Health inspection·February 14, 2025

F 0600 Level of Harm - Actual harm Residents Affected - Few and verbally abusive to the staff. After bringing him to this room, he went down again and confronted the resident on 200 halls, holding on to his wheelchair and they both were separated by staff. He then was put in his room. Neither one of the residents were hurt. R6's Progress Note, dated 12/7/24 at 10:10 AM, documents, Patient has been aggressive this morning and yelling, using fouled language, balling up his fist at staff as to hit them, and refused to let staff help him. Patient has been up in wheelchair this tour. R6's Care Plan, dated 4/15/24, documents R6 has a behavior problem, impaired cognitive function and a mood problem. There were not any interventions added after 1/11/24 on R6's care plan to address his aggression with other residents/staff to provide sufficient protection of the other residents from abuse. The Final Report and Conclusion of Incident, dated 1/24/25, documents a comprehensive investigation was initiated and found that on 1/24/25 at approximately 6:15 PM, at the nurse's station R5 told nursing that R6 had grabbed her arm while passing at the nurse's station. It was unwitnessed. Residents were immediately separated. R6 was moved into the hallway. Both residents were assessed with no injuries noted. V5 remains at baseline and shows no signs of mental anguish. The facility finds the allegation of willful abuse unsubstantiated. Both residents plans of care have been updated. 2. On 2/14/25 at 8:30 AM, R4 stated he had an agency CNA (Certified Nurse's Assistant), that came into his room and told him She wasn't f***** cleaning him up, he could clean himself off and to f*** off. R4 stated he had feces on his hand and asked the CNA to clean him and his hand off and she refused. R4 stated he hasn't had that problem before, and other staff came in and took care of him. R4 stated the CNA hasn't been in his room or taking care of him and he doesn't leave his room, so he isn't sure if the CNA works in the facility anymore but someone like her shouldn't be working anywhere with people. R4 stated he was amazed/shocked when it happened, not scared, just shocked, that someone would talk and treat me like that. R4's Face Sheet, undated, documents R4 has a diagnosis of Paraplegia. R4's MDS, dated [DATE], documents R4 has a BIMS score of 15, indicating R4 is cognitively intact and requires substantial/maximal assist with toileting and is dependent with hygiene. The Final Report and Conclusion of Incident, dated 2/10/25, documents a comprehensive investigation was initiated and found that on 2/10/2025 at approximately 8:45 AM, R4 advised a day shift agency CNA (V4) was being very unprofessional with him because he asked her to help get bowel movement off of his hands. R4 stated that the CNA refused to help him. The resident also had an audio recording of the Agency CNA cursing at him and refusing care. Administrator advised nurse to do an assessment. POA (Power of Attorney)/MD (Medical Doctor)/Police were notified. (V4) was DNR'd (Do Not Return) from facility. The Administrator also notified the licensing board about the agency CNA on the allegation of verbal abuse. There were no witnesses and none of the residents on the hall saw or heard anything out of the ordinary. R4 remains at baseline. The facility finds the allegation of willful verbal abuse substantiated. V1, Administrator stated R4 had an audio recording of V4 cussing at him. V1 reported it to the agency V4 worked for and he was taken off their schedule and placed on the do not return to facility list. V1 stated she also reported the incident to the licensing board. V1 stated the allegation was substantiated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145585 If continuation sheet Page 2 of 3 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 02/14/2025 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 0600 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The Abuse Prevention Program policy, dated 6/2008, documents the facility prohibits acts of mistreatment, neglect, abuse and/or crimes from being committed against it's residents. This facility desires to establish a resident sensitive and resident secure environment. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. Prevention of abuse will include resident assessment to ensure person-centered care approaches are individualized and communicated to facility staff. Event ID: Facility ID: 145585 If continuation sheet Page 3 of 3