Inspection·April 18, 2025

F 0656 precautions. Level of Harm - Minimal harm or potential for actual harm R31's current Care Plan indicates R31 has an alteration to her Genitourinary system due to ESBL. Care Plan intervention indicates R31 has Enhanced Barrier Precautions (EBP) in place. Residents Affected - Few On 4/17/25, at 9:30 am, V1/Administrator, confirmed the facility currently does not have an MDS (Minimum Data Set)/Care Plan Coordinator. On 4/17/25, at 9:35 am, V1 and V3/ADON (Assistant Director of Nursing)/IP (Infection Preventionist) both acknowledged the care plans should have been developed to include problem area of transmission based precautions and appropriate interventions. On 4/17/25 V3 confirmed R31 remains in Contact Precautions-not EBP and the care plan needs to be corrected. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145604 If continuation sheet Page 2 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145604 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2025 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review the facility failed to obtain smoking agreements and collect smoking paraphernalia for two (R1, R15) of two residents reviewed for smoking in a sample of 22. Residents Affected - Few Findings include: The facility policy and procedure titled, Smoking, revised October 1, 2024, documents, Policy- To ensure compliance with regulatory guidelines and safety protocols, the Facility prohibits smoking except for in specifically designated areas. To protect the safety of other residents and employees, the use of medical oxygen is prohibited in smoking areas. Residents deemed to need assistance to smoke should have this designation noted in the care plan. For purposes of this policy, electronic cigarettes Ce-cigarettes, pipes, cigars, and similar paraphernalia are to be treated as cigarettes. Procedure- 1. B. Residents are not permitted to have any smoking paraphernalia in their room or on their person. All smoking paraphernalia should be given to the nursing staff for safekeeping. Nursing staff should maintain records of residents' property and distribute it accordingly. Nursing staff are required to confirm the resident's status in the smoking log before distributing smoking materials to the resident. Residents who have been determined to require supervision must be actively supervised by a staff member while in the designated smoking area. E. Residents must sign a Smoking Agreement as part of the admission process. Smoking Agreements should be amended and re-signed when the resident's smoking status has changed. R1's admission Record documents R1's date of admission to the facility was 2/26/25 and her diagnoses on admission included: Cerebral Infarction, Major depressive Disorder Recurrent, Insomnia, Depression, Anxiety, Hyperlipidemia, Myocardial Infarction Type 2, and Type 2 Diabetes. R1's Minimum Data Set assessment, dated 3/6/25, documents R1 has a Brief Interview for Mental Status (BIMS) score of 13/15 indicating cognition intact. R1's Smoking Evaluation Assessment, dated 3/4/25, documents that R1 is a smoker. R1's current Care Plan documents R1 is a smoker and Cigarettes (or other smoking materials) and lighter are required to be stored at the nurse's station or med cart. On 4/15/25 at 1:51pm, R1 stated, I (R1) am a smoker. R1 also stated, I keep my smoking materials with me or in the top drawer of my husbands (R15) dresser in his room. R1's cigarette pack and lighter observed in R1's shirt pocket at this time. R15's admission Record documents R15's date of admission to the facility was 9/5/24 and his diagnoses on admission included: Cerebral Infarction, Metabolic Encephalopathy, Sepsis, Osteomyelitis, and Nicotine Dependence. R15's Minimum Data Set assessment, dated 3/11/25, documents R15 has a BIMS score of 13/15, indicating cognition intact. R15's Smoking Evaluation Assessment, dated 9/6/24, documents that R15 is a smoker. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145604 If continuation sheet Page 3 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145604 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2025 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 R15's current Care Plan documents R15 is a smoker and Cigarettes (or other smoking materials) and lighter are required to be stored at the nurse's station or med cart. On 4/15/25 at 10:53am, R15 stated, I am a smoker and I keep my cigarettes and lighter in the top drawer of the nightstand over there under the television set. R15's cigarette pack and lighter noted in top drawer of nightstand at this time. On 4/16/25 at 10:39am, R1 and R15's cigarettes and lighters observed in R15's nightstand, top drawer. R1 and R15 also stated they do not remember signing a smoking agreement on admission. On 4/16/25 at 11:00am, V5 (Licensed Practical Nurse/LPN) stated, There is no designated smoking times for residents, they go when they want if there is staff available to take them. Resident smoking supplies are kept at the nurses station. V5 (LPN) verified that smoking supplies were not at nurses' station and stated, They are usually kept here but I didn't work yesterday so I'm not sure where they are. On 4/17/25 at 10:00am, V5 (LPN) verified that R1 and R15's cigarettes and lighter were in R15's bedside table, top drawer and V5 (LPN) stated, they (cigarettes and lighter) should be kept at the nurse's station. On 4/17/25 at 10:14am, V1 (Administrator) stated, resident's cigarettes and lighters are to be kept at the nurse's station when they are not smoking. On 4/17/25 at 11:30am, V1 (Administrator) stated, Resident smoking agreement is a new form added when policy was revised in October of 2024 and has not been updated in our system. So, neither of our smokers (R1 and R15) have signed one. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145604 If continuation sheet Page 4 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145604 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2025 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview, observation, and record review the facility failed to attempt gradual dose reduction for one resident (R15) of five residents reviewed for unnecessary medications in a sample of 22. Findings include: The facility's Policy and Procedure, titled Psychotropic Gradual Dose Reduction (GDR), revised 11/5/19, documents, Policy statement- It is the policy of this facility that residents who use psychotropic drugs will receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue the use of these medications. Policy Interpretation and Implementation- 1. Residents who use psychotropic drugs will receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue the use of such drugs. 4. Our drug reduction program consists of tapering the resident's daily dose to determine if the resident's symptoms can be controlled by a lower dose or to determine if the dose can be eliminated altogether. Inquiries concerning drug reductions should be referred to the pharmacist, attending physician, psychiatrist, and/or to the director of nursing. The facility policy, entitled Psychotropic Medication Management, dated 12/4/2019, documents: Documentation within the clinical record to support one or more of the following diagnosis: Schizophrenia, Delusional Disorder, Organic mental syndromes (now called delirium, dementia, and amnesia and other cognitive disorders) with associated psychotic and/or agitated behaviors. 1. R15's admission Record documents R15's date of admission to the facility was 9/5/24 and his diagnoses on admission included: Cerebral Infarction, Metabolic Encephalopathy, Sepsis, Osteomyelitis, Other Specified Depressive Episodes, Anxiety Disorder, and Nicotine Dependence. R15's Minimum Data Set assessment, dated 3/11/25, Section C documents R15 has a BIMS score of 13/15, indicating cognition intact, Section E documents no behaviors exhibited, and Section N documents R15 currently takes Antidepressant Medications. R15's Physician Orders, dated 9/5/24, documents R15 takes Bupropion HCL ER (XL) Extended Release 24 Hour 300 milligram (mg) tablet (antidepressant) give one tablet by mouth one time a day related to Other Specified Depressive Episodes and Escitalopram Oxalate/Lexapro 20 mg tablet (antidepressant) give 20 mg by mouth one time a day for antidepressant. R15's current care plan documents R15 receives antidepressant medications for Depression and has an alteration in behavior related to depression. R15's Psychotropic Medication Monitoring Assessment, dated 9/5/24, documents R15 takes antidepressant medications of Bupropion ER (Extended Release) 300 mg daily and Escitalopram 20 mg daily. R15's Behavior- Depression/Withdrawn task documents no behaviors from 3/20/25 to 4/17/25. R15's psychiatry note, dated 2/15/25, documents, Gradual Dose Reduction (GDR) Lexapro/Escitalopram (antidepressant) 20 mg to 15 mg daily for depression. Continue Bupropion HCL ER (Extended Release) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145604 If continuation sheet Page 5 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145604 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2025 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 0758 300 mg daily for depression. Level of Harm - Minimal harm or potential for actual harm R15's psychiatry note, dated 3/12/25, documents, GDR of Lexapro from 20 mg to 15 mg daily for depression recommended last session but patient is still on Lexapro 20 mg by mouth (po) daily. Residents Affected - Few On 4/15/25, 4/16/25, and 4/17/25 R15 observed on several occasions calmly sitting in his wheelchair in room watching television. On 4/16/25 at 2:09 pm, V6 (Social Service Director/SSD) stated, The Director of Nursing/DON, Assistant Director of Nursing/ADON, and me (V6) get the psychiatry notes emailed to us. I (V6) document visit in the nurses' notes and nursing takes care of the recommendations for Gradual Dose Reductions/GDR's. On 4/16/25 at 2:10 pm, V1 (Administrator) stated, The Director of Nursing/DON monitors psychotropic medications and Gradual Dose Reductions/GDR's. The DON sends recommendations from psychiatric services to the facilities Nurse Practitioner to approve or decline, then documents response and changes orders if approved. On 4/17/25 at 9:54 am, V1 (Administrator) verified that on 2/15/25 psychiatry recommended to decrease R15's Escitalopram (antidepressant) from 20 milligrams(mg) daily to 15 mg daily and recommendation was not sent to Nurse Practitioner to approve or decline. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145604 If continuation sheet Page 6 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145604 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2025 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Based on interview and record review the facility failed to provide a Hospice created Care Plan, visit communication notes and to designate in writing a facility Hospice Coordinator for one resident (R28) of three residents reviewed for Hospice in the sample of 22. FINDINGS INCLUDE: Facility Policy Hospice Care, dated 11/5/2019, document: This facility will work in coordination with the contracted Hospice agency to provide a safe continuum of care for the resident's end of life. Nursing Facility Hospice, General Inpatient And Respite Care Services Agreement, dated 7/13/21, documents: Services to be Provided by Hospice: Hospice will develop, at the time a resident of the Facility is admitted into Hospice's program, a Plan of Care for the management and palliation of the resident's terminal illness. The Plan of Care will identify the care and services that are needed and will specifically identify which provider is responsible for providing respective functions that have been agreed upon and included in the Plan of Care. The Plan of Care will be updated as often as the patient condition requires, but no less frequently than every fifteen (15) calendar days. A copy of each updated Plan of Care will be furnished to the Facility upon each update, but no less frequently than every fifteen (15) days. Hospice will furnish a copy of each Hospice patient's Plan of Care to the Facility at the time of the resident's admission into the Hospice program. On 4/16/25, at 3:00 pm, V4/Business Office Manger and V9/Registered Nurse were unable to find the Hospice Company Care Plan at the nurses station where they both stated it would be kept. V4 stated That particular Hospice Company does not leave communication notes They haven't left them for a long time. No Hospice communication notes were found in R28's electronic medical record or in the binders at nurse station designated for the Hospice Company. There was no designation in writing found indicating who was the facility Hospice Coordinator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145604 If continuation sheet Page 7 of 7