Inspection·May 23, 2025

F 0692 Provide enough food/fluids to maintain a resident's health. 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 therapeutic diets as ordered for 1 (R13) of 6 residents reviewed for dietary supplements in the sample of 38. Residents Affected - Few Findings Include: R13's admission Record documented an admission date to the facility of 2/23/2024. Diagnoses listed include but not limited to unspecified dementia, severe with agitation, polyosteoarthritis, feeding difficulties, unspecified, dysphagia, and weakness. R13's Minimum Data Set (MDS) dated [DATE], under section C documented that R13 has a Brief Interview for Mental Status (BIMS) score of 03, indicating R13 is severely cognitively impaired. R13's Order Summary Report dated 1/17/2023 documented under Dietary-Supplements, ice cream one time a day for nutrition. R13's Plan of Care dated 5/9/2025 documented a focus area of R13 having a nutritional problem with an intervention to provide and serve diet as ordered. R13's Dietary Note dated 4/11/2025 by V7 (Registered Dietician/RD) documented .ice cream every day, fortified pudding every day, high calorie liquid nutritional supplement 120 milliliters twice a day. Meal consumption at review of available records documented 26-100% which appears usual and stable. No new concerns with chewing or swallowing noted in charting. Continue diet order which offers 100% of needs. Weight has been maintained with current interventions. Monitor intake, weight, and lab values for new concerns. On 05/20/25 at 1:00 PM observed R13 being served a pureed thin diet of chicken alfredo, power potatoes, mixed vegetables, and assorted dessert. No ice cream or substitute supplement served with meal. On 5/20/2025 at 1:05 PM, V5 (Family) stated family is present for every lunch meal. V5 stated, R13 should get ice cream for a supplement at lunch, but the facility had been out of ice cream for a few days. On 05/21/25 at 12:36 PM, R13 was observed being served pureed thin diet of sweet and sour pork, wild rice, broccoli with garlic, mashed potatoes, and assorted desert. No ice cream or substitute supplement was served with lunch meal. Review of R13's meal card documented R13 should be served pureed sweet/sour pork, wild rice, broccoli with garlic, mashed potatoes and assorted desert. Under supplement: 4-ounce assorted ice cream-supplement. On 05/21/25 at 12:39 PM, V6 (Certified Nurse Assistant/CNA) stated the facility had been out of assorted ice cream supplement the last 2 days. V6 stated, she did not know what R13 was supposed to receive in place of the ice cream supplement with her lunch meal. 05/21/25 12:42 PM, V4 (Dietary Director) stated the facility had been out of the assorted ice cream supplement the last 2 days and the ice cream should arrive on the truck this afternoon. V4 stated, R13 should have received fortified pudding in replace of the ice cream the last 2 days with her lunch meal. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145813 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 145813 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2025 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 0692 On 05/21/25 at 1:10 PM, V1 (Administration) stated her expectations are for staff to follow therapeutic diets as ordered. 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: 145813 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 145813 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to provide urinary catheter care per current infection control standards for 1 (R57) of 3 residents reviewed for urinary tract infections in the sample of 38. Residents Affected - Few Findings include: R57's admission Record documented an admission date of 3/9/24 with diagnoses including: neurocognitive disorder with Lewy bodies, Parkinson's disease with dyskinesia, and flaccid neuropathic bladder. R57's 5/13/25 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 4, indicating R57 had severe cognitive impairment, and was dependent on staff for personal hygiene. R57's Order Summary Report printed 5/22/25 documented a 4/24/24 order for catheter care every shift. On 5/22/25 at 9:54 AM, V9 (Certified Nursing Assistant/ CNA) preformed hand hygiene donned gloves and a gown preparing to provide urinary catheter care for R57. V9 placed a package of wipes on the fitted sheet and pulled out 3 wipes laying them on the fitted sheet. V9 picked up a wipe and wiped R57's perineal area from front to back. V9 carried the wipe across the room to the trash can to throw the wipe away. V9 picked up the trash can by the upper rim and carried the trash can to R57's bedside. V9 did not perform hand hygiene or change her gloves. V9 picked up 3 more wipes from the fitted sheet using 2 to cleanse R57's perineal area with one wipe from front to back and 1 wipe to cleanse R57's urinary catheter tubing from the insertion site outward. V9 did not perform hand hygiene or change her gloves. V9 adjusted R57's flat sheet back into place. V9 changed her gloves but did not perform hand hygiene. V9 used her gloved hand to open the bathroom door looking for a graduated cylinder to empty R57's urinary catheter drainage bag. V9 exited the bathroom and crossed the room using her gloved hand to open the bottom door of R57's night stand and removed a graduated cylinder. V9 emptied R57's urinary catheter bag into the graduated cylinder, stood, carried it to the bathroom opening the door with her gloved hand. V9 emptied the graduated cylinder into the toilet, exited the bathroom, and crossed the room opening R57's nightstand with her gloved hand and placed the graduated cylinder inside. V9 did not perform hand hygiene or change her gloves. V9 picked up the package of wipes off R57's fitted sheet with her gloved hands and placed it on the bedside table. V9 took off her gloves but did not perform hand hygiene. V9 picked up the package of wipes, exited the room, and placed the package of wipes on the supply cart in the hallway. On 5/22/25 at 10:06 AM, V2 (Director of Nursing/ DON) was asked if it was normal practice for packages of wipes to be brought into resident rooms then put back on the supply cart in the hallway, and V2 said yes that is typically what they do. On 5/23/25 at 11:24 AM, V2 said during urinary catheter care she would expect staff to preform hand hygiene and change their gloves if they picked up the trash can. V2 said she would expect staff to preform hand hygiene and change their gloves after preforming urinary catheter care and prior to emptying the urinary catheter drainage bag. V2 said she would expect staff to preform hand hygiene after emptying the urinary catheter drainage bag and prior to picking up wipes to return them to the supply cart. The facility's 1/2017 Catheter Care, Urinary policy documented in part . Purpose . The purpose of this procedure is to prevent catheter-associated urinary tract infections . Infection Control . 1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145813 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 145813 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Use standard precautions when handling or manipulating the drainage system . 2. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bags. A. Do not clean the periureteral area with antiseptics to prevent catheter-associated UTIs (Urinary Tract Infections) while the catheter is in place . Steps in the Procedure . 1. Arrange supplies so they can be easily reached . 2. Wash and dry your hands thoroughly . 5. Put on gloves . 8. With nondominant hand separate the labia of the female resident . Maintain the position of this hand throughout the procedure . 10. 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 stroke. Next, change the positon 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 . 12. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site outward . 15. Discard disposable items into designated containers. Remove gloves and discard into designated container. Wash and dry your hands thoroughly . Event ID: Facility ID: 145813 If continuation sheet Page 5 of 5