Health inspection·April 25, 2023

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few enabled through the use of technology. i. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual mist have intended to inflict injury or harm. ii. Sexual abuse is non-consensual sexual contact of any type with a resident. There may be some situations in which the psychosocial outcome to the resident may be difficult to determine or incongruent with what would be expected. In these situations, it is appropriate to consider how a reasonable person in the resident's circumstances would be impacted by the incident. k. Abuse includes unwanted sexual contact, which includes but is not limited to: 1. Unwanted touching of the breasts or perineal area; 2. A resident who fondles or touches a person's sexual organs and the resident being touched indicates the touching is unwanted through verbal and non-verbal cues; 3. Sexual activities where one resident indicates that the activity is unwanted through verbal and non-verbal cues 4. Sexual activity or fondling where one of the resident's capacity to consent to sexual activity is unknown; 8. Other unwanted actions for the purpose of sexual arousal or sexual gratification resulting in degradation or humiliation of another resident. R1's Facesheet documents R1 admitted to the facility on [DATE] with a diagnosis to include but limited to: Alzheimer's Disease. R1's Minimum Data Set/MDS Assessment, dated [DATE], documents: R1 with moderate cognitive impairment; R1 requires supervision of one person physical assist to ambulate throughout the facility; R1 uses a walker to ambulate; and R1 is not steady with ambulation but is able to stabilize without staff assistance. R1's Order Recap Report for the dates [DATE]-[DATE], documents orders for: Aripiprazole Tablet Five mg/milligram, Give 0.5 (half) tablet by mouth one time a day for sexual drive for seven days with an order start date of [DATE] and a discontinue date of [DATE]; Aripiprazole Tablet Five mg/milligram, Give 0.5 (half) tablet by mouth one time a day for sexual behaviors with an order start date of [DATE] and an order end date of [DATE]; Escitalopram Oxalate Tablet 10 (ten) mg Give one tablet by mouth one time a day for Depression; sexual urges with an order start date of [DATE] and a discontinue date of [DATE]; and Escitalopram Oxalate Tablet 20 MG Give one tablet by mouth one time a day for sexual urges with an order start date of [DATE] and no end date. R1's Care Plan documents the following: Focused area with an initiation date of [DATE] that R1 has an alteration in R1's behavior status related to Alzheimer's, Impaired memory/thinking and Increased sexual drive; R1 may exhibit behaviors such as: increased confusion, making inappropriate comments or physically attempting to touch staff, hospice staff, residents; R1 may be unable to comprehend or remember appropriate behavior due to R1's diagnoses; R1 gets agitated at times with staff and other residents; a goal that R1 will not engage in inappropriate sexual behavior; Interventions are documented as My (R1's) behaviors will be monitored every shift and documented with an initiation date of [DATE]; Intervene as Necessary to protect safety of others; R1 has expressed sexual desires with an initiation date of [DATE] and documents interventions as Intervene when risk, resident safety, or the safety of others is involved; Lexapro per MAR (Medication Administration Record) to control sexual urges with a revision date of [DATE]; and R1 is on Psychotropic Medications due to R1's sexual urges; R1's medication was increased on [DATE] for an unusual occurrence on [DATE]. R1's Nursing Progress Note, dated [DATE] at 3:00 PM, states, Sitting out here across from desk. Other resident (unknown) out here as well. He (R1) pulled penis out and started masturbating. Resident (R1) was directed to stop and could do this behavior in his room. R1's Nursing Progress Note on [DATE] at 1:54 PM documents a new order for Abilify 2.5 milligrams by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145604 If continuation sheet Page 2 of 15 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 145604 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Henry Rehab and Nursing 1650 Indian Town Road Henry, IL 61537 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 mouth was received for sexual behaviors from V15 (R1's Hospice Physician). Level of Harm - Immediate jeopardy to resident health or safety On [DATE] and [DATE], R1's room was located in the middle of the 400 resident hallway. R7's (female) room was at the end of the 400 hallway and R8's (female) room was directly across the hallway from R1's room. Residents Affected - Few On [DATE] at 1:35 PM and [DATE] at 2:35 PM, R1 was observed in R1's room. R1's room was located at the very end of the 400 resident hallway, immediately before the outside exit door and furthest from the Nurse's Station. R7's (female) room was located directly across the hall from R1's room. 1. R4's Facesheet documents R4 admitted to the facility on [DATE] with a diagnosis of Schizophrenia. R4's Care Plan documents the following: R4 is at high risk for Wandering/Elopement; safety will be monitored every shift by all staff; history of wandering, refusal of cares, insomnia, disorganized speech or behavior, difficulty with concentration, compulsive, slowness in activity, delusions, hallucinations; impaired safety awareness and will get close to other residents; and alteration to cognition. R4's Minimum Data Set/MDS Assessment, dated [DATE], contains a Brief Interview of Mental Status which documents R4 with severe cognitive impairment. On [DATE] at 10:29 AM, R4 was observed wandering aimlessly around the facility's Memory Care Unit. R4 was unable to answer questions due to R4's mental status. The facility's Serious Injury Incident Report, dated [DATE], documents this report as an initial and final report that on [DATE] at 11:15 AM, R1 and R4 were in a resident to resident altercation. This same report documents R1 as the perpetrator, R4 as the victim and V8/CNA/Certified Nursing Assistant as a witness. This report states, (V8) alerted (V2/Director of Nursing) that (R1) appeared to have his hand in (R4's) sweatpants. (R1) was sitting at his table in the dining room and (R4) was standing in front of (R1). (V8) separated (R1 and R4) immediately and notified (V2). R1's Nursing Progress Note on [DATE] at 12:31 PM, states, Hospice/POA/Power Of Attorney/MD/Medical Doctor notified of (R1's) sexual drive change. (R1) monitored in room at this time. Confusion noted. New order received for Abilify x (times) one week to control sexual drive. R1's Nursing Progress Note on [DATE] at 12:26 PM documents R1's room was moved due to inappropriate behaviors. V8's written statement, dated [DATE], states, I went to do personal cares on an (unknown) resident in their room. I had (R4) sitting in a chair in TV/Television Room. (R1) was in the dining room. When I came out of the (unknown) resident's room, I heard (R4) saying, 'No Daddy, No Daddy.' When I got to the dining room, (R1) was in his chair still. (R4) was standing in front of (R1) and (R1) had his hand down in (R4's) sweatpants. I said, '(R1) stop. Go to your room.' I took (R4) to the TV room and called (V2) immediately. R1's MDS/Minimum Data Set/Care Plan Note on [DATE] at 11:15 AM, states, Root Cause: (R4 and R1) both have impaired memory, safety awareness, and impaired decision making capability. Intervention: Separated immediately. (R1 and R4) assessed. New order for (R1) to start Abilify times one week trial (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145604 If continuation sheet Page 3 of 15 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 145604 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Henry Rehab and Nursing 1650 Indian Town Road Henry, IL 61537 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 - Immediate jeopardy to resident health or safety Residents Affected - Few for sexual drive/behavioral change. (R1) given more privacy and relocated (off of Memory Care Unit). Continue to monitor behaviors and location as able. On [DATE] at 12:10 PM, V8 stated that on [DATE], V8 walked out of an (unknown) residents room after providing cares and noticed that R1 had R1's hand at least up to the wrist down inside the front of R4's sweatpants. V8 stated it was unknown if R1 was inside R4's incontinence brief/underwear or not. V8 stated, I heard (R4) saying, 'No daddy. No daddy, stop. Daddy stop.' V8 stated that R4 is confused and wanders throughout the memory care unit. V8 stated that since R1 had admitted to the facility, R1 was having increased behaviors of masturbating. V8 stated that while V8 was providing cares in the unknown resident's room, no other staff members were present on the Memory Care Unit providing supervision of the residents, including R1 and R4. 2. R2's Facesheet documents R2 admitted to the facility on [DATE] with diagnoses to include but not limited to: Severe Vascular Dementia; Disorientation; and Wheelchair Dependency. R2's Minimum Data Set/MDS Assessment, dated [DATE], contains a Brief Interview of Mental Status which documents R2 with severe cognitive impairment. R2's Care Plan documents R2 is at risk for behavior symptoms related to Dementia; is difficult to redirect at times of behaviors; Attempts to assist other resident's with cares and difficult to educate and redirect due to cognitive impairment. R1's Nursing Progress Note on [DATE] at 10:15 PM, states, (R1) was inappropriately groping another resident (R2). Both residents (R1 and R2) separated and (R1) brought down the hall to be observed by staff. R2's Nursing Progress Note on [DATE] at 10:23 PM, states, (R2) unaware of unusual occurrence. Unable to recall or describe. (R2) had sling positioned in chair, ready to be transferred into bed for evening. Brief, long pants intact. The facility's Serious Injury Incident Report, dated [DATE], documents a final report that the Perpetrator/R1 and the Victim/R2 were in a resident to resident altercation on [DATE] at 10:25 PM. V5 (Certified Nursing Assistant/CNA) and V6 (CNA) are documented witnesses. This report states, (R1) had inappropriate behavior with (R2) by the nurse's station. (R1 and R2) were separated immediately. Final: (V5) notified (V4/Licensed Practical Nurse) that (R1) appeared to have his hand grabbing/groping (R2's) lap. (V5 and V6) separated immediately. Assessment was performed by (V4). V5's written statement, dated [DATE], states, I (V5) was at the nurse's station charting before dinner was served. I looked over and noticed (R2) sitting still next to (R1). I sat up to see what they were doing and I noticed (R1) had his hand on (R2's) vaginal area over (R2's) pants massaging the area. Once I realized what was happening between them, I stood up and removed (R2) from the area, while my co-worker (V6) started to remove (R1). Once (R2) was out of the area, (V5 and V6) told (R1) that behavior was inappropriate and moved him away from other female residents and had him sit in the hallway to eat dinner. Both (V5 and V6) informed our nurse (V4). V6's written statement, (undated) but has an electronic stamp [DATE], states, Last night ([DATE]) I was sitting at the desk charting, when the incident happened. I could not see it happen. Another CNA (V5) seen it. We approached (R1) and said, 'We don't do that, keep your hands to yourself, please.' (R1) was laughing in response and said 'ok'. (R1) was taken down the hall to his room. (R1) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145604 If continuation sheet Page 4 of 15 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 145604 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Henry Rehab and Nursing 1650 Indian Town Road Henry, IL 61537 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 finished supper and was (assisted) into bed. Level of Harm - Immediate jeopardy to resident health or safety V4's written statement (undated) states, The CNA (V5) came and got me and told me that (R1) had his hands in (R2's) lap grabbing her. We brought the resident (R1) down the hall closer to staff to be monitored. Residents Affected - Few On [DATE] at 10:41 PM per telephone interview due to third shift hours, V4 stated that V5 had reported to V4 that R1 was being inappropriate with R2 and R1 had touched R2 near R2's vaginal area. V4 stated that R1 was known to masturbate publicly throughout the facility. R1's Nursing Progress Note on [DATE] at 1:44 PM, states, Verbal consent received for increase in dose of Lexapro to treat sexual urges/behavioral issues. Continue to monitor behaviors. V14's (R1's Nurse Practitioner) Progress Note, dated [DATE], states, (R1) was having sexual behaviors and masturbating in public. (R1) has also had some inappropriate behaviors toward other residents. Two weeks ago, I changed (R1) from Abilify to Lexapro. Then two weeks later (R1) was increased from 10 milligrams/mg to 20 mg daily. On [DATE] at 3:27 PM, V5 (Certified Nursing Assistant) stated, (On [DATE]) I was sitting at the Nurse's desk. We keep a balloon on (R2's) wheelchair to help keep track of (R2) because (R2) is so mobile. I noticed (R2's) balloon was not moving which was not normal for (R2), so I sat up to see what (R2) was doing. That's when I noticed that (R1) had his hands in (R2's) pubic region and was massaging the area. We immediately separated the residents and I reported it to my nurse right away. I don't like to think about that happening to (R2). On [DATE] at 11:03 AM, V1 (Administrator) stated that R1 all of a sudden started masturbating in random places throughout the facility not long after R1 admitted to the facility. V1 stated that R1 has inappropriately touched two residents; R1 had put R1's hand down the front of R4's pants and R1 touched R2's lap area. On [DATE] at 11:12 AM, V2 (Director of Nursing) stated that on [DATE], around 9:00 or 10:00 in the morning, V2 was reviewing progress note charting from the night before ([DATE]). V2 stated that V2 found a note charted by V4, that R1 had inappropriately groped R2. V2 stated that V2 discussed the incident with the staff members who confirmed the incident. V2 stated that R1 had inappropriately touched another resident (R4) one other time when R1 touched R4's private area back in [DATE] when R1 was a resident on the Memory Care Unit. V2 stated that R1 was placed on psychotropic medications to help manage R1's sexual urges. As of [DATE], R1's medical record did not contain any behavior tracking logs for [DATE] or [DATE]. R1's behavior tracking log for [DATE] states, Problem: (R1) has a diagnosis of Alzheimer's Disease and increased sexual drive and may exhibit behaviors such as: Physical: Attempting to inappropriately touch staff, hospice staff and residents. Has doubled up fists when agitated at staff and residents. Interventions: 1. Remove resident/R1 from area and put in a quiet area, back to his room, draw curtain. 2. Offer tasks to distract resident from current thoughts, give an activity, snack, or go for a walk. This same form is blank on the dates [DATE]-[DATE]. On [DATE], it is documented a behavior occurred one time. R1's behavior tracking log for February 2023 states, Problem: (R1) has a diagnosis of Alzheimer's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145604 If continuation sheet Page 5 of 15 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 145604 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Henry Rehab and Nursing 1650 Indian Town Road Henry, IL 61537 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Disease and increased sexual drive and may exhibit behaviors such as: Physical: Attempting to inappropriately touch staff, hospice staff and residents. Has doubled up fists when agitated at staff and residents. Interventions: 1. Remove resident/R1 from area and put in a quiet area, back to his room, draw curtain. 2. Offer tasks to distract resident from current thoughts, give an activity, snack, or go for a walk. This same form documents behaviors occurred on the following dates either all or half the shift: [DATE]; [DATE]; [DATE]-[DATE]; [DATE]; [DATE]; and [DATE]-[DATE]. The following dates are documented that interventions were not effective: [DATE]; [DATE]; [DATE]; and [DATE] and [DATE]. The following dates are documented that interventions were effective and then R1 reverted back to the same behavior: [DATE]-[DATE]; [DATE]-[DATE]. No new or updated interventions are documented as being attempted or implemented. R1's behavior tracking log for [DATE] states, Problem: (R1) has a diagnosis of Alzheimer's Disease and increased sexual drive and may exhibit behaviors such as: Physical: Attempting to inappropriately touch staff, hospice staff and residents. Has doubled up fists when agitated at staff and residents. Interventions: 1. Remove resident/R1 from area and put in a quiet area, back to his room, draw curtain. 2. Offer tasks to distract resident from current thoughts, give an activity, snack, or go for a walk. This same form documents behaviors occurred on the following dates: [DATE]-[DATE] four times and [DATE] three times with interventions documented as not being effective. No new/different interventions are documented as being attempted or implemented. R1's behavior tracking log for [DATE] states, Problem: (R1) has a diagnosis of Alzheimer's Disease and increased sexual drive and may exhibit behaviors such as: Physical: Attempting to inappropriately touch staff, hospice staff and residents. Has doubled up fists when agitated at staff and residents. Interventions: 1. Remove resident/R1 from area and put in a quiet area, back to his room, draw curtain. 2. Offer tasks to distract resident from current thoughts, give an activity, snack, or go for a walk. This same form does not document monitoring of R1's behaviors on [DATE]-[DATE], as these areas are blank. R1's Social Service Behavior Summary dated [DATE] at 12:23 PM, states, SSD/Social Service Director (V16) gathered January's behavior charting. (R1 displayed physical behaviors throughout the month randomly, charting was rarely completed. SSD will continue to follow. In-services were completed and charting should be completed better for this month. R1's Social Service Behavior Summary dated [DATE] at 12:02 PM, states, SSD gathered February's behavior charting. (R1) displayed physical behaviors half the month with interventions working half the time. Verbal behaviors were displayed a couple days with interventions working. SSD will continue to follow. R1's Social Service Behavior Summary dated [DATE] at 10:44 AM, states, SSD gathered March's behavior charting. (R1) did display physical behaviors with interventions working occasionally, verbal behaviors were displayed the same as well as the interventions. Interventions generally revert back d/t (due to) his Dementia. SSD will follow. On [DATE] at 3:30 PM, V2 (Director of Nursing) verified no behavior tracking logs for R1 could be provided for [DATE] or [DATE]. V2 verified the first behavior tracking for R1 was initiated on [DATE]. V2 verified no documentation could be provided to indicate increased monitoring or supervision such as 15 minute checks being initiated for R1 after R1's [DATE] or [DATE] incidents. On [DATE] at 8:51 AM, V2 stated, I would have expected 15 minute checks to have been implemented (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145604 If continuation sheet Page 6 of 15 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 145604 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Henry Rehab and Nursing 1650 Indian Town Road Henry, IL 61537 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 - Immediate jeopardy to resident health or safety for (R1) for at least 24 hours after R1's ([DATE] and [DATE]) incidents. It's hard to check on someone every 15 minutes especially when it gets very busy. I feel like being on 15 minute checks too long, the staff gets desensitized to them. As of [DATE], R1's medical record did not document 15 minute checks or other increased monitoring was ever completed for R1 after R1's [DATE] or [DATE] resident to resident incidents. Residents Affected - Few The Immediate Jeopardy began on [DATE] when R1, who has known sexually inappropriate behaviors, engaged in non-consensual inappropriate sexual behavior with R2. R1 was found massaging R2's perineal/groin area with R1's hand. On [DATE], R1 was found with R1's hand down the front of R4's pants. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on [DATE] at 9:53 AM. The facility submitted the original Abatement Plan for F600 to the State Agency on [DATE] at 5:14 PM. Revisions was requested on [DATE] at 10:03 AM; 2:51 PM; and 5:02 PM. An amended Abatement Plan was submitted and accepted on [DATE]. On [DATE], the immediacy was not able to be removed because the facility failed to monitor and document R1's behavior each shift as stated in the facility's Abatement Plan and on R1's Care plan and failed to provide documentation that 1:1 monitoring for R1 or R2 was completed after R1 and R2's [DATE] resident to resident incident as stated in the facility's Abatement Plan. An amended Abatement Plan was submitted and accepted on [DATE] at 11:18 AM. On [DATE] the surveyor confirmed through observation, interview and record review that the facility took the following actions to remove the Immediate Jeopardy: R1 and R2 were immediately separated and assessed following the [DATE] incident. R2 has expired and is unable to be interviewed/observed. V16/Social Service Director, V1/Administrator and V2/Director of Nursing had 1:1 visit with R1 and then R2 separately to discuss and assess concerns, needs, feelings - determined both R1 and R2 unaware of situation with no recall of occurrence. On [DATE], V2/Director of Nursing/DON implemented motion alarm at R1's doorway to assist staff in monitoring R1's location. Observations made on [DATE]-[DATE] and 4/20 and [DATE] note motion sensor alarm in place and in functioning working order in R1's room. On [DATE], R1's Lexapro ordered for sexual urges was increased from 10 milligrams/mg to 20 mg daily by V13/R1's Physician. All staff educated on appropriate use of R1's motion alarm, completed by V2/DON. [DATE], Behavior Status Review completed by V3/Assistant Director of Nursing. Medication adjustments continue to be effective, As of [DATE], Behavior tracking was initiated in the facility's electronic charting system to help differentiate between R1's different targeted behaviors. On [DATE] and [DATE], R1 was seen by the Psychiatry Company for an initial evaluation and subsequent visit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145604 If continuation sheet Page 7 of 15 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 145604 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Henry Rehab and Nursing 1650 Indian Town Road Henry, IL 61537 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 On [DATE], Non-pharmacological interventions: offer book to read, turn on music, distraction (games/puzzles), offer assistance to activity room to play bingo added to R1's Care Plan by V2/DON. Level of Harm - Immediate jeopardy to resident health or safety All staff educated on Abuse Policy including preventing abuse on [DATE], done by V2/Director of Nursing and V1/Administrator. Residents Affected - Few All staff notified verbally and/or by mass communication of R1's plan of care on [DATE] by V1 and V2. [DATE], Audit tool created by V1 to ensure care plans are updated with effective interventions and staff aware of any changes, weekly times four, then monthly times four, then as needed based on QAPI (Quality Assurance and Performance Improvement) Team recommendations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145604 If continuation sheet Page 8 of 15 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 145604 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Henry Rehab and Nursing 1650 Indian Town Road Henry, IL 61537 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 Level of Harm - Minimal harm or potential for actual harm Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to immediately report an allegation of sexual abuse to the Administrator/Abuse Coordinator for one (R1 and R2) of five allegations of abuse reviewed. Residents Affected - Few Findings include: The facility's Elder Justice Act and Reporting Suspected Crimes Against Residents Policy and Procedure, dated 2022, states, B. The Facility has a duty to report all alleged violations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, as well as the results of all investigations of alleged violations pursuant to 42 CFR 483.12(c). B. Alleged violations under 42 CFR 483.1(c) a. Immediately (for alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) but not later than: i. Two hours if the alleged violation involves abuse or results in serious bodily injury. ii. 24 hours if the alleged violation does not involve abuse and does not result in serious bodily injury. k. Abuse includes unwanted sexual contact, which includes but is not limited to: 1. Unwanted touching of the breasts or perineal area; 2. A resident who fondles or touches a person's sexual organs and the resident being touched indicates the touching is unwanted through verbal and non-verbal cues; 3. Sexual activities where one resident indicates that the activity is unwanted through verbal and non-verbal cues 4. Sexual activity or fondling where one of the resident's capacity to consent to sexual activity is unknown; 8. Other unwanted actions for the purpose of sexual arousal or sexual gratification resulting in degradation or humiliation of another resident. R1's Nursing Progress Note on 3/7/2023 at 10:15 PM, states, (R1) was inappropriately groping another resident (R2). Both residents (R1 and R2) separated and (R1) brought down the hall to be observed by staff. The facility's Serious Injury Incident Report, dated 3/8/23, documents a final report that the Perpetrator/R1 and the Victim/R2 were in a resident to resident altercation on 3/7/23 at 10:25 PM. V5 (Certified Nursing Assistant/CNA) and V6 (CNA) are documented witnesses. This report states, (R1) had inappropriate behavior with (R2) by the nurse's station. (R1 and R2) were separated immediately. Final: (V5) notified (V4/Licensed Practical Nurse) that (R1) appeared to have his hand grabbing/groping (R2's) lap. (V5 and V6) separated immediately. Assessment was performed by (V4). V5's written statement, dated 3/7/23, states, I (V5) was at the nurse's station charting before dinner was served. I looked over and noticed (R2) sitting still next to (R1). I sat up to see what they were doing and I noticed (R1) had his hand on (R2's) vaginal area over her pants massaging the area. Once I realized what was happening between them, I stood up and removed (R2) from the area, while my co-worker (V6) started to remove (R1). Once (R2) was out of the area, (V5 and V6) told (R1) that behavior was inappropriate and moved him away from other female residents and had him sit in the hallway to eat dinner. Both (V5 and V6) informed our nurse (V4). On 3/28/23 at 10:41 PM per telephone interview due to third shift hours, V4 stated that V5 had reported to V4 that R1 was being inappropriate with R2 and had touched R2 near R2's vaginal area. V4 denied that V4 reported R1 and R2's incident to V1/Administrator/Abuse Coordinator. V4 stated, I charted a progress note and kept an eye on (R1). I did not report it to anyone. They told me the next day (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145604 If continuation sheet Page 9 of 15 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 145604 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Henry Rehab and Nursing 1650 Indian Town Road Henry, IL 61537 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 that I should have reported the incident immediately. Level of Harm - Minimal harm or potential for actual harm On 3/29/23 at 3:27 PM, V5 (Certified Nursing Assistant) stated, (On 3/7/23) I was sitting at the Nurse's desk. We keep a balloon on (R2's) wheelchair to help keep track of (R2) because (R2) is so mobile. I noticed (R2's) balloon was not moving which was not normal for (R2), so I sat up to see what (R2) was doing. That's when I noticed that (R1) had his hands in (R2's) pubic region and was massaging the area. We immediately separated the residents and I reported it to my nurse right away. I don't like to think about that happening to (R2). V5 stated, I told my nurse about it and that's it. We were in-serviced that this should have been reported to (V1) immediately. Residents Affected - Few On 3/28/23 at 11:12 AM, V2 (Director of Nursing) stated that on 3/8/23, around 9:00 or 10:00 in the morning, V2 was reviewing 24 hour charting from the night before (3/7/23). V2 stated that V2 found a note charted by V4, that R1 had inappropriately groped R2. V2 stated that V2 discussed the incident with the staff members who confirmed the incident occurred between R1 and R2. V2 stated that this incident should have immediately been reported to V1 and it was not. On 3/28/23 at 11:03 AM, V1 (Administrator) stated that staff did not immediately report R1 touching R2 inappropriately on 3/7/23 and should have. We started in-servicing on that right away. The facility's In-Service Sign-In Sheets, dated 3/9/23 and 3/10/23 documents the audience as All Staff and the topic as: Abuse Reporting; Abuse Prevention; Recognizing Abuse. The attached in-service sheet, dated and initialed by V1 on 3/9/23 states, Any abuse allegations need to be reported to (V1/Administrator/Abuse Coordinator). We only have two hours to report. Example: Inappropriate behaviors sexual or touching needs to be reported. Resident to resident needs to be reported. If you need to separate two residents, call me (V1). We know who has triggers. Move them before the incident happens, get them something to do. Take them to activities. Sit with them for a moment. Ask them to walk with you or go for a ride in wheelchair. These are things that need to happen before an incident occurs. Be proactive verses reactive. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145604 If continuation sheet Page 10 of 15 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 145604 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Henry Rehab and Nursing 1650 Indian Town Road Henry, IL 61537 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise a resident's plan of care for one of eight residents (R1) reviewed for care plans in the sample of eight. Findings include: The facility's Comprehensive Care Plan policy, revised 6/25/20, states, Policy Statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Policy Interpretation and Implementation: 1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 3. Each resident's comprehensive care plan has been designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; c. Build on the resident's strengths; d. Reflect treatment goals and objectives in measurable outcomes. 5. Care Plans are revised as changes in the resident's condition dictate. R1's Facesheet documents R1 admitted to the facility on [DATE] with a diagnosis to include but not limited to: Alzheimer's Disease. R1's current Order Recap Report documents an order for Escitalopram Oxalate 20 milligram tablet daily for sexual urges with an order start date of 3/11/23 and no end date. The facility's Serious Injury Incident Report, dated 12/23/22, documents this report as an initial and final report that on 12/23/22 at 11:15 AM, R1 and R4 were in a resident to resident altercation. This same report documents R1 as the perpetrator, R4 as the victim and V8/CNA/Certified Nursing Assistant as a witness. This report states, (V8) alerted (V2/Director of Nursing) that (R1) appeared to have his hand in (R4's) sweatpants. (R1) was sitting at his table in the dining room and (R4) was standing in front of (R1). (V8) separated (R1 and R4) immediately and notified (V2). The facility's Serious Injury Incident Report, dated 3/8/23, documents a final report that the Perpetrator/R1 and the Victim/R2 were in a resident to resident altercation on 3/7/23 at 10:25 PM. V5 (Certified Nursing Assistant/CNA) and V6 (CNA) are documented witnesses. This report states, (R1) had inappropriate behavior with (R2) by the nurse's station. (R1 and R2) were separated immediately. Final: (V5) notified (V4/Licensed Practical Nurse) that (R1) appeared to have his hand grabbing/groping (R2's) lap. (V5 and V6) separated immediately. Assessment was performed by (V4). R1's Care Plan documents the following: Focused area with an initiation date of 12/23/22 that R1 has an alteration in R1's behavior status related to Alzheimer's, Impaired memory/thinking and Increased sexual drive; R1 may exhibit behaviors such as: increased confusion, making inappropriate comments or physically attempting to touch staff, hospice staff, residents; R1 may be unable to comprehend or remember appropriate behavior due to R1's diagnoses; R1 gets agitated at times with staff and other residents; a goal that R1 will not engage in inappropriate sexual behavior; Interventions are documented as My (R1's) behaviors will be monitored every shift and documented with an initiation date of 12/23/22; Intervene as Necessary to protect safety of others; R1 has expressed sexual desires with an initiation date of 12/26/22 and documents interventions as Intervene when risk, resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145604 If continuation sheet Page 11 of 15 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 145604 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Henry Rehab and Nursing 1650 Indian Town Road Henry, IL 61537 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few safety, or the safety of others is involved; Lexapro per MAR (Medication Administration Record) to control sexual urges with a revision date of 3/10/23; and R1 is on Psychotropic Medications due to R1's sexual urges; R1's medication was increased on 3/10/23 for an unusual occurrence on 3/7/23. On 4/14/23 at 2:21 PM, V17 (Activity Director) stated that R1 is an active participant in activities/groups. V17 stated that R1 is invited to attend activities the same as the other residents and that R1 is not on 1:1 activities. V17 stated, (R1) isn't treated differently than any other resident as far activities goes. V17 stated that V17 is aware that R1 has a history of sexually inappropriate behaviors. V17 stated that V17 does not leave R1 alone in activities, V17 puts R1 at group activities with other male residents, and V17 has staff assist R1 to and from activities when needed. V17 stated these extra interventions for R1 should be documented on R1's Care Plan and stated that they are not. V17 stated, I will add them now. As of 4/14/23 at 12:30 PM, R1's Care Plan did not document interventions to protect other resident's from R1's sexual behavior during Activities. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145604 If continuation sheet Page 12 of 15 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 145604 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Henry Rehab and Nursing 1650 Indian Town Road Henry, IL 61537 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to safely transfer a resident according to their plan of care for one of three residents (R6) reviewed for accidents and supervision in the sample of ten. Findings include: The facility's Fall Reduction Policy, revised 11/5/19, states, Purpose: To provide an environment that remains as free of accident hazards as possible; To identify residents who are at risk for falling and to develop appropriate interventions to provide supervision and assistive devices to prevent or minimize fall related injuries. The facility's Safe Patient Mobility Policy, revised 11/5/19, states, Policy: All lifting, positioning and moving of patients will be done within a defined standard of care for the overall safety of the patient and the health care worker. Purpose: The purpose is to outline a specific standard for lifting, positioning and moving of patients safely and appropriately to prevent injury to healthcare workers and patients. Practice: It is the responsibility of employees to take reasonable care of their own safety, as well as that of their co-workers and patients during patient handling activities. It is preferable that two employees will be present during a transfer to stabilize and support the patient whenever possible to maintain safety. Procedure: b. Patient Lift/ Transfer Procedure: 1. Patient mobility needs are assessed upon admission, prior to performing a lift/transfer/move, every eight hours and on an on-going basis as needed. Types of transferring devices and amount of assistance required will be determined, documented and communicated to all employees taking care of the patient. 2. Prior to using a mechanical lift or transfer device, ensure proper planning for the lift/transfer has been accomplished and request assistance as applicable for any difficult lift/transfer. 3. Have proper equipment or personnel on hand and ensure everyone involved in the task understands his or her role in the transfer, lift, or move. R6's Facesheet documents R6 admitted to the facility on [DATE] with diagnoses to include but not limited to: Unspecified Abnormalities of Gait and Mobility; Unspecified Lack of Coordination; Cognitive Communication Deficit; Morbid (Severe) Obesity; Muscle Weakness (Generalized); and Repeated Falls. R6's current Order Summary Report documents orders for Mechanical Lift for Transfers (Brand Name of Total Mechanical Lift) with an order start date of 4/14/23; Monitor Site Hematoma Back of Head/Scalp every shift with an order start date of 4/19/23; Post fall monitoring every shift for three days-if any new injuries post fall place an order for the area of concern and do a progress note with an order start date of 4/19/23; and Eliquis (Anticoagulant) Tablet 2.5 milligram by mouth twice a day for DVT/Deep Vein Thrombosis prevention with an order start date of 10/27/22. R6's Quarterly Minimum Data Set/MDS Assessment, dated 3/11/23, documents R6 with the following: moderately impaired cognition; requires extensive assistance of two plus persons physical assist for bed mobility, transfers, and toilet use; and when moving from a seated to standing position and moving on and off the toilet, R6 is not steady and only able to stabilize with staff assistance. R6's Fall Risk Assessment, dated 1/7/23, documents R6 as a moderate fall risk. R6's current Care Plan documents R6 has had an actual fall due to unaware of safety needs. Falls (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145604 If continuation sheet Page 13 of 15 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 145604 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Henry Rehab and Nursing 1650 Indian Town Road Henry, IL 61537 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few are documented on 9/24/22, 10/7/22, 10/10/22, 10/14/22, 10/31/22 and 4/18/23. This same Care Plan states, 4/18/23-fall in room; Hematoma to scalp and documents R6 with an alteration to cognition due to memory loss and cognitive communication deficit. R6's Nursing Progress Note on 12/15/22 at 7:26 PM documents R6 lost consciousness when R6 stood up with two staff member assist. R6's Nursing Progress Note on 4/18/23 at 2:42 PM documents R6 fell to the floor and sustained a goose egg to the back of R6's head. R6's Physical Therapy Recertification, Progress Report and Updated Therapy Plan, dated 11/4/22 documents staff provides 100% (percent) assistance for transfers and states, (R6) Difficulty performing transfers d/t (due to) reduced safety awareness, weakness and cognitive status and (R6) unable to perform supported standing d/t LE (lower extremity) weakness, cognitive status and motivation. This same report states, Patient Progress: (R6) Presenting difficulty with improving standing tolerance and functional mobility d/t patient motivation and cognitive status. (R6) frequently is confused and resistive with treatment. Remaining Impairments: Balance Deficits; Decreased Safety Awareness; Strength Impairments; Safety Awareness Deficits; and Postural Alignment/Control. R6's POC (Point of Care) Response History, dated 4/14/23-4/21/23, states, Task: ADL (Activity of Daily Living)-Transferring (Brand Name of Total Mechanical Lift). The dates 4/14/23-4/15/23 and 4/17/23-4/18/23 documents a sit to stand lift was used with two plus persons physical assist. The facility's Incident by Incident Type Report, dated 1/21/23-4/21/23, documents on 4/18/23 at 2:30 PM, R6 sustained a staff assisted fall with injury incident. R6's Incident Report, dated 4/18/23 at 2:30 PM, documents the incident occurred in R6's bedroom. This report states, Nursing Description: (R6) on floor. Lying on his right side Had been transferring with the sit to stand lift. (R6) c/o (complained of) feeling dizzy and then slumped while in lift. (R6's) feet at the base of the lift/his head at the foot of his bed. CNA (Certified Nursing Assistant/V20) said (R6's) head hit the edge of foot board, she (V20) put her hand out to attempt to buffer it. Resident Description: I felt dizzy. Other Info: Was in lift became dizzy and slumped, causing fall. Witnesses: (V20/CNA) 4/18/23 (R6) transferring with sit to stand lift. All of a sudden (R6) slumped down causing to fall. (R6) hit his head on the foot board. I attempted to buffer him hitting his head by putting my hand out onto the foot board. V20's written statement, dated 4/18/23, states, I had (R6) strapped into the sit to stand sitting on the toilet. I lifted (R6) up in the lift to wipe his bottom. (R6) had been talking and alert. As soon as I started to pull the resident's brief and pants up, he stopped talking and began sliding down in the lift. I tried to get (R6) to the wheelchair but then decided it was safer to lower resident to the floor when I couldn't make it to the chair. I had my hands on his back and under his neck as I lowered him to the ground. (R6) started jerking and hit his head off the ground when I was lowering him. V18's (Licensed Practical Nurse) written statement, dated 4/19/23, states, (R6) fell on 4/18/23 at 2:30 PM. I responded to the call for a nurse. Upon entering (R6's) room, (R6) was lying on his right side, his head at the foot of his bed, his feet at the base of the sit to stand lift. (R6) was talking and his face flushed. He felt a little sweaty but not cool or clammy. Neuro (Neurological) checks and vital signs and his responses were normal limits. (R6) had a small goose egg on the back of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145604 If continuation sheet Page 14 of 15 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 145604 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Henry Rehab and Nursing 1650 Indian Town Road Henry, IL 61537 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 0689 his head. (R6) denied having any pain. Level of Harm - Minimal harm or potential for actual harm On 4/25/23 at 12:58 PM, V3 (Assistant Director of Nursing) that V3 was recently updating residents' transfer status on the Physician Order Sheets. V3 verified that V3 entered R6 to be a total mechanical lift. V3 stated at one point (R6) was either sit to stand or a total lift but (R6) has gotten weaker. V3 stated after R6's 4/18/23 fall, V19 (Physical Therapist) verified R6 should remain a total mechanical lift for transfers. Residents Affected - Few On 4/25/23 at 1:25 PM, V20 stated, I picked up a 2:00 PM-10:00 PM shift on 4/18/23. I usually work nights. Right at shift change, (R6) had to go to the bathroom. I got report from the day shift CNA and then she was pulled away to go with another aide. I went in (R6's) room and got him hooked up to the lift. I got (R6) to the toilet and then about five minutes later, (R6) had his call light on to get off the toilet. Everyone was giving shift change report or busy. I couldn't find my partner and (R6) was getting agitated, so I went into (R6's) bathroom by myself. We were having a conversation, I was getting him wiped up and pulling his pants up. (R6) then stopped talking. I pulled the lift out of the doorway to get behind (R6) and I was trying to turn the lift to get to (R6's) chair. (R6) was unresponsive and not talking to me. (R6) was sliding down out of the sling and I was having a hard time getting (R6) to the wheelchair. There was no where to go, so I tried to lower (R6) to the ground. (R6's) arms were above (R6's) head and he was sliding through. I was scared his shoulders were going to dislocate, so I lowered the arms of the lift to the halfway down position and then (R6) slid right through. I was trying to lower (R6) gently but (R6) is a very big guy and the fall wasn't graceful at all. (R6) hit his head on the floor. At this time, V20 stated that V20 would check with the previous CNA, the nurse or the POC (Point of Care) charting to see how a resident transfers. V20 verified that V20 should have had two staff members to transfer R6 and to provide after toilet cares. On 4/25/23 at 1:38 PM, V19 (Physical Therapist) stated that due to R6's cognition status, safety awareness and weakness, R6 should have two staff members present for all mechanical lift transfers and verified R6 should remain a total mechanical lift for all transfers. On 4/21/23 at 2:37 PM, V9 (CNA) stated that R6 should have two staff members present during R6's transfers. V9 stated, (R6) was standing for too long, passed out and slid out of the sling. For exactly that reason, is why you should always have two people. (R6) is a big guy and it's too much to do alone. On 4/21/23 at 2:42 PM, R6 was sitting in a wheelchair in R6's bedroom. R6 stated, They told me what happened. I blacked out. I have a sore spot on my (right) elbow and a bump to the back of my head. At this time, R6 rubbed the left posterior portion of R6's head and stated, It's hurts but it gets better each day. On 4/21/23 at 2:48 PM, V18 (Licensed Practical Nurse) stated that V18 was R6's nurse on 4/18/23 when R6 fell out of the sit to stand sling. V18 stated, (V20) said (R6) slumped and she couldn't hold him up. (V20) said (R6) hit the back of his head during the fall. There was a goose egg to the back of (R6's) head. He was talking when I entered the room. His face was flushed. I notified (R6's) physician. We didn't' send him out. At this time, V18 stated that two staff members should be present for all of R6's transfers. V18 stated, After (R6's 4/18/23) fall, the DON (V2/Director of Nursing) was in-servicing everyone on using two staff members for lift transfers. On 4/21/23 at 3:05 PM, V2 (Director of Nursing) stated that for residents who use the sit to stand, they must be able to bare their own weight and stand. Two staff members are used ideally. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145604 If continuation sheet Page 15 of 15