcers or falls during this assessment look back. R21's Progress Note dated 12/14/23 at 5:42 PM documents, Checked resident blood sugar @4:32 PM level at 548. 15 units given per sliding scale, rechecked at 5:40 PM level at 529. Called (V28, Medical Doctor), per phone order he directed this nurse to give resident 8 units of lispro and recheck blood sugar in 2 hours. This nurse repeated order back to physician and he confirmed. Also notified physician of patient having edema on right leg and bruising under left breast that appears dark purple. Resident leg and left arm are in pain when moved. Will continue to monitor resident, she is in bed with call light in reach. There is no documentation of notification of Administrator regarding bruise of unknown origin under R21's left breast. On 12/26/23 at 9:36 AM, V31, Hospital Wound Nurse stated R21 had been discharged from the hospital on [DATE] and readmitted to the hospital on [DATE]. V31stated there were pictures taken in the hospital of a bruise on R21's left lateral breast that were taken on 12/16/23. V31 stated it was more on the rib side of breast. V31 stated there were also pictures of bruises on R21's labia on 12/18/23, two days after she was admitted to the hospital. V31 stated the facility did not send any information regarding bruises or pressure ulcers when resident was admitted to hospital on [DATE]. V31 stated R21 was admitted with COVID and Altered Mental Status. V31 stated she saw R21 on 12/18/23 in the afternoon and saw deep purple-red bruises on R21's labia about a third of the way down her labia, area behind her vagina, up to rectum and some bruising around her rectum. V31 stated there was an area about midway down her thigh that could have been an abrasion that could have been from picking or if her diaper had been on too tight. V31 stated when she was trying to look at the bruises, R21 kept trying to pull the blanket back up and stated she has had other residents/patients do this when being examined and could be s/s of trauma or not. On 12/26/23 at 12:44 PM, V6, Director of Nursing (DON) stated she does not have any other abuse investigations or investigations of bruises of unknown origin in the last three months besides a resident-to-resident altercation between R29 and R30. The investigation regarding possible sexual abuse towards unknown resident by unknown staff that was reported to her on 12/21/23 by a surveyor. On 12/27/23 at 11:55 AM, V6, DON and V25, MDS Coordinator came in to talk to writer and had V1, Administrator on speaker phone on V6's cell phone. V1 stated the bruise on R21's breast was not reported to either of them or V2, Assistant Director of Nursing (ADON). V1 stated if it had been reported she would have sent in the initial report to IDPH (Illinois Department of Public Health (IDPH) and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145585 If continuation sheet Page 2 of 20 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 145585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Caseyville Nursing & Rehab Ctr 601 West Lincoln Avenue Caseyville, IL 62232 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 0609 started the investigation immediately. V1 stated any bruise of unknown origin is treated that way. Level of Harm - Minimal harm or potential for actual harm On 12/27/23 at 1:30 PM, V6 DON stated, We did have a report of bruises of unknown origin today for (R20) today and have sent the report and started an investigation. V6 stated the police and MD were notified. This investigation was started two days after the bruises were first documented in R20's progress notes on 12/25/23. Residents Affected - Few On 12/27/23 at 5:45 PM, V27 Licensed Practical Nurse (LPN) stated she documented a bruise was noted on R21's breast on 12/14/23. V27 stated a CNA was changing R21 and saw the bruise and reported this to V27. V27 stated V6 (DON) was working, and she asked her to look at the bruise and stated they went in and looked at it together. V6 stated she could tell the bruise was old by the color of it. V27 stated she did a full body assessment at the time and there were no other bruises noted. V27 stated she reported the bruise to V28, MD but he didn't really address it because he was more concerned with R21's high blood sugar readings and addressed those but disregarded the report of the bruise. V27 stated she is a new nurse, having just completed her boards in October, and that is why she asked V6 to assess the bruise on R21's breast because V6 had more experience. V27 stated R21 did appear to have pain with movement of her arm and leg so they took precautions of not lifting her arms during care. On 12/28/23 at 9:00 AM, V6 DON stated she does not remember the nurse showing her the bruise on R21's breast on 12/14/23 but stated she is not stating it didn't happen, she just doesn't remember because she has been so busy. V6 stated if she did see it she should have reported it to V1 immediately and an investigation should have been started right away. On 12/28/23 at 9:24 AM during phone interview, V29, CNA stated she did see bruise on R21's breast and on her right side above her hip, under her arm. V29 stated she did not see any bruises in R21's vaginal area or rectal area. V29 stated she did not remember exact date, but it was on 2 PM to 10 PM shift and she reported it to the nurse (could not remember her name). V29 said she and another nurse went to assess R21. V29 stated nobody asked her anything about it since she first reported it to the nurse. The facility's policy, Reporting of Abuse, Neglect, Theft and Crimes revised 2/2023 documents, Policy: It is the policy of this facility to establish internal reporting guidelines for facility staff in the event they become aware or formulate a reasonable suspicion that abuse, neglect, mistreatment, including injuries of unknown source, exploitation, theft or a crime has been committed against a resident of the facility. Policy Guidelines and Interpretation: 1. Internal Reporting: a. All covered individuals are required to immediately report any occurrences of potential mistreatment, abuse, neglect, mistreatment, including injuries of unknown source, adverse events, exploitation, theft, or crimes committed against a resident that they observe, hear about, or suspect to the administrator or to an immediate supervisor who must then immediately report it to the administrator. In the absence of the administrator, reporting can be made to an individual who has been designated to act as administrator in administrator's absence. External Reporting: a. Upon receipt of an allegation or upon the formulation of a reasonable suspicion that abuse, neglect, mistreatment, including injuries of unknown origin, exploitation, theft or that a crime has occurred against a resident, the facility Administrator or his/her designee will initiate external reports to the following: i. the Department: 1. The Administrator or his/her designee will immediately contact the department. ii. Law Enforcement: The facility will immediately contact local law enforcement authorities in the following situations: 2. Sexual abuse of a resident or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145585 If continuation sheet Page 3 of 20 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 145585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Caseyville Nursing & Rehab Ctr 601 West Lincoln Avenue Caseyville, IL 62232 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 0609 the reasonable suspicion that sexual abuse has been committed by a staff member, another resident, or a visitor. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145585 If continuation sheet Page 4 of 20 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 145585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Caseyville Nursing & Rehab Ctr 601 West Lincoln Avenue Caseyville, IL 62232 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 observation, interview and record review, the facility failed to operationalize their abuse policy and thoroughly investigate bruises of unknown origin for 2 of 4 residents (R20 and R21) reviewed for abuse in the sample of 30. Residents Affected - Few Findings include: 1. On 12/27/23 at 10:06 AM, V20 Certified Nursing Assistant (CNA) and V21 CNA provided incontinent care for R20 who had been incontinent of urine and feces. They unfastened R20's adult diaper and V21 used disposable wipes to wash away feces from R20's labia, groin and inner thighs. After feces was removed, there were two curved deep purple lines on her inner thighs where the diaper's elastic had been. It was bruised and did not fade after diaper removed. They then rolled R20 onto her right side and V21 cleansed the feces from her buttocks and rectum. After feces was removed there were two more easily visible dark purple linear bruises on R20's right and left lower buttocks where the elastic from the diaper was. These were bruises and did not fade after diaper removed. V21 stated, Those are from the diaper being too tight. I am leaving the diaper off and am going to report them to my charge nurse and the wound nurse. I am not going to put any cream on them until they look at these bruises because they won't be able to see them good with the cream on them. She doesn't need to be wearing a diaper and I am only going to leave the pad under her. R20's Face Sheet documents her diagnoses to include Rectal Cancer, Chronic Obstructive Pulmonary Disease, Anxiety, and Alcohol Abuse. R20's Minimum Data Set (MDS) dated [DATE] documents R20 is moderately cognitively impaired, has impaired range of motion to both lower extremities, is dependent on staff for toileting and transfers and assist with bed mobility, and is incontinent of bowel and bladder. R20's undated Care Plan documents: (R20) is at risk for skin breakdown and/or pressure ulcer formation d/t (due to) decreased mobility and bowel incontinence. No reddened or opened areas noted at present. Goal: will remain free of reddened or open areas through next review date. Interventions: Assist with T&P (Turning and Positioning) Q (every) 2 hrs. while in bed for pressure relief. Barrier cream after each episode to peri-area. Cushion to wheelchair. Pressure relief mattress to bed. Prompt incontinent care after each episode. Skin checks weekly. R20's Progress Note dated 12/25/2023 at 12:49 PM documents, C hall CNA report bruise this shift. Resident has bruise to the inner thigh left and right /front to back red in color shape of a line. Look like it may been produced by pulling of a depend. three small bruises on back red in color. Wound nurse made aware and ADON (Assistant Director of Nursing). There was no documentation of investigation of cause of these bruises or notification of Administrator, Family or Doctor. R20's Progress Note dated 12/27/2023 at 12:21 PM documents, Skin/Wound Note (HC): resident has a discoloration line from her right groin around her right buttock from her brief. hospice notified and new orders to cleanse area with NS (normal saline) or WC (wound cleanser), apply Calmoseptine and leave open to air, do not strap on brief. Monitor for s/s (signs and symptoms) of infection and notify md (medical doctor) if present. POA (Power of Attorney) and physician notified. There was no documentation of the bruises to R20's left groin and left buttock. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145585 If continuation sheet Page 5 of 20 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 145585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Caseyville Nursing & Rehab Ctr 601 West Lincoln Avenue Caseyville, IL 62232 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 Residents Affected - Few 2. R21's Face Sheet documents her diagnoses to include Anemia, Hypertension, End Stage Renal Disease, Diabetes Mellitus, Hyperlipidemia, Alzheimer's Disease, Anxiety, and Depression. R21's MDS dated [DATE] documents she is severely cognitively impaired, dependent on staff for all Activities of Daily Living (ADLS). It documents staff propel her in her w/c and she is always incontinent of bowel and bladder. Per the assessment, R21 had no pressure ulcers or falls during this assessment look back. R21's Progress Note dated 12/14/23 at 5:42 PM documents, Checked resident blood sugar @4:32 PM level at 548. 15 units given per sliding scale, rechecked at 5:40 PM level at 529. Called (V28, Medical Doctor), per phone order he directed this nurse to give resident 8 units of lispro and recheck blood sugar in 2 hours. This nurse repeated order back to physician and he confirmed. Also notified physician of patient having edema on right leg and bruising under left breast that appears dark purple. Resident leg and left arm are in pain when moved. Will continue to monitor resident, she is in bed with call light in reach. There is no documentation of notification of Administrator regarding bruise of unknown origin under R21's left breast. On 12/26/23 at 9:36 AM, V31, Hospital Wound Nurse stated R21 had been discharged from the hospital on [DATE] and readmitted to the hospital on [DATE]. V31stated there were pictures taken in the hospital of a bruise on R21's left lateral breast that were taken on 12/16/23. V31 stated it was more on the rib side of breast. V31 stated there were also pictures of bruises on R21's labia on 12/18/23, two days after she was admitted to the hospital. V31 stated the facility did not send any information regarding bruises or pressure ulcers when resident was admitted to hospital on [DATE]. V31 stated R21 was admitted with COVID and Altered Mental Status. V31 stated she saw R21 on 12/18/23 in the afternoon and saw deep purple-red bruises on R21's labia about a third of the way down her labia, area behind her vagina, up to rectum and some bruising around her rectum. V31 stated there was an area about midway down her thigh that could have been an abrasion that could have been from picking or if her diaper had been on too tight. V31 stated when she was trying to look at the bruises, R21 kept trying to pull the blanket back up and stated she has had other residents/patients do this when being examined and could be s/s of trauma or not. On 12/26/23 at 12:44 PM, V6, Director of Nursing (DON) stated she does not have any other abuse investigations or investigations of bruises of unknown origin in the last three months besides a resident-to-resident altercation between R29 and R30. The investigation regarding possible sexual abuse towards unknown resident by unknown staff that was reported to her on 12/21/23 by a surveyor. On 12/27/23 at 11:55 AM, V6, DON and V25, MDS Coordinator came in to talk to writer and had V1, Administrator on speaker phone on V6's cell phone. V1 stated the bruise on R21's breast was not reported to either of them or V2, Assistant Director of Nursing (ADON). V1 stated if it had been reported she would have sent in the initial report to IDPH (Illinois Department of Public Health (IDPH) and started the investigation immediately. V1 stated any bruise of unknown origin is treated that way. On 12/27/23 at 1:30 PM, V6 DON stated, We did have a report of bruises of unknown origin today for (R20) today and have sent the report and started an investigation. V6 stated the police and MD were notified. This investigation was started two days after the bruises were first documented in R20's progress notes on 12/25/23. On 12/27/23 at 1:00 PM, V6 provided the investigation of the allegation of sexual abuse that was presented to them by surveyor on 12/21/23. It documented: Initial Report: 12/21/23: Surveyor reported (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145585 If continuation sheet Page 6 of 20 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 145585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Caseyville Nursing & Rehab Ctr 601 West Lincoln Avenue Caseyville, IL 62232 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 Residents Affected - Few to this writer that someone complained of an employee sexually abusing a resident. No other details known at this time. Will update when more details are known. Thank you. Investigation started immediately. Final to follow. Police notified. On the back of this document there were handwritten notes that documented: 1:40 PM Attempted to get a hold of local police; could not get through. 2:00 PM Left message. 3:50 pm Left message for ombudsman-out of office. (Local) Police arrived 12/21/23 4:05 PM to get report from this writer. V6 stated all alert and oriented residents were interviewed during investigation, but no staff were interviewed because V6 and V1 felt this may have been called in by a disgruntled employee. V6 stated all the residents interviewed stated no one had been inappropriate towards them or touched them inappropriately. On 12/27/23 at 1:48 PM, V6 stated V1 Administrator had talked to a few of the department heads, including V6 but had not interviewed any nurses or CNAs yet regarding the allegation of sexual abuse related to the complaint. On 12/27/23 at 5:45 PM, V27 Licensed Practical Nurse (LPN) stated she documented a bruise was noted on R21's breast on 12/14/23. V27 stated a CNA was changing R21 and saw the bruise and reported this to V27. V27 stated V6 (DON) was working, and she asked her to look at the bruise and stated they went in and looked at it together. V6 stated she could tell the bruise was old by the color of it. V27 stated she did a full body assessment at the time and there were no other bruises noted. V27 stated she reported the bruise to V28, MD but he didn't really address it because he was more concerned with R21's high blood sugar readings and addressed those but disregarded the report of the bruise. V27 stated she is a new nurse, having just completed her boards in October, and that is why she asked V6 to assess the bruise on R21's breast because V6 had more experience. V27 stated R21 did appear to have pain with movement of her arm and leg so they took precautions of not lifting her arms during care. On 12/28/23 at 9:00 AM, V6 DON stated she does not remember the nurse showing her the bruise on R21's breast on 12/14/23 but stated she is not stating it didn't happen, she just doesn't remember because she has been so busy. V6 stated if she did see it she should have reported it to V1 immediately and an investigation should have been started right away. On 12/28/23 at 9:24 AM during phone interview, V29, CNA stated she did see bruise on R21's breast and on her right side above her hip, under her arm. V29 stated she did not see any bruises in R21's vaginal area or rectal area. V29 stated she did not remember exact date, but it was on 2 PM to 10 PM shift and she reported it to the nurse (could not remember her name). V29 said she and another nurse went to assess R21. V29 stated nobody asked her anything about it since she first reported it to the nurse. The facility's policy, Abuse Prevention Program, revised 2/2023 documents, Purpose: This facility affirms the right of our residents to be free from abuse (verbal, mental, sexual or physical), neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion and physical and chemical restraints that are not required to treat a resident's medical symptoms. This facility therefore prohibits acts of mistreatment, neglect, and/or crimes from being committed against its residents. This facility desires to establish a resident sensitive and resident secure environment. Under Definitions, the policy documents, Injuries of Unknown Source are defined as an injury of unknown source when both of the following conditions are met: The source of the injury was not observed by any person or the sources of the injury could not be explained by the resident; and The injury is suspicious because of the extent of the injury or the location of the injury (for example the injury is located in an area not generally vulnerable to trauma) ore the number of injuries (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145585 If continuation sheet Page 7 of 20 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 145585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Caseyville Nursing & Rehab Ctr 601 West Lincoln Avenue Caseyville, IL 62232 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 Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete observed at one particular point in time or the incidence of injuries over time. 4. The facility will develop and implement policies and procedures to assist in the identification and reporting of events, trends, and patterns that may constitute abuse or that may require further investigation. 5. Facility staff will investigate and report any allegations of abuse within timeframe's required by Federal law. 7. Any allegation of abuse will be reported immediately to the facility administrator or his/her designee who will follow Federal requirements for reporting to the following entities: a. State Licensing agency responsible for licensure of the facility, b. Law enforcement officials, c. The resident's representative, d. The resident's primary physician. Event ID: Facility ID: 145585 If continuation sheet Page 8 of 20 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 145585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Caseyville Nursing & Rehab Ctr 601 West Lincoln Avenue Caseyville, IL 62232 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review the facility failed to pass as needed (PRN) pain medications in a timely manner and failed to provide prescribed medications as ordered to 1 of 10 residents (R2) reviewed for medications in a sample of 30. The failure resulted in R2 experiencing continued pain and the inability to sleep. Residents Affected - Few Findings include: R2's Face Sheet, dated 12/14/23, documents R2 has diagnoses of fracture if unspecified part of neck of left femur and other acute postprocedural pain. R2's MDS, dated [DATE], documents R2 is cognitively intact and requires supervision or touching assistance with eating, partial/moderate assistance with oral hygiene, substantial/maximal assistance with repositioning, dependent with transfer, personal hygiene, dressing, bathing, toilet use, and has an indwelling catheter and is occasionally incontinent of bowel. R2's Care plan, with admission date of 11/30/23, documents R2 has acute/chronic pain. Fracture to left hip. The goal is R2's pain will be minimized with the use of scheduled and/or PRN pain meds and R2 will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Interventions include administer analgesia as per orders and monitor/record pain characteristics. Quality (example: sharp, burning); Severity (1 to 10 scale); Anatomical location; Onset; Duration (example: continuous, intermittent); Aggravating factors; Relieving factors. R2's Physician's order, dated 11/30/23 at 6:02 PM, documents Oxycodone HCI oral tablet 5 milligrams (mg), give one tablet by mouth every 6 hours as needed for pain. R2 is to get a Lidocaine External Patch 5 % (Lidocaine), Apply to left hip topically one time a day for pain at 12:00 PM (Noon). On 12/11/23 at 9:30 AM, R2 stated it takes the nurse over an hour sometimes to get him his pain medications when he asks for them. On 12/13/23 at 8:50 AM, when R2 was questioned about the 12/11/23 early morning requested pain medication R2 didn't receive, R2 stated he couldn't sleep, and he was hurting 'pretty bad'. On 12/15/23 at 10:50 AM, V3, R2's wife stated R2 called her on 12/10/23 at 7:30 PM, and stated he needed pain medication. V3 asked R2 why he didn't put his call light on, and he stated to her because he was unable to reach it. V3 stated she then called the facility and spoke with staff letting them know R2 needed pain medication. V3 stated she called R2 back about a half hour later to check and see if he had received his pain pill. V3 said R2 told her the nurse was coming now with the pain medication. V3 said around 4:45 AM 12/11/23, R2 called her again from his phone and stated to her he needed pain medication. V3 said she called the facility and spoke with staff and informed them R2 was in pain and needed some pain medication. V3 stated the staff told her the facility only has one nurse and the RN is passing out pain meds now. V3 said, the staff member told her the RN was agency and the RN must pass medications on all the halls and R2's hall is next. V3 stated she called the facility back around 6:30 AM and spoke with V6, Licensed Practical Nurse (LPN) about R2 not receiving any pain medication. V3 said V6 stated the facility only had one nurse last night and apologized and told V3 that R2 would be the first one she passed medications to and that she would get him his pain medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145585 If continuation sheet Page 9 of 20 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 145585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Caseyville Nursing & Rehab Ctr 601 West Lincoln Avenue Caseyville, IL 62232 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 0697 R2's Medication Administration Record (MAR), for the month of December 2023, was reviewed and documents R2 received an oxycodone 5mg on 12/10/23 at 7:56 PM (19:56). Level of Harm - Actual harm R2's MAR has no documentation he received any PRN pain medication throughout the night. Residents Affected - Few R2's MAR, dated 12/11/23 at 8:00 AM, documents R2 received an oxycodone 5mg for pain at this time. R2's Individual Resident Controlled Substance Record, for the month of December 2023, was reviewed and documents R2 received an oxycodone 5mg on 12/10/23 at 7:57 PM (1957), and 12/11/23 at 8:00 AM. There is no documentation R2 received any pain medication throughout the night between the times of 7:57 PM and 8:00 AM. On 12/14/23 at 11:05 AM, V4, Certified Nursing Assistant (CNA) stated she remembers R2's wife calling the facility and requesting R2 be given a pain pill. V4 stated the other CNA working on this night told her around 4:00 AM that R2's wife called and requested R2 be given a pain pill. On 12/11/23 at 11:15 AM V6, LPN stated when she came in the morning of 12/11/23, V3, R2's wife called the facility again and told her (V6), that she had called around 4:00 AM and requested R2 be given a pain pill but he was not given one. V6 said she told V3 she would make sure to give R2 is medications first and she would make sure she gave him a pain pill. On 12/20/23 at 12:57 PM, V9, Director of Nursing (DON) stated when it comes to PRN pain medication if it is time for the resident to have it then it should be given, that's why they have it. On 12/11/23 at 9:55 AM, R2's left hip was observed, and it did not have a Lidocaine (pain) patch placed on it at this time. On 12/11/23 at 12:15 PM, R2's left hip was observed, and it did not have a lidocaine patch in place at this time. On 12/11/23 at 1:10 PM, R2's left hip was observed, and there was no lidocaine patch placed at this time. On 12/11/23 at 1:38 PM, V6, Licensed Practical Nurse (LPN) stated she took R2's pain patch off at 8:00 AM this morning when she passed his (R2's) morning medications and R2's patch wasn't due until 2:00 PM. V6 said the patch was dated 12/10/23 at 14:00 (2:00 PM). When this surveyor made V6 aware the physician's order stated the patch was supposed to be applied at noon, V6 said she gets R2 and another resident mixed up. On 12/11/23 at 1:43 PM, V6, LPN was observed placing R2's lidocaine patch to his left hip. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145585 If continuation sheet Page 10 of 20 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 145585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Caseyville Nursing & Rehab Ctr 601 West Lincoln Avenue Caseyville, IL 62232 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 - Many 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 was sufficient nursing staff resulting in 6:00 AM medications not being passed for 6 of 10 residents (R1, R3, R12, R13, R19, R20) reviewed for medications in a sample of 30. This failure has the potential to affect all 83 residents residing in the facility. Findings include: 1. R1's Face Sheet, dated 12/19/23, documents R1 has diagnoses of pneumonitis due to inhalation of food and vomit, chronic obstructive pulmonary disease (COPD), type II diabetes mellitus, end stage renal disease, and dependence on renal dialysis. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact and requires supervision/or touching assistance with oral hygiene, personal hygiene, eating, dependent with toileting hygiene, toilet transfer, tub/shower transfer, and substantial/maximal assistance with shower/bathe. R1 is always incontinent of bowel and bladder. R1's Physician's orders reviewed on 12/11/23, documents R1 is to get the following medications at 6:00 A: Protonix 40 milligrams (mg), Gabapentin 100mg, Sevelamer 800mg, Calcium Carbonate 500mg two tabs, Dextran 70-Hypromellose Ophthalmic Solution 0.1-0.3 % one drop to both eyes, Acetaminophen 500mg, and Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML. R1's Medication Administration Record (MAR), for the month of December documents 9 (see nurses notes) on all his 6:00 AM medications on 12/11/23. R1's Progress notes, dated 12/11/23, documents no nurse available to pass medications. 2. R3's Face Sheet, dated 12/19/23, documents R3 has diagnoses of but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery, seizures, and hypertension (HTN). R3's MDS, not dated, documents R3 is severely cognitively impaired and is dependent on staff for all her ADLs including assisting with meals (eating). R3 is always incontinent of bowel and bladder. R3's Physician's Orders reviewed on 12/11/23, documents R3 is to receive the following 6:00 AM medications, Escitalopram 5mg, Furosemide 20mg, Omeprazole suspension 20mg, Eliquis 5mg, Keppra solution 100mg/milliliter (ml) dose of 5ml, Metoprolol 100mg, and Vimpat solution 10mg/ml dose of 10ml. R3's MAR, for the month of December 2023, documents 9 (see nurses notes) on all her 6:00 AM medications on 12/11/23. R3's Progress notes, dated 12/11/23, documents No nurse available to pass medications. 3. R12's Face Sheet, dated 12/19/23, documents R12 has diagnoses of pneumonia, venous insufficiency, urinary tract infection, and acute kidney failure. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145585 If continuation sheet Page 11 of 20 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 145585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Caseyville Nursing & Rehab Ctr 601 West Lincoln Avenue Caseyville, IL 62232 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 R12's MDS, not dated, documents R12 is cognitively intact and is dependent on staff for most of her activities of daily living (ADLs). R12's Physician's Orders, were reviewed on 12/12/23, and documents R12 is to receive the following 6:00 AM medications: Baclofen 5mg and Gabapentin 100mg. Residents Affected - Many R12's MAR, for the month of December 2023 documents 9 (see nurses notes) on all her 6:00 AM medications on 12/11/23. R12's Progress notes, dated 12/11/23, documents no nurse available to pass medications. 4. R13's Face Sheet, dated 12/19/23, documents R13 has diagnoses COVID-19, dementia, and HTN. R13's MDS, not dated, documents R13 is severely cognitively impaired supervision or touching assistance with transfer, toilet hygiene, shower, and bath, independent with dressing, bed mobility, and sit to stand. R13's Physician's Orders documents R13 is to receive the following 6:00 AM medication: Levothyroxine 25 micrograms (mcg). R13's MAR, for the month of December 2023 documents 9 (see nurses notes) on all her 6:00 AM medications on 12/11/23. R13's Progress notes, dated 12/11/23, documents no nurse available to pass medications. 5. R19's Face Sheet, dated 12/19/23, documents R19 has diagnoses dementia and cerebral infarction. R19's MDS, not dated, documents R19 is severely cognitively impaired and is dependent on staff for most of her ADLs. R19's Physician's Orders, were reviewed on 12/19/23, and documents R3 is to receive the following 6:00 AM medications, Famotidine 20mg and Lidoderm patch 5%. R19's MAR, for the month of December 2023, was reviewed and documents 9 (see nurses notes) on all her 6:00 AM medications on 12/11/23. R19's Progress notes, dated 12/11/23, documents no nurse available to pass medications. 6. R20's Face Sheet, dated 12/19/23, documents R20 has diagnoses fracture of unspecified part of neck of left femur, fracture of upper end of left humerus, and chronic obstructive pulmonary disease. R20's MDS, not dated, documents R20 is moderately cognitively impaired and is dependent on staff for showering, dressing, and personal hygiene. R20's Physician's Orders documents R20 is to receive the following 6:00 AM medications: Lidoderm patch 5% and Meclizine 25mg. R20's MAR, for the month of December 2023 documents 9 (see nurses notes) on all her 6:00 AM medications on 12/11/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145585 If continuation sheet Page 12 of 20 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 145585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Caseyville Nursing & Rehab Ctr 601 West Lincoln Avenue Caseyville, IL 62232 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 R20's Progress notes, dated 12/11/23, documents no nurse available to pass medications. Level of Harm - Minimal harm or potential for actual harm On 12/20/23 at 12:57 PM, V9, Interim Director of Nursing (DON) stated she would expect the scheduled meds to be passed on time and to all the residents. Residents Affected - Many The facility's Daily staffing summary policy, with revision date of 06/03/23, documents Policy: It is the goal of the facility to meet or exceed nursing staff levels required to provide quality care to our residents. The CMS-671, dated 12/21/23 at 9:53 AM, documents there are 83 residents residing at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145585 If continuation sheet Page 13 of 20 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 145585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Caseyville Nursing & Rehab Ctr 601 West Lincoln Avenue Caseyville, IL 62232 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 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide scheduled medications as ordered for 7 of 10 residents (R1, R2, R3, R12, R13, R19, R20) reviewed for medications in a sample of 30. Findings include: 1. R1's Face Sheet, dated 12/19/23, documents R1 has diagnoses of pneumonitis due to inhalation of food and vomit, chronic obstructive pulmonary disease (COPD), type II diabetes mellitus, end stage renal disease, and dependence on renal dialysis. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact and requires supervision/or touching assistance with oral hygiene, personal hygiene, eating, dependent with toileting hygiene, toilet transfer, tub/shower transfer, and substantial/maximal assistance with shower/bathe. He is always incontinent of bowel and bladder. R1's Physician's orders, were reviewed on 12/11/23, and documents R1 is to get the following medications at 6:00 AM, Protonix 40 milligrams (mg), Gabapentin 100mg, Sevelamer 800mg, Calcium Carbonate 500mg two tabs, Dextran 70-Hypromellose Ophthalmic Solution 0.1-0.3 % one drop to both eyes, Acetaminophen 500mg, and Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML. R1's Medication Administration Record (MAR), for the month of December 2023 was reviewed and documents 9 (see nurses notes) on all his 6:00 AM medications on 12/11/23. R1's Progress notes, dated 12/11/23, documents no nurse available to pass medications. 2. R3's Face Sheet, dated 12/19/23, documents R3 has diagnoses of but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery, seizures, and hypertension (HTN). R3's MDS, not dated, documents R3 is severely cognitively impaired and is dependent on staff for all her ADLs including assisting with meals (eating). she is also always incontinent of bowel and bladder. R3's Physician's Orders, were reviewed on 12/11/23, and documents R3 is to receive the following 6:00 AM medications, Escitalopram 5mg, Furosemide 20mg, Omeprazole suspension 20mg, Eliquis 5mg, Keppra solution 100mg/milliliter (ml) dose of 5ml, Metoprolol 100mg, and Vimpat solution 10mg/ml dose of 10ml. R3's MAR, for the month of December 2023, was reviewed and documents 9 (see nurses notes) on all her 6:00 AM medications on 12/11/23. R3's Progress notes, dated 12/11/23, documents no nurse available to pass medications. 3. R12's Face Sheet, dated 12/19/23, documents R12 has diagnoses of pneumonia, venous insufficiency, urinary tract infection, and acute kidney failure. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145585 If continuation sheet Page 14 of 20 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 145585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Caseyville Nursing & Rehab Ctr 601 West Lincoln Avenue Caseyville, IL 62232 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 R12's MDS, not dated, documents R12 is cognitively intact and is dependent on staff for most of her activities of daily living (ADLs). Level of Harm - Actual harm Residents Affected - Few R12's Physician's Orders, were reviewed on 12/12/23, and documents R12 is to receive the following 6:00 AM medications, Baclofen 5mg and Gabapentin 100mg. R12's MAR, for the month of December 2023, was reviewed and documents 9 (see nurses notes) on all her 6:00 AM medications on 12/11/23. R12's Progress notes, dated 12/11/23, documents no nurse available to pass medications. 4. R13's Face Sheet, dated 12/19/23, documents R13 has diagnoses COVID-19, dementia, and HTN. R13's MDS, not dated, documents R13 is severely cognitively impaired supervision or touching assistance with transfer, toilet hygiene, shower, and bath, independent with dressing, bed mobility, and sit to stand. R13's Physician's Orders, were reviewed on 12/19/23, and documents R13 is to receive the following 6:00 AM medication, Levothyroxine 25 micrograms (mcg). R13's MAR, for the month of December 2023, was reviewed and documents 9 (see nurses notes) on all her 6:00 AM medications on 12/11/23. R13's Progress notes, dated 12/11/23, documents no nurse available to pass medications. 5. R19's Face Sheet, dated 12/19/23, documents R19 has diagnoses dementia and cerebral infarction. R19's MDS, not dated, documents R19 is severely cognitively impaired and is dependent on staff for most of her ADLs. R19's Physician's Orders, were reviewed on 12/19/23, and documents R3 is to receive the following 6:00 AM medications, Famotidine 20mg and Lidoderm patch 5%. R19's MAR, for the month of December 2023, was reviewed and documents 9 (see nurses notes) on all her 6:00 AM medications on 12/11/23. R19's Progress notes, dated 12/11/23, documents no nurse available to pass medications. 6. R20's Face Sheet, dated 12/19/23, documents R20 has diagnoses fracture of unspecified part of neck of left femur, fracture of upper end of left humerus, and chronic obstructive pulmonary disease. R20's MDS, not dated, documents R20 is moderately cognitively impaired and is dependent on staff for showering, dressing, and personal hygiene. R20's Physician's Orders, were reviewed on 12/19/23, and documents R20 is to receive the following 6:00 AM medications, Lidoderm patch 5% and Meclizine 25mg. R20's MAR, for the month of December 2023, was reviewed and document 9 (see nurses notes) on all her 6:00 AM medications on 12/11/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145585 If continuation sheet Page 15 of 20 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 145585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Caseyville Nursing & Rehab Ctr 601 West Lincoln Avenue Caseyville, IL 62232 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 R20's Progress notes, dated 12/11/23, documents no nurse available to pass medications. Level of Harm - Actual harm 7. R2's Face Sheet, dated 12/14/23, documents R2 has diagnoses of fracture if unspecified part of neck of left femur and other acute postprocedural pain. Residents Affected - Few R2's MDS, dated [DATE], documents R2 is cognitively intact and requires supervision or touching assistance with eating, partial/moderate assistance with oral hygiene, substantial/maximal assistance with repositioning, dependent with transfer, personal hygiene, dressing, bathing, toilet use, and he has an indwelling catheter and is occasionally incontinent of bowel. R2's Care plan, with admission date of 11/30/23, documents R2 has acute/chronic pain. Fracture to left hip. The goal is R2's pain will be minimized with the use of scheduled and/or PRN pain meds and R2 will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Interventions include administer analgesia as per orders and monitor/record pain characteristics. Quality (example: sharp, burning); Severity (1 to 10 scale); Anatomical location; Onset; Duration (example: continuous, intermittent); Aggravating factors; Relieving factors. R2's Physician's Orders, were reviewed on 12/11/23 and document R2 is to get a Lidocaine External Patch 5 % (Lidocaine), Apply to left hip topically one time a day for pain at 12:00 PM (Noon) On 12/11/23 at 9:55 AM, R2's left hip was observed, and it did not have a Lidocaine (pain) patch placed on it at this time. On 12/11/23 at 12:15 PM, R2's left hip was observed, and it did not have a lidocaine patch in place at this time. On 12/11/23 at 1:10 PM, R2's left hip was observed, and there was no lidocaine patch placed at this time. On 12/11/23 at 1:38 PM, V6, Licensed Practical Nurse (LPN) stated she took R2's pain patch off at 8:00 AM this morning when she passed his (R2's) morning medications and his patch isn't due until 2:00 PM. She said the patch was dated 12/10/23 at 14:00 (2:00 PM). When this surveyor made V6 aware the physician's order stated the patch was supposed to be applied at noon, V6 said she gets R2, and another resident mixed up. On 12/11/23 at 1:43 PM, V6, LPN was observed placing R2's lidocaine patch to his left hip. On 12/20/23 at 12:57 PM, V9, Interim Director of Nursing (DON) stated she would expect the scheduled meds to be passed on time and to all the residents. The facility's medication administration general principles, revision date of 01/14/2020, documents Policy: Medications will be administered in a safe, efficient, and accurate manner to residents for whom they are prescribed and in accordance with current acceptable nursing practice. Policy guidelines and interpretation: 1. Only individuals licensed or permitted by this state may prepare, administer, and document the administration of medication in this facility. 2. Medications must be administered as ordered by the physician. It further documents 6. Medications will be administered in accordance with the six (6) Rights e. Right Time: Administer medications as instructed on the MAR and in accordance with the physician's orders. As a general rule of thumb medications should be administered within one (1) hour of their scheduled time unless other instructions are given (e.g., before or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145585 If continuation sheet Page 16 of 20 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 145585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Caseyville Nursing & Rehab Ctr 601 West Lincoln Avenue Caseyville, IL 62232 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 - Actual harm after meals). It also documents 14. If a drug is withheld, refused, given at a time other than the scheduled time, or not given for any other reason, the individual administering the medication shall initial and place the appropriate chart code/follow up code in the eMAR (electronic medication administration record) which will indicate the reason medication not administered as ordered. A progress note may be required. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145585 If continuation sheet Page 17 of 20 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 145585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Caseyville Nursing & Rehab Ctr 601 West Lincoln Avenue Caseyville, IL 62232 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure staff maintained an infection prevention and control program to help prevent the development and transmission of a communicable disease by staff not donning appropriate personal protective equipment (PPE) before entering a COVID positive resident's room, failed to have the correct signage in place for residents who were COVID positive, failed to provide bio-hazard receptacles in resident's rooms close to the door for proper discarding of PPE, failed to properly sanitize blood glucose monitors and failed to adhere to proper hand hygiene practices. This failure has the potential to affect all 83 residents residing at the facility. Residents Affected - Many Findings include: On 12/13/23 at 8:35 AM, R7's and R10's room which is a COVID-19 isolation room was observed and there was an isolation sign on the door that documented droplet isolation (keep door closed), the door was observed open at this time, and there were no bio-hazard bins observed in the room at this time. On 12/13/23 at 8:37 AM, R8's room, a COVID-19 room, was observed to be an isolation room. There was an isolation sign on the door that said, 'contact isolation'. There was no droplet signage observed on the door or on the wall beside the room. There were no bio-hazard bins for trash or soiled linen observed in the room, the door to the room was open, and there was a yellow disposable gown observed in the regular trash receptacle in the room. On 12/13/23 at 8:38 AM, R9's and R11's room which is a COVID-19 room, was observed to have a contact isolation sign hanging on the door. There was no droplet signage noted. There were no bio-hazard receptacles for trash or linen noted to be in the room and the door to the room was observed to be open at this time. On 12/13/23 at 8:40 AM, R14's room is a COVID-19 room, was observed to have only a contact isolation sign on the door. The door was observed to be open, and there were bio-hazard receptacles observed in the room, but they were located across the room by the sink and not by the door. On 12/13/23 at 9:42 AM, V11, Housekeeper was observed mopping R8's room with only a surgical mask on. V11 did not have on a gown, gloves, eye protection, or a N95 mask. V11 brought out the mop and rinsed it in the mop bucket then she went back into R8's room and mopped the rest of the floor. After V11 was done mopping the room, she then left the room without removing her mask, or gloves. V11 then went to her housekeeping cart and changed her gloves without performing any type of hand hygiene. On 12/13/23 at 9:46 AM, After finishing in R8's room V11, housekeeper went across the hallway into another room which did not have of any residents in it at this time and emptied the trash and mopped the floor with the same water. On 12/13/23 at 9:51 AM, V11, housekeeper then went into R14's room with no gown, gloves, eye protection, or N95 mask. V11 was observed still wearing the same mask she wore into R8's room. V11 did not perform hand hygiene or change her mask before leaving the room. On 12/13/23 at 9:54 AM, V11, housekeeper was observed leaving the 600 hallway. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145585 If continuation sheet Page 18 of 20 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 145585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Caseyville Nursing & Rehab Ctr 601 West Lincoln Avenue Caseyville, IL 62232 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 12/13/23 at 10:02 AM, V11, housekeeper was observed leaving the 200 hallway, which is on the other side of the building from the 600 hallway. V11went back down the 600 hallway and back into a room with no residents residing in it. On 12/13/23 at 10:12 AM, V11, housekeeper was observed leaving the 600 hallway again and was observed going to D (400) hallway. On 12/14/23 at 8:14 AM, V12, Licensed Practical Nurse (LPN) was observed giving insulin to R15 without wearing any gloves. On 12/14/23 at 8:19 AM, V12, LPN was observed wiping her hands off with a sanitation cloth and donning her gloves prior to obtaining R16's blood sugar. After obtaining R16's blood sugar V12 went to the medication cart, placed the glucometer on top of the cart without sanitizing it and retrieved R16's Novolog and Glargine insulin pens from one of the medication cart drawers wearing the same gloves. V12 proceeded to get the insulin pen needles and place them on the insulin pens after cleaning off the tops of the insulin pens. Wearing the same gloves V12 then went back into R16's room and gave R16 both of her insulin injections. When V12 finished giving R16 her insulin V12 went back to the medication cart and put R16's insulin pens back into the medication cart drawer. With the same gloves on V12 then pushed the medication cart down to R17's room. On 12/14/23 at 8:24 AM, V12, LPN was observed still wearing the same gloves from the previous resident. V12 touched the computer mouse with the dirty gloves and pulled up R17's medication information. V12 then got into the medication cart with the same pair of gloves and retrieved R17's insulin pen and needle. After preparing the insulin pen, V12 went into R17's room, cleansed R17's right lower abdomen and injected the insulin wearing the same dirty gloves. When V12 was finished giving R17's insulin she went back out to the medication cart and put R17's insulin pen back into the medication cart. V12 then got back into the computer and marked where she had given the insulin, and she continued to wear the same dirty gloves. On 12/14/23 at 8:31 AM, Wearing the same dirty gloves V12, LPN pushed the medication cart down to R18's room. V12 cleaned off the top of the medication cart and placed the glucometer, that had not been cleaned, back into the top drawer of the medication cart. V12 then removed the gloves and wiped her hands off with a sanitation wipe. On 12/19/23 at 2:39 PM, V9, Infection Preventionist stated there are 45 residents who are COVID-19 positive at this time. V9 said there are some that will be coming off isolation soon. V9 stated she would expect housekeeping who went into an COVID isolation room to have on gown, gloves, N95 mask, and eye protection. V9 said everyone who is on isolation for COVID-19 should also be on droplet precautions. On 12/21/23 at 8:40 AM, V15, Housekeeping and Laundry Supervisor stated it would depend on what type of isolation the resident was in on what PPE they would wear. V15 said if it was contact isolation, and the housekeepers would not have any contact with the resident then the housekeeper wouldn't need to use a gown. V15 stated if it was a resident who was on isolation for COVID he would expect the housekeeper to wear full PPE (gown, gloves, mask, and eye protection). On 12/26/23 at 9:55 AM, V2, Assistant Director of Nursing (ADON) stated she believes each of the medication cart has two glucometers on them so they would have one to use while the other one is being cleaned. V2 said she would expect the nurses to follow the infection control policy and what was in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145585 If continuation sheet Page 19 of 20 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 145585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Caseyville Nursing & Rehab Ctr 601 West Lincoln Avenue Caseyville, IL 62232 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 0880 the instruction manual. Level of Harm - Minimal harm or potential for actual harm The facility's COVID-19 Prevention and Control policy, revision date of 05/11/23, documents Policy: It is the policy of this facility to minimize exposures to respiratory pathogens and promptly identify residents, employees and visitors with Clinical Features and a Epidemiologic Risk for the COVID-19, RSV, and Flu, and to adhere to recommended prevention and transmission precautions. It further documents Health care workers must use proper PPE when exposed to a resident with suspected or confirmed COVID-19. If a resident is suspected or confirmed to have COVID-19 or other respiratory illnesses, at a minimum, HCP must wear an N95 respirator, eye protection, gown, and gloves. If the facility is experiencing an outbreak of COVID-19 or other respiratory illnesses, at a minimum, HCP must wear a well fitted mask while on the unit or floor experiencing an outbreak. In addition, facility may consider requiring an N95 respirator and eye protection (goggles, or a face shield) during all resident care, on the affected unit or floor. It further documents Hand Hygiene Hand Hygiene is a core infection control prevention measure and should be performed frequently to reduce the spread of organisms and the virus that causes COVID-19. It also documents Management of Positive Residents Facilities are not required to have a dedicated COVID-19 unit unless the number of positive residents would warrant such a unit. If residents can be safely managed in the general population, a facility can place a COVID-19 positive resident in a single room with appropriate isolation signage, and staff wearing N95 respirator, eye protection, gown, and gloves upon entry to room. Residents Affected - Many The blood glucose monitoring system owner's manual version 1.0 dated January 2020, documents Take care of your meter and strips to avoid the meter and test strips getting dirt, dust or other contaminants, please wash and dry your hands thoroughly before use. Cleaning 1. Tol clean the meter exterior, wipe with a cloth moistened with tap water or a mild cleaning agent, then dry the device with a soft and dry cloth. Do not flush with water. 2. Do not use organic solvents to clean the meter. The CMS-671, dated 12/21/23 at 9:53 AM, documents there are 83 residents residing at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145585 If continuation sheet Page 20 of 20