Inspection·February 28, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the Facility failed to perform hand hygiene and prevent cross contamination, for three separate wounds, during wound/skin care for one of five Residents (R37) reviewed for wound/skin care in a sample of 20 Residents Affected - Few Findings include: Facility Dry Dressing Policy, dated 7/2/23, documents: the purpose is to provide guidelines for the application of dry, clean dressings; perform hand hygiene, put on clean gloves, loosen tape and remove soiled dressing; pull glove over dressing and discard into plastic bag; perform hand hygiene, open dressing equipment using clean technique, place on clean field, perform hand hygiene and put on clean gloves, cleanse wound with ordered cleanser, if using gauze, use clean gauze for each cleansing stroke, clean from the least contaminated area to the most contaminated area; discard disposal items into the designated container; remove disposable gloves and discard into designated container; and perform hand hygiene. Facility Hand Washing Policy, dated 7/1/23, documents: to provide guidelines for adequate hand washing in order to reduce the transmission of organisms from Resident to Resident, Staff to Resident and Resident to Nursing Staff; the Facility considers hand hygiene the primary means to prevent the spread of infections and all staff will properly wash hands after direct contact with any contaminated substance, after direct Resident care, and as instructed; it is the responsibility of all staff to ensure that they properly wash their hands after direct contact with Resident, contaminated substances, and as needed; must wash their hands for fifteen to twenty seconds using antimicrobial, or non-antimicrobial soap and water after contact with blood, body fluids, secretions, mucous membranes or non-intact skin; and after handling items potentially contaminated with blood, body fluids or secretions. R37's Physician Order Sheet/POS, dated 2/27/24, documents diagnoses including Type Two Diabetes Mellitus with Foot Ulcer, Non Pressure Chronic Ulcer of Right Heel and Midfoot Limited Breakdown of Skin. R37's POS also documents wound/skin treatment orders for the following: apply skin adhesive ointment (Skin Prep) to Right Heel, then border gauze daily at night (HS) and as needed for dry eschar; cleanse Left Heel with wound cleanser, apply medicated cream (Calcium Alginate), then cover with a four by four (gauze) and cling wrap daily and as needed; and cleanse Right First Metatarsal with wound cleanser, apply medicated cream (Calcium Alginate) to wound bed, cover with dressing and change daily and as needed. On 2/27/24 at 11:07 am, V5 (Infection Preventionist/Wound Nurse) was performing Diabetic Ulcer wound care to R37's Left Heel, Right Heel and Right First Metatarsal. V5 removed R37's heel protector boots. R37 did not have a dressing on R37's Right Heel and Right First Metatarsal. V5 removed R37's Left Heel soiled dressing, and the medicated cream covering (Calcium Alginate), was still adhered to R37's Left Heel. V5 then applied wound cleanser to a stack of four-by-four gauze pads and cleansed R37's Right Heel, and with the same soiled gauze pads, cleansed R37's Left Heel. R37's Left Heel medicated cream pad (Calcium Alginate) fell onto R37's bed sheet. V5 picked up the medicated cream pad (Calcium Alginate) with the stack of cleansing four by four gauze pads and continued to cleanse R37's Left Heel and Right First Metatarsal. V5 did not use separate clean cleansing gauze pads, remove gloves, or perform hand washing between the wound care for R37's three diabetic wounds. On 2/27/24 at 12:45 pm, V2 (Director of Nursing) stated, (V5) is fairly new to this position and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145820 If continuation sheet Page 2 of 7 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 02/28/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm (V5) told me that (V5) was extremely nervous during (R37's) wound care. (V5) should have used different gauze pads to clean each individual wound, and also (V5) should have done hand hygiene and put on new gloves between each wound, so they would not get cross contaminated. . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145820 If continuation sheet Page 3 of 7 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 02/28/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on interview and record review the Facility failed to investigate a fall for one of four residents (R50) reviewed for falls in a sample of 20. Residents Affected - Few Findings include: Facility Policy Accidents and Incidents, dated 07/01/23, documents: all accidents/incidents involving a Resident will be documented in Risk Management. The nursing team will complete an investigation with the root cause and new interventions; Section Responsibility documents it is the responsibility of the Charge Nurse to complete the accident and incident in (a computerized charting system), notify attending Physician and responsible parties and document accordingly. It is the responsibility of the DON/Director of Nursing/Designee to investigate and ensure appropriate completion, notification, and follow-up on all accidents and incidents; Section Procedure: Reporting documents Accident and Incidents, including injuries of an unknown origin, must be reported to the department supervisor, and an accident/incident report should be completed on the shift that the accident or incident occurred; Section titled Medical Attention documents the charge nurse shall examine all accident/incident victims and the Medical Director or resident's personal Physician shall be notified of the accident/incident; Section Investigate and Follow Up Action documents the charge nurse must conduct an immediate investigation of the accident/incident and implement immediate appropriate interventions to affected parties, the accident/incident report must be completed, charge nurse will place the residents name on the 24-hour report summary, the DON, Interdisciplinary Team and/or designee will conduct an investigation of the accident/incident as well, findings will be indicated in the appropriate area, the Interdisciplinary Team/IDT will review within 24 hours or next business day and discuss and attempt to find out the root cause and implement an appropriate intervention to attempt to prevent further falls. R50's progress notes for 12/22/23 have no notes regarding R50's fall. R50's Progress Note, dated 12/23/23 at 7:25 pm, document: Staff were changing resident due to incontinence. Resident had five-inch-long x three-inch-wide bruise on left outer Thigh/Hip and (R50) was unable to verbalize how the bruise appeared. R50's Progress Note, dated 12/24/2023 at 8:35 am, written by V1 (Administrator) and linked to the 12/23/23 bruise note documents that R50 had a fall on 12/22/23 and was found on floor at bedside leaning to left side. There was no documentation of R50's fall prior to this progress note. On 12/24/2023 at 8:58 am, R50's progress note documents: that R50 has had no signs or symptoms of pain from previous fall on 12/22/23; noted dark purple bruise on left hip area; able to stand without any grimacing or yelling; no shortening of left leg or visual deformity noted or reported; and will notify Hospice Physician and Power of Attorney. On 02/26/24 at 11:23 am, V1 (Administrator) stated that, I was made aware of (R50's) fall as I received shift report on 12/23/23 at 6:00 am. V1 was unaware there had not been documentation on R50's fall. V1 began the reporting and investigation of R50's fall on 12/24/23. On 02/27/24 at 12:28 pm, V1 confirmed R50's fall had not been promptly documented in Risk Management, recorded in the computerized charting system, reported to R50's physician or power of attorney or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145820 If continuation sheet Page 4 of 7 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 02/28/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete investigated. V1 confirmed there was no documentation for R50's assessment, investigation, interventions or follow up documented until V1 began an investigation on 12/24/23. V1 stated (R50's) fall on 12/22/23 occurred at approximately 11:30 pm. V1 confirmed that R50's medical record did not document R50's 11/22/23 fall, examination or investigation until 12/24/23, and that R50's Physician was not immediately contacted. Event ID: Facility ID: 145820 If continuation sheet Page 5 of 7 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 02/28/2024 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 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to provide any treatment or counseling for a residnet with a diagnosis of PTSD (Post Traumatic Stress Disorder) and failed to identify triggers for PTSD for one resident (R29) of three residents reviewed for PTSD in a total sample of 20. Residents Affected - Few Findings Include: The Facility's undated Trauma Informed Care Procedure documents Nursing staff are trained on screening tools, trauma assessment and how to identify triggers associated with re-traumatization. Caregivers are taught strategies to help eliminate, mitigate or sensitively address a resident's triggers. R29's Care Plan dated 03/01/23 documents I suffered a traumatic life event. I was physically assaulted which resulted in bodily harm. I require ongoing support and intervention with a counselor. R29's Care Plan does not address any triggers or any situations for staff to avoid related to R29's PTSD. R29's Care Plan dated 09/01/23 documents This resident has a history that indicates they may have experienced significant trauma during their lifetime. Specifically, trauma related to unexpected loss of a loved one. On 02/27/24 at 9:00 AM, R29 stated I would feel triggered if I were alone with a man because of the history of my attack. My friend dying, I don't have any specific triggers, the grief comes in waves. On 02/26/24 at 1:30 PM, V2 (Director of Nursing) confirmed that R29 has no identified triggers for her PTSD diagnosis and has not been seen by a counselor since July 2023. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145820 If continuation sheet Page 6 of 7 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 02/28/2024 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 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 wash their hands and change gloves between two different residents (R8 and R33) of four residents reviewed for personal cares in a total sample of 20. Residents Affected - Few Findings Include: The Facility's Standard Precautions Policy dated 6/19/22 documents Standard Precautions are used in the care of all residents regardless of their diagnoses or suspected or confirmed infection status. Standard Precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. On 2/26/24 at 1:30 PM, V4 (Certified Nurse Aide) rolled R33 to his side, touched his buttocks while pointing out multiple small open areas. V4 then rolled R33 to his back and used both gloved hands to roll back the foreskin on R33's penis and repeatedly touched the tip of the penis while indicating where small open areas were on the penis. After V4 covered R33 back up, she went directly to R8's bed without changing gloves or sanitizing hands in any way, rolled R8 to his side and pulled down R8's skin folds to the back of the right thigh to indicate multiple small open areas. On 2/26/24 at 2:00 PM, V4 confirmed that she did not wash her hands or change her gloves between R33 and R8. V4 stated Oh yeah, I should of changed gloves and washed my hands. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145820 If continuation sheet Page 7 of 7