Health inspection·August 16, 2024

F 0636 be no later than 14 days from the ARD (ARD + 14 calendar days) . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145760 If continuation sheet Page 2 of 9 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 145760 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Robinson Rehab and Nursing 600 East Robinwood Drive Robinson, IL 62454 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 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure quarterly assessments were completed within the required time frames for nine (R13, R16, R25, R27, R47, R48, R49, R52 and R54) of nine residents reviewed for quarterly assessments in a sample of 35. Residents Affected - Some The Findings Include: R13's Face Sheet documented an admission date of 1/13/23. R13's most recent completed and submitted quarterly Minimum Data Set (MDS) Section A documented an Assessment Reference Date (ARD) of 4/27/24. The next quarterly MDS Section A was initiated with an ARD of 7/28/24 but had not been completed or submitted as of the date of this review on 08/16/24. This indicates more than 92 days between completion of assessments and shows R13's quarterly assessment had not been completed/submitted within 14 days after the ARD of 7/28/24. R16's Face Sheet documented an admission date of 10/12/22. R16's most recent completed and submitted quarterly MDS Section A documented an ARD of 4/16/24. The next quarterly MDS Section A was initiated with an ARD of 7/5/24 but had not been completed or submitted as of the date of this review on 8/16/24. This indicates more than 92 days between completion of assessments and shows R16's quarterly assessment had not been completed/submitted within 14 days after the ARD of 7/5/24. R25's Face Sheet documented an admission date of 1/6/23. R25's most recent completed and submitted quarterly MDS Section A documented an ARD of 4/12/24. The next quarterly MDS Section A was initiated with an ARD of 7/1/24 but had not been completed or submitted as of the date of this review on 8/16/24. This indicates more than 92 days between completion of assessments and shows R25's quarterly assessment had not been completed/submitted within 14 days after the ARD of 7/1/24. R27's Face Sheet documented an admission date of 2/13/20. R27's most recent completed and submitted quarterly MDS Section A documented an ARD date of 4/5/24. The next quarterly MDS Section A was initiated with an ARD of 7/4/24 but had not been completed or submitted as of the date of this review on 8/16/24. This indicates more than 92 days between completion of assessments and shows R27's quarterly assessment had not been completed/submitted within 14 days after the ARD of 7/4/24. R47's Face Sheet documented an admission date of 3/5/22. R47's most recent completed and submitted quarterly MDS Section A documented an ARD date of 4/9/24. The next quarterly MDS Section A was initiated with an ARD of 7/8/24 but had not been completed or submitted as of the date of this review on 8/16/24. This indicates more than 92 days between completion of assessments and shows R47's quarterly assessment had not been completed/submitted within 14 days after the ARD of 7/8/24. R48's Face Sheet documented an admission date of 11/8/22. R48's most recent completed and submitted quarterly MDS Section A documented an ARD date of 4/9/24. The next quarterly MDS Section A was initiated with an ARD of 7/8/24 but had not been completed or submitted as of the date of this review on 8/16/24. This indicates more than 92 days between completion of assessments and shows R48's quarterly assessment had not been completed/submitted within 14 days after the ARD of 7/8/24. R49's Face Sheet documented an admission date of 4/6/23. R49's most recent completed and submitted quarterly MDS Section A has an ARD date of 4/6/24. The next quarterly MDS Section A was initiated with an ARD of 7/5/24 but had not been completed or submitted as of the date of this review on 8/16/24. This indicates more than 92 days between completion of assessments and shows R49's quarterly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145760 If continuation sheet Page 3 of 9 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 145760 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Robinson Rehab and Nursing 600 East Robinwood Drive Robinson, IL 62454 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 0638 assessment had not been completed/submitted within 14 days after the ARD of 7/5/24. Level of Harm - Minimal harm or potential for actual harm R52's Face Sheet documented an admission date of 4/5/24. R52's most recent completed and submitted quarterly MDS Section A documented an ARD date of 4/7/24. The next quarterly MDS Section A was initiated with an ARD date of 7/6/24 but had not been completed or submitted as of the date of this review on 8/16/24. This indicates more than 92 days between completion of assessments and shows R52's quarterly assessment had not been completed/submitted within 14 days after the ARD of 7/6/24. Residents Affected - Some R54's Face Sheet documented an admission date of 9/7/23. R54's most recent completed and submitted quarterly MDS Section A documented an ARD date of 4/19/24. The next quarterly MDS Section A was initiated with an ARD of 7/8/24 but had not been completed or submitted as of the date of this review on 8/16/24. This indicates more than 92 days between completion of assessments and shows R54's quarterly assessment had not been completed/submitted within 14 days after the ARD of 7/8/24. On 8/15/24 at 2:00 PM, V3 (MDS Coordinator) confirmed that R13, R16, R25, R27, R47, R48, R49, R52 and R54's MDS Assessments had not been submitted timely due to V3 being pulled to the floor to cover shifts due to staff illness and call-ins. V3 stated that the MDS's were created/initiated in July, but she is now currently working on catching up on these. The Center for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual Chapter 2 documents the following: Assessment Schedule: An OBRA (Omnibus Budget Reconciliation Act) assessment (Comprehensive or Quarterly) is due every quarter unless the resident is no longer in the facility. There must be no more than 92 days between OBRA assessments. An OBRA comprehensive assessment is due every year unless the resident is no longer in the facility. There must be no more than 366 days between comprehensive assessments . According to the Center for Medicare and Medicaid Services (CMS) Resident assessment Instrument (RAI) Version 3.0 Manual Chapter 2: Assessments for the RAI .The MDS completion date (item Z0500B) must be no later than 14 days from the ARD (ARD + 14 calendar days) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145760 If continuation sheet Page 4 of 9 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 145760 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Robinson Rehab and Nursing 600 East Robinwood Drive Robinson, IL 62454 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide therapeutic diets as ordered for 1 (R47) of 2 residents reviewed for dietary supplements in the sample of 35. Findings Include: R47's Face Sheet documented an admission date of 11/13/23 and included the following diagnoses of unspecified protein-calorie malnutrition, dysphagia, oropharyngeal phase. R47's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. This same MDS documents under section I Active Diagnoses, a diagnosis of I5600 Malnutrition (protein, calorie) risk of malnutrition. R47's Physician Order Summary dated 5/13/2024 documented high protein pudding. On 8/13/2024 at 12:05 PM, R47 was sitting with V9 (Speech Language Pathologist/SLP) being served a regular mechanical diet of ground pulled pork with gravy, creamed corn, baked beans-no bacon, soft chopped fruit, and cornbread/margarine. R47's meal tray did not include high protein pudding. On 8/14/2024 at 12:05 PM, R47 was sitting with V9 (Speech Language Pathologist/SLP) being served a regular mechanical diet of ground meatballs with mushroom gravy, mashed potatoes and gravy, soft chopped California blend vegetables, frosted cake and bread/margarine. R47's meal tray did not include high protein pudding. On 8/14/2024 at 12:10 PM, V9 stated, R47 should have a high protein pudding with lunch and supper meals. On 8/14/2024 at 12:11 PM, V10 (Certified Nurse Assistant/CNA) stated she wasn't sure if R47 was supposed to have high protein pudding, but she would check with dietary. On 8/14/2024 at 12:15 PM, V11 (Dietary Manager) stated R47 should have high protein pudding with her lunch and dinner. V11 stated it was a dietary oversite that she did not get it the last two days. On 8/16/2024 at 11:32 AM, V1 (Administrator) stated she would expect dietary staff to follow physician orders and provide nutritional supplements. R47's menu ticket dated 8/13/2024 and 8/14/2024 documented Regular diet, mechanical soft texture diet. The following is documented under the Notes section: high protein pudding at lunch and supper. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145760 If continuation sheet Page 5 of 9 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 145760 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Robinson Rehab and Nursing 600 East Robinwood Drive Robinson, IL 62454 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide adaptive utensils for one (R21) of one resident reviewed for assistive devices in the sample of 35. Residents Affected - Few Findings include: R21's Face Sheet documented an admission date of 7/8/23 and includes the following diagnoses encephalopathy, unspecified, hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left non-dominant side, cerebral infarction due to unspecified occlusion or stenosis of other cerebral artery, and dysphagia, oropharyngeal phase. R21's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. This same MDS documents under section

K0100-Swallowing Disorder, C. coughing or choking during meals or when swallowing medications. R21's Physicians Orders dated 8/14/2024 documented an order for, Low Concentrated Sweets, diet, dysphagia mechanical texture, regular/thin consistency (No bread, toast, buns, pancakes, french fries, banana bread, biscuits.) R21's Care Plan dated 5/21/2024 documents nosey cups for liquids. No bread, toast, buns, pancakes, french fries, banana bread, biscuits. On 08/13/24 at 12:00 PM, during lunch in the dining room, R21 was observed sitting with V9 (Speech Language Pathologist/SLP) being served a regular mechanical diet of ground pulled pork with gravy, creamed corn, baked beans-no bacon, soft chopped fruit, and cornbread/margarine with two beverages served in regular cups with straws. On 8/14/2024 at 12:07 PM during lunch in the dining room, R21 was observed sitting with V9 (Speech Language Pathologist/SLP) being served a regular mechanical diet of ground meatballs with mushroom gravy, mashed potatoes and gravy, frosted cake and bread/margarine with two beverages served in regular cups with straws. On 8/14/2024 at 12:09 PM, R21 stated he does use a nose out cup to drink from. R21 stated, they are in his room. On 8/14/2024 at 12:10 PM, V9 stated R21 had been using cups with straws to drink from but does use his nose out cups as well. On 8/14/2024 at 12:11 PM, V10 (Certified Nurse Assistant/CNA) stated she is not sure if R21 uses nose out cups but will check with dietary. On 8/14/2024 at 12:15 PM, V11 (Dietary Manager) stated R21 does use the nose out cups but is unable to find them. V11 stated he thought they got thrown away. On 8/15/2024 at 10:11 AM, V1 (Administrator) stated V11 ordered four nose out cups yesterday for R21 and they found two in his room for him to use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145760 If continuation sheet Page 6 of 9 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 145760 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Robinson Rehab and Nursing 600 East Robinwood Drive Robinson, IL 62454 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 0810 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete R21's menu ticket dated 8/13/2024 and 8/14/2024 documented Regular diet, mechanical soft with no breads. Adaptative Equipment: Nose Out Cup. On 8/16/2024 at 2:30 PM, V1 (Administrator) stated, the facility does not have a policy regarding adaptive utensils for residents, however, she would expect staff to follow physician orders and provide adaptive utensils. Event ID: Facility ID: 145760 If continuation sheet Page 7 of 9 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 145760 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Robinson Rehab and Nursing 600 East Robinwood Drive Robinson, IL 62454 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** Based on observation, interview and record review, the facility failed to maintain aseptic technique while performing urinary catheter care and implement transmission based precautions for two (R23, R47) of two residents reviewed for infection control in a sample of 35. Residents Affected - Few Findings include: 1. R23's Face Sheet documented an admission date of 8/13/22. R23's Face Sheet included the following diagnoses: multiple sclerosis, neuromuscular dysfunction of bladder, unspecified, dementia, unspecified, cerebral infarction due to embolism of left middle cerebral artery. R23's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 3, indicating R23 had severe cognitive impairment. This same MDS documents under section H0100, Appliances yes for an indwelling catheter. R23's Physician Order Sheet (POS) documented an order dated 12/24/2022 Foley Catheter Care every shift. R23's Care Plan documented a focus area of an indwelling catheter related to neurogenic bladder with interventions to monitor for evidence of catheter blockage, signs and symptoms of urinary tract infection. On 8/15/2024 at 11:05 AM, V4 (Certified Nurse Assistant/CNA) provided indwelling urinary catheter care as well as incontinence/perineal care for R23. V4 set up on a clean surface with a water basin, washcloths, and a no rinse peri-wash. There was no hand sanitizer or extra gloves set up for care. V4 washed her hands prior to the procedure, donned gloves, gowns and proceeded to remove R23's brief that contained fecal matter. Once R23's dirty brief had been removed, V4 started cleaning the perineal area without donning new gloves or completing hand hygiene. After the procedure was completed, V4 applied a new brief to R23 without donning new gloves or completing hand hygiene. V4 was not observed to complete hand hygiene or gloves changed throughout the entire perineal/incontinence care procedure. On 8/15/2024 at 11:30 AM, V4 (CNA) stated she did not change her gloves during R23's perineal care. V4 stated she had not worked the floor as a certified nurse assistant for a while. V4 stated she was nervous and had forgotten to change her gloves. On 08/15/24 at 12:25 PM, V2 (Director of Nursing/DON) stated she would expect staff to follow the facility policy and procedure and use appropriate hand hygiene with donning and doffing gloves during incontinent/perineal care. V2 stated V4 did notify her that she did not change her gloves during the foley catheter procedure because she was nervous. On 8/15/2024 at 1:07 PM, V1 (Administrator) stated she would expect staff to use appropriate hand hygiene with donning and doffing gloves during incontinent/perineal care and follow the facility policy and procedure. The facility policy titled Perineal/Incontinence (revised 9/11/2020) documents under Procedure step 7 remove soiled brief/underpad from resident by rolling the brief/underpad to contain as much fecal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145760 If continuation sheet Page 8 of 9 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 145760 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Robinson Rehab and Nursing 600 East Robinwood Drive Robinson, IL 62454 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 - Few matter as possible. If gloves visibly soiled or you touch stool, remove gloves, complete hand hygiene and don new gloves. Step 14 remove gloves and perform hand hygiene. Step 15 Apply clean brief and reapply clothing. 2. R29's Face Sheet documented an admission date of 3/17/23 and included the following diagnoses: Alzheimer's disease, unspecified, altered mental status, and dementia. R29's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 2, indicating R29 had severe cognitive impairment. R29's Progress Note dated 8/12/2024 documented a positive coronavirus result reported to V6 (Physician). On 8/15/2024 at 11:15 AM, R29's door was closed with an isolation droplet precaution sign and report to nurse before entering sign on R29's door. There was a bin outside R29's door with personal protective equipment (PPE) that included gowns, gloves, mask, hand sanitizer, and disinfection wipes. V6 (Physician) observed walking into R29's room with no PPE on and left R29's door open while completing his assessment. On 8/15/2024 at 11:20 AM, V6 (Physician) stated, R29 was feeling better. V6 stated, the Coronavirus (Covid) is just a cold, and he does not believe residents should be isolated for it. V6 stated it affects the mental health of dementia residents to be isolated. On 8/15/2024 at 11:30 AM, V7 (Registered Nurse/RN) stated, she had requested V6 don PPE prior to entering R29's room and V6 declined. On 8/15/2024 at 12:25 PM, V2 (Director of Nursing/DON) stated, she would expect physicians to follow the Center for Disease Control (CDC) guidelines for Covid positive residents. V2 stated, V6 had been educated on wearing appropriate PPE in Covid positive rooms. On 8/15/2024 at 1:07 PM, V1 (Administrator) stated, V6 had been educated on wearing appropriate PPE in Covid positive resident rooms. V1 stated, she would expect physicians to follow the CDC guideline for Covid. R29's Physician Order Summary dated 8/12/2024 documented isolation droplet precaution related to covid. Every shift for isolation. The facility policy titled Coronavirus Disease (revised 9/26/2023) documented under section 11.6 Visitation of Residents on quarantine/Isolation: visitors should adhere to the core principles of infection prevention and control, which includes hand hygiene, well-fitting face covering, appropriate physical distancing and PPE. The Center for Disease Control (CDC) website, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#r1, (updated 3/18/2024) documents, any health care provider who enters the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145760 If continuation sheet Page 9 of 9