Inspection·December 19, 2022

F 0689 Re-education) for functional transfer training, core strength training, sitting and standing balance training with safety (education) to decrease fall risk. Level of Harm - Actual harm Residents Affected - Few R63's Physical Therapy (PT) Discharge summary, dated [DATE], documented, Skilled Interventions-Skilled PT interventions includes (lower extremity Active Range of Motion), strengthening, to further improve transfer techniques. static/dynamic standing balance training with standing aid to improve functional activity, balance during transfers. safety awareness/(technique)/education application to improve impulsiveness needed during mobility, transfers. R63's Event Report, dated 10/25/2022, documented, V26 (Certified Nurse Assistant/CNA) bathing resident in shower room. Resident leaned forward tipping shower chair, CNA could not stop resident from falling forward, resulting resident landing on (Right) hip. It continues, Describe surrounding environment. Shower Room, shower running, ground free of clutter or potential hazards, adequate lighting. It continues, Following fall, X-Ray performed in house, resulting negative. Resident consistent with pain, resident sent to (Emergency Room) for evaluation. It continues, Resident in shower room with V26 (CNA) performing bathing ADLs (activities of daily living). Resident leaned forward tipping shower chair. CNA could not stop resident from falling forward, resident landed on (Right) hip. No deformities or shortening noted upon assessment. X-Ray performed in house per V28 (Family Nurse Practitioner-Certified/FNP-C)) resulting negative. Resident consistent with pain complaint, sent to (Emergency Room) for further evaluation per (Power of Attorney)/Nursing Judgement. On 12/15/2022 at 8:45 AM, V26 (CNA) stated that she took R63 into the shower room in the shower chair that day. V26 stated that once there, she was standing in front of R63 facing him, untying his gown. V26 stated he was leaning forward, started to fall forward, she could not stop him, and he fell out of the chair. V26 stated that she was unable to recall if the floor was wet or not or if his feet were touching the floor or on the footrest of the shower chair. V26 stated that maybe if there were 2 of them (staff) or if the shower had floor mats, this may not have happened. On 12/15/2022 at 9:20 AM, the shower chair that R63 was sitting on at the time of his fall was observed. It was approximately 4 to 4.5 foot tall from top to bottom, had front and back wheel locks and had a footrest. On 12/14/2022 at 09:30 AM, V27 (Licensed Practical Nurse/LPN), stated that R63 was having behavior issues earlier in the day, but not when he was called into assess R63 after his fall in the shower room. V27 stated that he does not recall if the floor was wet or not when he came into the shower room. On 12/14/2022 at 10:00 AM, V28 (FNP-C) stated that this fall was probably situational and that everyone would like 2 staff in there during care. On 12/15/2022 at 8:55 AM, V1 (Administrator) stated that R63 was picked up for Physical Therapy and Occupational Therapy in June, July and August of 2022 and at that time he was able to sit for 10 seconds unsupported sitting on the mat with feet flat on the floor, no backrest or arm rest and they did not recommend a 2 person assist for showers. When asked why R63 was picked up by therapy in June, she stated that she did not know why. R63's Hospital Record, dated 10/26/2022, documented, 64 (year old) male with medical history that includes (Traumatic Brain Injury, Cerebral Vascular Accident, Chronic Obstructive Pulmonary Disease) and dysphagia admitted for oblique, comminuted intertrochanteric fracture of the right femur (status (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145733 If continuation sheet Page 2 of 17 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 145733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerseyville Manor 1251 North State Street Jerseyville, IL 62052 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few post) fall. Patient resides in (Nursing Home) and staff reports patient fell while in shower . It continues, Exam: CT (computed tomography) Pelvis w/o (without) contrast order date: 10/25/2022 (Reason for Procedure: Trauma/Injury Impression: 1 Highly comminuted right intra-trochanteric hip fracture. 2. There appear to be old healed bilateral superior and inferior rami fractures. No acute pelvic fracture see. 3. Moderate to severe fecal impaction of the colon and rectum. An Electronic mail to V1 (Administrator) dated 10/29/2022, V32 (Medical Director) documented, One thing you did not mention is that (R63) is completely flaccid on the right side. In addition, this causes a right sided neglect. It continues, His paralysis would have prevented him stopping the fall and hemi-neglect would have prevented him from even trying. On 12/12/2022 at 03:16 PM, R63 was lying in bed, asleep. The bed was in the lowest position and the call light within reach. There was no non-skid pad in his wheelchair seat. 2. R14's Care Plan, dated 12/12/2022, document Problem: Resident Care Information it also documents APPROACH: Safe Resident Handling Procedures-Transfer Method: Stand aid. Level of assistance: Assist x 1. R14's MDS, dated [DATE], documents that R14 is cognitively intact, always incontinent of bowel and bladder, and requires extensive physical assist of 1 staff member for toileting and transfers. On 12/12/22 at 9:40 AM, V4 (Certified Nurse Assistant/CNA) assisted R14 with toileting. Upon completion of voiding, V4 assisted R14 into the standing position using the stand aide. V4 performed care and dressed R14. V4 then closed the seat on the stand aide. V4 then transported R14 from the bathroom to the opposite side of the room and removed the seat, grabbed R14 by the waist and assisted R14 into the wheelchair. V4 did not apply a gait belt. R4's gait belt was observed around her waist during the transfer. 3. R28's Care Plan, dated 12/12/22, documents APPROACH: Safe Resident Handling Procedure: Transfer Method: Stand Pivot. Level of Assistance: Assist x 1. R28's MDS, dated [DATE], documents that R28 requires extensive physical assist of 1 staff member for toileting and transfers. On 12/14/2022 at 9:20 AM, V7(Certified Nurse Assistant/CNA) and V20 (Certified Nurse Assistant/CNA) assisted R28 with toileting. V7 assisted R28 onto the standing aide. V4 (CNA) then transported R28 across the room into the bathroom and on to the toilet. V7 then removed the seat and assisted R28 into a seated position onto toilet using R28's hips to assist. After R28 voided, V7 and V20 grabbed R28 under her shoulder and assisted R28 into a standing position. R28 grabbed a hold of the front bar of the stand aide. R28 knees buckled and R28 started lowering. V7 and V20 grabbed R28's shirt and hip and assisted R28 into a sitting position on the toilet. V7 grabbed a hold of R28's arm and assisted R28 into standing position. V7 performed peri care and assisted R28 with dressing. V7 closed the seat to the stand aide and V20 transported R28 from the bathroom across the room and on to the bed. V7 and V20 did not apply a gait belt to R28. 4. R72's Care Plan, dated 11/14/2022, documents PROBLEM: RCIS (Resident Care Information Sheet.), APPROACH: Safe Resident Handling Procedures -Transfer Method: Stand and pivot with gait belt. Level of assistance: Assist x 1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145733 If continuation sheet Page 3 of 17 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 145733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerseyville Manor 1251 North State Street Jerseyville, IL 62052 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 R72's MDS, dated [DATE], documents that R72 requires extensive assist with toileting and limited assist of 1 staff for transfers. Level of Harm - Actual harm Residents Affected - Few On 12/13/2022 at 10:10 AM, V4 (CNA) assisted R72 with toileting. Upon completion of toileting, V4 assisted R72 into a standing position by grabbing a hold of R72 right arm. R72 grabbed a hold and leaned forward on to the wheelchair's armrest. R72 balance was unsteady with R72 observed wavering back and forth. V4 pulled up R72 pants. V4 grabbed a hold of R72 waist and transferred R72 into the wheelchair. V4 did not apply or use a gait belt during the transfer. On 12/15/2022 at 12:50 PM, V33 (LPN) stated that she would expect the staff performing a manual transfer to utilize a gait belt. 5. R280's Care Plan, dated 12/1/22, documents (R280) is at risk for falling related to recent illness/hospitalization and new environment. Interventions: Instruct (R280) to call for assist before getting out of bed or transferring. Encourage (R280) to stand slowly, orient (R280) to room, surrounding areas, and use of call light system. Encourage (R280) to use side rails/enablers as needed, Therapy to evaluate and treat as ordered, Provide (R280) with specialized equipment (such as walker, wheelchair. It continues, Resident Care Information: Safe Resident Handling Procedures-Transfer Method: Stand pivot. Level of assistance: Assist x 2. R280's MDS, dated [DATE], documents that R280 has a moderate cognitive impairment and requires extensive assistance from two staff members for transfers, bathing, and toileting. R280 requires extensive assistance from one staff member for all other ADL's. On 12/13/22 at 11:40 AM, R280, was lying in bed as V15 (Certified Nurse Assistant/CNA) and V16 (Certified Nurse Assistant/CNA) entered the room to perform incontinence care on R280. After incontinent care was completed, both CNAs assisted R280 to the side of his bed, put a gait belt around him, assisted R280 to stand and pivot. Just as R280 had turned and pivoted, the unlocked wheelchair started to move backwards and V16 grabbed the wheelchair and pulled it toward R280 then they lowered him to his wheelchair. 6. R297's Care Plan, dated 12/5/22, documents (Safe Resident Handling Procedures-Transfer Method: Full Body mechanical lift. Level of assistance: Assist x 2. Sling Style: long seat Sling Size: XL. R297's MDS, dated [DATE], documents that R297 is total dependent on two staff members for transfers. On 12/13/22 at 10:05 AM, R297 was lying in bed with the mechanical lift device sling under him. V15 (CNA), V16 (CNA) and V17 (CNA) all in the room to transfer R297 from his bed to his recliner chair. V15 operated the lift device. The sling straps were attached to the lifting device, V15 lifted R297 off the bed and pulled R297 away from his bed to in front of his recliner and was freely swinging with no one having constant contact with R297 during this move. V16 and V17 did grab onto R297 once he was pushed over to his recliner and then assisted him down to the chair. R297 was unhooked from device, covered up with blanket, feet elevated, and call light on his lap. On 12/15/22 at 9:30 AM, V24 ( Licensed Practical Nurse/LPN) stated I use a gait belt for all resident transfers, including the stand-aides. The Facility's Safe Resident Handling Policy, dated 11/2012, documents Purpose: This program is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145733 If continuation sheet Page 4 of 17 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 145733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerseyville Manor 1251 North State Street Jerseyville, IL 62052 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete designed to limit and remove as much manual lifting as possible. Staff commitment is vital both to the success of the program and to experience its benefits. Facility has made a significant investment in modern, safe and easy to use equipment for staff to use. Every staff member is expected to support this program 100% and with that commitment, the program will be successful. It continues, 5. All staff members required to use the lifting devices will be oriented and trained on the proper use. Each staff member will have first-hand experience on what the lift feels like from a resident's perspective. Staff is to report any concerns about transfers that may pose an unacceptable risk for injury to a resident or staff to DON. Resident will then be reassessed for safe procedures. When using Full Mechanical lift, two staff members are used with additional help as needed. When using the non-mechanical standing device, one staff member is used with additional assist as needed. If care planned with two assist it must be used with two staff members. It continues, 9. When physically transferring residents, gait belts will be used to maintain appropriate transfer techniques. Event ID: Facility ID: 145733 If continuation sheet Page 5 of 17 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 145733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerseyville Manor 1251 North State Street Jerseyville, IL 62052 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. On 12/13/2022 at 9:35 AM, V30 (Certified Nursing Assistant/CNA) took a Personal Cleansing Cloth with left hand, and with right hand held open R119's abdominal fold and cleansed R119's abdominal fold. V30 threw cloth away, got another wipe, and then cleansed right groin area, with her left hand, and then retrieved another cleansing cloth, and cleansed R119's left groin area. V30 asked V31 (CNA) to help hold open R119's labia and V30 took a cleansing wipe and cleansed down the center of R119's perineum. None of these areas were dried after staff used a Personal Cleansing Cloth. V30 then took a Personal Cleansing Cloth, cleansed R119's right hip, obtained a new cloth and cleansed R119's perirectal area several times, with different wipes, due to R119 was smearing stool. These areas were not patted dry and were left wet. V30 and V31 rolled R119 over onto her right side. V30 cleansed R119's left hip with a Personal Cleansing Cloth, obtained a new personal cleansing cloth, and cleansed R119's peri rectal area again. No areas were dried after care. R119's Braden Scale, dated 11/1/2022 documented that she was at moderate risk for skin breakdown and that her skin was very moist. R119's Care Plan, dated 7/30/2022, documented, Provide incontinent care after each incontinent episode. On 12/13/2022 at 11:30 AM, V29 (Customer Service Representative) from the makers of Personal Cleansing Cloths, stated that the company does not give recommendations for use and that it is left up to the facility to put something in their policy. On 12/14/2022 at 11:15 AM, a test of the time for drying after use of personal cleansing cloth was performed. Antecubital area was cleansed with personal cleansing cloth. The antecubital was closed for 1 minute to provide skin to skin contact. After 1 minute of skin to skin contact the antecubital area remained moist. The facility's Perineal Care policy, dated 11/18, documents Objective 1. To cleanse the perineum. 2. To prevent infection and odors. It continues, Procedure: 4. Wash perineal area with soap and water, perineal cleanser or wipes. Begin cleansing from the cleanest area in front to the most soiled area in back. Be sure that a clean surface of the washcloth is used for each wipe. On a female resident, clean the labia and its folds first. The facility's Catheter Care Policy, dated 6/05, documents Objective 1. To cleanse the perineum. 2. To prevent infection and odors. It continues, Procedure 4. Wash perineal area with soap and water or perineal cleanser. Begin cleansing from the cleanest area in front to the most soiled area in back. Be sure that a clean portion of the washcloth is used for each wiping motion. On a female resident, clean the labia; then spread the labia to wash the inner folds. 5. After cleansing is complete, rinse if necessary, and then dry the resident by patting skin gently with a clean bath towel. Based on observation, interview and record review, the facility failed to perform complete catheter and incontinent care for 5 of 7 residents (R4, R14, R74, R119, R288) reviewed for toileting in the sample of 57. Findings include: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145733 If continuation sheet Page 6 of 17 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 145733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerseyville Manor 1251 North State Street Jerseyville, IL 62052 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm 1. R14's Care Plan, dated 12/12/2022, documents Problem: Resident Care Information it also documents Approach: Bowel and Bladder: Incontinent of both. Incontinence Products: Large brief. R14's Minimum Data Set (MDS), dated [DATE], documents that R14 is cognitively intact, always incontinent of bowel and bladder, and requires extensive physical assist of 1 staff member for toileting. Residents Affected - Some On 12/12/22 at 9:40 AM, V4 (Certified Nursing Assistant/CNA), performed incontinent care. R14 was incontinent of urine. R14 voided on toilet as well. V4 assisted R14 into the standing position. Using cleaning wipes, V4 cleansed R14's buttocks and peri area. V4 did not cleanse R14's inner labia and inner thighs. On 12/12/2022 at 9:43 AM, V4 stated that R14 was incontinent of urine. 2. R4's Care Plan, dated 12/13/2022, R4 has a (indwelling urinary) catheter related to obstructive uropathy. It continues Resident Care Information documents APPROACH: Provide catheter care as needed. R4's MDS, dated [DATE], documents that R4 has a catheter and requires limited physical assist of 1 staff for toileting. On 12/13/2022 at 8:50 AM, V5(Certified Nursing Assistant/CNA) and V6 (Certified Nursing Assistant/CNA) assisted R4 with toileting. R4 was incontinent of a small amount of bowel. R4 then had a bowel movement on the toilet. V6 then, using a personal cleansing cloth, performed peri care. V6 cleansed both sides of R4's groin. V6 then cleansed R4's outer and inner labia wiping from dirty to clean. V6 cleansed R4's inner labia and noted to have a large amount of stool on personal cleansing cloth. V6 did not provide any further peri care. V4 then cleansed R4's buttocks. V4 cleansed R4's anal area and stool noted on personal cleansing cloth. V4 placed cloth in trash can and assisted R4 with pulling up R4's brief and pants. V4 and V6 did not perform catheter care. 3. R74's Care Plan, dated 11/17/2022, documents PROBLEM: Resident Care Information. It continues APPROACH: Bowel and bladder: Continent of both. Incontinency product: Underwear. R74's MDS, dated [DATE] documents that R74 is continent of bowel and bladder and requires extensive physical assist of 1 for toileting. On 12/13/2022 at 9:10 AM, V5 (CNA) and V6 (CNA) assisted R74 with incontinent care. R74 was incontinent of a large amount of soft bowel. V6, using personal cleansing cloths, cleansed R74's penis, scrotum and groin area. V5 and V6 turned R74 onto his left side and cleansed R74's right buttock and partial left buttock. V5 and V6 then placed clean incontinent brief under R74. V5 and V6 then turned R74 onto his back and fastened R74's incontinent brief. V5 and V6 did not cleanse R74's entire left buttock. On 12/15/2022 at 11:30 AM, V2 (Director of Nursing/DON) stated that she would expect the CNAs to perform catheter care when performing incontinent and peri care. 4. R288's Care Plan, dated 11/10/22, documents (R288) Resident is at increased risk for skin breakdown related to decreased mobility, generalized muscle weakness following recent illness and hospitalization, malnutrition/low H&H (Hemoglobin and Hematocrit), and B&B (Bowel and Bladder) incontinence. Interventions: Provide incontinent care after each incontinent episode. It continues R288 has a UTI (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145733 If continuation sheet Page 7 of 17 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 145733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerseyville Manor 1251 North State Street Jerseyville, IL 62052 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (Urinary Tract Infection). Interventions: Assist (R288) with perineal care/incontinence care as needed, Encourage fluids, administer antibiotic as ordered. R288's MDS, dated [DATE], documents that R288 has a moderate cognitive impairment and requires extensive assistance from two staff members for most of his ADLs (activities of daily living). R288 requires extensive assistance from two staff members for toileting. On 12/13/22 at 10:35 AM, V18 (Certified Nursing Assistant/CNA) and V16 (Certified Nursing Assistant/CNA) went into R288's room to perform perineal care for R288. R288 was inquiring about why they are doing this and V18 stated that they had to show how they do perineal care. Both CNAs donned gloves without performing hand hygiene prior. R288 rolled over, and her brief/underwear pulled down and incontinence pad rolled under her. V18 doffed her gloves, donned clean gloves with no hand hygiene done. V18 wiped once across top of pubic area, once down each groin, once down R288's vagina, and then wiped the right and left outer buttocks. V18 did not wipe between R288's buttocks and anal area and there was no drying of R288 after any cleansing. V18 did not change her gloves after performing perineal care and began putting a clean incontinence pad onto the bed. R288 was rolled to her side and the soiled linen was removed. R288's underwear and pants were pulled up using the same soiled gloves. V16 and V18 then doffed their gloves and hand hygiene performed. R288 was still asking why they were doing this and V18 repeated to her that they had to show how they do perineal care. V18 stated that R288 was not incontinent and wore her own underwear and that she was not even wet, but they just wanted to show how to do perineal care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145733 If continuation sheet Page 8 of 17 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 145733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerseyville Manor 1251 North State Street Jerseyville, IL 62052 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Many Based on interview, observation, and record review, the facility failed to properly store and label medications. This has the potential to affect all 139 residents in the Facility. Findings include: On [DATE] at 3:20 PM, the medication storage room for the 400 and 500 halls was inspected. The medication room contained the following medication: 1-Bottle of Tubersol with no opened date. V10 (Licensed Practical Nurse/LPN) stated, I think that has been opened since the cap is off. On [DATE] at 1:48 PM, V21 (Licensed Practical Nurse/LPN) stated, We give the Tubersol on admission, then yearly, as needed. All the residents have standing orders to get it once a year. On [DATE] at 2:24 PM, V2 (Director of Nursing/DON), Tubersol has an expiration date on it, but it also has to have an opened date on it. The opened date is how we know when the product is expired. I would expect my nurses to put a date on it after opening. It is a multi-dose vial. Everyone receives it unless they have an allergy to it. On [DATE] at 3:10 PM, V1 (Administrator) and V2 (DON) stated that they were unsure whether the facility should follow manufacturer's instructions for Tubersol and would like to refer to their policy. The Facility's Pharmaceutical Procedures Policy revised [DATE] does not address multi-dose vials. Tuberculin Purified Protein Derivative (Mantoux) Tubersol package insert, dated [DATE], documents A vial of TUBERSOL which has been entered and in use for 30 days should be discarded. The Resident Census and Conditions of Residents, CMS 672, dated [DATE] documents the facility has 139 residents living in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145733 If continuation sheet Page 9 of 17 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 145733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerseyville Manor 1251 North State Street Jerseyville, IL 62052 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards. This has the potential to affect all 139 residents living in the facility. Findings include: On 12/13/22 at 11:45 AM, in the dry storage room, there was a large tub containing a white powdery substance labeled food thickener. There was no date on this container. On the shelf in the dry storage room, there was a plastic bag with macaroni that was wrapped up, but not labeled or dated. On 12/13/22 at 11:47 AM, in the walk-in freezer, there was a plastic bag full of biscuits that had been opened and tied up but was not labeled or dated. There was a bag containing pieces of oblong shaped meat that had been tied up but was not labeled or dated. V3 (Dietary Manager) stated, Those are pork riblets. On 12/13/22 at 11:48 AM, in the walk-in refrigerator, there was a container covered in aluminum foil with M/S chicken and 12/6-12/12 written in black marker. There was a container labeled coleslaw and 12/6/-12/12 on top. V3 (Dietary Manager) stated, These should have been thrown out on the twelfth. I'm going to get these out of here. On 12/13/22 at 11:55 AM, in the 100-hall satellite kitchen, temperatures were obtained from the steam table using metal calibrated thermometer. The mechanically altered beef measured 127 degrees Fahrenheit (F), and the pureed beef measured 127 degrees F. On 12/15/22 at 10:50 AM, V1 (Administrator) stated, I would expect my staff to follow our food service policies. The Facility's Purchasing, Receiving and Food Storage Policy revised 9/10 documents, It is the policy of the facility to provide quality and wholesome food by following assigned budget, and to receive and store food by following sanitation standards, which are in compliance with state and federal rules and regulations. Unless its identity is unmistakable, bulk food not stored in the original labeled container or package in which it was obtained shall be stored in a container labeled to identify the common name. The Facility's Food Temperatures-Measuring Procedure Policy adopted 8/19 documents, Hot foods should be held at least 135 degrees F or higher. 135 degrees F for hot holding-held in warming cabinet or on steam table. The Facility's Meal Service Procedure Policy, adopted 11/14/22, documents, Food items should be returned to the kitchen if hot food is below 135 degrees F. The Resident Census and Condition of Residents Form (CMS 672) dated 12/12/22 documents there are 139 residents living in the Facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145733 If continuation sheet Page 10 of 17 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 145733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerseyville Manor 1251 North State Street Jerseyville, IL 62052 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. 12/13/22 9:35 AM, V30 (Certified Nursing Assistant/CNA) and V31 (Certified Nursing Assistant/CNA) performed hand hygiene and donned gloves. V30 unfastened R119's soiled incontinent brief and rolled it down between R119's legs. Then V30 took a Personal Cleansing Cloth with left hand, and with right hand held open R119's abdominal fold and cleansed R119's abdominal fold with her left hand, threw cloth away, got another wipe, and then cleansed right groin area, with her left hand, and then retrieved another cleansing cloth and cleansed R119's left groin area. V30 continued to provide incontinent care without benefit of hand hygiene or glove changes. Residents Affected - Some 5. On 12/12/2022 at 10:54 AM, R114's nasal cannula tubing was lying on the floor. R114's Resident Face Sheet, undated, documents, diagnoses of Congestive Heart Failure and Pneumonia. R114's Physician Order Report, dated 10/21/2022, documents an order for O2 at 2 (liters/min) nasal cannula (as needed) for (shortness of breath). R114's Care Plan, dated 07/08/2022, documented, Oxygen: 2 liters as needed. 6. On 12/12/2022 at 11:12 AM, R123's Oxygen nasal cannula tubing was lying on the floor under his bed. R123 stated that he wears oxygen when they put it on him. R123's Resident Face Sheet, undated, documents, diagnoses of Anemia, unspecified and Chronic diastolic (congestive) heart failure. R123's Physician Order Report, dated 12/14/2022, documented, that he was on Palliative Care. It does not document an order for Oxygen usage. R123's Care Plan, dated 10/09/2022, documented an approach of O2 at 2 (liters/nasal cannula) as needed. R123's MDS, dated [DATE], documented that his cognition was moderately impaired. Based on interview, observation, and record review, the facility failed to adhere to infection control practices to prevent the spread of COVID 19 and other infectious organisms by failure to utilize appropriate PPE (Personal Protective Equipment), perform hand hygiene, and maintain clean oxygen equipment, for 5 of 7 residents (R12, R114, R119, R123, R281) reviewed for infection control in a sample of 57. Findings include: 1. On 12/14/22 at 7:55 AM, the door to R93's and R122's room, which is a Positive COVID (Coronavirus Disease) Isolation room, was left open and V19 (Housekeeper) was going in and out of the room, cleaning the floor in the room, placing the mop in the bucket outside the room and was only wearing a yellow surgical mask and no other PPE. V19 then left the unit with the housekeeping cart remaining in the unit. V19 was seen afterwards emptying trash in numerous rooms with the same yellow surgical mask on. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145733 If continuation sheet Page 11 of 17 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 145733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerseyville Manor 1251 North State Street Jerseyville, IL 62052 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 12/15/22 at 9:28 AM, V24 (Licensed Practical Nurse/LPN) stated For any COVID/Isolation room, everyone who enters must wear full PPE, including N-95 mask, gown, and goggles, regardless, if you are doing resident care or not. On 12/15/22 at 9:35 AM, V25 (Housekeeper) stated Anytime I walk into a COVID or Isolation room, I wear a N-95 mask, gown, and goggles. I take the gown off before I leave the room and do hand hygiene. I don't want to take that home. The trash we tie up and put with the regular trash unless it is wet. The linen we put into a red bag, double bag, and take it to laundry. R122's Care Plan, dated 12/7/22, documents R122 has respiratory symptoms consistent with COVID 19 with the Approach Droplet isolation precautions with eye protection. 2. R12's Care Plan, dated 12/12/22, documents (R12) is at increased risk for skin breakdown related to decreased mobility, weakness, occasional bladder incontinence, low albumin, potential for friction and shearing with transfers and repositioning. Interventions: Open area to top of right second toe will heal/improve by the next review: Monitor for signs and symptoms of infection. Treat as ordered. See TAR (Treatment Administration Record). Notify MD (Medical Doctor)/NP (Nurse Practitioner) for changes. R12 will have minimized risk for skin breakdown during this quarter: Provide perineal care following each episode of incontinence, assist resident with turning and repositioning. It continues (R12) Resident Care Information. Interventions: Incontinent of urine and bowel at times. Assist Incontinence Products: Large pullups. R12's Minimum Data Set (MDS), dated [DATE], documents that R12 has a severe cognitive impairment. R12 requires limited assistance from one staff member for most of her ADL's (Activities of Daily Living). R12 requires extensive assistance from one staff member for toileting and personal hygiene. R12 is always incontinent of both bowel and bladder. On 12/13/22 at 9:55 AM, V14 (Registered Nurse/RN) went into R12's room to perform wound care to R12's right second toe. V14 carried in supplies on a clean folded towel, dumped the wound care supplies onto R12's bed, with comforter on top, and used the clean folded towel to put under R12's right foot. V14 donned a pair of gloves, without performing hand hygiene prior to donning gloves and removed the old dressing, dated 12/13/22, from R12's right second toe open wound, pink in color, and had no drainage. V14 used the same soiled gloves to spray wound cleanser onto R12's toe and used a 4X4 gauze to cleanse the wound. V14 used the same soiled gloves and cut a piece of Alginate dressing and applied it to the open wound, V14 then applied a 2X2 gauze dressing on top of the Alginate and taped it to her toe. V14 used the same soiled gloves to get a pen located in his shirt pocket and dated the dressing, then put his pen back in his pocket. V14 then gathered the remaining supplies and some trash using the same soiled gloves and exited the room. V14 put the wound cleaner spray, the pair of scissors, and other dressing supplies back in the wound supply cart, then removed his soiled gloves and did not perform hand hygiene as he took the cart away from the room. 3. R281's Care Plan, dated 12/7/22, documents (R281) is at increased risk for skin breakdown related to decreased mobility, generalized muscle weakness following recent illness and hospitalization. Interventions: (12/6/22) (specific type/brand of mattress) mattress to bed, monitor for signs and symptoms of infection. treatments as ordered. See TAR. Notify MD/NP for changes, provide incontinent care after each incontinent episode, pressure reducing device in wheelchair and bed, assist resident with turning and repositioning, side rails/enablers to assist with turning and repositioning. It continues (R281) Resident Care Information. Interventions: Turning and Repositioning: As needed. two quarter rails, Skin Care: Barrier cream as needed. Skin Checks each shift, Bowel and Bladder: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145733 If continuation sheet Page 12 of 17 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 145733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerseyville Manor 1251 North State Street Jerseyville, IL 62052 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 0880 Incontinent of both. Incontinence Products: Medium brief. Level of Harm - Minimal harm or potential for actual harm R281's MDS, dated [DATE], is not completed. Residents Affected - Some On 12/13/22 at 9:05 AM, V12 (Certified Nursing Assistant/CNA) and V11 (LPN) in R281's room for wound care. Supplies setting on clean towel on bedside table. Both V11 and V12 performed hand hygiene and donned clean gloves. The old dressing was removed from R281's coccyx which was dated 12/13/22. V11 doffed her gloves and performed hand hygiene. V11 donned clean gloves and used normal saline and gauze pads to cleanse R281's wound. Using the same soiled gloves, V11 applied Xeroform to the wound, then a padded dressing applied and dated. V11 then doffed her gloves and performed hand hygiene. R281's Nurses Note, dated 12/6/22 at 11:04 AM, documents Called and informed POA (Power of Attorney) of shearing area to the right buttock area that measures 1 cm (centimeters) x 0.7 cm and new treatment orders explained and understanding met. R281's Physician Note, dated 12/6/22, documents Cleanse open area to right buttock and apply Xeroform gauze and padded dressing daily and PRN (As Needed). On 12/15/22 at 10:53 AM, V1 (Administrator) stated, I would expect the staff to follow the infection control guidelines, including the wearing of appropriate PPE when necessary, especially going into COVID or isolation rooms, the changing of gloves when soiled, and proper hand hygiene when indicated. The Facility's Standard Precautions Policy, dated 8/2009, documents Standard precautions will be used in the care of all residents regardless of any suspected or confirmed presence of an infectious agent. Standard precautions are based on principle that all, blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents. It continues Procedure: 1. Hand hygiene: a. Refers to washing hands with water and either plain soap or soap/detergent containing an antiseptic agent; or thoroughly applying an alcohol-based hand rub (ABHR). b. Wash hands when they are visibly soiled, before and after eating or handling food, before or after assisting a resident with meals, before and after assisting a resident with the toilet and after contact with a resident with infectious, whether or not gloves are worn. c. Hand hygiene should be performed immediately after gloves are removed, between resident contacts, and when otherwise indicated to avoid transfer or microorganisms to other residents or environment. Utilize hand hygiene between tasks and procedure on the same resident to prevent cross-contamination of different body sites. d. Unless hand washing is specifically required, antimicrobial agents are appropriate for cleaning hands and can be used for direct resident care. 2. Gloves: a. Wear gloves (clean, non-sterile) when touching blood, body fluids, secretions, excretions, and contaminated items. b. Put on clean gloves just before touching mucous membranes and non-intact skin. c. Change gloves between tasks and procedures on the same resident after contact with material that may contain infectious agents. d. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident. Wash hands immediately to avoid transfer of infectious agents to other residents or environments. The facility's COVID-19 Policy, dated 11/14/22, documents: The infection Control Program (ICP) at this facility recognizes Novel Coronavirus (COVID-19) as a highly contagious virus and has a focus to reduce the risk of unnecessary exposures among residents, staff, and visitors. Measures are based on guidance from the Centers for Disease Control (CDC), Center for Medicare and Medicaid Services (CMS) and state and local authorities. Interventions focus on prevention of exposure, early detection (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145733 If continuation sheet Page 13 of 17 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 145733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerseyville Manor 1251 North State Street Jerseyville, IL 62052 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 0880 Level of Harm - Minimal harm or potential for actual harm of symptoms, effective triage and isolation of potentially infectious residents. It continues Residents with confirmed COVID-19: 5. Resident with confirmed COVID-19 infection will be placed in a single-person room. The door should be kept closed (if safe to do so). Ideally, the resident should have a dedicated bathroom. It also documents, 8. Staff will wear N-95 respirators, eye protection, gowns and gloves when caring for residents with COVID-19. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145733 If continuation sheet Page 14 of 17 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 145733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerseyville Manor 1251 North State Street Jerseyville, IL 62052 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to establish an infection prevention and control program that reduces the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use in 5 of 5 residents (R26, R106, R303, R330, R331) reviewed for antibiotic stewardship in the sample of 57. Residents Affected - Some Findings include: 1.The Facility's Monthly Infection Log for the month of December 2022 does not document an organism causing R26's infection. The log documents R26 was treated with the antibiotic Azithromycin. R26's Physician Order Report for 12/1/22-12/14/22 documents order for 250mg (milligram) Azithromycin tablet - 2 tabs day 1, then 1 tab, oral for chronic obstructive pulmonary disease, unspecified, with start date of 12/6/22 and end date of 12/10/22. R26's Medication Administration Record (MAR) for the month of December 2022 documents R26 received 4 of 6 prescribed doses of Azithromycin. On 12/14/22 at 1:00 PM, documentation to justify the use of Azithromycin was requested. On 12/15/22 at 2:44 PM, no documentation was received. 2. The Facility's Monthly Infection Log for the month of July 2022 does not document an organism causing R106's infection. The log documents prophylactic for laceration and the use of antibiotic Cephalexin. R106's Physician Order Report from 7/1/22 to 12/14/22 documents order for 500mg Cephalexin capsule - 1 capsule oral every 8 hours for encounter for prophylactic measures, unspecified, with start date of 7/13/22 and end date of 7/20/22. R106's MAR for the month of July 2022 documents R106 received 27 of 27 prescribed doses of Cephalexin. On 12/14/22 at 1:00 PM, documentation to justify the use of the antibiotic Cephalexin was requested. On 12/15/22 at 11:45 AM, V2 (Director of Nursing/DON) stated, There was no culture. They were treating him prophylactically. That is very common. 3. R303 was not listed on the Facility's Monthly Infection Log for any month in 2022. R303's Physician Order Report from 7/14/22 to 12/14/22 documents order for 250mg Keflex (cephalexin) capsule oral, once a day, for trigeminal neuralgia with start date of 10/23/21 and end date open ended. R303's MARs for July 1, 2022 through December 14, 2022 document R303 received 167 doses of Keflex. On 12/14/22 at 1:00 PM, documentation to justify the use of the antibiotic Keflex was requested. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145733 If continuation sheet Page 15 of 17 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 145733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerseyville Manor 1251 North State Street Jerseyville, IL 62052 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 0881 On 12/15/22 at 2:44 PM, no documentation was received from the Facility. Level of Harm - Minimal harm or potential for actual harm 4. The Facility's Monthly Infection Log for the month of August 2022 does not document an organism causing R331's infection. The log documents prophylactic and use of the antibiotic Amoxicillin. Residents Affected - Some R330's Physician Order Report from 8/1-22 to 9/30/22 documents order for 250mg Amoxicillin capsule - 1 capsule oral with special instructions to take for 90 days per (V6, physician). The diagnosis was documented as encounter for prophylactic measures, unspecified with start date of 8/29/22 and discharge date of 9/15/22. R330's MARs for the months of August and September 2022 document R330 received 17 doses of Amoxicillin. On 12/14/22 at 1:00 PM, documentation to justify the appropriate use of the antibiotic Amoxicillin was requested. On 12/15/22 at 2:44 PM, no documentation was received from the Facility. 5. The Facility's Monthly Infection Log for the month of July 2022 does not document an organism causing R331's infection. The log documents prophylactic and the use of antibiotic Bactrim. R331's Physician Order Report from 7/14/22 to 12/14/22 does not document order for Bactrim but does document order for 250mg Zithromax Z-Pak (Azithromycin) tablets - 2 oral for other specified diseases of upper respiratory tract with start date of 7/19/22 and end date of 7/19/22. There is also an order for 250mg Zithromax Z-Pak (azithromycin) tablet - 1 oral for other specified diseases of upper respiratory tract with start date of 7/20/22 and end date of 7/23/22. R331's MAR from 7/1/22 to 7/31/22 documents R331 received 5 doses of Zithromax Z-Pak. On 12/14/22 at 1:00 PM, documentation to justify appropriate use of Zithromax Z-Pack was requested. On 12/15/22 at 2:44 PM, no documentation was received from the Facility. On 12/14/22 at 9:40 AM, V23 (Infection Control Preventionist/ICP) stated, I read progress notes, run reports, look up antibiotic reports for new antibiotics, and fill out the monthly infection control log first thing in the morning before the morning meeting. Every time I get an antibiotic order I check to see if it is warranted. I look at the results first, and if it says 'no culture to follow' I put 'no' on the log. If not, I check with the doctor. Usually, they will say not to continue or to discontinue it. The Facility's Antibiotic Stewardship Policy revised 12/18/19 documents, It is the policy of the facility to follow an Antibiotic Stewardship program, including the core elements as outlined by the CDC (Centers for Disease Control). The purpose of the program is to reduce inappropriate use of antibiotics, improve resident outcomes and lessen adverse events. The facility will track antibiotic use daily. The facility will communicate with the physician(s) prescribing antibiotics with a Utilization report on a monthly basis and as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145733 If continuation sheet Page 16 of 17 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 145733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerseyville Manor 1251 North State Street Jerseyville, IL 62052 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 0881 The Facility's Infection Control Policy revised 12/17/19 documents, Nursing staff will develop weekly reports on antibiotics, including review to ensure appropriate use of antibiotics. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145733 If continuation sheet Page 17 of 17