Inspection·April 18, 2025

F 0600 negative behaviors towards others. Level of Harm - Minimal harm or potential for actual harm R28's Progress Note, dated 2/5/25 at 2:25 PM, documents the following: The residents sitting in the dining room reported that this resident was the recipient of physical altercation with another resident (R18) while sitting in the dining room for breakfast. Resident (R28) went to stand up and lost her balance. she stated that she hit the top of her head. She was assisted off the floor by staff members and no injuries noted. Placed on neuro checks. Residents Affected - Few 2. The Abuse Investigation Final Report, dated 3/4/24, documents the following: Resident to resident altercation. Residents were separated immediately. R56 was sent out for a psychiatric evaluation due to increased behaviors due to non-compliance with medications. R81 had a head-to-toe assessment completed with no injuries. Upon final investigation and after interview of R81 and a witness, it was determined that R81 tried to grab a chair from R56 in the day area. R56 grabbed the chair back from R81. R81 told R56 that she wanted the chair to sit next to another residents, R56 threw the chair down and it made contact with R81's arm. The residents reside on the same hall, and both requested not to be moved. Since the altercation did not happen on the hall the facility granted their wishes. The facility provided the residents with a behavior contract in which they both signed. Residents have not had any further altercations at this time. R56's Face Sheet, undated, documents R56 has the following diagnoses: Alcohol Abuse, Dementia, Bipolar Disorder, Schizophrenia, Anxiety Disorder and Alzheimer's Disease. R56's MDS, dated [DATE], documents R56 has a BIMS score of 7, indicating R56 has severe cognitive impairment. R56's Care Plan, dated 5/6/21, documents R56 is at risk for abuse and neglect. R56's Progress Note, dated 3/4/25 at 6:54 AM, documents the following: Resident in front dining area when (R81) comes up to her and pushes her. (R56) picks up the chair she was moving to sit and attempted to hit (R81) with chair. Altercation continues with staff coming between both residents to prevent injury to either of them. (R56) cursing and yelling attempting to hit (R81). They were separated with (R81) going to back nursing station. Was informed by staff that both residents had been arguing all morning. This nurse was at back nurses' station where (R81) spent most of her night. R81's Face Sheet, undated, documents R81 has the following diagnoses: Schizoaffective Disorder of the Bipolar Type, Mild Intellectual Abilities and Bipolar Disorder. R81's MDS, dated [DATE], documents R81 has a BIMS score of 9, indicating R81 has moderate cognitive impairment and hallucinates. R81's Care Plan, dated 11/28/24, documents R81 is at risk for abuse and neglect and has symptoms such as: mood swings, talking to self, impulsive behavior and attention seeking behavior related to her diagnosis of Schizoaffective Disorder of the Bipolar Type. R81's Progress Note, dated 3/4/25 at 7:02 AM, documents the following: R81 and R56 in an altercation this am. R81 pushed R56, and she (R56) picked up her chair and attempted to hit R81. Staff got between both residents to deescalate the altercation. R56 and R81 both kept trying to hit the other. R81 was sent back to the back nurse's station where she sat with nurse there. R81 had been there most of shift. Day shift staff along with night shift staff witness to altercation. No injuries obtained (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145613 If continuation sheet Page 2 of 9 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 145613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Cahokia 3354 Jerome Lane Cahokia, IL 62206 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 to either resident. Level of Harm - Minimal harm or potential for actual harm On 4/17/25 at 1:35 PM, V1, Administrator, stated R56 had a psychiatric review for her behaviors, has been doing better and hasn't had any behaviors recently. R81 is on a rewards program. V1 stated R18, R28, R56 and R81 are all on a behavior management program to address their behaviors and to prevent further resident to resident altercations. Residents Affected - Few The Abuse Policy and Prevention Program, dated 10/2022, documents the following: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or other individuals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145613 If continuation sheet Page 3 of 9 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 145613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Cahokia 3354 Jerome Lane Cahokia, IL 62206 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 interview, and record review the facility failed to supervise residents during showering to prevent falls for 1 of 11 residents (R83) reviewed for falls in the sample of 42. Finding include: R83's Face sheet documents an admission date of 2/17/2024 with diagnoses to include Extradural and Subdural Abscess, Pseudoarthrosis after Fusion or Arthrodesis, Abnormal Gait and Mobility, Protein Calorie Malnutrition. R83's Minimum Data Set, MDS, dated [DATE] documents R83 has no cognitive impairments. R83's primary mode of transportation is wheelchair. R83 requires supervision or touching assist with showering. R83 requires partial/moderate assist with personal hygiene, sitting to standing, and tub shower transfer. R83's Care Plan, updated 12/5/2024, documents Activities of Daily Living, ADLs: R83 requires assist with daily care needs related to abnormalities of gait and mobility, unsteady on feet and lack of coordination. He is incontinent of bowel and bladder at times. He uses a wheelchair to ambulate through facility. Interventions include assist R83 with ADLs. R83's care plan updated 12/5/2024 documents Fall: R83 is at risk for falls related to Cognitive deficits and History of Falls. R83's Fall Investigation, dated 3/14/2025 documents this nurse was informed by V14, Licensed Practical Nurse, LPN, that R83 was on the floor inside the shower at approximately 4:10PM. Upon entering shower room, R83 was kneeling facing the door. R83 was assisted to a standing position then into his chair by V13, Licensed Practical Nurse, LPN and V14. R83's mother was aware as she noticed R83 had fallen. This nurse assessed R83 and noted redness to bilateral knees. R83 complained of pain to lower back. This nurse asked R83 to explain how he fell, and he stated he was standing up in the shower, washing my hair, then I went to sit down, and the chair moved back, and I fell. R83 was started on neuro checks at 4:30PM. R83 began to have some redness noted to center of forehead, with reddened eyes. R83's mother was concerned of R83's well-being. This nurse called Emergency Medical Services, EMS, at approximately 4:49PM to transfer R83 to local hospital to be evaluated. EMS arrived at 5:15PM to transport R83 to local hospital. R83's progress notes dated 3/15/2024 at 12:27AM documents: R83 returned to facility at approximately 12:05AM via (ride hauling company) per R83. No new orders at this time. R83 doing well thus far. R83 had a Cat scan, CT, done on head, cervical, lumbar, and thoracic spine which were negative. Care ongoing. On 4/17/2025 at 9:00AM R83 sitting in wheelchair in dining room. R83 stated I fell in the shower. No one was in there with me, and I need them to be. I stood up to wash my hair and fell. My equilibrium is off. They stay with me now. On 4/17/2025 at 10:00AM V2, Director of Nursing, DON, stated R83 is independent in a lot of ways. It looks like he forgot to lock his wheelchair. He is forgetful. If a resident is documented as requiring supervision, then someone needs to be with him during a shower. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145613 If continuation sheet Page 4 of 9 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 145613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Cahokia 3354 Jerome Lane Cahokia, IL 62206 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 On 4/17/2025 at 11:10AM V13, Licensed Practical Nurse, LPN, stated I was working when (R83) fell in the shower. I think he was missing his footwear, and the floor was slick. I don't know if he is supposed to have anyone stay with him. On 4/17/2025 at 12:40PM V16, Certified Nursing Assistant, CNA, stated (R83) takes showers on different shifts. If it's on day shift, I would watch him. If it's on evenings, he might not get watched as close. Everyone should be mindful to watch him. On 4/17/2025 at 12:50PM V17, CNA, stated I haven't worked with R83 for a while. When he was on my hall I stayed with him in the shower. Facility's fall policy with a revision date of 1/2024 states This facility is committed to maximizing each resident's physical, mental and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145613 If continuation sheet Page 5 of 9 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 145613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Cahokia 3354 Jerome Lane Cahokia, IL 62206 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to discontinue use of a resident's insulin after it was expired for 1 of 5 residents (R28) reviewed for labeling and storage of medications in the sample of 42. Findings include: On [DATE] at 1:45 PM the South Hall medication cart was reviewed with V4, Licensed Practical Nurse (LPN) and R28's Humalog Kwikpen was labeled as opened on [DATE] and expired on [DATE], indicating it had been expired for 8 days. V4 confirmed this is the only Humalog Kwikpen in the medication cart for R28 and would have been used to administer R28's sliding scale insulin. V4 stated this insulin should have been discarded on [DATE] and replaced with a new Humalog Kwikpen. R28 stated V4's blood glucose levels are checked three times a day and sometimes R4 gets Humalog insulin and sometimes she doesn't, depending on the blood glucose results. R28's Order Summary Report dated [DATE] documents an order dated [DATE], Insulin Lispro (Humalog) Inject as per sliding scale: if 70-150= 0; 151-200=2; 201-250=4; 251-300=6; 301-350=8; 351-400=10; above 400 give 12 units and contact MD (Medical Doctor) subcutaneously three times a day for diabetes mellitus. R28's Medication Administration Record (MAR) dated [DATE] to [DATE] documents R28 received insulin from the expired insulin pen twice on [DATE] and once on [DATE]. On [DATE] at 9:00 AM V2, Director of Nursing (DON) stated insulin pens are used for 28 days after opening. She stated the nurse should document on the pen when it is first opened and write the expiration date on the pen, and discard it when it expires. She stated the nurses should monitor this and order a new pen to have available when needed for replacement. The facility's policy, Medication Storage in the Facility reviewed on 6/2024 documents, Medications and biologicals are stored safely, securely, and properly following the manufacture or supplier recommendations. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. #14. Outdated, contaminated, or deteriorated drugs and those in containers, which are cracked, soiled or without secure closures will be immediately withdrawn from stock by the facility. They will be disposed of according to drug disposal procedures, and reordered from the pharmacy if a current order exists. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145613 If continuation sheet Page 6 of 9 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 145613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Cahokia 3354 Jerome Lane Cahokia, IL 62206 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 0814 Dispose of garbage and refuse properly. Level of Harm - Potential for minimal harm Based on observation, interviews, and record review the facility failed to ensure garbage in the facility dumpster was covered. This had the potential to affect all 105 residents residing in the facility. Residents Affected - Many The findings include: Observation made on 04/15/2025 at approximately 09:00 AM revealed three dumpsters for garbage located behind the kitchen. One dumpster lid was completely open to the environment and was observed to be approximately half full of disposable garbage bags. Observation made on 04/16/2025 at 02:43 PM revealed three dumpsters for garbage located behind the kitchen. All three dumpster lids were completely open to the environment and were observed to be approximately two thirds full of disposable garbage bags. During an interview on 04/15/2025 at approximately 10:00 AM, V7, Dietary Manager verified the observation and when asked why dumpster lids should be kept closed to the environment, stated, We need to keep the lids closed to keep the animals and the homeless out of the dumpsters. Review of the facility's policy Disposal of Garbage and Refuse with a review date of 10/2024, revealed, Procedure: 1. The facility will assure all garbage and refuse containers are in good condition (no leaks) and waste is properly contained in dumpsters or compactors with lids and covered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145613 If continuation sheet Page 7 of 9 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 145613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Cahokia 3354 Jerome Lane Cahokia, IL 62206 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility to justify the use of antibiotics for 3 of 4 residents (R10, R72, R306) reviewed for antibiotic stewardship in the sample of 42. Residents Affected - Few Findings include: 1.R10's Face Sheet, undated, documents her admittance date as and documents R10's medical diagnoses as Benign Prostatic Hyperplasia without Lower Urinary Tract Symptoms, Unspecified Intestinal Obstruction Unspecified as Partial versus complete, Unspecialized Conjunctivitis bilateral and allergic rhinitis. R10's Physician Order Summary (POS) dated March 2025 documents medications as Amoxicillin 500 Milligrams with a start date 4/1/25. R10's urine sample collected 3/26/25 documents no organism. The urine sample documents the urine sample indicated mixed flora. Further testing dated 3/27/25 documented no growth. R10's Electronic Medication Administration (eMAR) dated April 2025 documents R10 was administered 21 doses of the antibiotic Amoxicillin. On 4/17/25 at 4:00 PM R10 stated he did take antibiotics but did not know what kind and what for. 2. R72's Face Sheet undated documents R72's admittance date 3/18/25 and documents R72's pertinent medical diagnoses as Infection of Continent Stoma of Urinary Tract. R72's Physician Order Summary (POS) dated February 2025 documents medications as Cephalexin 500 Milligrams with a start date of 2/17/25. R72's urine sample collected 2/13/25 documents the organism as Escherichia coli (>10,000-50,000). Additional note stated organism may not respond to Cephalosporins. R72's Electronic Medication Administration (eMAR) dated February 2025 documents R72 was administered 14 doses of the antibiotic Cephalexin. On 4/17/25 at 3:30 PM R72 stated she have a UTI, but it has been taken care of. R72 did not know the name of the medication and she did not have any side effects from the medication. 3. R306's Face Sheet undated documents R306 admittance date 10/26/24 and medical diagnosis Personal history of Urinary Tract Infections and other Acuter Pancreatitis with Uninfected Necrosis. R306's Physician Order Summary (POS) dated December 2024 documents medication as Cefuroxime 500 Milligrams twice a day. R306's urine sample collected 12/23/24 and documents the organism Escherichia coli (ESBL). An additional note documented these organism may not clinically respond to treatment with Cephalosporins, extended -spectrum penicillin or aztreonam. R306's Electronic Medication Administration (eMAR) dated December 2024 documents R306 received 14 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145613 If continuation sheet Page 8 of 9 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 145613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Cahokia 3354 Jerome Lane Cahokia, IL 62206 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 0881 doses of the antibiotic Cefuroxime. Level of Harm - Minimal harm or potential for actual harm On 4/18/25 at 8:15 AM V3, Infection Control Preventionist, stated I thought I had it right. I tell the doctors to be mindful of organisms, but they do it anyway. Residents Affected - Few On 4/18/25 at 8:30 AM V1 Administrator, stated my expectations are that the facility's policy on antibiotic stewardship be adhered to and if there is a problem with the provider prescribing outside of those guidelines to notify me, immediately. The facility's policy on IC (Infection Control) Antibiotic Stewardship revision 4/2024 documents All residents who are ordered an antibiotic are reviewed utilizing the Point Click Care (PCC) Infection Control Program to determine, if appropriate criteria is met to continue therapy. The facility Infection Preventionist or designee should ensure that all antibiotic prescribed for the correct indication, dose, and duration to treat the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145613 If continuation sheet Page 9 of 9