Health inspection·August 11, 2022

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to complete quarterly assessments not less frequently than once every three months. This failure affects seven residents (R1, R2, R3, R4, R6, R8, and R12) out of nine reviewed for assessments on the sample list of 29. Residents Affected - Some Findings include: 1) R1's most recent quarterly Minimum Data Set (MDS) documents this MDS was transmitted as completed on 8/5/22. R1's previous quarterly MDS was dated 3/10/22. On 8/9/22 at 3:51 pm, V4, MDS Coordinator, stated and confirmed, I transmitted (R1's) most recent quarterly MDS on 8/5/22 and (R1's) previous MDS was dated 3/10/22. 2) R2's most recent quarterly Minimum Data Set documents this MDS was transmitted as completed on 8/5/22. R2's previous quarterly MDS was dated 3/15/22. On 8/9/22 at 3:51 pm, V4, MDS Coordinator, stated and confirmed, I transmitted (R2's) most recent quarterly MDS on 8/5/22 and (R2's) previous quarterly MDS was dated 3/15/22. 3) R3's most recent quarterly MDS was dated as completed on 8/6/22 but had not yet been transmitted. R3's previous quarterly MDS was dated 3/16/22. On 8/9/22 at 3:51 pm, V4, MDS Coordinator, stated and confirmed, I completed (R3's) most recent quarterly MDS on 8/6/22, it has not been transmitted, and (R3's) previous quarterly MDS was dated 3/16/22. 4) R4's most recent quarterly MDS was dated as completed 8/9/22 but had not yet been transmitted. R4's previous quarterly MDS was dated 3/18/22. On 8/10/22 at 3:51 pm, V4 MDS Coordinator, stated and confirmed, I just did (R4's) quarterly MDS yesterday, which was due in June (2022), but I have not transmitted it yet. (R4's) previous quarterly MDS was 3/18/22. 5) R6's most recent quarterly MDS was dated as completed 8/9/22 but had not yet been transmitted. R6's previous MDS was dated 3/24/22. On 8/10/22 at 3:51 pm, V4, MDS Coordinator, stated and confirmed, I finished (R6's) quarterly MDS yesterday but it has not been transmitted. (R6's) previous MDS was dated 3/24/22. 6) R8's most recent quarterly MDS was dated 3/25/22. There was not another more recent completed MDS in R8's medical record. On 8/10/22 at 3:51 pm, V4, MDS Coordinator, stated and confirmed, I am currently working on (R8's) quarterly MDS. (R8's) last completed quarterly MDS was dated 3/25/22. 7) R12's most recent MDS was dated 3/30/22. There was not another more recent completed MDS in R12's medical record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145631 If continuation sheet Page 2 of 12 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 145631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Newman Rehab & Health Care Ctr 418 South Memorial Park Drive Newman, IL 61942 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 0638 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete On 8/10/22 at 3:51 pm, V4, MDS Coordinator, stated and confirmed, I am currently working on (R12's) quarterly MDS. (R12's) last completed MDS was dated 3/30/22. On 8/10/22 at 4:15 pm, V4, MDS Coordinator, stated, You hit all of the ones I have on my list to complete. I know I am behind, but I am doing all the MDS duties, individual assessment duties, care plans, trying to cover some of the Director of Nursing duties as a Licensed Practical Nurse, and I get called to work the floor also. Event ID: Facility ID: 145631 If continuation sheet Page 3 of 12 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 145631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Newman Rehab & Health Care Ctr 418 South Memorial Park Drive Newman, IL 61942 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 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on record review and interview, the facility failed to develop and implement a Comprehensive Plan of Care for R135. R135 is one of one resident reviewed as a new admission on the sample list of 29. Residents Affected - Few Findings include: R135's Profile Sheet documents a facility admit date of 7/7/22. R135's Physician Order Sheet (POS) dated August 2022 includes the following medical diagnoses: Acute Cerebral Vascular Accident, Hypertension, Atrial Fibrillation, Anxiety, and Chronic Kidney Disease (Stage III). R135's Baseline Care Plan, dated 7/7/22 was located in the Medical Record, however, there was no Comprehensive Care Plan in the Medical Record for staff guidance in the ongoing care of R135. On 8/10/22 at 3:20 pm, V4, Care Plan Coordinator, confirmed R135's Comprehensive Plan of Care had not been completed, along with R135's Resident Assessment Instrument (RAI). V4 stated I am behind on RAI's and Care Plans and (R135) is one of them that I have not got to yet. V4 confirmed R135's Comprehensive Care Plan was due no later than 7/28/22. The facility policy titled Comprehensive Care Planning dated 11/1/17, documents the following directives to facility staff: It is the policy of (facility) to comprehensively assess and periodically reassess each Resident admitted to this facility. The results of this Resident Assessment shall serve as the basis for determining each Resident's strengths, needs, goals, life history, and preferences to develop a person centered comprehensive plan of care for each Resident that will describe the services that are to be furnished to attain or maintain the Resident's highest practicable physical, mental, and psychosocial well-being. The Resident Assessment Instrument (RAI) shall be the guide utilized for all comprehensive assessments, care assessments, and care planning. It is to be noted that the Care Plan is for planning care and services. Actual documentation of delivery of care is accomplished in the Nurse's Notes, administration records, flow records, and other locations throughout the chart as appropriate. Where frequent changes occur in orders, the care plan may contain a general intervention that references where in the chart more specific interventions/orders can be located. The following procedures shall be utilized in the development and maintenance of care plans: 1. The Comprehensive Care Plan (CCP) shall be developed within 7 days of the completion of the RAI. 2. Participants of the Interdisciplinary Team (IDT) in the development/revision of the CCP should include: the attending physician (or appointee), RN (Registered Nurse) with responsibility for the resident, CNA (Certified Nursing Assistant) with responsibility for the resident, member of the food services team, and the resident and/or resident representative as possible/appropriate. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145631 If continuation sheet Page 4 of 12 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 145631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Newman Rehab & Health Care Ctr 418 South Memorial Park Drive Newman, IL 61942 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a. Other appropriate staff or professional's participation in the IDT shall be based on resident care, services, and needs. 3. Components of the CPC (Comprehensive Plan of Care) may include: a. Care Plan Summary/Participation Record - Contains pertinent information about the Resident including a summary listing of healthcare information such as physician orders, dietary orders, therapy services, social services, PASARR (Pre-admission Screening and Record Review) recommendations, and discharge plans as appropriate for the resident at the time a conference is held and documents involvement of the resident/resident representative in the development, review, and revision of the care plan. e. Care Plan- Plan of care describing a need/problem and indicating approaches/interventions to be instituted to assist the Resident in maintaining/receiving care in relation to the need/problem. A care Plan may or may not specify a goal for a Resident. 4. Comprehensive Care Plans shall strive to describe: a. The resident's preferences, choices, and goals to the extent possible to assist in attaining or maintaining the resident's highest practicable quality of life. b. The resident's medical, nursing, physical, mental, and psychosocial needs and preferences. c. Person centered measurable objectives and timeframes for ease of evaluating resident progress toward achieving goals. d. Services not provided due to resident choice not to receive the service and how the facility and resident hope to meet the resident's need despite the declination of services. e. Specialized services of specialized rehab services as a result of PASARR recommendations. f. Discharge plans as appropriate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145631 If continuation sheet Page 5 of 12 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 145631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Newman Rehab & Health Care Ctr 418 South Memorial Park Drive Newman, IL 61942 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, record review, and interview, the facility failed to implement fall prevention interventions according to resident's care plans. This failure affects two residents (R1 and R11) out of five reviewed for falls on the sample list of 29. Findings include: 1) On 8/9/22 at 1:19 pm, R11 was seated in a wheelchair in the facility dining room. R11 did not have a personal alarm on the wheelchair. On 8/10/22 at 11:57 am, R11 was seated in the facility dining room in a wheelchair. There was not a personal alarm in the wheelchair for R11. R11's Care Plan for fall prevention documents R11 slid out of the wheelchair on 7/3/22 and a post fall intervention was documented for a personal alarm for R11 while R11 is in the wheelchair, dated as initiated 7/3/22. R11's Fall Risk assessment dated [DATE] documents R11 received 22 points with a score of 10 or more being rated as high risk for falls. On 8/10/22 at 12:38 pm, V4, Minimum Data Set/ Care Plan Coordinator, stated, The alarm is a current intervention for (R11). V4 then accompanied (surveyor) to R11 seated in the wheelchair in the dining room and confirmed, (R11) doesn't have the alarm on the wheelchair. 2) On 8/9/22 at 1:50 pm, R1 was in bed. There was not a floor mat beside R1's bed, nor was there a floor mat in R1's room. On 8/10/22 at 2:46 pm, R1 was in bed. There was not a floor mat beside R1's bed, nor was there a floor mat in R1's room. R1's Care Plan for fall prevention documents R1 has been known to attempt to get out of bed unattended, and a fall prevention intervention to have a floor mat, dated as initiated 3/2/22. R1's Fall Risk assessment dated [DATE] documents R1 received an evaluation of 13 points, with 10 or more points being rated as high risk for falls. On 8/11/22 at 2:01 pm, V4, Minimum Data Set/ Care Plan Coordinator, stated, The floor mat is a current fall prevention intervention for (R1). (R1) just had a room change a couple of weeks ago so I wonder of the mat didn't get moved with (R1). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145631 If continuation sheet Page 6 of 12 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 145631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Newman Rehab & Health Care Ctr 418 South Memorial Park Drive Newman, IL 61942 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, and interview, the facility failed to provide nutrition, according to Dietician recommendations and physician orders, through a gastrostomy tube for a resident experiencing weight loss. This failure affects one resident (R19) out of four reviewed for nutrition on the sample list of 29. Residents Affected - Few Findings include: On 8/9/22 at 10:25 am, R19 was in bed with a gastrostomy tube feeding pump delivering Fibersource HN 1.2 (tube feeding product) at 70 cubic centimeters (cc's) per hour to R19 through R19's gastrostomy tube. At 2:47 pm, R19 remained in bed with the gastrostomy tube feeding pump delivering Fibersource HN 1.2 to R19 at the same 70 cc's per hour. R19's Dietary Services Communication dated 7/21/22 documents R19 had lost 3 pounds in the past month, and 7 pounds in the last 3 months. This same Dietary Services Communication documents R19's gastrostomy tube feeding rate on 7/21/22 was 70 cc's per hour for 20 hours per day and documented a recommendation from the Registered Dietician (V5) to increase R19's tube feeding to 75 cc's per hour for 20 hours per day. This recommendation from V5 was signed into order on 7/25/22 by R19's Nurse Practitioner (V6). R19's current physician orders (August 2022) document a physician order for R19 to receive Fibersource HN at 75 cc's per hour for 20 hours per day, initiated 7/28/22. On 8/9/22 at 3:34 pm, V8, Registered Nurse, stated and confirmed, That pump is running at 70 cc's per hour, and oh, it is supposed to be running at 75 cc's per hour. I don't know why the rate is down at 70 but we will take care of it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145631 If continuation sheet Page 7 of 12 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 145631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Newman Rehab & Health Care Ctr 418 South Memorial Park Drive Newman, IL 61942 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to designate a Registered Nurse to serve as the Director of Nursing. This failure has the potential to affect all 43 residents residing in the facility. Findings include: On 8/9/22 at 9:30 am, V1, Administrator, stated, We do not have a Director of Nursing at this time. We do not have anyone acting as Director of Nursing. The facility's Quality Assurance Committee sign in sheets dated for 1/19/22, 4/20/22, and 7/20/22, have a blank line where a D.O.N. (Director of Nursing) should have signed. The Facility assessment dated [DATE] documents the facility requires the services of a Registered Nurse as full time Director of Nursing to provide competent support and care for the resident population, documented as 40% of the residents require skilled rehabilitation, 11% special high care, 8% clinically complex, 10% IV medications, and 75% isolation or quarantine for active infectious disease. On 8/10/22 at 4:15 pm, V4, MDS Coordinator/ Licensed Practical Nurse, stated, I know I am behind with the MDS (Minimum Data Sets), but I am doing all the MDS duties, individual assessment duties, care plans, trying to cover some of the Director of Nursing duties as a Licensed Practical Nurse, and I get called to work the floor also. On 8/11/22 at 12:57 pm, V1, Administrator, stated and confirmed, We do not have any one as a Director of Nursing right now. (V8, Registered Nurse/ Infection Preventionist) is kind of acting to help out but (V8) has Certified Nursing Assistant classes to teach. V1 further stated, (V8) will help out with the nursing aspect of care for a few hours after the classes and all day on Fridays, so maybe pushing 20 hours a week. It is our goal to have (V8) become Director of Nursing but that won't happen until after the classes are through maybe around the end of September. On 8/11/22 at 1:48 pm, V8, Registered Nurse/ Infection Preventionist, confirmed, I do try to help out each day after the Certified Nursing Assistant classes are over for the day, and all day on Fridays. I would say that totals to about 20 hours a week. The facility Resident Census and Conditions of Residents dated 8/9/22 documents 43 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145631 If continuation sheet Page 8 of 12 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 145631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Newman Rehab & Health Care Ctr 418 South Memorial Park Drive Newman, IL 61942 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 and record review the facility failed to complete Quarterly Psychotropic Medication Assessments and failed to complete an Abnormal Involuntary Movements Scale (AIMS). This failure effected one of five residents (R10) reviewed for Psychotropic Medications on the sample list of 29. Findings include: R10's Physician Order Sheet dated August 2022 documents R10 is diagnosed with Dementia, Major Depression, and Schizoaffective Disorder Mixed Type. R10 is prescribed Citalopram (Antidepressant) 40 milligrams once per day, Risperidone (Antipsychotic) 2 milligrams two times daily, and Geodon (Antipsychotic) 40 milligrams with breakfast and 60 milligrams with dinner. R10's Citalopram, Risperidone, and Geodon Psychotropic Medication Quarterly Evaluations dated 6/13/22 were the only quarterly evaluations the facility completed within the last year. R10's AIMS (Abnormal Involuntary Movement Scale) dated 6/8/22 and 7/18/22 were the only AIMS completed for R10's Antipsychotic medications Risperidone or Geodon within the last year. The facility's Psychotropic Medication Policy dated 11/28/17 documents any resident receiving psychotropic medications will have a Psychotropic Medication Assessment done at a minimum of every quarter. The same policy documents any resident receiving psychotropic medications will have an AIMS (Abnormal Involuntary Movement Scale) assessment completed at a minimum of every six months. On 8/11/22, at 1:38 PM, V1 Administrator confirmed the facility failed to assess R10's psychotropic medications at least quarterly and failed to complete an AIMS (Abnormal Involuntary Movement Scale) at least every six months within the last year. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145631 If continuation sheet Page 9 of 12 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 145631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Newman Rehab & Health Care Ctr 418 South Memorial Park Drive Newman, IL 61942 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to maintain the ice machine in a sanitary manner and failed to store food products with documented dates of opening packages and dates to discard opened food items. This failure has the potential to affect nearly all 43 residents who reside in the facility. Findings include: 1) On 8/9/22 at 10:27 am, the facility's ice machine, located in the facility kitchen, had thick encrusted mineral deposits streaking on multiple surfaces, and there was a pink slime substance on the plastic ice discharge chute on the interior of the ice machine (direct contact with the ice). V15, Dietary Manager, obtained a clean hand towel and wiped pink substance congealed onto the hand towel in a 1 inch area of thick red gelatinous residue. On 8/9/22 at 10:27 am, V15, Dietary Manager, stated, What is that. I suppose it doesn't matter what it is, it's dirty. On 8/11/22 at 1:58 pm, V15 stated, The ice machine is the only ice machine in the building. Every resident gets ice from that machine with the exception of 1 resident who is nothing by mouth (NPO), and 6 residents who receive thickened liquids, those 6 get thickened water but not ice. 2) On 8/9/22 at 10:27 am, there was an opened cardboard box of pre-cooked sausage patties in the facility's reach-in refrigerator. Inside this cardboard box was a plastic bag which was torn open and laying wide open exposing the sausage patties to air. This opened box of sausage patties was not dated as to when it was opened, nor dated as to when they should have been discarded. On 8/9/22 at 10:27 am, V15, Dietary Manager, stated, I need to get rid of those. 3) On 8/9/22 at 10:27 am, there was a previously opened plastic bag of breadcrumbs in the facility's dry storage area. This plastic bag was loosely twisted for a form of closure (not airtight) and was also undated as to when these breadcrumbs were opened, prepared, or when the breadcrumbs should be discarded. 4) On 8/9/22 at 10:27 am, there was a previously opened plastic bag of dry powdered milk in the facility's dry storage area. This plastic bag was undated as to when it was opened or when it should be discarded. 5) On 8/9/22 at 10:27 am, there were four plastic bins, loosely covered with hinged plastic lids, containing dry oat cereal in the shape of an o, sugar frosted flake cereal, flour, a thickening agent (used to make thickened liquids), and dry oatmeal. All of the plastic bins were not dated as to when the opened products had been placed in the bins or when the food products should be discarded. On 8/9/22 at 10:27 am, V15, Dietary Manager, stated, Typically we would date the opened food items but that is an oversight. V15 continued, We don't serve some of those items directly, we don't serve the powdered milk as the milk, but we do have recipes that call for those items which would be available for all residents except the one who is NPO. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145631 If continuation sheet Page 10 of 12 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 145631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Newman Rehab & Health Care Ctr 418 South Memorial Park Drive Newman, IL 61942 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many The facility policy Food Storage dated June 2006 documents, Store leftovers in covered, labeled, and dated containers under refrigeration or frozen. When using only part of a product, the remaining product should be in the original package or airtight container, labeled and dated. The facility policy Refrigerator and Freezer Storage dated 10/2014 (October 2014) documents, Mark the date that the original container is opened or date of preparation. Label refrigerated, potentially hazardous food prepared and held for more than 24 hours with the day/ date the food shall be consumed or discarded. The facility's Resident Census and Conditions of Residents dated 8/9/22 documents 43 residents reside in the facility, nearly all of whom consume food prepared by the facility kitchen, excepting for one resident having nothing by mouth. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145631 If continuation sheet Page 11 of 12 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 145631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Newman Rehab & Health Care Ctr 418 South Memorial Park Drive Newman, IL 61942 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to include a minimum required member, the Director of Nursing, in their Quality Assessment and Assurance Committee for the past three quarterly meetings. This failure has the potential to affect all 43 residents residing in the facility. Residents Affected - Many Findings include: On 8/9/22 at 9:30 am, V1, Administrator, stated, We do not have a Director of Nursing at this time. We do not have anyone acting as Director of Nursing. The facility's Quality Assurance Committee sign in sheets dated for 1/19/22, 4/20/22, and 7/20/22, have a blank line where a D.O.N. (Director of Nursing) should have signed as attending the meeting. The facility assessment dated [DATE] documents the facility requires the services of a Registered Nurse as full time Director of Nursing. The facility Resident Census and Conditions of Residents dated 8/9/22 documents 43 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145631 If continuation sheet Page 12 of 12