Inspection·November 17, 2022

F 0656 Level of Harm - Minimal harm or potential for actual harm R68's Physician's orders, dated 11/15/22, document an order for R68 to have a indwelling urinary catheter 16 French/10 ml (milliliters) balloon to be changed every four weeks for the diagnosis of urinary retention. R68's care plan has no documentation of a comprehensive care plan addressing R68's indwelling urinary catheter. Residents Affected - Few On 11/16/22 at 1:24 p.m., V7 (MDS Coordinator) confirmed that R68 did not have a comprehensive care plan addressing R68's indwelling urinary catheter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145720 If continuation sheet Page 2 of 8 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 145720 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Clara's Rehab & Senior Care 1450 Castle Manor Drive Lincoln, IL 62656 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, interview, and record review, the facility failed to provided ROM (Range of Motion) programming for a resident with limited ROM for one of one resident (R10) reviewed for limited ROM in the sample of 36. Findings include: The facility's Contracture Prevention Program policy, dated 1/15/11, documents, Objective: To maintain residents at the highest level of physical functioning possible. To stimulate circulation and prevent edema. To prevent fixation of a joint for long periods of time. To prevent atrophy of muscles. Procedure: The plan of care established by physical therapy or nursing when a contracture is present or the resident is at risk for developing contracture may include goals, positioning aids, treatment plans and potential for improvement. Those individuals having limited range of motion and fair to good potential for resolution may be placed in therapy or restorative/rehabilitation program. On 11/14/22 at 11:51 AM, R10 was alert leaning over to her right side in her recliner. R10 stated that she has no function on her left side due to her diagnosis of Cerebral Palsy. R10 also stated that staff do not help her with exercises, but she would really like them to. R10's Contracture Risk Evaluation, dated 9/6/22, documents, ROM limited on left related to Cerebral Palsy. R10's MDS (Minimum Data Set), dated 9/6/22, documents in Section G Functional Status that R10 has functional limitation in range of motion on one side of her upper and lower extremities. R10's current care plan has no documentation of R10 receiving any type of ROM programming. R10's CNA (Certified Nursing Assistant) Task list, dated 11/15/22, has no documentation of CNAs providing ROM programming to R10. On 11/16/22 at 12:05 PM, V2 (Director of Nurses) confirmed that R10 does not have any restorative ROM programming. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145720 If continuation sheet Page 3 of 8 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 145720 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Clara's Rehab & Senior Care 1450 Castle Manor Drive Lincoln, IL 62656 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview, and record review the facility failed to post nurse staffing hours. This failure had the potential to affect all 91 residents within the facility. Residents Affected - Many Findings include: The facility's CMS (Centers for Medicare and Medicaid Services) Form 672 dated 11-14-22 and signed by V7 (MDS/Minimum Data Set Coordinator) documents 91 residents reside within the facility. On 11-14-22 from 9:30 AM through 11:15 AM, a tour of the facility was conducted. During the tour the nurse staffing hours information was not posted. On 11/15/22 at 09:23 AM V2 (Director of Nursing) stated, Nurse staffing information has not been posted since at least July 2022. The ball got dropped. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145720 If continuation sheet Page 4 of 8 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 145720 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Clara's Rehab & Senior Care 1450 Castle Manor Drive Lincoln, IL 62656 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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to develop a comprehensive plan of care to address Dementia needs and treatments for three of three residents (R5, R56,R63) reviewed for Dementia Care in the sample of 36. Residents Affected - Few Findings include: R5, R56, and R63's Electronic Health Record Diagnoses Listings document R5, R56, and R63 have a diagnosis of unspecified Dementia without Behavioral Disturbance. R5, R56, R63's current Care Plans do not include a Comprehensive Care Plan of R5, R56, R63's goals and treatments to address R5, R56, R63's diagnosis of Dementia. On 11/15/22 at 01:42 PM, V2 (Director of Nursing) stated, The facility has not comprehensively assessed (R5, R56, and R63's) physical, mental, and psychosocial needs associated with (R5, R56, and R63's) Dementia and has not developed a person-centered plan of care with goals and treatments to address (R5, R56, and R63's) diagnosis of Dementia. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145720 If continuation sheet Page 5 of 8 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 145720 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Clara's Rehab & Senior Care 1450 Castle Manor Drive Lincoln, IL 62656 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. 2. R56's Physician's Order Sheets dated 11-15-22 document R56 has the diagnoses of Dementia without Behaviors, Mood Disorder, Bipolar Disorder, Anxiety, and Depression. R56's Physician's Order dated 10-5-21 and signed by V5 (R56's Psychiatrist) document, Abilify (antipsychotic)10 mg (milligrams) daily for the diagnosis of Major Depression. R56's Physician's Order Sheets dated 10-5-21 through 11-16-22 do not include a GDR attempt of R56's Abilify. R56's Health Status Note dated 9/2/22 documents, (R56) is very confused. (R56) keeps saying that she is able to walk and keeps attempting to get up on her own. (R56) keeps wanting to go to the other house down the way to get her things. Call placed to (V4's/R56's Primary Physician) office. Awaiting return call. R56's Physician's Order dated 9-3-22 an signed by V4 (R56's Primary Physician) documents, (Increase) Abilify to 15 mg by mouth at bedtime for mood. R56's MDS (Minimum Data Set) Assessments dated 3-30-22, 6-21-22, and 9-20-22 document R56 has had no behavioral symptoms and is not a danger to herself or others. R56's MDS Assessments dated 6-21-22 and 9-20-22 document R56 has not had a GDR (Gradual Dose Reduction) attempt of R56's Abilify and a GDR has not been documented by a physician as clinically contraindicated. R56's current Care Plan and Behavior Monitoring Logs dated 8-1-22 through 11-16-22 do not include an individualized anti-psychotic care plan addressing R56's specific behavioral signs/symptoms with interventions for the use the Abilify. On 11/14/22 at 11:04 AM V6 (Registered Nurse) stated, (R56) does not have any behaviors except for trying to get up unassisted. 11/16/22 10:30 AM V2 (Director of Nursing) stated, It looks like (R56's) Abilify was increased to 15 mg every night on 9-3-22 by (V4/R56's Primary Physician) due to (R56) attempting to get out of bed unassisted. (R56) knows she cannot walk. (R56's) current Care Plan and Behavior Tracking Reports do not document the specific behavior signs/symptoms (R56) has for the use of Abilify. The staff should have contacted (V5/R56's Psychiatrist) to manage (R56's) Abilify dose. (R56) was originally ordered Abilify for Depression and somehow throughout the medical record the use of Abilify got changed to Mood Disorder. (R56) has not had a GDR attempt of the Abilify within the last year and the physician had not documented why a GDR is clinically contraindicated. Based on observation, interview, and record review, the facility failed to document appropriate diagnoses/condition to warrant the use of an antipsychotic medication, have documented behaviors to justify the use of an antipsychotic medication, implement an individualized care plan for the use of antipsychotics, perform a gradual dose reduction of an antipsychotic medication for two of three residents (R63 and R56) reviewed for antipsychotic medications in the sample of 36. Findings include: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145720 If continuation sheet Page 6 of 8 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 145720 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Clara's Rehab & Senior Care 1450 Castle Manor Drive Lincoln, IL 62656 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The Facility's Psychotropic Medication Policy dated 11/28/17, documents, Intent: Residents are free from unnecessary psychotropic medication use. These medications are to be given to treat specific condition/medical symptoms that is diagnosed and documented in the clinical record. Additionally, Antipsychotic medication may be indicated for use if: 1) Behavioral symptoms present a danger to the resident or others; 2) Expressions or indications of distress that are significant distress to the resident; 3) If not clinically indicated, multiple non-pharmacological approaches have been attempted but did not relieve the symptoms which are presenting a danger or significant distress; 4) GDR (Gradual Dose Reduction) was attempted, but clinical symptoms returned. Gradual Dose Reduction: 1) Resident's should receive the lowest effective dose of psychotropic medication for the resident's physical, mental, and psychosocial well-being. 2) GDR is to be attempted within the first year in two separate quarters, (with at least one month between attempts), unless clinically contraindicated. 3) If treating expression or indications of distress related to dementia, the GDR may be contraindicated for the following reasons: a) Target symptoms returned or worsened after attempt of GDR, and b) Physician has documented rationale why a reduction would impair residents' function or increase distressed behavior. R63's current POS/Physician Order Sheet documents, Quetiapine Fumarate (antipsychotic) 25 mg (milligrams) three times a day related to Unspecified Dementia with Behavioral Disturbance. R63's current Care Plan and Behavior Monitoring Logs dated 8-1-22 through 11-16-22 do not include an individualized anti-psychotic care plan addressing R63's specific behavioral signs/symptoms with interventions for the use of Quetiapine. R63's Physical Device/Psychoactive Medication Initial and Quarterly Evaluation dated 10/11/22 documents under Reduction Attempts: Specify current drug order: Quetiapine 25 mg three times daily. Date of most recent reduction attempted 7/25/22. Response to reduction attempts: Medication increased 7/28/22 per POA (Power of Attorney) request. R63's medical records do not include any behaviors after the reduction of Quetiapine to 25 mg twice daily to justify the increase back to Quetiapine 25 mg three times daily. On 11/14/22 at 10:15 am., R63 was laying in her chair in her room. R63 was confused and had no behaviors. On 11/16/22 at 11:15 am., R63 was resting in her room in her chair. R63 made conversation and was pleasant at this time and showed no behaviors. On 11/16/22 at 9:50 am, V1 (Administrator) stated, No, (R63) is not a threat to herself or to other residents. She has behaviors towards staff only. On 11/16/22, at 10:00 am., V2 (DON/Director of Nursing) stated, (R63) is not a threat to herself or other residents. (R63) seldom comes out of her room. (R63) has issues with African American staff. (R63's) POA is set on not reducing (R63's) Quetiapine so (R63's) Quetiapine was increased back three days after the reduction. There were no behaviors exhibited to increase the Quetiapine back. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145720 If continuation sheet Page 7 of 8 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 145720 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Clara's Rehab & Senior Care 1450 Castle Manor Drive Lincoln, IL 62656 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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Potential for minimal harm Based on interview and record review, the facility failed to state in the arbitration agreement that the agreement can be rescinded within 30 days of signing it and that it is not required to sign an agreement for binding arbitration as a condition of admission to, or to continue to receive care at, the facility. They also failed to explain the arbitration agreement in a manner that the resident and their representative understands and acknowledge if the resident and their representative understood the agreement. This had the potential to affect all 91 residents residing in the facility. Residents Affected - Many Findings include: The facility's Contract between resident and select facility has no documentation in the arbitration agreement that the agreement can be rescinded within 30 days of signing it, nor that it is not required to sign an agreement for binding arbitration as a condition of admission to, or to continue to receive care at, the facility. R68's Contract Between Resident and Facility, dated 5/6/20, documents that R68 signed the binding arbitration. On 11/16/22 at 01:05 PM, R68 stated that she was unaware of what the arbitration agreement meant when she signed it, and no one explained it to her. She also stated she wasn't aware of giving up her rights to litigation. R143's Contract Between Resident and Facility, dated 10/21/22, documents that V10 (R143's family member) signed the binding arbitration. On 11/16/22 at 01:02 PM, V10 stated, The admission process was very rushed. They just kept pushing papers in front of me to sign. I didn't know exactly what I was signing. I surely didn't know I was signing to give up my right to litigation in a court. This would have been nice to know before I signed everything. On 11/16/22 at 01:37 PM, V8 (Social Services Director) stated that both V8 and V9 (Social Services Assistant) do the admission contract with residents when they are admitted to the facility. V8 and V9 both confirmed that they were unaware of the full meaning of agreeing to an arbitration agreement, and during the admission process all they explained was that if a lawsuit was filed it would go through mediation. On 11/14/22 at 02:45 PM V1 (Administrator) stated, All of our admissions sign the full contract including the arbitration section. The facility's CMS (Centers for Medicare and Medicaid Services) Form 672 dated 11-14-22 and signed by V7 (MDS/Minimum Data Set Coordinator) documents 91 residents reside within the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145720 If continuation sheet Page 8 of 8