Inspection·May 2, 2024

F 0690 Level of Harm - Minimal harm or potential for actual harm R17's MDS, dated [DATE], documents that R17 is severely cognitively impaired, is totally dependent on staff for toiling hygiene, and is always incontinent of bowel and bladder. On 5/2/24 at 10:35 AM, V9, was questioned why she did not why she did not completely clean R17, V9 stated, I didn't notice any stool on the cloth. Residents Affected - Few On 5/2/24 at 10:47 AM, V2, Director of Nurses, stated, During incontinent care, I expect the groin, pubic area, thighs and labia cleansed with more than just one wipe. The policy Perineal Cleansing, undated, documents, Female Resident. 12. Wash the pubic area including upper inner aspect of both thighs and front portion of perineum. a. Use long strokes from the most anterior down to the base of the labia. b. After each stroke, refold the washcloth to allow use of another area. 13. Follow same procedure for rinsing 14. Dry thoroughly. 15. Instruct or assist resident to turn to their side with tope leg slightly bent. 16. Wet the washcloth and soap, other cleansing agent. 17. Wash peri-anal thoroughly with each stroke beginning at the base of the labia and extending up over the buttocks. a. Refold the cloth, as before, to provide clean area. b. Washing should alternate side to side, ending with center anal area. 18. Rinse cloth and entire area in same sequence as above. Dry thoroughly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145851 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 145851 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastside Health and Rehabilitation Center 1400 East Washington Street Pittsfield, IL 62363 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on record review and interview the facility failed to provide a Registered Nurse (RN) 8 hours a day seven days a week. This has the potential to affect all 50 residents residing at the facility. Residents Affected - Many Findings include: On 04/29/24 at 1:20 PM, the facility daily staffing sheets were reviewed. The staffing sheets documents there was no RN coverage for 8 hours a day in the facility for the following dates: 4/6/24, 4/7/24, 4/20/24 and 4/21/24. On 4/29/2024 at 3:09 PM, V1, Administrator, stated the facility does not have a policy on staffing. V1 stated a RN should be on duty 8 hours a day seven days a week. The CMS 671 Facility Application for Medicare and Medicaid, dated 4/29/2024, documents a census of 50 residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145851 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 145851 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastside Health and Rehabilitation Center 1400 East Washington Street Pittsfield, IL 62363 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 3. On 04/29/24 at 01:38 PM, V2 entered R7's room to hang / run an IV (Intravenous) of Piperacillin and Tazobacton 3.375 grams in 100 ML (milliliters) of Normal Saline (NS). V2 performed and hygiene, donned gloves, spiked the IV bag, primed a new IV line, cleansed IV catheter hub with alcohol, flushed with 10 ML of NS and attached the line. V2 set the IV pump to run at 100 ml/hr (hour). V2 removed her gloves and exited the room. V2 failed to perform hand hygiene. Residents Affected - Some On 5/2/24 at 10:20 AM, V2, stated, I was talking to (R7) and just forgot. I was trying to keep him happy. On 5/1/24 at 3:30 PM, V20 stated that all staff should wash hands before putting on gloves and after removing them. The policy Hand Hygiene, dated 8/14/23, documents, Hand washing can also be used routinely in the following clinical situations: 6. Removing gloves. 4. On 04/30/24 at 9:45 AM, V9, Certified Nurse Aide, (CNA) and V10, CNA entered R17's room to lay her down and provide incontinent care. R17's pants and incontinent brief was removed. During care, V9 left the bedside to go wash her hands. V10 stayed at bedside. R17 reached down with both hands and began to scratch at her pubic area. V10 stated, Oh no get your hands out of there. V10 then assisted R17 with placing her hands on her stomach. V10 failed to wash R17's hands. On 5/2/24 at 11:13 AM, V10, was questioned why she did not offer to wash R17's hands, V10 stated, Oh my gosh, I forgot. On 5/2/24 at 11:15 AM, V1, Administrator, stated, We do not have a policy specifically toward washing of a residents hands, but I would expect staff to help and encourage residents to wash their hands when needed. Based on observation, interview and record review, the facility failed to do complete hand hygiene, assist residents with handwashing, maintain a clean field during a wound dressing change, and ensure resident rooms and common resident-use areas are cleaned in a manner that prevents the spread of infection for 9 of 24 residents (R6, R7, R9, R11, R17, R18, R23, R33, R48) reviewed for infection control in the sample of 39. Findings include: R6's Laboratory Result, dated 4/9/24, documents R6 wound to R6's right leg is positive for Methicillin Resistant Staph Aureus (MRSA). On 4/30/24 at 9:13 AM, V13, Housekeeper, was seen cleaning R6's room. R6 was on contact isolation for MRSA. V13 stated that she uses this same cart to clean all rooms. V13 pulled a washcloth out of a bucket of water on the cart and took it into R6's room, began wiping things down, then placed the washcloth into a plastic bag. V13 used the toilet brush off her cart and cleaned R6's toilet and replaced it back on the cart. V13 used the broom off the cart, swept the floor, then put the broom back on the cart. V13 then used the mop sitting in the mop bucket and mopped R6's floor, then placed the mop back into the mop bucket of water. V13 finished R6's room and took the cleaning cart down the hall and began cleaning the West-Hall restroom/shower room with the same contaminated broom, mop, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145851 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 145851 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastside Health and Rehabilitation Center 1400 East Washington Street Pittsfield, IL 62363 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 mop water that was used in R6's isolation (MRSA) room. Level of Harm - Minimal harm or potential for actual harm On 5/2/24 at 9:03 AM, V13, Housekeeper, stated that she changes her mop water whenever it looks dirty. V13 stated that on isolation rooms, she tries to change the water after every room, but sometimes she gets confused and forgets. V13 stated that the other day when she was cleaning (R6's) room, she did go into the shower room on the west-hall to clean that room after cleaning R6's. Residents Affected - Some On 5/2/24 at 9:08 AM, V21, Housekeeper, stated that she starts out her shift with a clean mop bucket of water, she will clean and mop the non-isolation rooms first, then change the mop water, and then do the isolation rooms. When she is done with the isolation rooms, she will change the mop water and mop head. V1, Administrator, provided a list of residents who received a shower in the West-Hall shower room on 4/30/24. This was after V13 used contaminated mop water to clean the shower room. There were six residents R9, R11, R18, R23, R33, and R48 who received a shower in that shower room that day. On 5/2/24 at 9:28 AM, V20, Regional Nurse, stated the Routine and Terminal Cleaning of Isolation Rooms Policy, does not address mopping the floor, or when to change the mop water or mop head. V20 stated that she would expect the housekeeper to clean the broom and change the mop water and mop head after cleaning an isolation room. The Facility's Routine and Terminal Cleaning of Isolation Rooms, dated 5/30/14, documents To ensure all resident isolation rooms are clean and to prevent the spread of microorganisms. 2. On 5/1/24 at 9:42 AM, V16, Licensed Practical Nurse (LPN) was performing wound care on R6. V16 donned PPE (personal protective equipment) and removed the old dressing from R6's right leg. V16 donned new gloves with no Hand Hygiene done in between glove changes. V16 went into the restroom and got a paper towel from the wall dispenser, wet it from the restroom sink, then walked back to R6 and began wiping his wound on his right leg with the wet paper towel. V16 then used a dry paper towel from the restroom dispenser and dried off the wound. V16 doffed PPE and walked out of room and gathered supplies from the wound cart. V16 took out the Calcium Alginate from the original package and placed it on the top of the cart, without wiping the cart down or having a clean barrier. V16 then picked up the dry dressing, dated it, obtained Kling wrap, and tape, and again placed all supplies on top of the cart while donning PPE again. V16 then entered the room with supplies, and applied the Calcium Alginate to the wound, wrapped R6's leg with Kling, and secured with tape. R6's Laboratory Result, dated 4/9/24, documents R6 wound to his right leg has MRSA. R6's Wound Center Physician Order, dated 4/30/24, documents Cleanse the wound with mild soap and water, gently pat dry prior to applying clean dressing. Apply primary dressing to wound: Begin Calcium Alginate with Silver then dry gauze and roll gauze and tape. Change dressing every day. On 5/2/24 at 10:00 AM, V22, LPN, stated that she will clean R6's wound with wound cleaner or water and 4X4's, will pat dry, then apply the Calcium Alginate and cover with a non-stick pad and tape or wrap to his leg. On 5/2/24 at 10:13 AM, V2, Director of Nursing (DON), stated that she would expect the nurses to maintain a clean and/or sterile field while performing wound care, and to follow physician orders for appropriate wound care and cleaning. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145851 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 145851 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastside Health and Rehabilitation Center 1400 East Washington Street Pittsfield, IL 62363 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 The Facility's Dressing Change Policy, dated 7/2007, documents To avoid introducing organisms into a wound. Procedure: 7. Set up clean area for supplies. 13. Wash your hands. 17. Cleanse wound per physician's order or use gauze and forceps or cotton applicators. 19. Apply dressing without touching wound or side of dressing. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145851 If continuation sheet Page 6 of 6