Health inspection·July 1, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were treated with dignity and respect for 10 (R5, R23, R25, R28, R31, R39, R42, R45, R114, R166) of 19 residents reviewed for resident rights in the sample of 40. Findings include: 1. R114's Resident Face Sheet documents R114 was admitted to this facility on 6/21/2025 with diagnoses of orthopedic aftercare for right rotator cuff surgery, muscle weakness, hemiplegia and hemiparesis following cerebral vascular infarction affecting the left dominate side and abnormalities of gait/mobility. R114's Care Plan documents R114 has a focus problem area of decreased mobility r/t (related to) right shoulder fracture, anemia and vitamin deficiency. Interventions for this focus problem include, R114 will grab side rails to assist with turning and repositioning in bed with one assist. R114 also has a focus problem area of minimal risk for injury related to falls. Interventions for this focus area include, instruct R114 to call for assist before getting out of bed or transferring. R114 is alert, oriented and able to answer questions appropriately. On 6/24/2025 at 7:45am, R114 said she put on her call light at 5:00am that morning because she needed to go to the toilet to have a bowel movement. R114 said by 5:30am, no one had came to answer her call light. R114 said she did not want to mess the bed so she got herself up and out of bed without assistance to go to the toilet. R114 said she was scared to go to the bathroom by herself and needs staff assistance to transfer, but could not wait any longer. R114 said she had a stroke and it paralyzed her left side causing her to have difficulty walking and her left hand is flaccid. R114 said she just had rotator cuff surgery on her right shoulder and can't use her right arm very well yet and it's in a sling. R114 said staff did not answer her call light until 5:45am, but by then she had already gotten back into bed by herself. 2. R25's Resident Face Sheet documents R25 was admitted to this facility on 6/9/2021 with diagnoses of congestive heart failure, type 2 diabetes mellitus, abnormal posture and right sided sciatica. R25's Minimum Data Set (MDS) dated [DATE] documented R25 has a Brief Interview for Mental Status (BIMS) score of 13, indicating R25 is cognitively intact. This same MDS documents R25 has impairment to both lower legs and is dependent of staff for toileting, showering and all transfers. On 6/24/2025 at 9:00am, R25 said around 3:00am that same morning, she had to wait over an hour for her call light to be answered by staff. R25 said she had urinated in the bed and needed to be changed. R25 said at 4:00am, staff finally answered her call light and changed her bed. R25 said she frequently has to wait long periods of time for her call light to be answered, especially during the Page 1 of 16 145666 145666 07/01/2025 Centralia Manor 1910 East McCord Rte 161 East Centralia, IL 62801

F 0550 evenings and at night. Level of Harm - Minimal harm or potential for actual harm 3. R166's Resident Face Sheet documented R166 was admitted to this facility on 6/17/2025 with diagnoses of aftercare for surgical amputation of left leg above the knee, Abnormalities of gait and mobility, muscle weakness and type 2 diabetes mellitus among others. R166's Care Plan included a focus problem area of decreased mobility r/t above the knee amputee, kidney disease, heart disease and diabetes mellitus with neuropathy. Planned interventions for this focus problem area included R166 will grab side rails to assist with turning and positioning in bed with one assist. R166's Care Plan also has a focus problem area of R166 is at risk for falls r/t left above the knee amputee. Planned interventions included instruct R166 to call for assist before getting out of bed or transferring. R166 is alert oriented and able to answers questions appropriately. Residents Affected - Some On 6/24/2025 at 9:05am, R166's call light was noted to already be activated. After a total of 34 minutes at 9:39am, staff responded to R166's request for assistance. At 9:45am, R166 said she activated her call light because she needed assistance from staff to urinate. R166 said sometimes it takes a very long time for the staff to answer her call light, but she has not been here very long and hopes the long wait times get better. On 6/24/2025 at 8:45am, V5 (Activities Director) said in April, May and June resident council meetings, the residents have repetitively complained about long call light response times. On 6/25/2025 at 8:45am, V16 (Local Ombudsman) said she attended the resident council meeting held on April 1, 2025. V16 said the residents who attended the meeting complained about having long call light wait times during the meeting and this has been an on-going problem for awhile. Resident Council meeting minutes for meeting date of 6/5/2025 documented residents still had concerns about long call light response times. Resident council meeting minutes for meeting date of 5/5/2025 documented long call light response times still needed improvement. Resident council meeting minutes for meeting date of 4/1/2024 documented a majority of the residents expressed prolonged call light wait times and the long wait times are interfering with resident needs and care. On 6/25/2025 at 1:00pm, V8 (Certified Nursing Assistant/CNA) said the facility trained her to answer call lights as quickly as possible which to her means within a minute or two of the call light being activated. V8 said call lights not being answered for over 30 minutes is way too long of a wait time. On 6/25/2025 at 1:03pm, V7 (CNA) said call lights are to be answered within 5 minutes or less. V7 said she would consider call light wait period of 30 minutes or more as not being very prompt and is too long of a wait period. On 6/25/2025 at 1:05pm, V9 (CNA) said call lights are to answered as soon as possible, which to her means within 5 minutes of resident activation. V9 said a call light response time of 30 minutes or more is too long for a resident to wait for assistance. On 6/25/2025 at 1:07pm, V10 (CNA) said call lights are to be answered as soon as possible, which to her means within 2 minutes of resident activation. V10 said a 30 minute or more call light response time is way too long. On 6/25/2025 at 3:45pm, V2 (Director of Nursing) said she expected her staff to answer call lights 145666 Page 2 of 16 145666 07/01/2025 Centralia Manor 1910 East McCord Rte 161 East Centralia, IL 62801

F 0550 Level of Harm - Minimal harm or potential for actual harm within 10-15 minutes. V2 said this is her definition of promptly answering a resident's call light. V2 said 30 minute response time is way to long for a resident to wait for staff assistance. On 6/25/2025 at 3:50pm, V1 (Administrator) said she expected the staff to answer resident call lights within 10-15 minutes. V1 said 30 minutes is too long for a resident to wait for staff assistance. Residents Affected - Some Facility policy titled Call Light with revision date of 05/25 documented the objective of this policy is to respond to resident's request and needs. Procedure: answer call light promptly, knock before entering room, turn off call light, listen to resident's request and respond to request. 4. 4. On 06/23/25 at 11:45 AM, lunch service began to the main dining room. On 06/23/25 at 11:52 AM, R42 was served his lunch and was eating for 10 minutes before his tablemate R28 received his lunch tray at 12:02 PM. R42 was already finished eating before R28 received his meal. On 06/23/25 at 11:51 AM, R23's table began receiving lunch trays. R23's tablemate received her food and was eating for 12 minutes before R23 received her food at 12:03 PM. R23's tablemate was finishing up her lunch by the time R23 started eating. On 06/23/25 at 12:06 PM, R39 was observed to be almost done eating lunch when tablemate R5 just received her lunch tray. On 06/24/25 at 11:45 AM lunch service to the main dining room began. On 06/24/25 at 11:45 AM, R39 received her lunch, while her tablemate R5 waited approximately 13 minutes to receive her lunch tray. At 11:58 AM, R5 received her food, with eleven other residents served between. On 06/24/25 at 11:45 AM, R45 received her food and her tablemate, R31 waited 9 minutes before receiving her food at 11:54 AM, with other eight residents served between. On 06/26/25 at 10:56 AM, V2 (Director of Nursing) stated, residents sitting at the same table in the dining room should be served at similar times, not with several residents served in-between. V1 stated serving residents at the same time promotes dignity and a homelike environment for the residents. The facility policy dated 08/22 titled, Meal Service in Dining Room or Other Area documents: 15 Meals should only be served when residents are seated in the dining room. Staff shall serve meals to all residents at a table at the same time. All available Nursing staff and Department Heads shall assist in serving residents during meal times, if applicable. 145666 Page 3 of 16 145666 07/01/2025 Centralia Manor 1910 East McCord Rte 161 East Centralia, IL 62801

F 0561 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Based on interview and record review, the facility failed to respect resident choices for one (R163) of one resident reviewed for self-determination in a sample of 40. Residents Affected - Few Findings include: R163's Resident Face Sheet documented an admission date of 06/09/25 with diagnoses including: fracture of lower end of right ulna, atrial fibrillation, weakness, syncope and collapse, and elevated white blood cell count. R163's Care Plan documents a problem area of: resident care information dated 06/10/25 with an approach dated 06/10/25 listed as: preferred time up: 8:00 AM and bedtime 10:00 PM. On 06/23/25 at 10:15 AM, R163 was alert to person, place and time and stated she has told facility staff she does not like to get up early but lately they have been getting her up early again. R163 said today (06/23/25) they got her up at around 6:00 AM and that is before she wanted to be up. R163 said when she gets up that early, she then has to sit in her chair for two hours and wait for breakfast and that would not be her preference. On 06/25/25 at 10:05 AM, R163 stated they have still been getting her up around 6:00 AM and she just does not understand why. On 06/25/25 at 10:07 AM, V15 (Family) stated it has been around 6:00 AM that they have been getting R163 up lately and she does not like to get up that early. On 06/26/25 at 10:15 AM, V9 (Certified Nurse Aide/CNA) stated she works the hall R163 is on. V9 stated, she starts getting residents up shortly after she arrives to work, so at approximately 5:30 AM. V9 stated, there are no residents that she does not encourage to get up at that time. On 06/25/25 at 2:20 PM, V1 (Administrator) stated, residents should be woken up prior to breakfast or at any other time that they request. If a resident requests not to get up until right before breakfast, staff shouldn't wake them up at 6:00 AM, they should be woken up at 7:45 AM - 8:00 AM. 145666 Page 4 of 16 145666 07/01/2025 Centralia Manor 1910 East McCord Rte 161 East Centralia, IL 62801

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to consistently identify hazards/risks related to falls and ensure individualized, resident centered interventions were developed and implemented for prevention of falls for 4 of 7 residents (R13, R17, R28, R263) reviewed for accidents in a sample of 40. This failure resulted in R17 receiving a laceration to the back of the head, requiring emergency room treatment which included 3 staples to the back of R17's head. Findings include: 1. R17's Resident Face Sheet documented an admission date of 04/23/20 and included diagnoses of Alzheimer's disease, unspecified and difficulty in walking, not elsewhere classified. R17's MDS dated [DATE], documented a BIMS should not be completed, indicating R17 is rarely or never understood. Section GG-Functional Abilities documented that R17 requires partial/moderate assist with transferring. R17's Care Plan documented R17 is at risk for falls with interventions including emergency room evaluation on 03/01/25 and an antibiotic for 7 days related to a urinary tract infection with an initiation date of 03/02/2025. R17's Progress Note documented on 03/01/2025 at 9:02pm RN (Registered Nurse) heard screaming coming from unit. Upon entry into unit, CNA (Certified Nursing Assistant) in hallway stating, resident fell. Upon entry into resident room, resident laying supine on floor with head towards bathroom sink. CNA witnessed fall with resident, no loss of consciousness noted. Blood noted behind head. RN and CNA assisted resident into a sitting position, pressure applied to head. Laceration to back of head noted. 911 called and pressured applied until arrival. R17's Progress Note documented on 03/02/2025 at 02:14am RN took call from (name of RN) at (local hospital) with update on resident. CT (Computed Tomography) of abdomen/pelvis, brain and spine normal with no fractures noted. 3 staples to laceration to back of the head. Resident diagnosed with UTI (urinary tract infection), Ceftin 1 tab po daily X 7 days. Resident to return to facility. R17's Progress Note documented on 03/02/2025 at 5:59am, Resident was heard yelling help by RN. RN opened door into resident's room, resident laying supine on floor. Resident denies any pain. No injuries noted. Staples remained intact; no bleeding noted. Resident wearing non-skid socks. Resident positioned back in bed with RN and CNA. Resident refusing vitals and attempting to hit staff. Staff stepped away from resident. Resident's bed in lowest position. Resident laying in bed with eyes closed and respirations even and non-labored. R17's Progress Note documented on 03/02/2025 at 9:00pm CNA notified RN that resident was found sitting on floor between bathroom and resident room. Upon entry into room, resident in sitting position, pants were laying by bed. Resident denies no pain. No injuries noted. CNA and RN assisted resident back to bed. Resident bed in lowest position. Door to resident room open. R17's Progress Note documented on 03/03/2025 at 10:13am Root cause analysis: resident fell on ground when putting clothes on. Observed by the CNA who was in the room when incident happened. IDT met 145666 Page 5 of 16 145666 07/01/2025 Centralia Manor 1910 East McCord Rte 161 East Centralia, IL 62801

F 0689 and intervention in place to provide safe resident handling education. Level of Harm - Actual harm R17's Progress Note documented on 03/03/2025 at 10:15am Root cause analysis: resident found laying supine on ground. Resident is unable to express what she was trying to do. Assisted back to bed and resident became combative with staff. Resident reapproached later. Residents Affected - Few R17's Progress Note documented on 03/03/2025 at 10:17am Physical Therapy to eval resident. R17's Event Report for falls on 03/02/25 at 6:02am documented that R17 was observed by the nurse sleeping 10 minutes prior to the fall and was found lying supine (on her back) on the floor. Facility fall log with a run date of 06/25/25 documented for the month of March, R17 had a fall on 03/01/25 at 9:14pm and 03/02/25 at 5:10am. On 06/24/25 at 9:36am, V1 (Administrator) confirmed there was only one fall investigation for R17 on 03/02/25. On 06/26/25 at 2:03pm, V2 (Director of Nursing/DON) stated that if a resident were found sitting or lying in the floor it should be treated as a fall and investigated, unless it is a behavior they were care planned for. V2 stated if a resident was found laying supine on the floor and had fallen from their bed after having been previously witnessed sleeping, she would expect there to be more interventions than just an evaluation by physical therapy. V2 stated an evaluation by physical therapy is not going to hurt them, but it isn't going to do anything to address the cause of the fall or prevention. 2. R13's Resident Face Sheet documented an admission date of 03/12/25 and included diagnoses of displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, difficulty in walking, not elsewhere classified and unsteadiness on feet. R13's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 2, indicating R13 is severely cognitively impaired. Section GG-Functional Abilities documents that R13 requires substantial/maximum assist with transfers. R13's Care Plan documented R13 was at risk for falling with interventions including a touch pad call light with an initiation date of 03/18/25 and encourage resident to take wheelchair to bathroom with an initiation date of 03/24/25. R13's Event Report dated 03/18/25 documented the resident slid while transferring self to the bathroom. R13's Progress Note documents on 03/18/2025 at 10:10am, Resident's roommate came up to nurses station and stated resident (R13) was in the bathroom on floor. Signee observed resident sitting on floor with her feet towards the toilet and her back to wall. Resident stated she was taking herself to the bathroom, slid and fell onto her knees. Resident had no shoes on. Wheelchair was locked and next to toilet. Bathroom clear of clutter. ROM (range of motion) WNL's (within normal limits) performed per resident. No injuries observed at this time. No complaints of pain nor discomfort voiced at this time. R13's Progress Note documents on 03/18/2025 at 10:36am Soft touch call light switched out for 145666 Page 6 of 16 145666 07/01/2025 Centralia Manor 1910 East McCord Rte 161 East Centralia, IL 62801

F 0689 resident for easier usage to call staff. Level of Harm - Actual harm On 06/26/25 at 2:03pm, V2 (Director of Nursing) stated if a resident fell in their bathroom attempting to toilet herself and she was barefoot and slid down, a soft call light would not be an appropriate intervention for the fall, it does not address the root cause of the fall. Residents Affected - Few 3. R28's Resident Face Sheet documented an admission date of 08/02/22 and included diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, muscle weakness (generalized) and unsteadiness on feet. R28's MDS dated [DATE], documented a BIMS score of 10, indicating R28 has moderate cognitive impairment. Section GG-Functional Abilities documented that R28 requires partial/moderate assist with transferring. R28's Care Plan documented R28 was at risk for falls with corresponding interventions of; therapy screen with an initiation date of 02/27/25, touch pad call light with an initiation date of 03/03/25 and encourage leg bag as tolerated, with an initiation date of 03/26/25. R28's medical record contains Event reports for falls on 02/27/25, 03/01/25 and 03/26/25. R28's Progress Note documented on 02/27/2025 at 8:45am, Resident found laying in floor by CNA. Upon assessment, resident was laying on his left side with foley catheter tubing wrapped around ankle and bowel on his leg and brief. Resident said he was trying to get up and tripped on catheter tubing. c/o (complaint of) left shoulder and left knee pain. stated he hit his head. moving all extremities evenly and without difficulty. no bumps or redness to head. No obvious injuries. neuros initiated r/t (related to) unwitnessed fall . R28's Progress Note documented on 03/01/2025 at 9:44pm, Resident had unwitnessed fall in room. Observed wedged between recliner and bed facing TV with head against wall. Resident assessed and reported pain to left arm, left leg and back . (Name of physician) notified and order received to send resident to ER (Emergency Room) for evaluation. POA (Power of Attorney) called. Left message to call facility. DON (Director of Nursing) and Administrator notified. R28's Progress Note documented on 03/03/2025 at 10:10am, Root cause analysis: resident observed on floor when attempting to take himself to the bathroom. IDT met and interventions in place to provide touchpad call light and therapy to see resident. On 06/26/25 at 12:47pm, R28's room was observed. R28 had a regular call light, no soft touch call light was observed in place in his room. On 06/26/25 at 2:03pm, V2 (DON) stated if a resident had fallen due to being tangled in their catheter tubing and incontinence was present, an evaluation by physical therapy would not be an appropriate intervention. 4. R263's Resident Face Sheet documented an admission date of 06/21/24 and a discharge date of 05/10/25 with diagnoses that included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, muscle weakness (generalized), difficulty in walking and multiple fractures of pelvis without disruption of pelvic ring, subsequent encounter for fracture with routine healing-right side. 145666 Page 7 of 16 145666 07/01/2025 Centralia Manor 1910 East McCord Rte 161 East Centralia, IL 62801

F 0689 Level of Harm - Actual harm Residents Affected - Few R263's MDS dated [DATE], documented a BIMS score of 11, indicating R263 is moderately cognitively impaired. Section GG-Functional Abilities documented R263 required supervision or touch assistance for transfers. R263's Care Plan documented R263 was at risk for falling with interventions including, therapy to evaluate with a start date of 05/05/25. R263's medical record contains an Event Report for falls on 03/01/25 and 05/04/25. R263's Progress note documented on 03/04/25 at 11:33am, As POA/dtr (name of daughter) was leaving 200 hall, she notified signee that she just saw res (resident) face plant onto her bed, stating that res had left her walker by the sink et (and) attempted to walk from there to her bed. Also stated she has noticed res leave her walker in D/R (dining room) et walk to table. Concerned since res had fall in room recently . R263's medical record does not contain any evaluation or further documentation regarding the 3/4/25 incident. Facility fall log with a run date of 06/25/25 documents for the month of March, R263 had a fall on 03/01/25 at 12:30pm. On 06/25/25 at 12:48pm, V21 (Certified Nursing Assistant/CNA) stated if she witnessed a resident sitting or lying on the floor, or if a family member reported seeing a resident faceplant their bed from a standing position, she would report it as a fall or change of plane to a nurse. On 06/26/25 at 12:43pm, V22 (Licensed Practical Nurse/LPN) stated if a visitor reported to her that they witnessed their family member faceplant their bed from a standing position, she would consider it a fall. She stated if it was reported to her or she witnessed a resident sitting or lying in the floor, she would consider it a fall and treat it as such. She stated she would assess the resident. On 06/26/25 at 1:36pm, V23 (LPN) stated if it had been reported to her by a visitor that they witnessed a resident face plant their bed from a standing position they would consider it a fall and assess the resident and open an investigation. On 06/26/25 at 2:03pm, V2 (DON) stated she would consider a resident face planting their bed as a change in plane. Facility document titled Observation Detail List Report found in R263's medical record dated 03/11/25 documented A fall is defined as an unintentional change in position coming to rest on the ground, floor or onto the next lower surface (e.g., onto a bed, chair or bedside mat). Facility Policy titled, Emergencies with a revision date of 04/03/18 documents under the section titled Falls: 1. Check the resident immediately for ability to move extremities; check for bruised areas and/or cuts. 2. Check resident's ability to explain what happened; evaluate resident's condition before the fall. 3.Check if, or with anyone who witnessed the accident. Determine, if possible, where, how, and when the accident occurred. 145666 Page 8 of 16 145666 07/01/2025 Centralia Manor 1910 East McCord Rte 161 East Centralia, IL 62801

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for two (R7 and R213) of 7 residents reviewed for nutrition in a sample of 40. This failure resulted in further contributing to continued harm for R7, who is documented to be severely underweight with a Body Mass Index of 16.66%. Residents Affected - Few Findings include: R7's Resident Face Sheet documents an admission date of 01/30/2018 with diagnoses that included dementia, atherosclerotic heart disease, osteoarthritis, dysphagia, major depressive disorder, cachexia, pain in right arm, ventral hernia without obstruction or gangrene, abnormal weight loss, anxiety disorder, heartburn, vitamin deficiency, gastro-esophageal reflux disease without esophagitis, and vitamin B12 deficiency anemia. R7's Minimum Data Set (MDS) dated [DATE] documented no Brief Interview for Mental Status was performed due to resident is rarely/never understood. R7's eating ability is documented as setup or clean-up assistance needed. R7's Care Plan document a problem area of nutritional status dated: 09/17/2020 of R7 may be at risk for nutritional deficit related to decreased appetite related to dementia and an eating disorder with approaches dated 06/03/2025 of plastic plate with meals, 06/08/2024 provide supplement: regular diet with house supplements, 05/12/2022 shakes TID as tolerated, and 09/17/2020 staff assist with eating and drinking as tolerated. R7's vitals record documents a weight for R7 dated 06/04/2025 at 3:29 PM documents weights of 77 lbs (pounds), R7's weight dated 05/07/25 at 3:26 PM is documented as: 79 lbs, R7's weight dated 04/08/25 at 12:05 PM is documented as 81 lbs. R7's dietitian assessment dated [DATE] at 10:56 AM documents: R7 is on a Regular diet with house supplement at meals. Serve double meat or eggs at breakfas and dry cereal (sweet) at breakfast. R7's intakes are 25-75% and less at times. R7 has a Boost supplement 8 oz. TID (three times a day) between meals. R7's family does not want tube feeding. R7's weights: (6/4): 77 lbs, (5/7): 79 lbs, (3/6): 82 lbs, and (12/9): 84 lbs. R7's current weight trend is noted and she is below IBW (ideal body weight) range 89-115 lbs. R7's body mass index is 16.66% (Underweight). R7's dietitian quarterly assessment dated [DATE] at 11:39 AM documents: R7 is on a regular diet with house supplement at meals. Serve double meat or eggs at breakfast , and dry cereal (sweet) at breakfast. R7's intakes are 25-75% and less at times. R7 has a Boost supplement 8 oz. TID between meals. Family does not want tube feeding. R7's weights: (4/8): 81 lbs, (3/6): 82 lbs, (1/8): 86 lbs, and (10/15): 88 lbs. R7's current weight is down 7 lbs (8.0%) x/6 months. R7 is below IBW range 89-115 lbs. R7's body mass index is 17.53% (Underweight). R7's dietitian assessment dated [DATE] at 11:32 AM documents R7 is on a regular diet with house supplement at meals. Serve double meat or eggs at breakfast , and dry cereal (sweet) at breakfast. R7's intakes are 25-75% and less at times. R7 has a Boost supplement 8 oz. TID between meals. Family does not want tube feeding. R7's weights: (2/15): 81 lbs, (1/8): 86 lbs, (11/7): 86 lbs, and (8/6): 85 lbs. R7's current weight is down 5lbs (5.8%) x/1 month. R7 is below IBW Range 89-115 lbs. R7's body 145666 Page 9 of 16 145666 07/01/2025 Centralia Manor 1910 East McCord Rte 161 East Centralia, IL 62801

F 0692 mass index is 17.53 (Underweight). Level of Harm - Actual harm R7's Physician Order Report dated 05/25/25-06/25/25 documented an order for house supplement with a start date of 06/08/24 an end date listed as open ended. Residents Affected - Few R7's Dietary Card did not list a house supplement on the card. R7's dietary card documented: likes: ice cream. On 06/23/25 at 11:52 AM, R7's lunch tray was observed with no house supplement included on her tray. R7 sat with her lunch in front of her with no food eaten off of the plate and making no effort to eat. At 11:59 AM, R7 picked up her plate and was tilting it and almost dumped her food in her lap. At 12:00 PM, a staff member grabbed R7's plate, set it on the table and assisted R7 with one bite and walked away. At 12:07 PM, R7 still had not eaten any food or made any attempts to eat. At 12:08 PM, a staff member asked R7 if she wanted to try her dessert as she walked by, but R7 did not take any bites. At 12:10 PM, a staff member brought R7 some chocolate milk that she drank, but did not encourage her to eat any food. At 12:17 PM, R7 was yelling out and had still not eaten any of her food. At 12:22 PM, a staff member began encouraging R7 to eat and she ate approximately 0.25 percent of her food. On 06/24/25 at 11:56 AM, R7 received her lunch tray with ice cream but no health shake. At 11:59 AM, R7 did not make any effort to eat her food, but did pick up her ice cream and was licking it out of the cup. On 06/25/25 at 2:16 PM, V1 (Administrator) stated, if staff see a resident is not eating they should encourage or assist the resident within approximately five minutes or so. V1 stated, if the resident has an order for a supplement, they should receive the supplement. On 06/25/25 at 2:18 PM V2 (Director of Nursing/DON) stated, if staff see a resident is not eating they should encourage or assist the resident within approximately five minutes or so. V2 stated she would not consider R7 to be set up or clean up assistance only, R7 needs encouragement or assistance to total assistance at times. On 06/26/25 at 1:13 PM, V17 (Dietary Manager) stated, she does not know why R7 does not have her supplement listed on the dietary card. V7 said there must have been a breakdown in communication getting dietary the order, because as soon as she gets the orders she puts them in the program and the supplements are printed on the resident's dietary card. On 06/26/25 at 12:46 PM V24 (Registered Dietitian/RD) stated, R7 is underweight and she should have had the supplements that were ordered for her, she would expect her to receive them. The undated facility policy documents: 9. the weight committee will review all residents with significant weight gains or losses and other residents of concern and refer to the RD as needed, 10. the dietician will review significant weight losses and any other residents referred by the weight committee, on a monthly basis, and make recommendations to physicians as necessary. 2. R213's Resident Face Sheet documents an admission date of 06/12/25 and included diagnoses of noninfective gastroenteritis and colitis, type 2 diabetes mellitus with diabetic chronic kidney disease, pain, muscle weakness, abnormalities of gait and mobility, cognitive communication deficit, macular degeneration, severe protein calorie malnutrition, malaise, fatigue, vitamin deficiency, and 145666 Page 10 of 16 145666 07/01/2025 Centralia Manor 1910 East McCord Rte 161 East Centralia, IL 62801

F 0692 cachexia. Level of Harm - Actual harm R213's Care Plan documented a problem area dated 06/18/25 of R213 has a BMI (body mass index) of 14.45, at risk for weight loss with interventions documented of regular diet with house supplement, Megase continues as ordered, notify physician and dietician as needed, and obtain weights dated 06/18/25. R213's problem area dated 06/12/25 of resident care information documents: snacks between meals as requested, regular diet with house supplement at meals dated 06/12/25. Residents Affected - Few R213's Dietary Note dated 06/18/25 at 11:07 AM, documents: dietitian/admit (admission) assessment: [AGE] year old female admitted (6/12) on regular diet, intakes 25-75%, she has a diagnosis of malnutrition and on Megace to stimulate appetite. R213's diabetic preferences: offer reduced sugar condiments, beverages, and half portions of desserts. R213's weight (06/13) 84.2 (pounds) with a ideal body weight index of 14.45 (underweight). R213 has no edema, she is on an antibiotic for a urinary tract infection. R213's plan is to boost intakes 1) add house supplement at meals. R213's Physician Order Report documented an order for house supplement during meal time dated 06/19/25 with an end date of open ended listed. On 06/23/25 at 11:52 AM, R213's already had her lunch sitting in front of her with one or two bites taken from the mashed potatoes. R213 did not receive a house supplement. R213 did not answer any questions when asked. R213 was sitting in front of her food with her head slumped down making no effort to eat. At 12:02 PM, R213 still had not eaten any food and still had not received any encouragement or assistance. At 12:12 PM, R213 still had not made any effort to eat any of her food when V9 (Certified Nurse Assistant/CNA) sat down and began to assist R213 with her lunch. R213 ended up eating approximately 25% of her food. On 06/24/25 at 11:58 AM, R213 did not receive a house supplement with her meal. On 06/25/25 at 12:05 PM, R213 did not receive a house supplement with her meal. On 06/25/25 at 2:16 PM, V1 (Administrator) stated, if staff see a resident is not eating they should encourage or assist the resident within approximately five minutes or so and any resident that has an order for a supplement should receive it. On 06/25/25 at 2:18 PM, V2 (Director of Nursing/DON) stated, if staff see a resident is not eating they should encourage or assist the resident within approximately five minutes or so. The undated facility policy documents: 9. the weight committee will review all residents with significant weight gains or losses and other residents of concern and refer to the RD as needed, 10. the dietician will review significant weight losses and any other residents referred by the weight committee, on a monthly basis, and make recommendations to physicians as necessary. 145666 Page 11 of 16 145666 07/01/2025 Centralia Manor 1910 East McCord Rte 161 East Centralia, IL 62801

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to ensure that pain management was provided for one (R53) of one resident reviewed for pain management in a sample of 40. This failure resulted in R53 experiencing prolonged severe pain without relief for several hours. Residents Affected - Few Findings include: R53's Resident Face Sheet documented an admission date of 06/05/25 and included diagnoses of urinary tract infection, disorder of the skin and subcutaneous tissue, rash and other nonspecific skin eruption, muscle weakness, unilateral primary osteoarthritis in the left hip, pain, anxiety disorder, spinal stenosis in the lumbar region with neurogenic claudication, atrial fibrillation, and osteoarthritis. R53's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 08, indicating moderate cognitive impairment. R53's Care Plan documents a problem area with a start date of 06/05/25 of R53 has (or risk for) pain related to osteoarthritis and spinal stenosis with approaches listed as: administer pain medication as ordered and monitor for side effects and assist resident with non-pharmacological pain relief methods and reposition as tolerated. R53's Physician Order Sheet documents orders for: acetaminophen 500 mg (milligrams) every six hours PRN (as needed) with a start date of 06/18/25 and an end date of 'open ended,' morphine schedule II tablet immediate release 15 mg, 1 tablet twice a day with a start date of 06/05/25 and an end date of 'open ended,' and oxycodone - schedule II tablet 5 mg 1 tablet every 4 hours as needed for moderate to severe pain with a start date of 06/05/25 and an end date of 'open ended.' On 06/23/25 at 9:50 AM, R53's face was grimaced, she appeared agitated and kept trying to adjust herself in her wheelchair. R53 stated her back hurts really bad, she stated she is not supposed to stay in her chair that long and she has been in it since around 6:00 AM. R53 stated it hurts so bad she would rather be dead. R53 stated she was given some pain medication maybe an hour ago but it is not helping at all. R53 said she told the nurse and stated, sometimes it is better if she lays down. On 06/23/25 at 9:58 AM, V12 (Licensed Practical Nurse/LPN) stated she has given R53 some pain medication not too long ago. V12 stated, she is going to call the doctor to find out about medication. On 6/23/25 during continuous observations, R53 was sitting in her wheelchair at 9:55 AM, 10:02 AM, 10:10 AM, 10:18 AM, 10:20 AM, 10:26 AM, 10:42 AM, 10:45 AM, and 10:55 AM. On 06/23/25 at 11:05 AM, R53 stated her back and her hip really still hurt, it is just excruciating. On 6/23/25 at around 12:07 PM, R53 was laid down. R53's Medication Administration Record dated 06/01/25 - 06/24/2025 documents on 06/23/25 at 10:14 AM, acetaminophen 500 mg (milligrams) was administered, and oxycodone 5 mg was not given. 145666 Page 12 of 16 145666 07/01/2025 Centralia Manor 1910 East McCord Rte 161 East Centralia, IL 62801

F 0697 On 06/23/25 at 1:10 PM, R53 stated now that she has laid down and has a heating pad it is starting to help, the pain is starting to feel some better. Level of Harm - Actual harm Residents Affected - Few On 06/24/25 at 10:10 AM, R53 stated, the pain is not as bad today. R53 stated, the pain in her hip is always there but sometimes it will get so bad and then her back will also hurt where she can barely stand it and people do not understand until they feel pain like that. R53 stated sometimes a heating pad will help with the medication and sometimes the medication is not enough. When this surveyor asked R53 if she gets more pain medication or a heating pad, R53 asked, do I have to ask for that? R53's Medications Administration History dated 6/1/25-6/24/25 documents an order to assess pain every shift using the 0-10 pain scale or verbal descriptor scale with a start date of 6/5/25. R53's pain level is documented as the following: 6/7/25 on shift 3 pain level of a 4, 6/8/25 on shift 3 pain level of a 3, 6/10/25 on shift 2 there is no pain level documented, 6/14/25 on shift 1 pain level of a 4, 6/20/25 on shift 3 pain level of a 3, 6/21/25 on shift 3 pain level of a 5, 6/22/25 on shift 1 pain level of a 6, and on 6/24/25 on shift 1 a pain level of a 10. R53's pain level is documented as a 0 for all other entries. R53's Pain Management Observation dated 06/05/25 (date of admission) documents: Pain Interview: should pain assessment interview be conducted with 'not assessed' marked. The section titled, staff assessment of pain documents: should the staff assessment for pain be conducted? with 'not assessed' marked. The section titled, Pain Management documents: pain: received scheduled pain medication regimen; at any time in the last 5 days, has the resident received scheduled pain medication regimen with 'yes' marked, at any time in the last 5 days, has the resident received PRN (as needed) pain medications or was offered and declined with 'yes' marked, at any time in the last 5 days has the resident received non-medication intervention for pain with 'not assessed' marked. The section titled, Description of pain documents: if the resident answered yes to having had pain in the last 5 days, please ask the resident to rate their pain on a zero to ten scale, with zero being no pain and ten being the worst pain you can imagine with '8' being marked, what is the resident's stated acceptable level of pain with '2' marked. Under pain site; 'back pain' is marked. Under character of pain-how does the resident describe pain, with 'unable to describe' marked. Under onset of pain, 'early morning' is marked. Under duration of pain, 'constant/persistent' is marked. Under other expressions of pain, 'agitation/restlessness' is marked. The section titled, alleviating factors asks what alleviates or decreases pain with 'medication,' 'positioning/repositioning,' and 'rest/relaxation' marked. On 06/25/25 at 2:16 PM, V1 (Administrator) stated R53's pain level should be asked and documented for every shift because they do not want to wait until the pain gets so bad it makes it hard to get control of. V1 stated, if it helps for R53 to lay down when her back starts to hurt, then staff should lay her down quickly when she starts having pain. On 06/25/25 at 2:22 PM, V2 (Director of Nursing/DON) stated, knowing that R53 came to the facility with an order for Morphine and an as needed order for Oxycodone, a pain assessment should have been completed for her. R53's pain level should be assessed and documented every day. V2 stated, when R53 stated she had a high level of pain on the morning of 06/23/25, she should have been given the as needed Oxycodone instead of the Tylenol. If R53's pain was more like a three then she would have given Tylenol. The facility policy dated 03/03/22 titled, Pain Management documents: the facility is dedicated to the philosophy that all residents should be as free of pain as possible, through a combination of medical intervention and functional therapy. 3. Residents will be observed/asked about pain at a 145666 Page 13 of 16 145666 07/01/2025 Centralia Manor 1910 East McCord Rte 161 East Centralia, IL 62801

F 0697 Level of Harm - Actual harm Residents Affected - Few minimum of each shift by the nurse using a standardized 1-10 scale or verbal descriptor scale (VDS) to determine pain intensity. 6. If the resident's pain is not being controlled, an event will be initiated to track pain and response to medication and/or treatment. 7. Residents will be monitored until pain is resolved or is under control and periodically thereafter. 8. Licensed staff will document any complaints of pain and the resident's response to the medication/treatment in resident's record. 11. Alternative methods of pain control will also be attempted: for example: a repositioning, b. therapy evaluation (if ordered by physician), c. offering a back rub, d. hot packs, e. warm bath, and f. ice bags. 145666 Page 14 of 16 145666 07/01/2025 Centralia Manor 1910 East McCord Rte 161 East Centralia, IL 62801

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the correct diet consistency to meet resident needs for 1 (R2) of 12 residents reviewed for menus and nutritional adequacy in the sample of 40. The findings include: 1. R2's Resident Face Sheet dated 06/26/25 documented an admission date of 08/06/24 (latest return) with diagnoses that included wedge compression fracture of third lumbar vertebra, chronic obstructive pulmonary disease, hypertension, osteoarthritis, and muscle weakness. R2's Minimum Data Set (MDS) dated [DATE], documented Brief Interview for Mental Status (BIMS) score of 08, indicating R2 has moderate cognitive impairment. Section GG, Functional Abilities and Goals documented under Eating that R2 requires setup and clean-up assistance. Section K, Swallowing and Nutritional Status documented R2 has a mechanically altered diet. R2's Care Plan with a revised date of 05/29/25, documented a problem area under resident care information with an approach listing Mechanical soft diet, Liquids: Regular, thin; Food Preferences: DislikesEggs; feeds self: snacks as requested. R2's Physician Orders document an order for Diet: Mech (Mechanical) Soft continuous with a start date of 08/06/24 and a end date of open ended. On 06/23/25 at 12:12PM, R2 was in her room with her lunch tray. R2 had mechanical soft chicken with gravy, red roasted potatoes with peppers, apple crumble, milk, water and tea. While eating the red roasted potatoes, R2 appeared to have a difficult time trying to chew the potato skins and peppers that were in the red roasted potatoes. R2 was taking pieces of the potatoes and peppers out of her mouth and placing them on the side of her tray. At this time, R2 stated she was having a hard time trying to chew up the roasted red potatoes and the peppers that were in it. R2 said that she wasn't really a fan of the peppers anyway, but that she doesn't have a lot of teeth left to be able to chew the red roasted potato skins or the peppers up. R2 said that she did try to eat them, but probably wouldn't be able to eat anymore of them. On 06/30/25 at 9:10AM, V25 (Dietary Aide/Cook) stated that on 06/23/25, R2 should not have received roasted red potatoes. V25 stated that R2 is on a mechanically altered diet and she should have received mashed potatoes with gravy instead. V25 said that the diet spreadsheet for 06/23/25 shows that a mechanically altered diet should have received mashed potatoes with gravy. The facility diet spreadsheet with the date of 23 Monday documents under Mechanical Soft lunch as ground baked Caesar chicken with gravy, mashed potatoes with gravy, soft winter blend vegetables, bread/margarine, apple crumble, beverage, ground meatloaf with gravy and creamed spinach. The facility policy titled Liberalized Diets with a revised date of 06/2010 documents under purpose: Increase ability to maintain acceptable weight and nutritional status, and improve, quality of life for residents, improve residents' nutritional status, improve dietary compliance, enhance caloric and nutrient intake and ultimately increase resident satisfaction. Under Procedure: E Mechanical Soft Diet- the mechanical soft diet is designed to minimize the amount of chewing necessary for the 145666 Page 15 of 16 145666 07/01/2025 Centralia Manor 1910 East McCord Rte 161 East Centralia, IL 62801

F 0803 Level of Harm - Minimal harm or potential for actual harm ingestion of food. There are no restrictions of any type of soft regular foods if all are tolerated by the individual. The mechanical difficulties of each resident should be given consideration; foods may be chopped, ground, or pureed. Residents Affected - Few 145666 Page 16 of 16