Inspection·November 21, 2023

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to have a physician order to keep medications at bedside, identify which medications were safe to keep at bedside, and develop a plan of care for self-administration of medications for one of one residents (R57) reviewed for self-administration on the sample list of 39. Residents Affected - Few Findings include: 1. On 11/19/23 at 8:27 AM, three inhalers (Ventolin, Combivent, and Symbicort), two nasal sprays (Azelastine and Fluticasone), and one unlabeled syringe of medication was sitting on top of R57's bedside table. R57 was sitting in a chair next to the table and stated those are for my breathing and my mouth sores. R57's Medication Administration Record (MAR) documents physician orders dated 6/27/23 for Azelastine HCl Nasal Solution 0.1 %, 2 sprays in both nostrils two times a day for allergies, Fluticasone Propionate Nasal Suspension 50 MCG/ACT (microgram/actuation) 2 spray in both nostrils two times a day for allergies, Ventolin HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate), 2 puff inhale orally every 4 hours as needed for wheezing/ Shortness of breath. This MAR includes a physician order dated 6/29/23 for Combivent Respimat Inhalation Aerosol Solution 20-100 MCG/ACT (Ipratropium-Albuterol)1 puff inhale orally three times a day related to Chronic Obstructive Pulmonary Disease (COPD)with Acute Exacerbation. An order dated 7/31/23 for Symbicort Inhalation Aerosol 160-4.5 MCG/ACT 2 puff inhale orally two times a day for COPD. This MAR also documents a physician order dated 6/30/23 for Nystatin Mouth/Throat Suspension 100000 UNIT/Milliliter, give 5 ml by mouth three times a day related to Malignant Neoplasm of Laryngeal Cartilage. These physician orders do not document that R57 may keep these medications at bedside. R57's Self Administration assessment dated [DATE] documents R57 is eligible for the self-administration of medication but does not specify which medications R57 can self-administer. R57's Care Plan with a revision date of 10/13/23 does not include a plan of care for self-administration of medications. On 11/20/23 at 11:00 AM, V2 Director of Nursing stated R57's medication assessment does not document which medications were able to be kept in the room, there is not a physician order to keep medications at bedside or an order to self-administer medications or a care plan for the self-administration of medications. V2 stated the syringe on R57's table contained Nystatin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145636 If continuation sheet Page 2 of 28 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 145636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charleston Rehab and Nursing 716 Eighteenth Street Charleston, IL 61920 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to provide Advance Beneficiary Notices to two of three residents (R54, R57) reviewed for reviewed for Beneficiary Protection Notifications on the sample list of 39. Residents Affected - Few Findings include: 1.) R54's Beneficiary Protection Notification Review documents R54's last covered Medicare day is 8/9/23, the facility/provider initiated the discharge, and R54's Medicare Part A days were not exhausted. This form documents R54 was not given an Advanced Beneficiary Notice of Non-Coverage (ABN). The explanation documented is R54 met R54's maximum potential and a recommendation that R54 continues to reside in the facility for 24-hour supervision. 2.) R57's Beneficiary Protection Notification Review documents R57's last covered Medicare day is 8/31/23, and R57 was not given an ABN. This form documents the reason as R57 met maximum potential and chose to remain in the facility. On 11/20/23 at 10:35 AM V10 Social Services Director stated V10 provides residents the NOMNC (Notice of Medicare Non-Coverage) form when residents have met their maximum potential, and discharge from Medicare services with benefit days remaining. V10 was unsure if residents are given an ABN. At 10:46 AM V10 confirmed there is only documentation that R54 was given a NOMNC, and not an ABN. V10 stated V10 is new to the position as of October 2023, and V10 has only been providing NOMNC forms. On 11/20/23 at 10:58 AM V1 Administrator stated V10 was giving out the Beneficiary Protection Notification forms, but V1 is going to have V21 Business Office Manager take over since V21 is more familiar with the forms and process. V1 confirmed ABN forms should be given when benefit days remain. On 11/20/23 at 11:30 AM V1 confirmed an ABN form should have been given to R57 and R54. The Skilled Nursing Facility Beneficiary Notice - Quick Reference dated 5/7/2018, provided by V1, documents an ABN is required when a resident discharges from Medicare Part A services due to no longer requiring daily skilled services and remains in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145636 If continuation sheet Page 3 of 28 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 145636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charleston Rehab and Nursing 716 Eighteenth Street Charleston, IL 61920 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a clean, orderly, homelike environment for two of three residents (R8, R19) reviewed for Environment on the sample list of 39. Findings include: 1. R8's undated Medical Diagnoses List documents R8 is diagnosed with Schizoaffective Disorder, Dementia, Alzheimer's Disease, Epilepsy, Severe Intellectual Disability, Violent Behavior, and Anxiety Disorder. R8's Minimum Data Set, dated [DATE] documents R8 is severely cognitively impaired. On 11/19/23 at 10:07 AM R8 was seated in a reclining chair in his room. R8's room appeared very dirty with dirt and spots of blood on the floor, no bed linens on his bed, a dirty and stained mattress, dirty fall mat in the corner of the room, food debris and crust dried all over his recliner, a broken chair sitting next to his recliner, and a dirty and stained wheelchair seat cushion. 2. R19's undated Medical Diagnoses List documents R19 is diagnosed with Intellectual Disabilities, Schizophrenia, Anxiety, Epilepsy, and Cerebral Palsy. R19's Minimum Data Set, dated [DATE] documents R19 is severely cognitively impaired. On 11/19/23 at 9:25 AM R19 was sitting in a reclining chair in his room. R19's room appeared very dirty and unkept. R19's left side arm padding on his wheelchair was almost all the way off of the bar. R19's wheelchair seat cushion cover was peeling and cracked open exposing the foam. There were multiple items all over the floor of R19's room. Clutter covered R19's dresser and items appeared to be thrown into the closet and were spilling out onto the floor. The floor was dirty and had debris around the bed and in the corners on of the room. On 11/19/23 at 2:37 PM V2 Director of Nurses confirmed staff should be keeping resident's living environment clean and orderly. V2 confirmed items should not be stored on the floor. V2 confirmed items in resident's rooms should be wiped off and cleaned on a regular basis and when soiled. V2 confirmed staff should have alerted maintenance department about R19's wheelchair arm falling off. On 11/20/23 at 1:37 PM V14 Maintenance Supervisor stated staff never reported to him R19's broken wheelchair arm. V14 stated staff need to report things that need repaired to him right away so he can take care of it otherwise he doesn't have anyway of knowing unless he just happens to see it. On 11/21/23 at 2:00 PM V15 Environmental Services Director stated he is embarrassed about the condition of R8 and R19's rooms on 11/19/23. V15 stated there is no excuse for resident rooms to be dirty and unkempt. V15 confirmed resident rooms need to be kept clean, items off the floor, and equipment in safe working condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145636 If continuation sheet Page 4 of 28 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 145636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charleston Rehab and Nursing 716 Eighteenth Street Charleston, IL 61920 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to attempt to reduce the use/form of a physical restraint for one (R6) out of one resident reviewed for restraints in a sample list of 39 residents. Residents Affected - Few Findings include: R6's Medical Record documents medical diagnoses of Cerebral Palsy, Scoliosis, Personal History of Non-Suicidal Self Harm, Epilepsy, Hemiplegia Affecting Right Dominant Side, Dysphagia, Profound Intellectual Disabilities and Dependence on Wheelchair. R6's Physician Order Sheet (POS) dated November 2023 documents a physician order starting 1/24/23 to attach seat belt to special wheelchair when up in wheelchair due to spastic movement secondary to Cerebral Palsy (CP). Release every two hours and as needed. R6's Care Plan documents R6 utilizes a specialized wheelchair with a halter belt attached to wheelchair. R6's Minimum Data Set (MDS) dated [DATE] documents R6 is severely cognitively impaired. This same MDS documents R6 requires total dependence on two people with total body mechanical lift for transfers, toileting, and total dependence of two people for bed mobility, dressing and personal hygiene. R6's Medical Record does not document a attempt to reduce R6's Physical Restraint to a less restrictive form. This same medical record does not document physician documentation why R6's physical restraint could not be reduced to a less restrictive option. On 11/20/23 at 11:00 AM R6 was sitting upright in an adapted wheelchair with a halter vest style physical restraint covering the front of R6 with straps that were attached to the back of R6's wheelchair out of R6's reach. R6 was also restrained by a seatbelt that was a separate part of R6's halter vest restraint that clasped in the front of R6. V12 Certified Nurse Aide (CNA) asked R6 to release the seatbelt and halter vest style physical restraint. R6 looked at V12 but made no attempts at releasing physical restraint. On 11/20/23 at 11:05 AM V12 Certified Nurse Aide (CNA) stated R6 is not able to remove the physical restraint without help from the staff. V12 stated I have never seen anything else on (R6) to try to keep her safe. That is the only restraint (R6) has ever used. On 11/21/23 at 1:00 PM V2 Director of Nurses (DON) stated There haven't been any attempts to reduce (R6's) physical restraints. I know we (facility) are going to get cited for this, but I just can't do anything about it. (R6) needs the restraint to help her from falling out of the wheelchair. (R6) has been in that restraint for as long as I have been here for the last three years, and no one has ever tried to reduce it to a less restrictive version. The facility policy titled 'Physical Restraint/Enabler Policy' revised 7/24/18 documents staff will initiate restraint elimination/reductions program ninety days from application. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145636 If continuation sheet Page 5 of 28 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 145636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charleston Rehab and Nursing 716 Eighteenth Street Charleston, IL 61920 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 Residents Affected - Few 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 timely report an allegation of staff to resident abuse to the administrator and to the state survey agency for one of one residents (R21) reviewed for abuse in the sample list of 39. Findings include: The facility's Abuse Prevention Program dated February 2019 documents employees are to immediately report allegations of abuse/mistreatment to a supervisor and to the administrator. This policy documents a written report of the allegation will be submitted to the Illinois Department of Public Health (IDPH). This policy documents to report reasonable suspicions of crime that result in serious bodily injury or sexual abuse within two hours after forming the suspicion, otherwise the report must be made within 24 hours. This policy does not include reporting to IDPH within two hours of the allegation. R21's Social Service Note dated 8/2/2023 at 9:00 AM documents the following: A dayshift Certified Nursing Assistant (V17 CNA) reported that R21 told V17 that a 3rd shift staff member took R21's call light away, turned off R21's lights, and shut R21's door because R21 was being a bother. R21 confirmed R21's statement and also stated the 3rd shift CNA told R21 We see why your son dropped you off here, so he doesn't have to put up with your (expletive). R21 has a Brief Interview for Mental Status score of 15 (cognitively intact) and R21 is aware of R21's surroundings. This situation was reported to the (former) Social Services Director (SSD). R21's Social Services Note dated 8/2/23 at 7:05 PM documents R21's complaint reported to former Social Service Assistant (V10 SSD) was reported to V1 Administrator and Director of Nursing, and an investigation was initiated. The facility's Investigation of R21's abuse allegation was provided by V1. The Final Report dated 8/10/23 documents on 8/3/23 it was reported to V1 and V2 Director of Nursing (DON) that R21 had complaints of facility staff. There is no documentation as to who reported the allegation to V1 or the time that the allegation was reported. The Incident Report Form - IDPH Notification documents R21's alleged incident occurred on 8/3/23 (no time identified). The electronic facsimile dated 8/3/23 at 4:48 PM documents R21's abuse allegation was submitted to IDPH (over 24 hours later). On 11/21/23 at 1:55 PM V10 SSD stated (in reference to R21's note dated 8/2/23) V17 CNA reported R21 told V17 that an unidentified 3rd shift CNA made the comments documented in V10's note and that the CNA took away R21's call light. V10 stated V10 immediately interviewed R21 and R21 told V10 the same story that was told to V17. V10 stated V10 reported the incident to the former SSD who informed V1. On 11/21/23 at 2:10 PM V17 CNA stated at approximately 6:00 AM (on 8/2/23) R21 told V17 that an unidentified CNA on the prior shift (3rd shift 8/1/23) took away R21's call light, turned off R21's lights which R21 prefers to have on, and shut R21's door. V17 stated R21 was unable to give the CNAs name, but V17 believed the CNA was V20. V17 stated R21 was very upset about the incident and V17 described R21 as being very alert and cognizant that day. V17 stated V17 reported R21's allegation to an unidentified nurse and social services. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145636 If continuation sheet Page 6 of 28 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 145636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charleston Rehab and Nursing 716 Eighteenth Street Charleston, IL 61920 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 Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 11/21/23 at 2:00 PM V1 stated V1 conducted the investigation of R21's abuse allegation and the allegation was reported to V1 by V2 on 8/3/23. V1 confirmed all of the documentation of the investigation was provided. At 2:50 PM V1 stated the allegation was reported to V1 sometime in the morning on 8/3/23. V1 stated V1 was not aware that R21 initially reported the allegation to V17, and V17 should have reported R21's abuse allegation immediately to V1 since V1 is the abuse coordinator for the facility. V1 stated V1 has 24 hours to report abuse allegations to IDPH, and V1 was unaware of the two hour reporting requirement. Event ID: Facility ID: 145636 If continuation sheet Page 7 of 28 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 145636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charleston Rehab and Nursing 716 Eighteenth Street Charleston, IL 61920 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to thoroughly investigate and thoroughly document an abuse allegation for one (R21) of one resident reviewed for abuse in the sample list of 39. Residents Affected - Few Findings include: The facility's Abuse Prevention Program dated February 2019 documents the investigator will obtain a copy of any documentation relative to the incident and follow the Resident Protective Investigative Procedures. This policy documents the final report will include the original allegation including the date, time, location, the specific allegation, by whom, and witnesses; facts determined during the investigation including a review of the resident's medical record and interviews with witnesses. A summary of all interviews conducted, including names, should be attached to the final investigation report. This policy documents the investigative procedures include reviewing written reports, interviewing the person who reported the incident, interviewing staff who had contact with the resident during the time of the alleged incident, and interviewing other residents who have regular contact with the alleged perpetrator. R21's Social Service Note dated 8/2/2023 at 9:00 AM documents the following: A dayshift Certified Nursing Assistant (V17 CNA) reported that R21 told V17 that a 3rd shift staff member took R21's call light away, turned off R21's lights, and shut R21's door because R21 was being a bother. R21 confirmed R21's statement and also stated the 3rd shift CNA told R21 We see why your son dropped you off here, so he doesn't have to put up with your (expletive). R21 has a Brief Interview for Mental Status score of 15 (cognitively intact) and R21 is aware of R21's surroundings. This situation was reported to the (former) Social Services Director (SSD). R21's Social Services Note dated 8/2/23 at 7:05 PM documents R21's complaint reported to former Social Service Assistant (V10 SSD) was reported to V1 Administrator and Director of Nursing, and an investigation was initiated. The facility's hall assignment sheet dated 8/1/23 documents V19 and V20 CNAs worked 3rd shift on R21's unit. The facility's Investigation of R21's abuse allegation was provided by V1. The Final Report dated 8/10/23 documents on 8/3/23 it was reported to V1 and V2 Director of Nursing (DON) that R21 had complaints of facility staff. There is no documentation as to who reported the allegation to V1 or the time that the allegation was reported. R21 complained that facility CNAs stated during care that they understand why R21's son left R21 in a nursing home, the CNAs turned off R21's light and shut R21's door. R21 was interviewed and was unable to state when the incident occurred and was unable to name or describe the CNAs. This investigation does not document that other residents on R21's unit were interviewed about the CNAs assigned to that unit. This investigation documents V1 and V2 interviewed Unit CNAs, none of which reported any incidents involving R21 or conversation referencing R21's son. This investigation does not identify the names of the CNAs that were interviewed and does not document that V10 was interviewed. There is no documentation that the facility identified the alleged incident occurred on 3rd shift or identified an alleged perpetrator. The investigative file did not include copies of the hall assignment sheet for 8/1/23. On 11/21/23 at 1:55 PM V10 SSD stated (in reference to R21's note dated 8/2/23) V17 CNA reported (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145636 If continuation sheet Page 8 of 28 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 145636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charleston Rehab and Nursing 716 Eighteenth Street Charleston, IL 61920 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R21 told V17 that an unidentified 3rd shift CNA made the comments documented in V10's note and that the CNA took away R21's call light. V10 stated V10 immediately interviewed R21 and R21 told V10 the same story that was told to V17. V10 stated V10 reported the incident to the former SSD who informed V1. At 3:03 PM V10 stated R21 specifically told V10 that the alleged incident occurred on the night of 8/1/23. On 11/21/23 at 2:10 PM V17 CNA stated at approximately 6:00 AM (on 8/2/23) R21 told V17 that an unidentified CNA on the prior shift (3rd shift 8/1/23) took away R21's call light, turned off R21's lights which R21 prefers to have on, and shut R21's door. V17 stated R21 was unable to give the CNA's name, but V17 believed the CNA was V20. V17 stated R21 was very upset about the incident and V17 described R21 as being very alert and cognizant that day. V17 stated V17 reported R21's allegation to an unidentified nurse and social services. On 11/21/23 at 2:00 PM V1 stated V1 conducted the investigation of R21's abuse allegation and the allegation was reported to V1 by V2 on 8/3/23. V1 confirmed all of the documentation of the investigation was provided and the investigation does not identify the staff that were interviewed. V1 stated the facility was unable to identify an alleged perpetrator. At 2:50 PM V1 stated V20 was interviewed as part of the investigation and V20 stated V20 did not say any of the alleged comments and denied the incident happened. V1 stated the allegation was reported to V1 sometime in the morning on 8/3/23. V1 and V2 confirmed V17 was not interviewed as part of the investigation. V1 stated V1 was not aware that R21 initially reported the allegation to V17. V1 stated V1 would have interviewed V17 if V17 had reported R21's abuse allegation to V1. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145636 If continuation sheet Page 9 of 28 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 145636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charleston Rehab and Nursing 716 Eighteenth Street Charleston, IL 61920 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 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop a care plan for smoking, anticoagulants and the use of psychotropic medications for three (R57, R21, and R9) of 24 residents reviewed for care plans on the sample list of 39. Findings include: The facility's Comprehensive Care Plan policy with a revision date of 11/1/17 documents the components of the Comprehensive care plan will include, 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. This policy also documents that the Comprehensive Care Plan shall strive to describe the resident's medical, nursing, physical, mental, and psychosocial needs and preferences. 1. On 11/19/23 at 8:25 AM, R57 had a pack of cigarettes and a lighter on a bedside table. R57 stated R57 smokes cigarettes and is allowed to keep them in the room. R57's care plan with a revision date of 10/13/23 did not contain a care plan for smoking or that R57 is an independent when smoking and can keep smoking materials at bedside. On 11/20/23 at 11:56 AM, V2 Director of Nursing stated R57 is an independent smoker. V2 confirmed that there was not a care plan for R57 for smoking. 2.) R9's November 2023 Medication Administration Record (MAR) documents R9 receives Xarelto (anticoagulant) 20 milligrams (mg) by mouth daily. R9's Minimum Data Set (MDS) dated [DATE] documents R9 receives an anticoagulant daily. R9's Care Plan revised on 7/18/23 does not document R9's anticoagulant use or monitoring for potential side effects or complications. On 11/20/23 at 3:45 PM V2 Director of Nursing provided R9's care plan which only included two problem areas. V2 confirmed R9's care plan does not address anticoagulant use and monitoring. 3.) R9's November 2023 MAR documents R9 receives Lexapro (antidepressant) 20 mg daily and Aripiprazole (antipsychotic) 2 mg daily. R9's Care Plan revised 7/18/23 does not document R9's psychotropic medication use, targeted behaviors, and nonpharmacological interventions. On 11/20/23 at 3:45 PM V2 confirmed R9's care plan does not address psychotropic medication use, behaviors, and nonpharmacological interventions. On 11/20/23 at 11:11 AM V25 Care Plan Coordinator stated V25 is behind in care plans and V25 started in the position approximately a month ago. 4.) R21's Active November 2023 Physician's Orders include an orders for Quetiapine (antipsychotic) 25 mg daily for agitation and aggression related to Major Depressive Disorder, Sertraline (antidepressant) 75 mg daily (8/4/23), Mirtazapine (antidepressant) 15 mg daily (11/16/23), and Lorazepam (antianxiety) 2 mg/ml (milliliter) give 0.5 ml every 4 hours as needed (10/24/23). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145636 If continuation sheet Page 10 of 28 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 145636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charleston Rehab and Nursing 716 Eighteenth Street Charleston, IL 61920 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 FORM CMS-2567 (02/99) Previous Versions Obsolete R21's Care Plan dated as revised 8/10/23 documents R21 has fluctuations in mood related to dementia and major depressive disorder, demonstrated by resisting cares, being verbally inappropriate, calling out and making false accusations towards staff. This care plan does not document R21 receives psychotropic medications or monitoring for side effects. On 11/21/23 at 10:59 AM V2 stated V25 should be updating the care plans to include psychotropic mediation use. Event ID: Facility ID: 145636 If continuation sheet Page 11 of 28 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 145636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charleston Rehab and Nursing 716 Eighteenth Street Charleston, IL 61920 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to ensure a resident's record identified the hospice company, included active hospice orders, and included hospice in the care plan for one (R1) of one residents reviewed for hospice in the sample list of 39. Residents Affected - Few Findings include: R1's Active November 2023 Physician Orders do not include orders for hospice or identify the hospice company. R1's electronic medical record did not contain a care plan. R1's care plan dated as reviewed 5/17/23, provided by V2 Director of Nursing, documents R1 has a signed Do Not Resuscitate Order and as of February 2023 R1 receives hospice/end of life care. This care plan does not identify which hospice company and contact information, hospice admitting diagnoses, or coordination of hospice services for symptom management. On 11/19/23 at 9:43 AM V5 Registered Nurse stated R1 is on hospice care and receives hospice visits two to three times per week. V5 stated V5 thinks R1 is on hospice for cardiac diagnoses. On 11/20/23 at 11:35 AM V9 Licensed Practical Nurse stated V9 usually puts the hospice form (includes hospice company and contact information) in the front of the resident's paper chart to identify what hospice company the resident has. V9 confirmed R1's paper chart does not include the hospice company and contact information in the front of R1's chart. On 11/20/23 at 12:30 PM V3 Assistant Director of Nursing stated there should be hospice orders listed under R1's current orders. V3 stated R1 has been on hospice for awhile now, and R1's hospice orders must not have carried over when the facility implemented electronic medical records. V3 stated hospice should be included in the resident's care plan located in the resident's electronic medical record. On 11/20/23 at 11:11 AM V25 Care Plan Coordinator confirmed R1's electronic medical record does not contain a current comprehensive care plan. V25 stated V25 is behind in care plans and started in the position approximately a month ago. The Protocol and Agreement of Hospice Services dated 8/11/22 documents Hospice will develop the comprehensive Hospice plan by the interdisciplinary team and the written plan will include hospice physician orders, hospice services, goals, medications, and supplies that will be needed to meet end of life needs. This plan will identify which of these things will be furnished by hospice. This agreement documents the hospice nurse will coordinate the hospice plan with facility staff and includes hospice contact information and that staff are available 24 hours per day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145636 If continuation sheet Page 12 of 28 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 145636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charleston Rehab and Nursing 716 Eighteenth Street Charleston, IL 61920 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 0687 Provide appropriate foot care. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents received foot care including toenail care for one of one resident (R8) reviewed for Foot Care on the sample list of 39. Residents Affected - Few Findings include: The facility's undated Nail Care policy documents staff will keep residents' nails clean and trimmed. R8's undated Medical Diagnoses List documents R8 is diagnosed with Schizoaffective Disorder, Dementia, Alzheimer's Disease, Epilepsy, Severe Intellectual Disability, Violent Behavior, and Anxiety Disorder. R8's Minimum Data Set, dated [DATE] documents R8 is severely cognitively impaired. On 11/19/23 at 10:07 AM R8 was sitting in his recliner with bare feet. R8's feet were dry and scaly and his toenails were extremely long and dirty. On 11/19/23 at 2:37 PM V2 Director of Nurses stated although R8 has behaviors and can become combative with care, staff should still care for R8's feet and nails. R8 should not have toenails that long. On 11/20/23 at 11:50 AM V2 Director of Nurses confirmed the facility could have done more to ensure R8's feet and toenails were cared for. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145636 If continuation sheet Page 13 of 28 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 145636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charleston Rehab and Nursing 716 Eighteenth Street Charleston, IL 61920 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 report a fall to the resident representative, implement post fall interventions, document post fall interventions on the care plan, complete fall risk assessments, and investigate a bruise to identify root cause and interventions. These failures affect two (R28, R49) of seven residents reviewed for accidents in the sample list of 39. Findings include: 1.) On 11/19/23 at 8:42 AM R28 stated R28 does not like R28's wheelchair, it's uncomfortable, and R28 has a bruise on R28's shoulder from the wheelchair. R28 stated R28 has told staff that R28 does not like R28's wheelchair, but nothing has been done. R28 was slouched down in R28's wheelchair. On 11/20/23 at 11:16 AM R28 was slouched down in R28's wheelchair with R28's head resting on the top of the cloth backing of the wheelchair. V18 Certified Nursing Assistant (CNA) stated R28's bruise has been there for 5 days and R28 requires one person assistance for transfers. V18 pulled up R28's shirt and R28 had a red bruise to R28's right upper arm. R28 stated R28 got the bruise from hitting R28's arm on the wheelchair, and R28 pointed to the wheelchair handlebar. R28's Minimum Data Set (MDS) dated [DATE] documents R28 as cognitively intact. There is no documentation in R28's medical record that R28's bruise was identified, reported, measured, or investigated; or any follow up to R28's wheelchair concern. R28's Shower/Abnormal Skin Report dated 11/20/23, provided by V2 Director of Nursing, documents R28 has discoloration to R28's right upper/inner arm. On 11/2023 at 12:30 PM V3 Assistant Director of Nursing confirmed the facility investigates bruises and V3 stated V3 was unaware that R28 had a bruise. V3 stated V3 was not aware that R28 does not like R28's wheelchair. On 11/20/23 at 2:13 PM V2 stated bruises should be identified, measured, reported, and investigated, and should be documented in a nursing note. V2 stated bruises are reported to V2 and V2 was not aware of R28's bruise. V2 confirmed V2 had no documentation to provide regarding R28's bruise. V2 stated V2 was not aware of R28's wheelchair concerns and V2 will have therapy evaluate R28 and R28's wheelchair. The facility's Skin Condition Monitoring policy dated as revised 3/16/23 documents nurses will assess and document skin abnormalities and notify the physician to obtain treatment orders. This policy documents documentation of the abnormality must occur weekly until healed, include measurements/assessments, and prevention techniques used. 2.) On 11/19/23 at 8:55 AM R49 was sitting in a wheelchair near the [NAME] Hall nurse's station. There was no foam cushion attached to the wheelchair or positioned across R49's lap. R49 had a fading bruise to R49's right cheek. R49 stated R49's bruise was due to a fall when R49 attempted to self-transfer out of R49's wheelchair. R49's MDS dated [DATE] documents R49 has moderate cognitive impairment. R49's Active Diagnoses List documents cognitive communication deficit, repeated falls, muscle weakness, and reduced mobility. R49's medical record does not document a fall risk assessment was completed after 5/4/23 until 11/8/23. R49's Fall Risk assessment dated [DATE] is not completed/filled out. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145636 If continuation sheet Page 14 of 28 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 145636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charleston Rehab and Nursing 716 Eighteenth Street Charleston, IL 61920 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 R49's Nursing Note dated 11/4/2023 at 5:31 PM documents R49 had an unwitnessed fall at approximately 3:55 PM and R49's responsible party/family was not notified of the fall. This note documents R49 was sent to the emergency room for treatment and a (lap cushion) was initiated and care planned. R49's Nursing Note dated 11/5/23 at 12:35 PM documents R49 was treated in the emergency room yesterday following unwitnessed fall and received three sutures to over the right eye. This note documents R49 continues to be impulsive but does not document the use of a (lap cushion). R49's Fall Investigation dated 11/10/23 documents it is believed that R49's fall was caused when R49 leaned too far forward out of R49's wheelchair, as R49 often sits in the wheelchair with R49's elbows on R49's knees. This investigation documents R49's care plan was updated to include a new intervention for a (lap cushion) for proper positioning, R49 was assessed and demonstrated the ability to place and remove the device. R49's Active November 2023 Physician Orders do not include an order to use a (lap cushion). There is no documentation in R49's nursing notes after 11/4/23 of the use of a (lap cushion) or R49's refusal or removal of the (lap cushion). R49's Care Plan dated 11/7/23 documents R49's fall on 11/4/23 but does not document an intervention for the use of a (lap cushion) prior to 11/20/23. On 11/19/23 at 9:50 AM V5 Registered Nurse stated about two weeks ago, R49 had leaned forward out of R49's chair, resulting in a fall and a bruise to R49's cheek and an eyebrow laceration. V5 stated V5 sent R49 to the hospital and R49 received stitches to close the eyebrow laceration. At 11:57 AM V5 stated V5 attempted to notify R49's Family of R49's fall, but there was no answer and V5 was unable to leave a message. V5 stated a (lap cushion attached to the wheelchair) was placed on R49 when R49 returned from the hospital, but R49 won't keep it in place. V5 stated R49 still has the order for the (lap cushion) so it can be used if needed. On 11/20/23 at 1:49 PM V18 CNA stated R49 still uses a (lap cushion), but R49 removes it and refuses to wear it. V18 stated we are supposed to try and put it on R49 every day, but R49 removed the (lap cushion) and removes it in the dining room. On 11/20/23 at 3:13 PM V2 Director of Nursing stated an order for a (lap cushion) was implemented after R49's fall on 11/4/23 and it is still a current intervention. V2 stated R49 removes the (lap cushion) and it is not considered to be a restraint. V2 confirmed there is no order for the use of a (lap cushion) in R49's medical record. V2 stated the staff should be applying the (lap cushion) when R49 is sitting in the wheelchair, and staff should reapply the (lap cushion) when R49 removes it and after it has been removed during mealtime. V2 stated the (lap cushion) should be on R49's care plan. V2 stated fall risk assessments are to be completed quarterly and after each fall. V2 confirmed R49's 8/2/23 Fall Risk Assessment is incomplete, and a fall risk assessment was not completed on 11/4/23 following R49's fall. On 11/21/23 at 10:59 AM V2 stated notifications for falls should be documented in nursing note, and V2 confirmed there is no documentation that R49's Family was notified of the fall on 11/4/23. V2 stated V2 updated R49's care plan on 11/20/23 to include the (lap cushion.) The facility's Fall Prevention policy dated as revised 11/10/18 documents fall assessments should be completed on admission, quarterly, and with changes in condition. This policy documents the nurse will document circumstances of the fall in the nurses notes or on an AIM (Assess, Intervene, Monitor) for Wellness form, including new interventions. This policy documents falls will be reviewed during the Morning Quality Assurance meetings and new post fall interventions will be updated on the resident's care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145636 If continuation sheet Page 15 of 28 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 145636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charleston Rehab and Nursing 716 Eighteenth Street Charleston, IL 61920 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident's urinary catheter bag was stored off the floor, failed to obtain orders for a resident's urinary catheter and failed to document urinary catheter care for two of three residents (R8, R21) reviewed for urinary catheters on the sample list of 39. Findings include: The facility's Catheter Care policy dated February 2018 documents catheter care is to be provided on a daily basis and as needed to all residents who have an indwelling catheter to reduce the risk of infection. 1. R8's undated Medical Diagnoses List documents R8 is diagnosed with Schizoaffective Disorder, Dementia, Alzheimer's Disease, Epilepsy, Severe Intellectual Disability, Violent Behavior, and Anxiety Disorder. R8's Physician Order Sheet (POS) documents an order for a urinary catheter to bedside drainage. R8's Minimum Data Set, dated [DATE] documents R8 is severely cognitively impaired. On 11/19/23 at 10:07 AM R8 was sitting in his recliner chair, R8's urinary catheter was hanging down with the collection bag sitting on the floor and no privacy bag in place. On 11/20/23 at 2:37 PM V2 Director of Nurses confirmed urinary catheter bags should not be stored on the floor for infection control purposes and catheter bags should be placed in a privacy bag up off the floor to promote resident's dignity. 2.) On 11/19/23 at 8:23 AM R21 was lying in bed and R21's urinary catheter drainage bag was hanging on the bed frame. On 11/20/23 at 1:37 PM R21 was lying in bed. R21's urinary catheter tubing contained cloudy sediment. V4 and V19 Certified Nursing Assistants (CNAs) performed R21's catheter care and R21's urinary catheter was secured with a device attached to R21's right thigh. R21's Active November 2023 Physician Orders do not include orders for the size of urinary catheter or the frequency of changing the catheter. R21's Physician Order dated 11/2/23 documents to perform catheter care and record urine output every shift. R21's September 2023-November 2023 Treatment Administration Records (TARs) do not document routine cleaning/care of R21's urinary catheter prior to 11/2/23. R21's Care Plan dated 7/14/23 and revised 9/14/23 documents R21 uses an indwelling urinary catheter and includes an intervention to perform catheter care every shift. This care plan does not include the size of catheter used, the frequency for changing the catheter, or to use a securement device. R21's Physician's Orders dated 7/17/23 document to keep tension off of R21's catheter to prevent urethral pressure necrosis and to follow up in three months for catheter exchange. R21's Hospice Note dated 10/18/23 documents hospice was consulted regarding R21's upcoming urology appointment, and per R21's hospice care plan R21's catheter is to be changed only as needed if malfunction. R21's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145636 If continuation sheet Page 16 of 28 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 145636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charleston Rehab and Nursing 716 Eighteenth Street Charleston, IL 61920 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 0690 catheter was flushed and patent at this time. Level of Harm - Minimal harm or potential for actual harm On 11/20/23 at 11:40 AM V4 CNA stated catheter care is done every shift, sometimes every couple of hours, and is documented as part of the electronic CNA charting. On 11/21/23 at 9:35 AM V5 Registered Nurse stated catheter care is documented on the TAR and the nurses are responsible for ensuring the CNAs complete catheter care. Residents Affected - Few On 11/21/23 at 9:25 AM V2 Director of Nursing confirmed R21's physician's orders do not include orders for catheter size or the frequency of changing the catheter. On 11/21/23 at 2:27 PM V2 confirmed there is no documented routine catheter care/cleaning for R21 prior to 11/2/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145636 If continuation sheet Page 17 of 28 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 145636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charleston Rehab and Nursing 716 Eighteenth Street Charleston, IL 61920 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure oxygen tubing was kept off of the floor, failed to clean and store bilevel positive airway pressure (BIPAP) and continuous positive airway pressure (CPAP) machines/tubing/masks in a sanitary manner, failed to change and label oxygen tubing weekly and failed to administer the accurate amount of oxygen for seven of seven residents (R5, R13, R19, R31, R1, R28, R57) reviewed for respiratory care on the sample list of 39. Residents Affected - Some Findings include: The facility's Oxygen Therapy policy dated March 2019 documents oxygen should be administered with a written physician order. Oxygen tubing/mask/cannula should be changed on a weekly basis, dated, and documented as changed on the treatment administration sheet (TAR). The facility's CPAP/BIPAP policy dated March 2013 documents CPAP and BIPAP machine circuits and filters will be cleaned weekly. 1. R5's undated Medical Diagnoses list documents R5 is diagnosed with Dementia, Congestive Heart Failure, and Diabetes. R5's Physician Order Set (POS) documents an order for oxygen at one liter per nasal cannula to keep oxygen saturation above 92 percent. On 11/19/23 at 9:44 AM R5's oxygen tubing was hung over the top of the oxygen concentrator and laying partially on the floor. 2. R13's undated Medical Diagnoses list documents R13 is diagnosed with Morbid Obesity, Congestive Heart Failure, Obstructive Sleep Apnea, Emphysema, and Diabetes. R13's Physician Order Set (POS) dated November 2023 documents an order for CPAP to wear at night while asleep as resident tolerates/allows. On 11/19/23 at 10:13 AM R13's CPAP machine/tubing/mask were laying on his bedside dresser. They had not been cleaned and were not stored in a sanitary way. R13 stated he does not believe staff ever clean his machine. 3. R19's undated Medical Diagnoses List documents R19 is diagnosed with Intellectual Disabilities, Chronic Respiratory Failure, Asthma, Epilepsy, and Cerebral Palsy. R19's Physician Order Set (POS) dated November 2023 documents an order for CPAP to wear at night for Obstructive Sleep Apnea and to clean circuits, filters, tubing and mask every Saturday night shift and as needed. On 11/19/23 at 9:35 AM R19's BIPAP machine/tubing/mask were laying on his bedside dresser. They had not been cleaned and were not stored in a sanitary way. R19 confirmed he uses the BIPAP at night. 4. R31's undated Medical Diagnoses List documents R31 is diagnosed with Congestive Heart Failure, Obstructive Sleep Apnea, and Acute Respiratory Failure. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145636 If continuation sheet Page 18 of 28 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 145636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charleston Rehab and Nursing 716 Eighteenth Street Charleston, IL 61920 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R31's Physician Order Set (POS) dated November 2023 documents an order for CPAP to wear at night while asleep as resident tolerates/allows and to clean circuits, filters, tubing and mask every Sunday night shift and as needed. On 11/19/23 at 9:59 AM R31's CPAP machine/tubing/mask were laying on his bedside dresser. They had not been cleaned and were not stored in a sanitary way. On 11/19/23 at 2:37 PM V2 Director of Nurses (DON) confirmed oxygen tubing needs to be stored in a plastic bag when not in use for infection control purposes. V2 also confirmed oxygen tubing should not touch the floor. V2 confirmed CPAP and BIPAP masks should be wiped clean daily and stored in a plastic bag and the tubing, circuits, filters should be cleaned weekly or as needed. 5. On 11/19/23 at 8:25 AM, R57's oxygen tubing was lying on the floor. The tubing and humidification bottle were not dated with the date they were changed. On 11/20/23 at 11:57 AM, V2 Director of Nursing stated oxygen tubing and humidification bottles should be dated and changed weekly. 6.) On 11/19/23 at 9:46 AM R1 was in R1's room wearing oxygen at 1 liter per minute (l/min) per nasal cannula. R1's oxygen tubing was not labeled with a date and the humidification bottle was dated 11/11/23. R1's Active November 2023 Physician Orders includes an order dated 11/2/23 to change the oxygen tubing and humidifier weekly. On 11/20/23 at 11:58 AM V2 Director of Nursing stated oxygen tubing should be changed weekly. V2 confirmed the tubing should be labeled with the date. 7.) On 11/19/23 at 8:42 AM R28 was in R28's room wearing oxygen at 3 l/min per nasal cannula. The oxygen tubing was dated 10/8/23 and was connected to a portable oxygen tank. On 11/20/23 at 11:16 AM R28 was wearing oxygen at 3 l/min per nasal cannula. R28's Active November 2023 Physician Orders includes an order dated 2/1/23 for oxygen at 2 l/min per nasal cannula and an order dated 11/4/23 to change and date/label oxygen tubing and canister weekly. On 11/20/23 at 11:58 AM V2 Director of Nursing stated oxygen tubing should be changed weekly. V2 confirmed the tubing should be labeled with the date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145636 If continuation sheet Page 19 of 28 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 145636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charleston Rehab and Nursing 716 Eighteenth Street Charleston, IL 61920 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 - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. R31's undated Medical Diagnoses List documents R31 is diagnosed with Dementia with Agitation and Depression. R31's Physician Order Set (POS) dated November 2023 documents an order for Seroquel (Antipsychotic) 25 milligrams 1/2 of a tablet by mouth one time a day for Dementia. The same POS documents an order for Depakote Sprinkles (anticonvulsant) Delayed Release Sprinkles 125 milligrams by mouth one time a day related to Dementia with Agitation. On 11/21/23 at 2:47 PM V2 Director of Nurses (DON) confirmed the facility has no record of quarterly psychotropic medication assessments or Abnormal Involuntary Movement Scale (AIMS) for R31's psychotropic medications. 3. R4's Physician order dated 6/6/23 documents an order for Clozapine (antipsychotic) 50 milligrams, one tablet by mouth every morning. R4's physician order dated 11/6/23 documents an order for Duloxetine (antidepressant) 20 milligrams one capsule by mouth once a day. R4's medical record did not contain an assessment for R4's use of Clozapine or Duloxetine. On 11/21/23 at 9:00 AM, V2 Director of Nursing stated a psychotropic medication assessment was not completed for R4's use of Clozapine or Duloxetine. 4. R54's Physician orders dated 6/17/23 document orders for Quetiapine Fumarate (antipsychotic) Oral Tablet 25 milligrams one tablet two times a day for Dementia with Behavior Disturbances and an order for Sertraline 50 milligrams one tablet once a day for Depression. R54's Psychotropic medication assessment dated [DATE] does not document that R54 has the presence of mood or behaviors, does not documents that alternative treatments were attempted prior to the use of psychotropic medications, does not document the targeted behaviors/symptoms for which R54 is being treated. On 11/21/23 at 9:00 AM, V2 Director of Nursing confirmed that R54's assessment does not document that R54 has the presence of mood or behaviors, does not documents that alternative treatments were attempted prior to the use of psychotropic medications, and does not document the targeted behaviors/symptoms for which R54 is being treated. Based on interview and record review the facility failed to complete psychotropic medication assessments, identify and monitor/track targeted behavioral interventions and nonpharmacological interventions, document clinical rational and orders to continue PRN (as needed) antianxiety medication, complete AIMS (Abnormal Involuntary Movement Scale) assessments, and follow up on pharmacy recommendations to attempt gradual dose reductions of psychotropic medications for five (R9, R21, R4, R54, R31) of five residents reviewed for unnecessary medications in the sample list of 39. Findings include: The Psychotropic Medication Policy revised 11/28/17 documents: It is the policy of this facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145636 If continuation sheet Page 20 of 28 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 145636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charleston Rehab and Nursing 716 Eighteenth Street Charleston, IL 61920 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 - Some that residents shall not be given unnecessary drugs. Unnecessary drug is any drug used: 1. In an excessive dose, including duplicative therapy 2. For excessive duration 3. Without adequate monitoring 4. Without adequate indications for use. 5. In the presence of adverse consequences that indicate the drugs should be reduced or discontinued. Procedure: 1. Attempt to rule out social and environmental factors as causative agents of the maladapted behavior. 2. Psychotropic medications shall not be prescribed prior to attempted non-pharmacological interventions to decrease behavior. 3. Initiate a Pre-Psychotropic Medication Assessment prior to administration of a newly prescribed psychotropic medication. 7. Any resident receiving such medications shall have a psychiatric diagnosis or documented evidence of maladaptive behavior, which can be considered harmful to themselves or others, destructive to property, or if emotional problems exist which cause the resident frightful distress. 8. the Behavioral Tracking sheet of the facility will be implemented to ensure behaviors are being monitored. 9. Residents who use antipsychotic drugs shall receive gradual dose reductions and behavior interventions, unless clinically contraindicated, in an effort to discontinue the drugs. Any resident receiving psychotropic medications will be reviewed at a minimum of every quarter by the interdisciplinary team. 10. Reductions shall be attempted at least twice in one year unless the physician documents the need to maintain the resident regimen according to the Regulatory Guidelines for such. 11. Nursing Administration will meet with the consultant Pharmacist on a monthly basis to discuss any resident who may need or is due for a possible medication reduction. 12. The consultant Pharmacist will request medication reductions as decided on a monthly basis. Recommendations will be printed and sent to the physician in a timely manner. 15. Psychotropic medications may be prescribed on a PRN basis in certain situations. These situations may be while the dose is adjusted, to address acute or intermittent symptoms, or in an emergency. Residents must not have PRN orders for psychotropic medications unless the medication is necessary to treat a diagnosed specific condition. The attending physician or prescribing practitioner must document the diagnosed specific condition and indication for the PRN medication in the medical record. Refer to the additional limitations for PRN psychotropic (and) PRN antipsychotic medication. 17. Any resident receiving psychotropic medications will have an AIMS assessment done at a minimum of every six (6) months. 18. Any resident receiving psychotropic medication will have the Psychotropic Medication Assessment done at a minimum of every quarter. The table included in the policy documents a 14-day time limitation for PRN psychotropic medications that are not antipsychotics, and the order may be extended past the 14 days if the physician extends the order and documents the rational to extend the order for a specified duration. 1.) R9's Active November 2023 Physician's Orders includes an order dated 6/22/23 for Aripiprazole (antipsychotic) 2 milligrams (mg) by mouth once daily for depression. R9's November 2023 Medication Administration Record documents R9 receives Lexapro (antidepressant) 20 mg daily. R9's Minimum Data Set, dated [DATE] documents R9 has severe cognitive impairment, R9 had no behaviors during the 7-day review period, R9 receives an antidepressant and antipsychotic routinely, and has not had a Gradual Dose Reduction (GDR). R9's medical record does not contain routine assessments for the use of Aripiprazole, including behavior tracking/monitoring, specific targeted behaviors, and nonpharmacological interventions/responses to R9's behaviors. R9's Care Plan updated 7/18/23 does not document the use of psychotropic medications, targeted behaviors, or nonpharmacological interventions. The only AIMS assessment in R9's medical record is dated 3/23/23, three months prior to R9's Aripiprazole was initiated. The Pharmacy Consultation Reports dated 9/21/23 and 10/16/23 document that R9 receives Lexapro 20 mg daily and Abilify (Aripiprazole) and includes a recommendation to attempt a GDR of Lexapro to 15 mg daily. These forms are not completed and are not signed by a physician/nurse practitioner. There (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145636 If continuation sheet Page 21 of 28 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 145636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charleston Rehab and Nursing 716 Eighteenth Street Charleston, IL 61920 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 is no documentation that a GDR has been attempted for Lexapro or Aripiprazole. Level of Harm - Minimal harm or potential for actual harm On 11/21/23 at 10:55 AM V4 Certified Nursing Assistant and V5 Registered Nurse stated R9 does not have any behaviors. Residents Affected - Some On 11/20/23 at 12:55 PM V2 Director of Nursing stated V2 has been trying to catch up on the recommendation. V2 stated GDRs have not been attempted for R9. V2 stated AIMS should be completed quarterly with the MDS assessments and documented as part of the resident's electronic medical record when a resident is on an antipsychotic medication. V2 stated pharmacy has been giving notifications that AIMS need to be done. On 11/21/23 at 10:59 AM V2 stated V2 thought R9 has a diagnosis of dementia with behavioral disturbances and R9 takes Lexapro for depression. V3 Assistant Director of Nursing stated R9's Aripiprazole was started in June 2023, and R9 has behaviors of yelling out after all cares have been provided. V2 stated R9 gets upset because R9 wants R9's family to take R9 home and care for her at home. V2 stated V2 was unable to locate documentation of R9's behaviors to warrant the use of psychotropic medications. V2 confirmed R9 does not have documented behavior tracking/monitoring with nonpharmacological response/interventions. At 2:08 PM V2 confirmed R9's pharmacy recommendations are incomplete and were not followed up on. At 2:27 PM V2 stated V2 was unable to locate psychotropic medication assessments and additional AIMS for R9. 2.) R21's MDS dated [DATE] documents R21 as cognitively intact, R21 receives routine antipsychotic medication and has not had a GDR attempted. R21's Active November 2023 Physician's Orders include an orders for Quetiapine (antipsychotic) 25 mg daily for agitation and aggression related to Major Depressive Disorder, Sertraline (antidepressant) 75 mg daily (8/4/23), Mirtazapine (antidepressant) 15 mg daily (11/16/23), and Lorazepam (antianxiety) 2 mg/ml (milliliter) give 0.5 ml every 4 hours as needed (10/24/23) with no stop date. R21's March 2023 MAR documents R21 receives Quetiapine 25 mg daily as of 2/1/23 and Zoloft 50 mg daily was ordered from 2/1/23 through 8/3/23. R21's October 2023 MAR documents Lorazepam 2 mg/ml give 0.25 ml every 4 hours as needed ordered on 8/29/23, was given on 10/1/23 at 10:28 AM, 10/2/23 at 4:18 PM, 10/3/23 at 8:00 AM, and 10/24/23 at 1:00 PM. R21's November 2023 MAR documents Lorazepam was given on 11/11/23 at 3:56 PM. There is no documentation of what behaviors R21 had, and the nonpharmacological interventions attempted prior to administering Lorazepam on the dates listed. R21's Care Plan dated as revised 9/14/23 documents R21's diagnoses include dementia with behavioral disturbances. R21's Care Plan dated as revised 8/10/23 documents R21 has fluctuations in mood related to dementia and major depressive disorder, demonstrated by resisting cares, being verbally inappropriate, calling out and making false accusations towards staff. The only nonpharmacological interventions listed are R21 prefers room well-lit to reduce delusions and hallucinations at night, enjoys watching movies, and ensure DVD (digital versatile disc) player is functioning to provide redirection when behaviors occur. This care plan does not identify R21 receives psychotropic medications. R21's Behavior Monitoring and Interventions Report dated 7/1/23-11/21/23 document R21's last recorded behaviors of frustration/anger towards others, screaming, and disruptive sounds occurred on 9/22/23. The interventions listed do not include the use of movies/DVD player as stated on R21's care plan. R21's medical record does not contain documented assessments for the use of Sertraline after March 2023. There are no documented assessments for the use of Quetiapine, Mirtazapine, or Lorazepam. There are no documented AIMS assessments after 3/23/23. There is no documentation that R21's PRN Lorazepam was limited to a duration of 14 days or that R21 was evaluated by a practitioner to document clinical rational and to continue/extend the order past a 14-day duration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145636 If continuation sheet Page 22 of 28 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 145636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charleston Rehab and Nursing 716 Eighteenth Street Charleston, IL 61920 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 The Pharmacy Consultation Report dated 8/16/23 documents to complete an AIMS if not done within the last six months. This form is incomplete and does not document follow up was completed. The Pharmacy Consultation Reports dated 8/16/23 and 10/16/23 document a recommendation for a GDR of Seroquel (Quetiapine) to 12.5 mg daily. These forms are incomplete and do not document the review and signature of a physician/nurse practitioner. There is no documentation a GDR has been attempted for Quetiapine. Residents Affected - Some On 11/20/23 at 11:23 AM V4 CNA stated R21 does not have many behaviors anymore, other than R21 will yell out help. V4 stated we ask R21 simple questions to see if R21 wants a snack, drink, or care needs such as needing incontinence care. On 11/20/23 at 12:55 PM V2 Director of Nursing stated V2 has been trying to catch up on the recommendation. V2 stated GDRs have not been attempted for R21. V2 stated AIMS should be completed quarterly with the MDS assessments and documented as part of the resident's electronic medical record when a resident is on an antipsychotic medication. V2 stated pharmacy has been giving notifications that AIMS need to be done. On 11/21/23 at 10:59 AM V2 stated R21 has dementia with behavioral disturbances, major depressive disorder, insomnia. V2 stated R21 has delusions/hallucinations, yells out, exhibits physical aggression, and makes false accusations. V2 stated R21 is on hospice and hospice should be documenting the clinical rational and evaluation to continue the PRN Lorazepam past a 14-day duration. V2 was unable to provide documentation of this. At 2:08 PM V2 confirmed R21's pharmacy recommendations for GDR were not followed up on. At 2:27 PM V2 provided R21's psychotropic medication assessments and AIMS and confirmed that was all the documentation V2 was able to locate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145636 If continuation sheet Page 23 of 28 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 145636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charleston Rehab and Nursing 716 Eighteenth Street Charleston, IL 61920 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. Based on observation, interview, and record review the facility failed to date an insulin pen and bottle when opened for two (R26, R15) of 12 residents reviewed for insulin on the sample list of 39. Findings include: The facility's Procurement and storage of medications policy with a revision date of 3/16/23 documents, 7. All medications containers shall be labeled with the date opened by the person breaking the container seal. 1. On 11/21/23 at 8:53 AM, the east hall medication cart contained one Lantus insulin pen for R26. The insulin pen was not dated with an open date. At that time, V9 Registered Nurse confirmed that the insulin pen had been used but not dated when opened. 2. On 11/21/23 at 8:54 AM, the east hall medication cart contained one bottle of Lantus insulin for R15. This insulin bottle was not dated when the bottle was opened. At that time, V9 Registered Nurse confirmed that the bottle was not dated and stated the bottle was delivered on 10/19/23 so it would be over 30 days since delivered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145636 If continuation sheet Page 24 of 28 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 145636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charleston Rehab and Nursing 716 Eighteenth Street Charleston, IL 61920 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide routine dental care for one of one resident (R13) reviewed for dental services on the sample list of 39. Residents Affected - Few Findings include: The facility's undated Dental Services policy documents the facility must offer access to necessary routine and emergency dental services to maintain resident dental health. R13's undated Medical Diagnoses list documents R13 is diagnosed with Morbid Obesity, Congestive Heart Failure, Obstructive Sleep Apnea, Emphysema, Paraplegia, and Diabetes. R13's Minimum Data Set, dated [DATE] documents R13 is cognitively intact, has cavities and broken natural teeth, has mouth/facial pain and difficulty chewing, and requires extensive assistance of one person for personal hygiene including brushing his teeth. On 11/19/23 at 10:13 AM R13's teeth were rotting, broken off, or missing entirely. On 11/19/23 at 10:15 AM R13 stated he needs dentures however has only seen a dentist at the facility once since admission. R13 stated most of his teeth are rotted or have fallen out and he is have trouble eating anything that isn't soft in texture. R13 stated sometimes the teeth can cause him pain and discomfort. On 11/20/23 at 12:04 PM V2 Director of Nurses (DON) stated R13's teeth are broken, missing and rotting this is an issue that needs to be addressed. V2 confirmed R13 should have seen the dentist more frequently with all of his ongoing dental issues. V2 stated if R13 wants dentures the facility needs to make that happen for him. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145636 If continuation sheet Page 25 of 28 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 145636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charleston Rehab and Nursing 716 Eighteenth Street Charleston, IL 61920 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to serve palatable food for three of three residents (R59, R50, R12) reviewed for palatability of food on the sample list of 39 residents. Residents Affected - Few Findings include: The facility Resident Council Minutes dated 9/1/23 documents new business Meal of the Month: Did not like the hamburgers. They were overcooked. The facility Grievance/Complaint Report dated 10/2/23 documents (V22) (R59's) family member reported (R59) was served burnt grilled cheese at lunch time meal. (V22) stated this is unacceptable and it should have not made it out of the window for anyone. On 11/19/23 12:25 PM R50 stated The food here is awful. It is either raw or burnt or cold. Even when I ask them to heat something it still comes back cold and awful. It is like they don't even have a cook here or anything. The facility Week Two Menu documents 11/20/23 lunch meal as Salisbury steak with gravy, baked potato with margarine, peas and frosted pumpkin bar. On 11/20/23 at 12:45 PM Dietary Staff were serving pumpkin bars with butter cream icing to residents during the lunch meal. The pumpkin bars were not uniform sizes with the majority of servings being broken pieces of cake on plates. The icing on the pumpkin bars was splattered over the cake and cake plate. The icing had multiple cream-colored clumps with clear liquid pooled on plate. On 11/20/23 at 1:00 PM R12 stated This food is terrible. The least they (staff) could do is give us a good dessert, but they can't even do that right. That cake (iced pumpkin bar) looks like it has been chewed up and spit out by someone else already. On 11/20/23 at 1:10 PM V8 Certified Dietary Manager (CDM) stated V8 made the pumpkin bars and then V16 [NAME] came in and iced them. V8 stated V16 didn't realize the pumpkin bars had just come out of the oven and iced them when they were still too warm. V8 stated the icing started as butter cream and ended as a sloppy mess. V8 stated they didn't have time to make any other dessert. On 11/20/23 at 1:15 PM V16 [NAME] stated I should have checked if the pumpkin bars were warm or not. The icing wouldn't have melted all over and splattered like that if the bars were cooled. Those desserts were really a mess. We (facility) don't normally serve food that looks that way. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145636 If continuation sheet Page 26 of 28 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 145636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charleston Rehab and Nursing 716 Eighteenth Street Charleston, IL 61920 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to document three compartment sink temperatures and sanitizer levels, failed to properly store and label perishable foods, and failed to maintain a sanitary kitchen environment. These failures have the potential to affect all 64 residents residing in facility. Findings include: The daily midnight census report dated 11/19/23 documents 64 residents residing in facility. 1.) The facility policy titled 'Refrigerator and Freezer Storage' revised 10/14 documents any item to be placed in the refrigerators and freezers must be covered, labeled and dated with a date-marking system that tracks when to discard perishable foods. On 11/19/23 at 8:35 AM the facility kitchen was toured with the following observations: --The reach in cooler contained a clear bag of unlabeled, sliced white deli meat (turkey) with handwritten dates '11/12/23-11/18/23' written in black marker on the bag. --The upright freezer contained a large clear bag of unlabeled, undated, dozens of boneless, skinless chicken breasts with edges slightly thawed. --The freezer contained a large clear bag of unlabeled, undated, dozens of round breaded chicken cutlets with edges slightly darker brown and felt softer than centers. --The freezer contained a medium sized clear bag of 15-20 cooked breaded pork fritters with no date or label. --The reach in refrigerator contained dozens of unlabeled undated peanut butter and jelly sandwiches and salami and yellow sliced cheese sandwiches. --The large chest cooler contained a empty full sized pan sitting sideways over cartons of eggs. Spilled red liquid gelatin dessert was all over the egg cartons, and on sealed boxes of protein shakes, two full gallons of milk, two packaged whole turkeys and a box of whole [NAME] melons. --The bottom of the milk cooler was littered with multiple pieces of food debris, pieces of paper, other unidentifiable debris, and pooled red gelatin. --The floor in the dry storage area was littered with multiple pieces of food debris, used open sugar packets, paper towel pieces, cloth towels, and a variety of other pieces of debris and spilled liquids. --The metal roller window just above the food service area was splattered with food and unidentifiable debris over the bottom half of the window. On 11/19/23 at 9:05 AM V8 Certified Dietary Manager (CDM) stated I know this kitchen needs a good (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145636 If continuation sheet Page 27 of 28 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 145636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charleston Rehab and Nursing 716 Eighteenth Street Charleston, IL 61920 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 cleaning. I was embarrassed to see it in the condition it is in. I have a lot of high school staff working on the weekends and they just don't understand how to pick up after themselves. V8 CDM stated all of the sandwiches were discarded. V8 stated Someone put the gelatin dessert in the milk cooler right over the milk and eggs. That should not have happened but then it looks like the cooler got bumped or someone spilled the gelatin dessert all over the milk, eggs, melons, and turkeys. All of the foods were in their containers but whoever spilled the gelatin should have cleaned it up. That cooler really just needs a thorough cleaning anyway. 2.) The facility 'Three Compartment Sink Temperature/Sanitizer Log' dated November 2023 documents on 11/1/23 breakfast meal dishwashing water in three bay sink was 120 degrees Fahrenheit (F), the rinse sink temperature was 110 F and the Sanitizer sink contained 150 parts per million (PPM) of sanitizing liquid. There are no other entries for the month of November 2023. On 11/21/23 at 11:45 AM a sign hanging on the wall just above the three-compartment sink instructs staff (Sanitizer) testing solution should be at room temperature 65-75 degrees Fahrenheit (F). Dip paper for ten seconds. On 11/21/23 at 11:50 AM V23 Dietary Aide obtained the sanitizer solution level of the three-compartment sink filled with sanitized water. V23 obtained the temperature of the sanitized water as 120 degrees Fahrenheit. V23 attempted several times to determine the parts per million (PPM) level of the sanitized water at 120 degrees F. V8 Certified Dietary Manager (CDM) then instructed V23 Dietary Aide to check the PPM using room temperature sanitized water. V23 Dietary Aide then checked the PPM level of the room temperature sanitized water with a result of 150 PPM. On 11/21/23 at 11:55 AM V8 Certified Dietary Manager (CDM) stated the facility temperature log for the three compartment sinks should have been filled out. V8 stated the resident dishes are ran through the dishwasher and the pots, pans and whatever the cook uses are washed by hand in the three compartment sinks. V8 stated I see the staff checking the temperatures and using the litmus strips when they wash the dishes, but they just aren't writing them down. I will have to Inservice all the staff on how to do this so everyone knows. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145636 If continuation sheet Page 28 of 28