Health inspection·September 24, 2025

F 0550 Level of Harm - Actual harm Residents Affected - Few Resident Care Information with an approach of - continent of bowel and bladder, safe resident handling procedure transfer method stand aid level of assist: assist x1. On 09/22/25 at 12:45PM, R2 stated that the call light system has been down since she was admitted . R2 said that they give residents, bells, horns and whistles to use when they need help, and it is a joke. R2 said that staff is so loud or playing music and don't hear when we are using out devices to get help. R2 said she has a horn, and her roommate has bells, but it doesn't matter which one you have they don't hear any of them. R2 said she was supposed to wait for help from staff and she would honk her horn, and no one would come and answer her horn. R2 said she had had several accidents where she urinated on herself waiting on someone to come help. R2 said it was humiliating she said that she is [AGE] years old, and she does not want to be urinating all over herself if she doesn't have to. R2 said she did have to sit in her own urine for a while as she waited for a staff member to figure out who was honking or when they finally heard that she was honking for help. R2 said she finally got tired of waiting on staff to answer her horn and she just started taking herself to the bathroom instead of waiting on someone to help her. R2 said she has been working with therapy and she was supposed to be waiting on staff to assist her to the bathroom, but now she just does it on her own instead of waiting and urinating on herself. R2 said that this call system they have in place right now is a joke and they need to get the other system working so they can figure out who needs help and when they need help. 3. R4's Face Sheet dated 09/23/25 documents an admission date of 06/18/25 with diagnoses in part of periprosthetic fracture around other internal prosthetic joint, aftercare following joint replacement surgery, muscle weakness, other abnormalities of the gait and mobility, type 2 diabetes mellitus, and chronic kidney disease. R4's MDS dated [DATE] documents in Section C a BIMS score of 11 which indicates R4 is moderately cognitively impaired. Section GG documents toileting as dependent. R4's Care Plan documents a problem area of Resident Care Information with an approach of bowel and bladder continent, and safe resident handling procedure transfer method mechanical lift level of assistance x2.On 09/22/25 at 9:31AM, R4 stated that she has bells she is supposed to jingle when she needs help. R4 stated that staff doesn't really hear the bells when she is ringing them, and she has her roommate will honk her horn just so she can get someone to come take her to the bathroom or when she needs a bed pan. R4 said that she has had accidents and peed on herself waiting for staff to answer the bells or horn she said that it has taken staff over an hour she has had to wait, and it upset her so much. R4 said that she is usually able to control her urine most of the time and she doesn't like to wet herself it embarrasses her, and she hates it. R4 said she had one staff member who told her she had an incontinent brief and that she could pee in it that is what it is there for. R4 stated that one staff member told her that she needs to stop having her roommate honk her horn for her, if she needs something she needs to ring her bells herself. 4. R6's Face Sheet dated 09/23/25 documents an admission date of 09/05/25 with diagnoses in part of lumbago with sciatica, type 2 diabetes mellitus, muscle weakness, neuralgia, overactive bladder, and lower back pain. R6's MDS dated [DATE] documents in Section C a BIMS score of 15 which indicates R6 is cognitively intact. Section GG documents toileting as partial/moderate assistance. R6's Care Plan documents a problem area of Resident Care Information an approach of- bowel and bladder continent and safe resident handling procedure transfer stand aid level of assistance assist x2. On 09/22/25 at 9:49AM, R6 stated that she has a whistle to blow on when she needs assistance. R6 stated she gets winded because she must keep blowing in the whistle until staff finally comes in and helps her. R6 stated is takes staff a while to come when she is blowing her whistle, because there are several residents that have whistles, and staff must try and figure out what hall and which residents whistle is being blown on. R6 said she has had an accident while (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145666 If continuation sheet Page 2 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145666 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centralia Manor 1910 East McCord Rte 161 East Centralia, IL 62801 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 0550 Level of Harm - Actual harm Residents Affected - Few she was waiting on staff to answer her whistle. R6 said she does get upset if she has an accident while waiting on staff to answer her whistle. 5. R7's Face Sheet dated 09/23/25 documents an admission date of 06/24/25 with diagnoses in part of acute on chronic diastolic heart failure, diabetes mellitus, parkinsonism, unsteadiness on feet, muscle weakness, overactive bladder, and other abnormalities of gait and mobility. R7's MDS dated [DATE] documents in Section C a BIMS score of 15 which indicates R7 is cognitively intact. Section GG documents toileting as substantial/maximal assistance. R7's Care Plan document a problem area of Resident Care Information with an approach of bowel and bladder continent, continent toileting assist x2 and safe resident handling procedure transfer method stand pivot with walker level of assistance assist x 2. On 09/22/25 at 9:56AM, R7 stated that staff doesn't hear her horn when she squeezes it. R7 said that it takes the staff a long time before they do answer the horn when she is squeezing it. R7 said staff has told her to give them time to try and answer when she is squeezing her horn. R7 said she has had several incontinent episodes waiting on staff to answer her horn she said they have to figure out who is honking the horn first. R7 stated she doesn't know how long it had taken staff to assist her. R7 said she can't hold her urine long when she honks the horn. R7 said that she doesn't like when she has an incontinent episode on herself. On 09/22/25 at 2:36PM, V6 (Certified Nurse Assistant/CNA) stated that she usually works 300, 400, and 500 halls. V6 stated that she thinks the call light system for 300, 400, and 500 halls went out around the end of August. V6 stated that it is hard to figure out which hall the resident is whistling, honking or jingling the bells from. V6 said they go down every hall trying to figure out who needs help. V6 said the residents know to keep honking their horns, blowing their whistles, and jingling their bells until we figure out who it is. V6 said even from the nurses' station which is located between all the halls it is hard to figure out which direction the sound is coming from especially if they have staff and residents talking at the nurse's station. V6 said it is especially hard to hear the horns, whistles and bells when the residents are at the end of the hallway. V6 stated that yes some of the residents have had accidents while waiting on us to try and figure out what location the sounds are coming from. V6 said she did have a resident who was really embarrassed because she wet herself and she was really upset she said that resident was R2. On 09/22/25 at 2:37PM, V7 (CNA) stated that she usually works 300, 400, and 500 halls. V7 said that the call light system went down on those halls around the end of August. V7 said it is hard to head some of the bells, whistles, and horns especially if a resident is at the end of a hallway. V7 stated it is also hard to figure out who's whistles, horn, or bells are ringing. V7 said they must go down the halls and see what hall it is. V7 said it also makes it hard to hear those devices when a resident has their door closed. V7 said they did have a resident who kept trying to honk her horn and the horn wasn't working, and they did get the resident a new horn. V7 said that she has had several residents who were really embarrassed, and those residents were R1 and R2. V7 said that R1 and R2 both were really upset. On 09/23/25 at 9:00AM, V8 (CNA/Shift Coordinator) stated that the call light system on 300, 400, and 500 hallways quit working a couple of weeks ago. V8 said they gave the residents on those halls whistles, bike horns, and bells to be able to notify the staff when they need something. V8 said that it is very hard trying to figure out which hall or where the resident is honking, ringing or whistling from. V8 said they will go down the halls and yell out to tell the resident to keep honking, whistling, or ringing until they figure out who it is. V8 said that is does take longer for them to respond to the resident whistle, bells, or horn because they must figure out who it is that is making the noise first. V8 said when they hear a sound from the nurse's station, they get up right away and start checking all of the halls and see who it might be. V8 said that they do have resident who will honk their horns (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145666 If continuation sheet Page 3 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145666 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centralia Manor 1910 East McCord Rte 161 East Centralia, IL 62801 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 0550 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete for other resident in the same room such as R1 for R4. V8 said that R4 did have a horn, but she was trying to use it the wrong way and kept trying to honk the horn, but it wasn't' making any noise so she ended up with bells. V8 said it is harder to hear some of the resident who are on the end of the halls. On 09/23/25 at 10:05AM, V4 (Licensed Practical Nurse/LPN) stated that the facility call light system on 300, 400, and 500 hallways went out around the end of August. V4 stated they gave the resident whistles, bells, and horns to be able to ring and notify staff that they need them. V4 said she thinks that staff can hear the whistles, bells, and horns but it is challenging trying to figure out where the sound is coming from. V4 said she does think it takes the staff long to be able to answer when the resident is ringing, whistling, or honking because they must figure out who it is. V4 stated that she does know there have been a couple of residents that complained that they had an incontinent episode, but she didn't know if it was because of the bells, whistles, or horns and staff not being able to find out who it was or if it is because they have a lot of resident to care for. V7 said that she thinks a lot of the residents wait till the last minute and then try to get staff to help them and staff might be in another room taking care of another residents. On 09/23/25 at 11:40AM, V1 (Administrator) stated that the call light system on 300, 400, and 500 hallways went out on 08/29/25. V1 stated she called someone right away to see what was wrong with the call light system on those halls, but the soonest someone could come look at it was on 09/03/25. V1 said they did come in and look at the call light system and they told her that the system has just out lived its life and that they need to replace the system on those halls. V1 said that when the system went down on 08/29/25 that they did get an alternative call system of whistles, horns, and bells for the residents, so they had a way to communicate when they need help from staff. V1 said that they did try different things with the residents to make sure that they could use the device they gave each resident. V1 said she is not aware of any resident that can't use the device they have been given. V1 said staff has told her that they do have a hard time hearing the devices if the resident has their doors closed or if the resident is at the end of the hall. V1 said she did have a resident complain to her since the call light system was down it was taking a long time for staff to respond to her device. V1 said that on 09/05/25 they gave them an estimate on the new call light system for 300, 400, and 500 hallways. V1 said on 09/08/25 they ordered the new system and then on 09/16/25 they sent in payment for the new call light system. V1 said the company who is installing the new call light system said it could take 2-3 weeks before they could install the new call light system. On 09/23/25 at 12:33PM, V2 (Director of Nursing/DON) stated that they did have a problem with the call light system on 300, 400, and 500 halls it went out around the end of August. V2 said they gave the residents an alternative method to be able to call for help like whistles, horns, and bells. V2 said the shift coordinators also said something about doing 15-minute checks on those residents as well. V2 stated that she didn't know how they were tracking it the 15-minute checks. V2 stated that they don't have any documentation stating that the 15-minute checks were done on those residents. V2 said she has heard resident complain that staff has been in places where it was hard for them to hear the whistle, bells, and horns and that they tell the residents to keep whistling, honking, or jingling the bells until they figure out who it was the was making the sound with their device. On 09/24/25 at 11:00AM, V1 stated that the facility does not have a policy on dignity. The facility policy titled Call Light with a revised date of 01/04 documents under objective: To respond to resident's request and needs. Equipment documents: Functioning call light. Event ID: Facility ID: 145666 If continuation sheet Page 4 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145666 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centralia Manor 1910 East McCord Rte 161 East Centralia, IL 62801 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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 a functional call system for the 32 residents living on the 300, 400, and 500 halls.The findings include: 1. On 09/22/25 at 9:32AM, R1 stated that the call light system on her hall has been down almost since she was admitted to the facility. R1 said they gave her a bike horn to be able to get a hold of staff when she needs help. R1 said she thinks that staff can hear the horn most of the time. R1 said that other times she doesn't know if they can hear it. R1 said one time it took them 45 minutes to answer her horn. R1's MDS (Minimum Data Set) dated 08/28/25 documents in Section C a BIMS (Brief Interview for Mental Status) score of 14 which indicates R1 is cognitively intact. 2. On 09/22/25 at 12:45PM, R2 stated that the call light system has been down since she was admitted . R2 said that they give the residents, bells, horns and whistles to use when they need help, and it is a joke. R2 said that staff is so loud or playing music and don't hear when we are using out devices to get help. R2 said she has a horn, and her roommate has bells, but it doesn't matter which one you have they don't hear any of them. R2 said that this call system they have in place right now is a joke and they need to get the other system working so they can figure out who needs help and when they need help. R2's MDS dated [DATE] documents in Section C a BIMS score of 15 which indicates R2 is cognitively intact.3. On 09/22/25 at 11:55AM, R3 stated that the call light system has been down since she was admitted to the facility. R3 said that staff gave them things like bells, whistles and horns to try and get staffs attention when they need something. R3 said that staff has a hard time trying to figure out who's whistle is going off. R3 said that staff will walk up and down the halls trying to figure out who is whistling, honking or ringing for help and they have several halls to go down to figure that out. R3's MDS dated [DATE] documents in Section C a BIMS score of 14 which indicates R3 is cognitively intact.4. On 09/22/25 at 9:31AM, R4 stated that she has bells she is supposed to jingle when she needs help. R4 stated that staff doesn't really hear the bells when she is ringing them, and she has her roommate will honk her horn just so she can get someone to come take her to the bathroom or when she needs a bed pan. R4's MDS dated [DATE] documents in Section C a BIMS score of 11 which indicates R4 has moderately impaired cognition.5. On 09/22/25 at 9:49AM, R6 stated that she has a whistle to blow on when she needs assistance. R6 stated she gets winded because she must keep blowing in the whistle until staff finally comes in and helps her. R6 stated is takes staff a while to come when she is blowing her whistle, because there are several residents that have whistles, and staff must try and figure out what hall and which residents whistle is being blown on. R6's MDS dated [DATE] documents in Section C a BIMS score of 15 which indicates R6 is cognitively intact.6. On 09/23/25 at 8:57AM, R11 who was alert and oriented stated that when she needs assistance to go to the bathroom, she will just wheel over to the hallway and find a staff member. R11 stated that she didn't have a whistle, bells, or horn. R11 stated that she just must look for someone. R11 stated that she uses to hit the button on that white cord on the wall when she needed help, but it stopped working.On 09/23/25 at 8:58AM there were no whistles, bells, or horns observed in R11's room, that could be seen in plain sight. On 09/23/25 at 3:28PM observed V2 (Director of Nursing/DON) in R11's room looking for R11's alternative call light. V2 found R11's whistle in a bin on resident bedside table covered up under papers.On 09/23/25 at 3:32PM, R11 stated that she doesn't like to use the whistle it is too loud, she will just go and get someone in the hallway when she needs help.7. On 09/23/25 at 2:10PM observed R12 laying in bed. R12 had no bells, no whistle, and no horn next to her while she was laying in bed. Observed a bedside table next to the empty bed in R12's room that had bells laying on the table out of reach of the resident. On Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145666 If continuation sheet Page 5 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145666 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centralia Manor 1910 East McCord Rte 161 East Centralia, IL 62801 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 09/22/25 at 2:34PM observed bells jingling from the nurses' station unable to locate if the jingling was coming from 400 hall or 500 hall. Observed staff going down the halls trying to figure out who was jingling the bells. During observation another resident was sitting by the nurses' station singing which was making it harder to hear the ring from the bells.On 09/22/25 at 2:36PM, V6 (Certified Nurse Assistant/CNA) stated that she usually works 300, 400, and 500 halls. V6 stated that she thinks the call light system for 300, 400, and 500 halls went out around the end of August. V6 stated that it is hard to figure out which hall the resident is whistling, honking or jingling the bells from. V6 said they go down every hall trying to figure out who needs help. V6 said the residents know to keep honking their horns, blowing their whistles, and jingling their bells until we figure out who it is. V6 said even from the nurses' station which is located between all the halls it is hard to figure out which direction the sound is coming from especially if they have staff and residents talking at the nurse's station. V6 said it is especially hard to hear the horns, whistles and bells when the residents are at the end of the hallway. On 09/22/25 at 2:37PM, V7 (CNA) stated that she usually works 300, 400, and 500 halls. V7 said that the call light system went down on those halls around the end of August. V7 said it is hard to head some of the bells, whistles, and horns especially if a resident is at the end of a hallway. V7 stated it is also hard to figure out who's whistles, horn, or bells are ringing. V7 said they must go down the halls and see what hall it is. V7 said it also makes it hard to hear those devices when a resident has their door closed. V7 said they did have a resident who kept trying to honk her horn and the horn wasn't working, and they did get the resident a new horn. On 09/23/25 at 9:00AM, V8 (CNA/Shift Coordinator) stated that the call light system on 300, 400, and 500 hallways quit working a couple of weeks ago. V8 said they gave the residents on those halls' whistles, bike horns, and bells to be able to notify the staff when they need something. V8 said that it is very hard trying to figure out which hall or where the resident is honking, ringing or whistling from. V8 said they will go down the halls and yell out to tell the resident to keep honking, whistling, or ringing until they figure out who it is. V8 said that is does take longer for them to respond to the resident whistle, bells, or horn because they must figure out who it is that is making the noise first. V8 said when they hear a sound from the nurses' station, they get up right away and start checking all of the halls and see who it might be. V8 said that they do have resident who will honk their horns for other resident in the same room such as R1 for R4. V8 said that R4 did have a horn, but she was trying to use it the wrong way and kept trying to honk the horn, but it wasn't' making any noise so she ended up with bells. V8 said it is harder to hear some of the resident who are on the end of the halls. On 09/23/25 at 10:05AM, V4 (Licensed Practical Nurse/LPN) stated that the facility call light system on 300, 400, and 500 hallways went out around the end of August. V4 stated they gave the resident whistles, bells, and horns to be able to ring and notify staff that they need them. V4 said she thinks that staff can hear the whistles, bells, and horns but it is challenging trying to figure out were the sound is coming from. V4 said she does think it takes the staff long to be able to answer when the resident is ringing, whistling or honking because they have to figure out who it is. On 09/23/25 at 11:40AM, V1 (Administrator) stated that the call light system on 300, 400, and 500 hallways went out on 08/29/25. V1 stated she called someone right away to see what was wrong with the call light system on those halls, but the soonest someone could come look at it was on 09/03/25. V1 said they did come in and look at the call light system and they told her that the system has just out lived its life and that they need to replace the system on those halls. V1 said that when the system went down on 08/29/25 that they did get an alternative call system of whistles, horns, and bells for the residents, so they had a way to communicate when they need help (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145666 If continuation sheet Page 6 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145666 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centralia Manor 1910 East McCord Rte 161 East Centralia, IL 62801 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete from staff. V1 said that they did try different things with the residents to make sure that they could use the device they gave each resident. V1 said she is not aware of any resident that can't use the device they have been given. V1 said staff has told her that they do have a hard time hearing the devices if the resident has their doors closed or if the resident is at the end of the hall. V1 said she did have a resident complain to her since the call light system was down it was taking a long time for staff to respond to her device. V1 said that on 09/05/25 they gave them an estimate on the new call light system for 300, 400, and 500 hallways. V1 said on 09/08/25 they ordered the new system and then on 09/16/25 they sent in payment for the new call light system. V1 said the company who is installing the new call light system said it could take 2-3 weeks before they could install the new call light system. On 09/23/25 at 12:33PM, V2 (Director of Nursing/DON) stated that they did have a problem with the call light system on 300, 400, and 500 halls it went out around the end of August. V2 said they gave the residents an alternative method to be able to call for help like whistles, horns, and bells. V2 said the shift coordinators also said something about doing 15-minute checks on those residents as well. V2 stated that she didn't know how they were tracking it the 15-minute checks. V2 stated that they don't have any documentation stating that the 15-minute checks were done on those residents. V2 said she has heard resident complain that staff has been in places where it was hard for them to hear the whistle, bells, and horns and that they tell the residents to keep whistling, honking, or jingling the bells until they figure out who it was the was making the sound with their device.The facility resident bed list report dated 09/22/25 documents 13 residents reside on 300 hall, 16 residents reside on 400 hall, and 3 residents reside on 500 hall. The facility policy titled Call Light with a revised date of 01/04 documents under objective: To respond to resident's request and needs. Equipment documents: Functioning call light. Event ID: Facility ID: 145666 If continuation sheet Page 7 of 7