Inspection·July 12, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to add interventions to prevent falls for one of two residents (R22) reviewed for falls in the sample of 41. Findings include: R22's Face Sheet documented an admission date of 11/8/23 and listed diagnoses including Alzheimer's Disease, Diabetes Type 2, and Abnormalities of Gait and Mobility. R22's Minimum Data Set (MDS) dated [DATE] documented a Brief Inventory for Mental Status Score of 10, indicating R22 has moderate deficits in cognition. The same MDS documented that R22 requires the use of a wheelchair for mobility. Review of R22's Fall Investigations documented that R22 sustained falls from self transfers on 11/12/23, 12/8/23, 12/31/23, 1/14/24, 1/28/24, 2/9/24, 2/12/24, 3/14/24, 4/4/24, 4/27/24, 5/12/24, and two falls on 5/22/24. R22's Care Plan dated 6/27/24 documented a problem area, (R22) is at risk for falls. There were no Care Plan interventions added for the 11/12/23, 12/31/23, 1/14/24, 1/28/24, and 4/4/24 falls. On 7/11/24 at 12:03 pm, R22's Care Plan was reviewed with V9 ( Registered Nurse, Care Plan/Minimum Data Set Coordinator). V9 confirmed no new fall interventions were added to the Care Plan on the above referenced dates. V9 confirmed new Care Plan interventions are to be added after each fall. A Fall Policy dated 9/17/19 documented,Following any falls, the facility staff completes an Occurrence Report. Details of the fall will be recorded and potential causal factors identified and investigated. Interventions will be implemented and the Care Plan updated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145813 If continuation sheet Page 2 of 6 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 145813 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Metropolis Rehab & Hcc 2299 Metropolis Street Metropolis, IL 62960 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 - Few 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** Based on observation, interview, and record review the facility failed to provide catheter care in accordance with current standards of practice for 1 of 2 residents (R24) reviewed for catheter care in the sample of 41. The findings include: R24's admission record notes she was admitted to the facility on [DATE]. The same admission record notes R24's diagnoses to include: cerebral infarction, spastic hemiplegia affecting right dominant side, dysphagia. R24's order summary report dated July 1-July 31 2024 note R24 has a foley catheter (18 fr (French)/10 cc (cubic centimeter) r/t (related to) urinary retention. The same Physician's orders also documents an order dated 6/19/24 for catheter care every shift. R24's MDS (Minimum Data Set) dated 6/26/24 documents R24 has a BIMS (Brief Interview of Mental Status) of 10 which indicates R24 has moderate cognitive impairment. Section H of the same MDS documents R24 has an indwelling catheter. R24's Care Plan notes a focus area of R24 has a catheter. Some of the interventions listed are catheter care every shift and prn (as needed), the resident has an 18 FR/10cc Foley. Position catheter bag and tubing below the level of the bladder and away from entrance room door, monitor/record/report to MD (Medical Doctor) for s/sx (signs/symptoms) of UTI (Urinary Tract Infection): pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. On 7/10/24 at 3:30 pm, catheter care was observed on R24, being performed by V6 (CNA/Certified Nurse Assistant) and V7 (CNA). V6 had wash cloths and basin of water with peri wash. Using left hand, she held the catheter where it meets the labia. She then used her right hand to cleanse the catheter with wet wash cloth from the top of the catheter down. This was repeated several times. At no time did she separate the labia or cleanse the urinary meatus. Facility Document labeled Catheter Care, Urinary note (revised 01/2017) with non-dominate hand separate the labia of the female resident. For a female resident: Use a washcloth with warm water and soap to cleanse the labia. Use one area of the washcloth for each downward, cleansing stroke. Change the position of the washcloth with each downward stroke. Next, change the position of the washcloth and cleanse around the urethral meatus. Do not allow the washcloth to drag on the resident's skin or bed linen. With a clean washcloth, rinse with warm water using the above technique. On 7/11/24 at 10:40am, V5 (Interim ADON/Assistant Director of Nursing) said she would expect the labia to be separated when performing catheter on a female resident. On 7/11/24 at 10:45am, V2 (DON/Director of Nursing) said she would expect the labia to be separated when a female resident is receiving catheter care. On 7/12/24 at 9:45am, V6 said she does separate the labia and clean them good when she does catheter care but was just very nervous yesterday and just didn't do it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145813 If continuation sheet Page 3 of 6 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 145813 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Metropolis Rehab & Hcc 2299 Metropolis Street Metropolis, IL 62960 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to administer a residents' tube feeding accordance with physician's orders for 1 of 1 resident (R47) reviewed for tube feeing in the sample of 41. The findings include: R47's admission record documents an admission date to the facility of 7/02/2022 with diagnoses including cerebral infarction, unspecified, gastrostomy status, cognitive communication deficit, other speech and language deficits following other cerebrovascular disease, muscle weakness. R47's Minimum Data Set (MDS) dated [DATE] documents in section K0520 under nutritional approaches in section B. marks yes to a feeding tube. This same document in section K0710, swallowing/nutritional status documents under section B marks an average fluid intake per day by tube feeding of 501 cubic centimeters (CC)/day or more. R47's Care plan with a review date 6/29/2023 documented a focus area of R47's requires tube feeding with interventions listed of the resident is dependent with tube feeing and water flushes. See MD (Medical Doctor) orders for current feeding orders. R47's July 2024 Order Summary documented an order for Nutren 2.0 continuous feeding infuse at 40 ml every hour with 120ML water flush every two hours every shift for nutrition and hydration every shift. NPO (Nothing by mouth). R47's Medication Administration Records dated May 2024-July 2024 documented an order for Nutren 2.0 continuous feeding infuse at 40 ml every hour with 120ML water flush every two hours every shift for nutrition and hydration every shift being completed. On 07/09/24 at 10:31 AM, R47 was lying in bed, head of bed elevated. R47 was alert but not oriented to person, place, or time, and most of her answers were unintelligible. An enteral feeding pump was infusing Nutren 2.0 continuous feeding supplement at a rate of 30 ml per hour into R47's gastric tube. On 7/09/2024 at 1:42 PM, R47 was lying in bed, head of bed elevated. An enteral feeding pump was infusing Nutren 2.0 continuous feeding supplement at a rate of 30 ml per hour into R47's gastric tube. Handwritten documentation on bag dated 7/09/2024, time hung at 11:00 AM at 30 milliliters (ML)/hour in tube feeding orders. On 7/10/2024 at 9:20 AM, R47 was lying in bed, head of bed elevated. An enteral feeding pump was infusing a Nutren 2.0 continuous feeding supplement at a rate of 30 ml per hour into R47's gastric tube. Handwritten documentation on bag dated 7/10/2024, time hung at 3:00 AM at 30 milliliters (ML)/hour in tube feeding orders. On 7/10/2024 at 12:10 PM, V3 (Licensed Practical Nurse/LPN) stated, she is unable to recall the tube feeding order for R47. V3 stated, at this time the infusion rate is running at 30ML/hour but would need to check the order. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145813 If continuation sheet Page 4 of 6 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 145813 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Metropolis Rehab & Hcc 2299 Metropolis Street Metropolis, IL 62960 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 7/10/2024 at 12:15 PM, V2 (Director of Nursing/DON) and V4 (LPN) stated, they are unable to recall the tube feeding order rate for R4. V2 and V4 both stated, the infusion rate on the pump at this time is infusing at 30ML/hour. V4 stated, after review of the order in R47's electronic health record, the infusion rate should be 40ML/hour. The facility's Protocol for Enteral Tube Medication Administration Policy dated May 2019 documents under procedure listed, 5. Caloric content per milliliter is verified before administration to assure the correct dosage is given to achieve caloric objectives . Event ID: Facility ID: 145813 If continuation sheet Page 5 of 6 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 145813 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Metropolis Rehab & Hcc 2299 Metropolis Street Metropolis, IL 62960 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 Residents Affected - Few 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. Based on observation, interview, and record review the facility failed to label insulin vials and insulin pens with the date of opening for 2 of 5 (R49 and R52) residents reviewed for medication storage out of a sample of 41. Findings include: 1. R49's face sheet documented an admission date of 6/14/24 with diagnoses including: calculus of gallbladder, type 2 diabetes mellitus, epilepsy, dysphagia, anemia. R49's Order Summary Report documented a 6/16/24 order for insulin Lispro inject 8 unit subcutaneously 3 times a day and a 6/16/24 order for insulin Glargine inject 10 unit subcutaneously at bedtime. On 7/9/24 at 9:57 AM, R49's insulin Lispro and insulin Glargine was observed in the medication cart to be open and without an opening date. On 7/9/24 at 10:03 AM, V4 (Licensed Practical Nurse/ LPN) verified R49's insulin Lispro and insulin Glargine did not have opening dates. V4 said R49's insulin vials would have to be disposed of and new ones would be obtained. 2. R52's face sheet documented an admission date of 11/8/23 with diagnose including: acute kidney failure, type 2 diabetes mellitus, dysphagia, major depressive disorder. R52's Order Summary Report documented an 11/29/23 order for insulin Lispro inject 2 unit subcutaneously before meals and an 11/8/24 order for insulin Glargine inject 10 unit subcutaneously one time a day. On 7/9/24 at 9:57 AM, R52's insulin Lispro and insulin Glargine was observed in the medication cart to be open and without an opening date. On 7/9/24 at 10:03 AM, V4 (Licensed Practical Nurse/ LPN) verified R52's insulin Lispro and insulin Glargine did not have opening dates. V4 said R52's insulin vials would have to be disposed of and new ones would be obtained. On 7/12/24 at 12:48 PM, V1 (Administrator) said she expected all insulin vials would have an opening date on them. V1 said if insulin vials are found not having an opening date they should be disposed of and new insulin vials should be obtained. The facility's May 2019 Medication Storage In The Facility policy documented in part . Medications and biologicals are stored safety (sic), securely, and properly following the manufacturer or supplier recommendations . The facility provided a April 2019 Insulin Storage Recommendations form documenting opened room temperature insulin Lispro and insulin Glargine should be disposed of 28 days after opening. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145813 If continuation sheet Page 6 of 6