Inspection·September 2, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident coffee, snacks, Jello due to resident may be wanting what roommate was eating. We offered to take him to the restroom, sit in his wheelchair, and go into the hallway to sit with staff. Noted 2 small bruises to left forearm and a small scratch next to bend of elbow. To resolve the situation roommate was moved to another room for the night.R1's Progress Note, dated 08/25/2025 at 5:53 AM, documents the following: Resident slept through the night. Noted slight agitation while being changed by staff.R1's Progress Note, dated 08/25/2025 at 6:10 AM, documents the following: Resident up in wheelchair propelling self. Noted resident approach another resident and pushed him to the floor. Staff intervened immediately. Resident placed 1:1 (one on one) with staff.R1's Progress Note, dated 08/25/2025 at 7:00 AM, documents the following: Continues to be 1:1 with staff. EMS (Emergency Medical Services) in the facility to transport resident to the ER (Emergency Room) for evaluation. Resident was cooperative with transfer to gurney. 7:15 AM-Left facility per stretcher via ambulance accompanied by 2 EMS.R1's Progress Note, dated 08/25/2025 at 1:52 PM, documents the following: Writer spoke with son regarding this morning's incident. Son informed of investigative details thus far. Son reports the local hospital suggested, and he agrees that R1 be transferred to a smaller home that can accommodate a private room. Son is very understanding of the need to keep others safe. He asked that his things be packed up and he will be in later this week to retrieve them. Will continue to monitor.R2's Face Sheet, undated, documents R2 has the following diagnoses: Fracture of the Right Femur, Heart Failure, HTN, COPD, Unsteadiness on Feet, Weakness, Cognitive Communication Deficit, OA, Atrial Fibrillation, Severe Dementia with Anxiety, Insomnia, and Muscle Weakness.R2's MDS, dated [DATE], documents R2 has a BIMS score of 15, indicating R2 is cognitively intact. R2 has no mood indicators and has verbal behaviors directed towards others.R2's Care Plan, dated 6/24/25, documents R2 is adjusting to changes in his status, routine and surroundings. R2 has exhibited verbal and rejection of care behaviors. He will become focused on a topic and remain there and will make repetitive comments which leads to other behaviors. He often talks about going home and will ask others to assist him there. Herb exhibits exit seeking behaviors. R2 is voicing delusional statements. R2 has been crawling on the floor per his preference and states he prefers to sleep there and needs to fix items. R2 has exhibited physical behaviors towards staff.R2's Care Plan, dated 8/22/25, documents R2 has Anxiety and Insomnia.R2's Progress Note, dated 07/16/2025 at 5:44 AM, documents the following: Resident yelling out off and on throughout the night. Staff assists residents with his needs, reorientated resident when he is confused about time, place and situation. However, resident will continue to yell out moments later. O2(Oxygen) in place per NC (Nasal Cannula) @ 2L/min. No SOB (Shortness of Breath) or respiratory distress present. Continent of B/B (Bowel/Bladder). Melatonin administered @ HS (Bedtime) as order states with very little effectiveness this shift. Bed placed in lowest locked position. Call light placed within reach.R2's Progress Note, dated 08/15/2025 at 7:18 PM, documents the following: Previous shift reported that resident yelled out most of the night. Numerous attempts to get up without assist. O2 at 2L/NC. LCTA (Lungs Clear to Auscultation). Occasional nonproductive cough noted. Fluids encouraged. Afebrile. Incontinent care provided as needed.R2's Progress Note, dated 08/21/2025 at 3:45 PM, documents the following: Resident has been displaying extreme anxiety/agitation. He has made attempts to exit, stating his car is in the parking lot, and he needs to leave. He has been yelling at staff (not due to being HOH (Hard of Hearing), and is unable to comprehend anything said to him, which is only exacerbating the agitation. Staff has attempted offering food/fluids, has attempted to lay resident down, and then gotten right back up due to climbing OOB (Out of Bed), attempted to involve in activities, therapy, and even 1:1. Any/All redirection attempts have been unsuccessful. Family came and sat with resident for an hour and was finally able to calm only some of his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145733 If continuation sheet Page 2 of 5 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 09/02/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few anxiety. Daughter and son are upset, stating resident would have never displayed these kinds of behaviors, and they are requesting he get something for anxiety. MD (Medical Doctor) aware.R2's Progress Note, dated 08/24/2025 at 12:30 PM, documents the following: Resident exit seeking. Accusing others of hiding his tractor keys. Looking for a trailer to back up. Cursing at staff, insisting that he had to go home. Staff attempting to redirect. Resident put himself on the floor in dining room, crawling under table. Saying that he needed to fix, flip a lever. Nurse unable to straight catheter to obtain urine specimen due to anatomical abnormality. Attempting to obtain due to no void and acute mental status changes. POA (Power of Attorney), MD, NP (Nurse Practitioner) and nursing management aware. Resident sent to ER (Emergency Room) per family request. R2's Progress Note, dated 08/25/2025 at1:03 AM, documents the following: Returned from ER at approximately 7:30 PM. His behaviors have continued since, literally crawling on the floor. Stated I want to sleep down here Redirected many times to no avail, medication including pain med were given by the nurse. The local hospital completed scan of the bladder and found small amount of urine in bladder (350 ml (milliliters). Resident did not void for more than 12 hours and had only 350 ml of urine in his bladder and has increased behaviors and restlessness. Can we try some fluids please, Message was sent to MD, NP, DON and ADON (Assistant Director of Nurses).R2's Progress Note, dated 08/25/2025 at 4:43 AM, documents the following: Resident has been putting himself on the floor throughout the entire night, continuously yelling and screaming out for help. resident is very confused and grabbing and reaching for things that are not there. resident is very hard of hearing and complaining of pain to the right hip. pain medication was given for the pain and didn't seem to help. resident is confused and asking staff if they have a vehicle and stating that he needs a ride home and needs to get out of there, asking where our dads are, if our dads are home, and stating that his parents are needing him at the house.R2's Progress Note, dated 08/25/2025 at 6:10 AM, documents the following: Resident sitting at nurse's station. Noted another resident approach this resident and pushed this resident to the floor from wheelchair. Staff intervened immediately. No injury noted. Assisted back to wheelchair with two staff members.R1 and R2's Abuse Investigation, dated 8/24/25 and 8/25/25, documents the following: In conclusion, on Sunday, 8/24/25, during the evening medication pass, staff were alerted to room R2's room after hearing R2 yelling for help. When staff entered the room, they noted that R2 had spilled his Jello and R1 became angry. After multiple attempts, staff were unable to determine why R1 was upset. At no time did R1 make contact with R2. The staff immediately removed R2 from the room and had him sleep in room [ROOM NUMBER] for the night. The next morning, after morning ADL (Activities of Daily Living) care, R1 propelled his wheelchair from the 200 hall into the common area, located R2, who was sitting in his wheelchair in front of the oxygen room. R1 lunged at R2 and pulled him from the wheelchair, onto the floor, while attempting to hit and kick him. Staff immediately intervened and the residents were separated. No injuries were noted to either individual. Family and physician aware, local police department notified and R1 was placed on 1:1 monitoring until he was sent to the local hospital for evaluation. The local hospital recommended that R1 be transferred to a smaller home that can better meet his needs.On 9/2/25 at 7:55 AM, V4, Housekeeping, stated R1 and R2 both resided on the Bounce Back/400 hallway, not as roommates, and R1 had moods, not good, would hit at others. R2 did have some behaviors but not too much. V4 stated she is not aware of any altercations between R1 and R2.On 9/2/25 at 8:00 AM, V5, RN (Registered Nurse), stated R2 will crawl on the floor, he thinks he's working on trucks or tractors, hollers, curses, and is exit seeking. V5 stated R2's family comes and sits with him every day. V5 stated R2 is confused. V5 stated she is unaware if R1 had behaviors prior to moving to the 200 hallway, she hadn't worked with him prior. V5 stated R1 and R2 had gotten into a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145733 If continuation sheet Page 3 of 5 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 09/02/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few yelling match, unsure of date, but there was no physical contact made.On 9/2/25 at 8:05 AM, V6, CNA, stated R2 yells but she thinks it's because he can't hear. V6 stated R1 had just moved to room [ROOM NUMBER] with R2 a couple of days prior and R1 wasn't happy that he had moved from his prior room on the Bounce Back (Rehab) hall to the nursing home side. V6 stated she is not aware of any behaviors with R2 and was unaware of any altercations between R1 and R2. On 9/2/25 at 8:10 AM, V2, DON, stated she was not here when the altercation between R1 and R2 took place. V2 stated R1 was a brand-new stroke patient when he was admitted to the facility. He didn't have any behaviors but due to the stroke he would become tearful and cry. On 9/2/25 at V3, R2's Family, stated on Friday morning, 8/22/25, R1 was moved into the room with R2, things were fine 8/23/25 and during the day on 8/24/25. On 8/24/25, she had gone with R2 to the hospital and by the time they returned to the facility, it was 7:15 PM, R2 was hungry, so she alerted staff, and they got him a plate of food. When staff brought the tray in, R1 became agitated, the nurse and CNA were trying to calm R1 down, they offered food, drinks, etc. V3 stated R2 was in bed at that time so she left the facility around 7:45 PM. V3 stated around 8:00 PM, she was notified that there was a commotion in the room and R1 was trying to get to R2. R1 kicked the nurse and twisted the CNAs arm. V3 stated she was told by staff that they had separated R1 and R2. V3 stated on 8/25/25 at 6:45 AM, she received a call that R2 was up, dressed, and at the nurse's station, waiting to go to breakfast. R1 was going to the dining room for breakfast and grabbed R2 by the shirt and was trying to hit and kick him. V3 stated the facility sent R1 out but R2 didn't have any injuries so he was not evaluated at the hospital. V3 stated R1 had a stroke and was paralyzed on the left side and couldn't speak. V3 stated R1 was not confused. V3 stated there has been conflicting information provided by V1, Administrator, and other staff. V3 stated the police were called but there were no arrests or investigations completed, and no police report was filed. V3 stated R2 was traumatized for about a week afterwards but is fine now. V3 stated R2 would doze off, wake up upset and clenching his fists. V3 stated the physician's assistant ordered R2 an anti-anxiety medication the day the incident happened. V3 stated R1 was mad because he went from the Bounce Back unit to the regular nursing home side. V3 stated she is not aware of R1 having any behaviors prior to being moved on the 200 hallway, into the room with R2.On 9/2/25 at 8:50 AM, V1, Administrator, stated R1 was on the Bounce Back unit and was moved to the 200 hallway. V1 stated R1 was admitted to the facility with a new stroke, was aphasic, and was only in room [ROOM NUMBER] for 3 days. V1 stated there hadn't been any problems that Friday and Saturday night, then on Sunday 8/24/25, R1 became frustrated was trying to talk, but was unable to. V1 stated V3, R2's Family, was at the facility, and told her that staff tried to get R1 to calm down, they were offering him food, drinks, etc., but R1 was angry and kicked the nurse and twisted the CNAs wrist. V1 stated they moved R2 to a room on the 300 hallway for the night. V1 stated the next morning R2 was at the nurse's station waiting to go to breakfast as R1 was going to breakfast, and R1 pulled R2 out of his wheelchair, was hitting and kicking R2. Staff separated them. V1 stated R1 hadn't had any behaviors prior to this incident, and she would have never thought this would have happened. V1 stated neither resident was hurt during the incident and R1 was sent to the local hospital and then to a Geriatric Psychiatric unit at another hospital for further intervention. V1 stated R1 didn't have any behaviors or mental illness diagnosis that would have alerted the facility staff that R1 would be capable of this.On 9/2/25 at 9:25 AM, V8, Speech Language Pathologist, stated she had worked with R1 since he was admitted to the facility on communication, expressive and receptive. V8 stated R1 would mostly answer yes/no questions. V8 stated they tried to utilize a communication board with numbers, but he wasn't always accurate in his responses. V8 stated R1 was comfortable on the Bounce Back unit, he knew the staff and other (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145733 If continuation sheet Page 4 of 5 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 09/02/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete residents, then he was moved to the 200 hallway, where he didn't know the staff or other residents. V8 stated R1 wasn't confused, he wasn't always able to fully understand different scenarios or situations. V8 stated R1 also had a history of UTIs. V8 stated she had never observed R1 being aggressive, his emotions would fluctuate, he would be happy/sad/tearful at times. V8 stated she worked with R1 for a long time and didn't see any anger or aggression with him. V8 stated she has not seen R1 since he was moved to the 200 hallway, they were waiting on more visits to be approved prior to R1 being sent to the hospital.On 9/2/25 at 10:13 AM, V10, LPN (Licensed Practical Nurse) stated she was passing medications on 8/24/25, when she heard R2 yelling, upon entering the room, R1 was agitated, she was unsure why and R2 was unable to explain what had happened or what was wrong. V10 stated R1 stood up from his bed and attempted to go towards R2, they attempted to redirect R1 but were unable to, so they moved R2 to a room on the 300 hallway and once R2 was moved from the room, R1 calmed down and R2 was calm and okay in the other room. V8 stated prior to this incident, she had seen R1, he wasn't agitated, aggressive, or irritable, he seemed fine but was growling and rolling his eyes. She talked with him briefly, then left the room, and about an hour later was when the incident with R1 and R2 in their room happened. V8 stated the next morning, R1 found R2, pushed him to the ground, R1 was also kicking/hitting at staff when they were trying to intervene. V8 stated they were able to deescalate the situation and R1 was placed on 1:1 observation.On 9/2/25 at 10:25 AM, V11, CNA, stated she was charting and heard R2 yelling, she thought he had crawled onto the floor, which he frequently did. V11 stated she entered the room and found that R2 had spilled his Jello and was upset. V11 stated she helped R2 clean it up, while doing this R1 ripped the curtain back and looked like he was going to hit R2, she tried to get R1 to calm down, but he wasn't listening. V11 stated R1 was trying to rip through them to get to R2. V11 stated they finally got R1 to sit down on the bed, but that didn't help, he began kicking V10, LPN, and twisted her (V11's) arm. V11 stated they were keeping R1 away from R2 and moved R2 to another hallway. V11 stated once R2 left the room, R1 calmed down. V11 stated she was not aware of any prior incidents with R1 or R2. The Abuse Prohibition and Reporting Policy, dated 11/1999, documents the following: The facility actively prohibits resident abuse including neglect, corporal punishment, involuntary seclusion, misappropriation of property, injuries of unknown source, exploitation, and use of any physical or chemical restraint not required to treat resident symptoms. Special attention will be given to identifying behavior that increases the residents potential for abusing self or others or being the victim of abuse, These behaviors would include residents with a history of aggressive behaviors, residents who have behaviors such as: entering other residents rooms, residents with self-injurious behaviors, residents with communication disorders, and those who require heavy nursing care and/or are totally dependent on staff. Event ID: Facility ID: 145733 If continuation sheet Page 5 of 5