Inspection·December 20, 2023

F 0758 Level of Harm - Minimal harm or potential for actual harm 'mothering' someone. R1 always has felt the needed to assist and take care of or 'mother other people'. Both residents continue at baseline. Investigation concluded that allegation of willful abuse unsubstantiated related to investigation findings that (R1) was trying to show motherly affection to (R2). Follow Up Action Taken: (R1) was placed on 1:1. Care plan reviewed and updated. Medication review completed, new medication added. Residents Affected - Few On 12/20/23 at 11:12 a.m., V11 stated she witnessed (R2) sitting on the couch, and (R1) bent over and kissed (R2). She had never witnessed (R1 & R2) be affection towards each other or any other residents. V11 also stated that she didn't think (R1) purposely was trying to be affectionate in an inappropriate way. R1's Nurses' notes, dated 10/30/23 at 1:28 p.m., documents, Nurse Practitioner here to see resident. New order Risperdal (antipsychotic) 0.5 mg (milligrams) at HS (bedtime). Diagnosis: Dementia with inappropriate behaviors. The facility's Report to the State Agency, dated 11/17/23, documents, On 11/14/2023 (9:23 a.m.) a verbal resident to resident allegation was reported to the administrator. Residents were immediately separated, and investigation initiated. Investigation concluded that (R1) was using profanity at the dining room table, staff present attempted to verbally redirect her and (R1) picked up a piece of toast and tossed it across the table. The toast landed in front of (R3) who picked it up and tossed it back towards (R1). Neither resident was hit by the toast. (R1) continued to use foul language and staff were able to encourage (R1) to leave the dining room where staff provided 1:1 until behavior subsided. (R1) could not recall the incident during investigation interview related to cognitive deficits associated with diagnosis of Dementia with behavioral disturbances and a BIMS of 3 (Severely Cognitively Impaired). (R3) was unable to recall any events that occurred related to the incident due to cognitive deficits associated with diagnosis of Dementia and a BIMS of 4 (Severely Cognitively Impaired). (R1) and (R3) have remained at baseline and show no signs of mental anguish. The facility finds the allegation of willful abuse unsubstantiated. Follow-Up Actions Taken: Both Residents plan of care have been updated. The facility will continue to monitor residents as needed. Doctor increased (R1's) Risperdal and added Sertraline (antidepressant). R1's Nurses' notes, dated 11/14/23 at 3:45 p.m., document, Physician here to see resident. New order to increase Risperdal to 0.5 mg, BID (twice a day AM & HS). Sertraline 25 mg daily for dementia and behaviors. The facility's Report to the State Agency, dated 12/15/23, documents, A comprehensive investigation was initiated and found that on 12/12/23 at approximately 2:30 p.m. (V12 Activity aide) witnessed a physical interaction between two residents. During the interview (V12) stated that (R1) was in the dining room attending an activity with other residents. She suddenly started to try to back away from the table and when she was unable to she started flailing her arms around and made contact with (R4's) right upper arm. (R1) could not recall he incident during investigation interview related to cognitive deficits associated with diagnosis of Dementia with behavioral disturbances and a BIMS of 3 (severely cognitively impaired). (R1 and R4) have remained at baseline and show no signs of mental anguish. The facility finds the allegations of willful abuse unsubstantiated. Follow-Up Actions Taken: Both residents plan of care have been reviewed. The facility will continue to monitor residents as needed. Doctor increased (R1's) Risperdal. Facility interviews, dated 12/12/23, document, (V12) stated that she was hosting an activity with the recollections residents in the dining room doing puzzles. (V12) was going around the table (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145820 If continuation sheet Page 2 of 4 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 12/20/2023 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 providing oversite. (R1) was seated with (R4) to the left of her. (R1) who had been sitting at the table clapping hands and observing all of the sudden tried to back away from the table. She was unable to get away from the table because another resident wheelchair was blocking her. At this point, (R1) started swinging her arms around making contact with open hands to (R4's) upper right arm. R1's Nurses' notes, dated 12/12/23 at 6:00 p.m., document to increase R1's Risperdal to 1 mg by mouth twice a day. R1's Nurses' notes, dated 12/13/23 at 9:13 a.m., document, Reached out to (V13 R1's POA-Power of Attorney) to update on (R1) and that we are trying to keep resident in house while we wait to see if the medication for UTI (Urinary Tract Infection) was causing the increase in behaviors. While on the phone with (V13) staff from the unit came and let me know that resident behaviors were further elevated and they were having to be 1:1 with her in the activity room . (R1) has not approached any co-residents this morning but is striking out at staff and making threats. (V13) did agree for us to send to hospital for evaluation and treatment. R1's Nurses' notes, dated 12/13/23 at 3:06 p.m., document, Resident returned to facility via ambulance. New orders include Seroquel (antipsychotic) 25 mg BID (twice a day), may increase to 50 mg BID after 2 days for delirium. Haldol (antipsychotic) 2 mg IM (intramuscularly) PRN up to two times daily for severe agitation. R1's Nurses' notes, dated 12/13/23 at 5:17 p.m., document, New order given to discontinue Risperdal due to resident starting Seroquel. R1's Order Summary Report, dated 12/18/23, documents that as of this date R1 has orders to receive Haldol 2 mg IM every eight hours as needed for severe agitation related to diagnosis of Dementia and Seroquel 50 mg twice a day for delirium related to Dementia. R1's Behavior Monitoring, dated 10/1/23-12/18/23, document that R1 is being monitored for the behavior of change in mood with one episode of being angry/annoyed occurring for the month of October and two for the month of December. On 12/18/23 at 1:15 p.m., V14 (Registered Nurse) stated that she had never seen (R1) have any type of altercations with (R1) and any other residents. (R1) can be combative with staff, but not residents. I've never witnessed her have any sexually inappropriate behaviors either. On 12/20/23 at 12:15 p.m., V2 (Director of Nursing) stated that profanity, yelling and having a hard time resting were the behaviors that she has exhibited as to why the facility started R1 on the Risperdal, and the diagnosis of Dementia with behaviors. On 12/20/23 at 11:35 a.m., V6 (Minimum Data Set Coordinator) stated that (R1's) behaviors are yelling out and cursing and she's grabby. She likes to grab staff hands and rub them or kiss them. It's not always aggressive. I have not seen any sexually inappropriate behaviors from her. With the kissing incident, she is known to try to kiss staff on the cheek being affectionate and telling them she loves them. On 12/20/23 at 12:15 p.m., V2 (Director of Nursing) stated that (R1) was admitted on [DATE]. She's been using profanity mainly. She can be very affectionate and maternal she likes to hug and kiss staff. She likes to hold hands as well. We've tried giving her a fake cat to take care of. Profanity, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145820 If continuation sheet Page 3 of 4 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 12/20/2023 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 FORM CMS-2567 (02/99) Previous Versions Obsolete yelling, and having a hard time resting were the behaviors that she has exhibited as to why we started the Risperdal, and the diagnosis of Dementia with behaviors. V2 also confirmed that R1's Haldol should have a stop date of no longer than 14 days from when it was started on her PRN Haldol. On 12/20/23 at 12:30 p.m., V1 (Administrator) stated that on 10/28/23, (V11) was very clear that (R2) was seated and (R1) was talking to him standing over him with her hands behind her back and leaned over and kissed him. It was nothing sexual. Which was behaviors that she had displayed with the other staff and wanting to be motherly. The incident (11/14/23) with (R3) was basically (R1) tossed her toast and it landed in front of (R3). (R3) then picked it up and tossed back across the table. The way it (12/12/23 incident) was presented to me she was sitting in activities, she's impulsive, she attempted to back up and she couldn't back up because a wheelchair was behind her and she got frustrated. Once she hit that wheelchair and couldn't get away she felt trapped she started flailing her arms. Her arms flailing was not directed at (R4). We called the doctor about the incident, and she wanted the medication increased. The next day she woke up mad and we had to keep staff with her. She was being really threatening and aggressive towards the staff. So, we sent her to the hospital to get medical clearance. I've recommended against the Haldol. I think she would need to be unable to redirect anyway shape or form in order to give her the Haldol PRN. I'm not ok with them giving it. She would really have to be going after residents and unable to be redirected. When we started the Risperdal, (R1) was showing more elevated behaviors, for instance the clapping, and we were trying to calm her. She was having a lot of verbal behaviors and frustrated with staff. If you spend time with her, she was not being hateful she just wasn't good on the inside. Event ID: Facility ID: 145820 If continuation sheet Page 4 of 4