Inspection·December 15, 2022

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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 develop and implement restorative programs and a plan of care to treat R18's decline in Activities of Daily Living (ADL's) for one of one resident (R18) reviewed for ADL decline in the sample of 19. Residents Affected - Few Findings include: The facility General Requirements for Nursing and Personal Care policy dated 6-29-11 documents, The facility shall provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychological well-being of the resident, in accordance with each resident's comprehensive care plan. Adequate and properly supervised nursing care and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident. Restorative measures shall include, at a minimum, the following procedures: All nursing personnel shall assist and encourage residents so that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that diminution was unavoidable. This includes the resident's abilities to bathe, dress, and groom, transfer and ambulate, toilet, eat, and use speech, language, or other functional communication systems. R18's MDS (Minimum Data Set) assessment dated [DATE] documents R18 required limited assistance of one staff physical assistance for bed mobility, toilet use, and personal hygiene, limited assistance of set-up only for eating, and extensive assistance of one staff physical assistance for dressing. R18's MDS assessment dated [DATE] documents R18 had a decline in ADLs since the last MDS assessment dated [DATE] to requiring extensive assistance of two staff physical assistance for bed mobility, toilet use, personal hygiene, and dressing, and extensive assistance of one staff physical assistance for eating. R18's MDS Assessments dated 8-4-22 and 11-1-22 document R18 does not receive therapy or restorative nursing programs to address R18's decline in bed mobility, toilet use, personal hygiene, dressing, and eating. On 12/12/22 from 12:28 PM to 1:15 PM V7 (R18's Family Member) was observed feeding R18 in the dining room. During this time staff did not do any restoratives with R18 to maintain or increase her functional status while eating. On 12/13/22 at 10:35 AM V6 (CNA/Certified Nursing Assistant) stated, (R18) does not get any therapy or restoratives. We (the staff) just do everything for (R18). (R18) has required a lot more assistance lately. On 12/13/22 at 10:42 AM V1 (Administrator) stated, We (the facility) do not have a restorative aide or nurse at the moment. On 12/13/22 at 11:55 AM, V2 (Director of Nursing) stated, There should have been a restorative program developed for all of R18's declines in ADL's. According to (R18's) record I do not believe (R18's) ADL declines have been addressed and (R18) has not had a care plan developed to address (R18's) ADL decline. We have not had a restorative nurse or aide for a little while now. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145820 If continuation sheet Page 2 of 15 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 145820 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount Sterling Health and Rehab Center 435 Camden Rd Mount Sterling, IL 62353 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 ensure a resident's toenails were trimmed for one of two residents (R21) reviewed for activities of daily living (ADL) care in a sample of 19. Residents Affected - Few Findings include: A facility General Requirements for Nursing and Personal Care policy (undated) states, Adequate and properly supervised nursing care and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident, and A resident who is unable to carry out activities of daily living shall receive the necessary services to maintain good nutrition, grooming, and personal hygiene. In addition, this policy states, Each resident shall have proper daily personal attention, including skin, nails, hair, and oral hygiene, in addition to treatment ordered by the physician. A list of R21's current diagnoses includes Down's Syndrome, Generalized Muscle Weakness, Muscle Wasting and Atrophy. R21's Minimum Data Set (MDS) assessment dated [DATE] documents that R21 is severely cognitively impaired, requires extensive assistance for personal hygiene and is totally dependent on staff for bathing. On 12/13/22 at 9:51 AM R21 was lying in bed. V5 (Registered Nurse) entered R21's room to evaluate the condition of R21's feet and toenails. R21's toenails were a grayish discoloration with R21's great toe on each foot having an approximate one-quarter inch thick nail rising above the top of the great toe which were also approximately one-quarter inch in length. R21's remaining toenails were long and misshapen. V5 stated that R21's Nurse Practitioner, V16, had just evaluated R21 and wrote an order for R21 to see a podiatrist as soon as possible. V5 stated, It's been a while, since R21 had his toenails trimmed and that a podiatrist would normally do this procedure. R21's physician's orders dated 12/12/22 documents, Needs podiatrist ASAP (As soon as possible). R21's practitioner's progress notes dated 12/12/22 and documented by V16 states, Needs podiatrist for long, thick toenails as soon as possible. On 12/14/22 V2 (Director of Nurses) stated, If a residents' toenails need trimming, the nurse should have done that. V2 also stated that a Podiatrist has not visited the facility in several months. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145820 If continuation sheet Page 3 of 15 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 145820 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount Sterling Health and Rehab Center 435 Camden Rd Mount Sterling, IL 62353 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 prevent the development of a Deep Tissue Injury (DTI) for one of one resident (R21) reviewed for pressure ulcers in a sample of 19. Residents Affected - Few Findings include: A Wound and Ulcer Policy and Procedure dated as revised 1/10/18 states, It is the policy of this facility to provide nursing standards for assessment, prevention, treatment, and protocols to manage residents at any level of risk for skin breakdown and for wound management, and All residents will be assessed to determine the degree of risk of developing a pressure ulcer using the Braden Scale-Ulcer Risk Assessment. This policy states that protocols for pressure ulcer prevention are, based upon the needs and condition of the resident. In addition, this policy defines a DTI as, Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying tissue from pressure and/or shear, and The wound may further evolve and become covered by thin eschar (devitalized tissue). R21's Minimum Data Set (MDS) assessment dated [DATE] documents R21 is severely cognitively impaired and requires extensive assistance from staff for bed mobility, transfers, and dressing. R21's Braden Scale for Predicting Pressure ulcer Risk dated 11/7/22 documents R21 is at risk for the development of pressure ulcers. R21 has risk factors which includes R21 is chairfast with his ability to walk severely limited or non-existent, cannot bear weight and/or must be assisted into a chair or wheelchair, and makes frequent though slight changes in body or extremity position independently. On 12/13/22 at 9:51 AM R21 was observed lying in bed. R21's ankles appeared to be weak causing R21's feet to drop downward in a foot drop position. V5 (Registered Nurse) entered R21's room to assess a new pressure wound which had developed on R21's left great toe. R21 proceeded to examine the tip of R21's left great toe which had an intact blood-filled blister to the outer edge which measured approximately 2.3cm (centimeters) long x 2.0cm wide. V5 stated that R21 has a new wheelchair which has one solid foot plate which both feet rest on when R21 is up in the wheelchair. V5 stated that R21 normally does not wear shoes while he is in his wheelchair. V5 stated she noticed that R21 presses his feet and toes against the foot plate of his wheelchair. V5 stated she believes R21's pressure ulcer developed because of that pressure from his toe on the foot plate of the wheelchair. V5 stated that V16 (R21's Nurse Practitioner) examined R21's wound yesterday and called it a blood-filled blister. V5 demonstrated how R21's wheelchair has a single hard foot pedal on the bottom of R21's specialized wheelchair where R21 rests both of his feet. R21's physician's orders sheet (POS) dated 12/13/22 states, Monitor and apply betadine to blood blister on left great toe. Keep pressure off. R21's practitioner's progress notes dated 12/12/22 and documented by V16 states, OT (Occupational Therapy) to evaluate proper positioning in wheelchair. On 12/13/22 at 12:30 PM R21 was seated in the dining room in a specialized wheelchair. R21 was not wearing any shoes and R21's feet and toes, including where R21's pressure ulcer was located, appeared to be pressing against the single foot pedal of R21's wheelchair. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145820 If continuation sheet Page 4 of 15 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 145820 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount Sterling Health and Rehab Center 435 Camden Rd Mount Sterling, IL 62353 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one of one residents (R26) reviewed for range of motion in a sample of 19. Findings include: A Restorative Program Checklist dated 6/26/13 states, A restorative assessment is completed prior to implementing the (restorative) program and at least quarterly thereafter, and Measurable objectives & interventions are documented in the care plan and clinical record. A Contracture Prevention Program policy dated 1/15/11 gives as its objectives, 1. To maintain residents at the highest level of physical functioning possible. 2. To stimulate circulation and prevent edema. 3. To prevent fixation of a joint for long periods of time. 4. To prevent atrophy of muscles. In addition, this policy states, The plan of care established by physical therapy or nursing when a contracture is present or the resident is at risk for developing a contracture may include goals, positioning aids, treatment plans and potential for improvement. R26's Minimum Data Set (MDS) assessment dated [DATE] documents R26 requires extensive assistance of two people for transfers, bed mobility, dressing, toileting and personal hygiene. This same MDS documents that R26 has a functional limitation in range of motion to both R26's upper and lower extremities but is not receiving any range of motion nursing restorative programs. R26's current care plan does not include interventions to address R26's decreased range of motion to her upper and lower extremities. R26's physician's orders sheet (POS) dated 11/21/22 documents R26 was ordered to have Occupational Therapy (OT) dynamic activities including the use of balance strategies, strengthening and range of motion techniques to improve performance of a functional task or activity three times weekly for 30 days. On 12/12/22 at 10:41 AM R26 was observed seated in a wheelchair in her room. R26 stated that she has a decrease in range of motion because of severe Osteoarthritis to her arms, legs, and fingers. R26 stated that she does not receive any range of motion exercises to her upper and lower extremities from the facility's nursing staff but does receive therapy to her upper extremities from the OT department. R26 stated she is unable to move her legs and hips very well and requires the use of a mechanical sit/stand lift for transfers and requires extensive assistance from staff to move in her bed. On 12/14/22 at 2:30 PM V19 (Occupational Therapy Aide) stated that R26 was referred for Range of motion exercises and to evaluate for the need of adaptive equipment such as specialized eating utensils because of R26's severe Osteoarthritis. V19 stated that Osteoarthritis has affected R26 everywhere. However, V19 stated she is only providing therapy to R19's upper extremities. V19 stated that she gave R26 a choice of what part of her body she wanted to do therapy to and that R26 chose to work on just her arms. V19 stated that R26 said she didn't think she would benefit from therapy to her legs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145820 If continuation sheet Page 5 of 15 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 145820 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount Sterling Health and Rehab Center 435 Camden Rd Mount Sterling, IL 62353 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 12/14/22 at 9:30 AM V2 (Director of Nurses) stated that although R26 uses a sit/stand mechanical lift for transfers, that type of transfer provides some weight bearing for R26 but no lower extremity range of motion benefit. V2 stated the facility has just hired a new Restorative nurse who has not been there long enough to evaluate residents for their range of motion needs. On 12/14/22 at 10:33 AM V6 (Certified Nurse Aide) stated that R26 is not on a range of motion program from nursing staff. Event ID: Facility ID: 145820 If continuation sheet Page 6 of 15 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 145820 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount Sterling Health and Rehab Center 435 Camden Rd Mount Sterling, IL 62353 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to accurately assess residents for the use of bed rails and ensure bed rails were not left in the up position for residents who could not turn or reposition independently in the bed for five of five residents (R21, R1, R22, R26, R18) reviewed for bed rail safety in a sample of 19. Findings include: A Bed Rails policy dated as revised 1/10/18 states that bed rails may be used under certain circumstances which includes to, Assist in transfer into and out of their bed. To enable the resident('s) ability to independently make subtle position changes for comfort and pressure relief. To enable the residents (') ability to participate with staff in assistance to turn and reposition. This policy does not address residents who cannot independently utilize bed rails to reposition, or other safety concerns including impaired cognition or residents' individualized entrapment risks. 1. A list of R21's current diagnoses includes Down's Syndrome, Generalized Muscle Weakness, Muscle Wasting and Atrophy, and Major Depressive Disorder. R21's Minimum Data Set (MDS) assessment dated [DATE] documents that R21 is severely cognitively impaired, requires extensive assistance of two people for bed mobility, transfers, dressing and toilet use; and is always incontinent of bowel and bladder. This same MDS documents R21 requires substantial/maximal assistance from staff to roll to R21's side and roll to R21's back again. In addition, this MDS documents an attempt to walk R21 during this assessment was not made due to R21's medical condition or a safety concern. R21's care plan intervention dated 10/11/21 states, (R21) requires assist x (times) 2 for bed mobility. (R21) is not able to use his bed rails due to cognition. R21's Bed Rail Evaluation dated 12/1/22 documents R21 uses one-quarter side rails on both sides of R21's bed. This evaluation documents under alternatives attempted prior to using bed rails as, (R21) is unable to assist staff with his bed mobility without the rails. (R21) is able to grasp the side rail with verbal cues and hand guidance from staff to hold onto. The use of side rails promotes independence allowing (R21) to participate in his own mobility. R21's Bed Rail Evaluation's bed rail risk section with boxes to check for all of R21's risks for using bed rails including incontinence, reduced range of motion, decreased ability to ambulate or perform routine activities, symptoms of withdrawal/depression/reduced social contact, skin integrity issues, and entrapment was left blank. In addition, R21's Bed Rail Evaluation describes how the use of bed rails increases R21's ability to function or improve R21's quality of life as, Side rail use promotes independence with (R21's) bed mobility and allows him to assist staff. On 12/12/22 at 11:18 AM R21 was lying in bed with one-quarter bed rails in the up position on either side of R21's bed. V5 (Registered Nurse) and V6 (Certified Nurse Aide) were providing R21 with extensive assistance to reposition in the bed. During this process, R21 did not reach for the side rails or provide any assistance with repositioning. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145820 If continuation sheet Page 7 of 15 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 145820 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount Sterling Health and Rehab Center 435 Camden Rd Mount Sterling, IL 62353 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. R1's list of current diagnoses includes Severe Intellectual Disabilities and Spastic Hemiplegic Cerebral Palsy. R1's Minimum Data Set (MDS) assessment dated [DATE] documents that R1 is severely cognitively impaired, is totally dependent on two people for bed mobility, transfers, dressing and toilet use; has functional limitation to both R1's upper and lower extremities, and is dependent on staff to roll to R1's side and roll to R1's back again. In addition, this MDS documents an attempt to walk R1 during this assessment was not made due to R1's medical condition or a safety concern. This same assessment documents R1 is always incontinent of bowel and bladder. R1's care plan focus dated 12/23/16 states R1 has an activities of daily living self-care deficit related to Cerebral Palsy which gives R1 little control over the movements of R1's extremities. This same care plan documents R1 has extreme difficulty at times carrying out verbal cues. In addition, this care plan states that staff will provide R1 with verbal cues to assist in bed mobility by pushing up with his feet. R1's care plan does not indicate that R1 has bed rails kept in the up position on his bed or under what circumstances bed rails will be used. R1's Bed Rail Evaluation dated 8/29/22 documents R1 uses one-quarter side rails on both sides of R1's bed. This evaluation documents under alternatives attempted prior to using bed rails as, (R1) uses side rails to perform bed mobility by grasping onto the side rail when staff assisting rolling from side.) Resident hangs onto the side rail much of the time while he is in bed. Without the use of side rails (R1) is no longer able to assist with these actions. (R1) is unable to use trapeze bar or bolster mattress due to limited ROM (range of motion) and decreased upper body strength. R1's Bed Rail Evaluation's bed rail risk section with boxes to check for all of R1's risks for using bed rails including incontinence, reduced range of motion, decreased ability to ambulate or perform routine activities, symptoms of withdrawal/depression/reduced social contact, skin integrity issues, and entrapment was left blank. In addition, R1's Bed Rail Evaluation describes how the use of bed rails increases R1's ability to function or improve R1's quality of life as, (R1) uses side rails to assist in independent bed mobility and as security while in bed. On12/12/22 at 2:34 PM R1 was lying in bed with one-quarter bed rails in the up position on each side of R1's bed. R1 was grasping both bed rails with R1's hands but not turning or repositioning himself in the bed. V15 (Certified Nurse Aide/CNA) and V13 (CNA) entered R1's room to provide R1 with incontinence care. R1 let go of the bed rails while V15 and V13 physically turned and repositioned R1 from side-to-side during incontinence care. R1 did grasp the bed rails during R1's care but did not use them to assist with any aspect of turning or repositioning. R1 also did not use his legs to help V15 and V13 boost R1 up in bed. On 12/13/22 at 1:30 PM V13 stated that R1 likes to hold onto the bed rails while in bed or while receiving care but that R1 cannot use the bed rails for independent bed mobility. 3. R22's list of current diagnoses includes Osteoarthritis, Neurocognitive Disorder with Lewy Bodies, Depression, Insomnia, Anxiety Disorder, History of Falling. R22's Minimum Data Set (MDS) assessment dated [DATE] documents R22 is severely cognitively impaired, requires extensive assistance of two people for dressing and bed mobility, is totally dependent on two people for transfers and toilet use; and is always incontinent of urine and occasionally incontinent of bowel. R22's MDS documents that walking R22 was not attempted due to R22's medical condition or safety concerns. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145820 If continuation sheet Page 8 of 15 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 145820 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount Sterling Health and Rehab Center 435 Camden Rd Mount Sterling, IL 62353 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 0700 Level of Harm - Minimal harm or potential for actual harm R22's care plan focus dated 8/26/22 documents that R22 has, both short and long-term memory deficits and confusion. (R22 is) able to make simple daily decisions with verbal cues and supervision to ensure (R22) make(s) the safest most appropriate decisions. R22's care plan does not indicate R22 has bed rails attached to R22's bed, is able to use bed rails independently or requires staff supervision while using bed rails for bed mobility. Residents Affected - Some R22's Bed Rail Evaluation dated 11/14/22 documents R22 uses one-quarter bed rails on both sides of R22's bed. This evaluation documents under alternatives attempted prior to using bed rails as, (R22) is unable to use trapeze to help with turning and getting out of bed due to lack of upper arm strength and body size. (R22) uses bed rails to assist staff with turning and repositioning. R22's Bed Rail Evaluation's bed rail risk section with boxes to check for all of R22's risks for using bed rails including incontinence, reduced range of motion, decreased ability to ambulate or perform routine activities, symptoms of withdrawal/depression/reduced social contact, skin integrity issues, and entrapment was left blank. In addition, R22's Bed Rail Evaluation describes how the use of bed rails increases R22's ability to function or improve R22's quality of life as, (R22) is able to complete bed mobility independently with the bed rails up. When bed rails were lowered (R22) had a hard time turning. (R22) maintains more independence with her ADLs (activities of daily living) with the use of bed rails. On 12/12/22 at 11:12 AM R22 was lying in bed with one-quarter bed rails in the up position on both sides of the bed. R22 stated she could use her bed rails to help her turn and reposition in the bed. At 11:22 AM V17 (Certified Nurse Aide/CNA) and V6 (CNA) entered R22's room to provide incontinence care. V17 and V6 instructed R22 that they needed to turn R22 to her right side. Only after R22 was turned to the right did she grab onto the bed rail to help keep herself on her side. Once R22 was repositioned onto her back, R22 stated that she could grab onto the bed rails to hold on once she was turned by staff to the side, but that R22 could not reach across her chest to grab the bed rail to independently turn to her side. On 12/13/22 at 1:30 PM V13 (CNA) and V14 (CNA) stated they were R13's CNAs for that day. V13 and V14 stated that R22 has bed rails in the up position on her bed but that R22 is unable to use the bed rails without staff assistance. 4. R26's list of current diagnoses includes Polyosteoarthritis and Scoliosis. R26's Minimum Data Set (MDS assessment dated [DATE] documents that R26 is cognitively intact, requires extensive assistance of two people for bed mobility, transfers, and toilet use, and has a functional limitation in both upper and lower extremities. This same MDS documents R2 is always incontinent of urine, occasionally incontinent of bowel, and requires substantial/maximal assistance from staff to roll to R26's side and roll to R26's back again. In addition, this MDS documents an attempt to walk R26 during this assessment was not made due to R26's medical condition or a safety concern. R26's care plan intervention dated 12/27/21 states, BED MOBILITY: (R26) needs staff assistance to turn and reposition in bed encourage her to use her bed rails to assist with turning. R26's Bed Rail assessment dated [DATE] documents R26 uses one-quarter side rails on both sides of R22's bed. This evaluation documents under alternatives attempted prior to using bed rails as, Due to limited ROM (range of motion) in upper arms (R26) is unable to use trapeze or bolster mattress to pull herself up or over in bed. Bed rails were lowered, and resident was a total assist for bed mobility and to sit up on side of bed. Bed rails were raised, and resident was able to use rails to help (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145820 If continuation sheet Page 9 of 15 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 145820 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount Sterling Health and Rehab Center 435 Camden Rd Mount Sterling, IL 62353 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some turn and sit on side of the bed. R26's Bed Rail Evaluation's bed rail risk section with boxes to check for all of R26's risks for using bed rails including incontinence, reduced range of motion, decreased ability to ambulate or perform routine activities, symptoms of withdrawal/depression/reduced social contact, skin integrity issues, and entrapment was left blank. In addition, R26's Bed Rail Evaluation describes how the use of bed rails increases R26's ability to function or improve R26's quality of life as, Bed rails enables resident to help staff turn and reposition self in bed and sit up on side of bed. Resident is unable to use any other alternatives due to limited ROM and pain. On 12/13/22 at 1:22 PM R26 was seated in a wheelchair in her room. R26's bed had one-quarter bed rails on either side of R26's bed in the up position. R26 stated that she is unable to use the bed rails independently and that she requires staff to assist her to turn and reposition while in the bed because of pain and upper and lower extremity weakness related to Osteoarthritis. On 12/14/22 at 11:50 AM V8 (MDS/ Care Plan Coordinator) stated she is also the facility's Restorative Nurse and is new to the position. V8 stated, as part of her restorative duties, she performs residents' bed rail assessments. V8 stated that residents whose Bed Rail Evaluations don't have any risks marked in the check boxes don't have any of the conditions which might place them at risk. V8 stated that R26 is cognitively intact and can accurately describe her bed mobility limitations. V8 stated that she thought once staff turns R22 to her side and R22 holds onto the bed rail, that indicated R22 could use the bed rail independently. V8 stated that R1 likes to hold onto the bed rail while he is in bed because it makes him feel secure. V8 verified that R21 was assessed as being unable to use the bed rails without staff assistance for verbal cues and guidance. V8 also verified that R21's care plan states R21 is unable to use bed rails due to R21's cognitive status. 5. R18's Bed Rail Evaluation dated 11-1-22 and signed by V8 (MDS/Minimum Data Set) Assessment documents, Type of bed rail ordered: 1/4 (One-Quarter) side rails. Indications for use: 1. Enhanced bed mobility/comfort positioning. 2. Provide comfort for fear of falling/injury. 3. Serve as a reminder not to get up without assistance if unsafe to do so. 4. Decrease physical and/or cardiac exertion. 5. Promote independence and positive self-esteem. 6. Decrease exertional pain. Risks for bed rail use: (Section not completed). Resident Evaluation: Is the resident physically able to release bed rails? No. Resident Cognition: Confused. Mobility in and out of bed: Partial dependence on staff with or without assistive devices. Resident has been determined to be a fall risk based on the fall assessment: Yes. Continence with bladder and bowel? Incontinence. Ability to toilet self safely: No. R18's MDS (Minimum Data Set) assessment dated [DATE] documents R18 is severely cognitively impaired and requires extensive assistance of two staff physical assistance for bed mobility, toilet use, personal hygiene, and dressing, and extensive assistance of one staff physical assistance for eating. R18's current Plan of Care does not include a plan of care regarding R18's use of side rails along with risks and interventions to reduce those risks associated with side rail use. On 12/13/22 at 10:30 AM R18 was lying in bed with bilateral one-quarter length side rails in the raised position. R18 was confused at this time. V6 (CNA/Certified Nursing Assistant) asked (R18) to use grab the side rail to turn herself. R18 was unable to understand V6's request and unable to use the side rails. On 12/13/22 at 10:35 AM V6 (CNA/Certified Nursing Assistant) stated, (R18's) side rails are always raised when she is in bed. (R18) cannot use her side rails on her own. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145820 If continuation sheet Page 10 of 15 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 145820 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount Sterling Health and Rehab Center 435 Camden Rd Mount Sterling, IL 62353 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete On 12-14-22 at 11:00 AM V2 (Director of Nursing) stated, (R18's) bed rail evaluation is inaccurate and does not identify (R18's) entrapment risks and other risks associated with bed rail use. On 12/14/22 at 11:44 AM V8 (MDS/Minimum Data Set) Assessment stated, (R18) would have a risk of entrapment since she is cognitively impaired and cannot use her side rails on her own. The bed rail assessment is inaccurate and should have had risks identified with the use of side rails. Event ID: Facility ID: 145820 If continuation sheet Page 11 of 15 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 145820 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount Sterling Health and Rehab Center 435 Camden Rd Mount Sterling, IL 62353 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on observation, interview, and record review the facility failed to document behaviors to justify the use of anti-psychotic medications and failed to implement non-pharmacological behavioral interventions prior to the use of anti-psychotic medications for one of three residents (R27) reviewed for anti-psychotic medications with the diagnosis of Dementia in the sample of 19. Findings include: The facility's Psychotropic Medication policy dated 11-28-17 documents, Intent: Residents are free from unnecessary psychotropic medication use. Specific condition/medical symptoms alone are not enough to justify pharmacological use. An evaluation must be done to determine other possible physical, mental, behavioral, and psychosocial needs. Indications for use for psychotropic medication may include but not limited to 1. Expressions or indications of distress. 2. Symptoms are clinically signification that is causing a functional decline. 3. Non-pharmacological approaches were implemented and not effective or were clinically contraindicated. Behavioral symptoms present a danger to the resident or others. Dose, Duration, and Monitoring: 2. Evaluation of the effectiveness of the non-pharmacological approaches prior to medication administration. R27's OBRA (Omnibus Budget Reconciliation Act) Initial Screen dated 3-19-21 documents R27 has no history of mental illness prior to admission. R27's Electronic Physician's Order Sheets dated 12-12-22 document R27 has diagnoses of Restlessness, Agitation, and Unspecified Dementia with Other Behavioral Disturbance and has received Quetiapine Fumarate (anti-psychotic medication) 25 mg (milligrams) by mouth at bedtime related to restlessness and agitation since 3-28-22. R27's MDS (Minimum Data Set) Assessments dated 10-27-22, 7-29-22, and 4-28-22 document R27 is severely cognitively impaired, has no physical, verbal, or other behaviors, and does not have behaviors that impact harm to herself or others. R27's current Care Plan documents, Focus: I am receiving anti-psychotic medication due to restlessness and agitation. I have a diagnosis of Dementia with behaviors. Monitor for target behaviors of pacing, disrobing, inappropriate response to verbal communication, violence/aggression towards others. R27's Psychoactive Medication Initial and Quarterly Evaluation dated 10-31-22 documents, Medication Diagnosis or Indication for use of anti-psychotic medication: Behaviors that interfere with judgement. R27's Progress Notes, Behavior Task Notes, and Social Service Notes dated 3-28-22 through 12-13-22 document R27 has only had two behaviors on 7-15-22 and 7-18-22 of yelling out. These same behavior notes do not include any non-pharmacological interventions implemented for R27's behaviors of yelling out. On 12/12/22 at 11:10 AM R27 was observed sitting quietly in a high back padded chair in the dining room. R27 was having no behaviors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145820 If continuation sheet Page 12 of 15 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 145820 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount Sterling Health and Rehab Center 435 Camden Rd Mount Sterling, IL 62353 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 0758 On 12/12/22 at 9:42 AM R27 was sitting in a high back padded chair receiving a nebulizer treatment by mask. R27 was sitting quietly and was having no behaviors. Level of Harm - Minimal harm or potential for actual harm On 12/12/22 at 10:04 AM V6 (CNA/Certified Nursing Assistant) stated, (R27) never has any behaviors. Residents Affected - Few On 12/12/22 at 11:05 AM V5 (Registered Nurse/RN) stated, (R27) does not have any behaviors. On 12-13-22 at 1:15 PM V2 (Director of Nursing) stated, (R27) does not have behaviors to warrant the use of an anti-psychotic medication. There is no documentation that staff are using non-pharmacological interventions for any behaviors that (R27) may have had. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145820 If continuation sheet Page 13 of 15 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 145820 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount Sterling Health and Rehab Center 435 Camden Rd Mount Sterling, IL 62353 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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Potential for minimal harm Based on interview and record review, the facility failed to state in their arbitration agreement that the agreement can be rescinded within 30 days of signing it and that it is not required to sign an agreement for binding arbitration as a condition of admission to, or to continue to receive care at, the facility. The facility also failed to have the resident, or their representative acknowledge if they understood the agreement. This had the potential to affect all 37 residents residing in the facility. Residents Affected - Many Findings include: The facility's Arbitration Agreement between Facility and Resident is part of the admission Contract. The Mediation/Arbitration is in Section N on page ten of the admission Contract. The resident or their representative is required to initial after this section. The last page of the Contract, page 16, documents The undersigned acknowledge that each has read and understood this Contract, and that each voluntarily consents to all its terms. I further understand that I have the ability to refuse to enter into this contract and instead, remove the Resident from the Facility's Care. There is no documentation in the arbitration agreement that it is voluntary for the resident or representative to sign the agreement for binding arbitration, and it does not have any condition in which the agreement can be rescinded. It also does not define what arbitration is in language that the resident or their representative acknowledged they understand, and the arbitration agreement is a condition of admission or to continue to receive care. R3's Contract between Resident and Facility, dated 7/30/22, documents that V11 (R3's family member) initialed the binding arbitration agreement and signed the contract. On 12/13/22 at 4:30 PM, V11 (R3's Family Member) stated I don't recall what I was told about the arbitration agreement. I was only thinking that I needed to get (R3) admitted into the facility. R33's Contract between Resident and Facility, dated 7/29/22, documents that V10 (R33's family member) initialed the binding arbitration agreement and signed the contract. On 12/13/22 at 4:50 PM, V10 stated, I don't specifically know what the arbitration agreement was about. That was a whirlwind of a week. They went over a lot of paperwork at one time. They may have explained it, but I don't specifically remember the arbitration agreement being discussed and didn't know I was giving up legal rights. On 12/14/22 at 10:11 AM, V9 (Social Services) stated that she does not read the arbitration agreement verbatim to the resident or their representative. I try to make it simple, so they understand it but I'm not sure if they do. Everyone must initial the agreement and sign the contract, or they will not be admitted . I have never had anyone refuse to initial the arbitration agreement but there is a specific clause on the signature page that says they will agree to all terms or take the resident home. On 12/14/22 at 11:05 AM, V1 (Administrator) acknowledged that the arbitration agreement was a condition of admission, did not document that it was voluntary, and it does not have any condition in which the agreement can be rescinded. It also does not define what arbitration is in language that the resident or their representative acknowledged they understood. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145820 If continuation sheet Page 14 of 15 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 145820 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount Sterling Health and Rehab Center 435 Camden Rd Mount Sterling, IL 62353 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 0847 The facility's CMS (Centers for Medicare and Medicaid Services) Form 672 dated 12/12/22 and signed by V2 (Director of Nursing) documents 37 residents reside within the facility. Level of Harm - Potential for minimal harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145820 If continuation sheet Page 15 of 15