Inspection·June 6, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Both residents assessed with no injury noted. Both residents PCP (personal care physician), POA (power of attorney)/resident representative. Ombudsman and local PD (police department) notified. Investigation initiated. Will send a follow up report within 5 working days. A Written statement dated 12/4/2024 at 12:05 PM V19, CNA (Certified Nurses Assistant) documented, I was sitting at the assist table and seen (R160) propelling her w/c (wheelchair) out of the dining room when she accidentally bumped (R37's) wheelchair and (R37) became upset and hit her. I immediately got up and helped (R160) out of the dining room then (R37) was fine. V1 documented this written statement. A Written Statement dated 12/4/2024 at 12:15 PM staff asked R160 what happened, and she stated, I'm not sure. I was trying to get out of the dining room. I had my head down I didn't see him until I seen his hand. Staff asked did he say anything to you? R160 responded, Not that I heard. Staff asked did you say anything to him? R160 responded, No, I didn't. V1 documented this written statement. On 6/4/2025 at 10:00 AM R37 lay in bed. R37 didn't respond to any questions asked by the IDPH surveyor. On 6/5/2025 at 11:30 AM R37 lay in bed. No response from resident regarding hitting (R160) on 12/4/2024, he just stared at me. On 6/6/2025 at 10:45 AM, V1 Administrator stated she recalled the altercation between (R37) and (R160.) V1 stated the altercation was witnessed by a CNA who reported (R37) hit (R160) across on the cheek in December 2024. V1 stated staff separated the residents immediately and there was no red mark on (R160's) cheek. V1 stated (R37) doesn't have a history of hitting other residents before this incident and hasn't hit any resident since the incident. V1 stated (R160) didn't have behaviors while she resided at the facility. The Facility's Typed Letter dated 12/11/2024 documents this letter will serve as a follow up to the initial notification sent on 12/4/2024 regarding an allegation of a resident-to-resident physical altercation between (R37) and (R160). On 12/4/2024 at approximately 12:15 PM V19, CNA reported an allegation of resident-to-resident physical altercation between (R37) and (R160.) Both residents were immediately separated and assessed with no injury noted. The facility-initiated investigation per protocol including notification of both resident's physician's and families, the ombudsman and the local police department. (R37) was interviewed and voiced (R160) bumped into his wheelchair as she was leaving the dining room. (R37) alleges a verbal exchange between them but was unable to voice what was said. (R160) was interviewed and voices she is unsure what happened. (R160) voices that she had her head down and the next thing she saw was (R37's) hand. (R160) voices she did not speak to (R37.) Staff interviews reveal that (R160) did bump into (R37's) wheelchair while attempting to leave the dining room. No one voiced witnessing any conversation between (R160) and (R37.) V19, CNA was interviewed and stated she was at the table assisting a resident and witnessed (R160) bumping into (R37's) wheelchair but she did not hear any conversation between the two residents. She immediately got up and assisted (R160) out of the dining room. This typed follow-up letter did not document that staff (V19, CNA) observed (R37) hit (R160) in the dining room during the resident-to-resident altercation. The Facility's Abuse Prevention Policy revised 11/28/2016, documents this facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as denied below. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145851 If continuation sheet Page 2 of 10 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 06/06/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment, The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our residents. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145851 If continuation sheet Page 3 of 10 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 06/06/2025 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure progressive interventions are documented on resident's care plan for 1 of 5 (R12) residents in a sample of 23. Findings include: R12's Undated Face Sheet, documents she was initially admitted to the facility on [DATE] and diagnoses included dementia, chronic pain, GERD (Gastroesopageal Reflux Disorder), hypertension, depression, IBS (Irritable Bowel Syndrome), insomnia, anxiety, malnutrition and osteoarthritis. R12's Quality Care Reporting Form, dated 2/4/2025 documents R12 sustained a left lower extremity skin tear during a transfer by bumping it on wheelchair pedal. Leg sleeves for the intervention documented. R12's Quality Care Reporting Form, dated 2/5/2025 documents R12 sustained a right forearm skin tear from bumping arm on wheelchair arm rest. Arm sleeves for the intervention documented. R12's Bruise/Skin Discoloration Incident Report, dated 3/19/2025 documents nursing description: during ADL care noted to have 6.5 CM (Centimeter) x 5.5 CM dark purple bruise to right lower arm poor nutrition, hospice care, fragile, restless with transfers causing arm to hit w/c (Wheelchair) requiring area. Resident description: Unable to answer. Incident witnessed: No. Questioned what happened and if it hurt, denies pain, MD (Medical Doctor) notified. DON (Director of Nursing) notified. POA (Power of Attorney) notified. Injuries observed at time of incident: bruise on right forearm. Other info: needs frequent reminders to wait for assistance for transfers. No intervention documented on the incident report form. On 6/5/2025 at 11:30 AM V16, LPN (Licensed Practical Nurse) stated she was familiar with (R12) and recalled in March 2025 she was very confused and had a UTI (Urinary Tract Infection) so that increased her confusion. V16 stated (R12) consistently hit her arms against her wheelchair arms and that is how the bruise was sustained. V16, LPN stated she transferred (R12) from her wheelchair to her recliner that day she noted the bruise on (R12's) right forearm and documented it. V16 stated the bruise didn't occur during the transfer as it was already there and that it most likely occurred because (R12) was so restless and hit her arms on the wheelchair arms during that time. V16 stated she notified V2 of the bruise but she didn't recall what intervention was put in place at that time. R12's Undated Care Plan documents skin integrity resident is at risk for skin breakdown d/t (due to) frail skin and can be resistive with peri care at times. Interventions: 6/4/2025 leg sleeves on AM off HS (bedtime) to wear at all time d/t frail skin with risks for s/t's (skin tears.) 2/6/2025: Observe skin with AM/PM care and with toileting for redness, rashes, open areas, pain, swelling and report them to team leader. Weekly skin check. No intervention of arm sleeves documented for skin tear that was sustained on 2/5/2025. Leg sleeves were not documented on R12's care plan until 6/4/2025 for skin tear sustained on 2/4/2025 and no intervention documented to prevent futher bruising to R12's arms. On 6/5/2025 at 2:00 PM V20, Care Plan Coordinator stated she works Monday through Friday and when she is at the facility and a new intervention is added for a resident she documents it on the care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145851 If continuation sheet Page 4 of 10 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 06/06/2025 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few plan either the same day or the next day and on the weekends the nurse starts the intervention immediately and she is notified of the new intervention and she documents the new intervention on the resident's care plan on Monday. During an interview on 6/6/2025 at 9:20 AM V2, DON stated according to the incident report dated 3/19/2025 its documented the bruise (R12) sustained on her right forearm occurred during a transfer but V16 documented the incident wasn't witnessed so she was confused by this documentation. V2 stated if (R12) was restless and hitting her arms against her wheelchair arms an appropriate intervention would be to pad the wheelchair arms to prevent further bruising/injuries. V2 stated nurses have access to resident's care plans and she expected the assigned nurse to add an intervention to the resident's care plan the same shift the incident occurred. The Facility's Care Planning Policy dated 12/2024, documents every resident will be assessed using the Minimum Data Set (MDS) according to the guidelines in the Resident Assessment Instrument (RAI) manual. The comprehensive plan of care must address all care issues that are relevant to the individual. No documentation on the care planning policy to show what timeframe to add/document progressive interventions on resident's care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145851 If continuation sheet Page 5 of 10 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 06/06/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide adequate supervision to prevent falls and implement progressive interventions for accidents and falls for 3 of 4 residents (R35, R12, R46) reviewed for accidents and hazards in the sample of 23. Findings include: 1. R35's Face Sheet documents R35 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, chronic obstructive pulmonary disease, and mild dementia. R35's Minimum Data Set (MDS) dated [DATE] documented R35 was moderately cognitively impaired and required supervision with showering. R35's Care Plan revised 3/11/25 documents R35 has risk factors requiring monitoring to reduce the potential for self-injury. R35's Fall Risk assessment dated [DATE] documented R35 was at risk for falls. R35's 3/22/25 Fall Investigation by V17, Licensed Practical Nurse (LPN), documents V17 entered the bathroom and found R35 sitting on her buttocks in front of the shower stall. R35 stated she was adjusting towel on the seat of the shower chair before sitting down and lost her balance, landing on her buttocks. Injuries included bruises to sacrum, right forearm, and left forearm. R35's Skin Inspection assessment dated [DATE] documents R35 had bruises to sacrum, left forearm and right forearm related to fall. On 6/5/25 at 2:45 PM, R35 stated she was alone when she fell in the shower room. She remembers an aide stepping out of the room prior to her fall, but she cannot remember which aide it was. R35 got up to get shampoo, then was putting a towel on the shower seat when her legs gave out and she landed on her bottom. She stated she still has trouble with that hip, because it hurts when she gets out of bed in the morning, and it still just is not right. On 6/5/25 at 2:35 PM, V17 was not available for interview by phone. On 6/5/25 at 1:38 PM, V1, Administrator, stated staff were not with R35 when she fell and would expect staff to stay with residents who require supervision with showering. 2. R12's Undated Face Sheet, documents she was initially admitted to the facility on [DATE] diagnoses included dementia, anxiety, depression and hypertension. R12's Undated Care Plan, documents no documentation of bruises or interventions to prevent resident from bruising. R12's Nurse Progress Note, dated 3/19/2025 at 7:23 PM documents a 6.5 CM (centimeter) x 5.5 CM dark purple bruise noted to right lower forearm. Resident states IDK (I don't know) when asked what happened. Denies pain. DON (Director of Nurses), POA (power of attorney) and MD (physician) updated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145851 If continuation sheet Page 6 of 10 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 06/06/2025 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 0689 Will monitor until healed. Level of Harm - Minimal harm or potential for actual harm R12's Bruise/Skin Discoloration Incident Report, dated 3/19/2025 documents nursing description: during ADL (Activities of Daily Living) care noted to have 6.5 CM x 5.5 CM dark purple bruise to right lower arm poor nutrition, hospice care, fragile, restless with transfers causing arm to hit w/c (Wheelchair)requiring area. Resident description: Unable to answer. Incident witnessed: No. Questioned what happened and if it hurt, denies pain, MD notified. DON notified. POA notified. Injuries observed at time of incident: bruise on right forearm. Other info: needs frequent reminders to wait for assistance for transfers. Residents Affected - Few R12's Significant Change Minimum Data Set (MDS) dated [DATE] documents no physical or verbal behaviors and no rejection of care. On 6/5/2025 at 11:30 AM V16, LPN stated she was familiar with (R12) and recalled in March 2025 she was very confused and had a UTI (Urinary Tract Infection) so that increased her confusion. V16 stated (R12) consistently hit her arms against her wheelchair arms and that is how the bruise was sustained. V16 stated she transferred (R12) from her wheelchair to her recliner that day she noted the bruise on (R12's) right forearm and documented it. V16 stated the bruise didn't occur during the transfer as it was already there and that it most likely occurred because (R12) was so restless and hit her arms on the wheelchair arms during that time. V16 stated she notified V2 of the bruise but she didn't recall what intervention was put in place at that time. On 6/5/2025 at 11:45 AM V11, CNA (Certified Nurse Assistant) stated (R12) is confused and she gets upset at times and hits her arms against her wheelchair arms. V11 reviewed the daily staffing dated 3/19/2025 and stated according to the staffing document she was assigned to (R12) on 3/19/2025 but she didn't recall (R12) hitting her arms on her wheelchair or observing a bruise on (R12's) arm that day. On 6/5/2025 at 10: 20 AM V14, CNA stated she is assigned to (R12) today and stated (R12) is confused and gets physical at times, hitting her arms against her wheelchair arms when she gets mad. On 6/5/2025 at 12:10 PM V15, CNA stated (R12) is confused and does hit her arms on her wheelchair at times when she is upset. On 6/5/2025 at 12:10 PM R12 lay in bed with her eyes open. IDPH surveyor asked her if she knew how she got the bruise on her arm on 3/19/2025, (R12) laughed and shrugged her shoulders and said, I don't remember. On 6/5/2025 at 1:40 PM, V2 Director of Nurses (DON) and V3 Assistant Director of Nurses (ADON) assessed (R12's) arms. V2 removed R12's geri sleeve on her left arm. V3 stated there was a dark pinkish/purple bruise mid forearm that measured 2.0 cm x 1.5 cm, V3 asked (R12) how she got that bruise and (R12) stated probably from the fall. V2 removed (R12's) geri sleeve on her right arm. V2 stated there was a purplish/pink bruise mid forearm that measured 1.4 cm x 1.9 cm. V2 asked (R12) how she got that bruise and (R12) stated probably from the fall. V3 stated (R12) had fell but that was a while ago. V2 stated (R12) probably got the bruises from bumping them against her wheelchair. During an interview on 6/6/2025 at 9:20 AM V2, DON stated according to the incident report dated 3/19/2025 its documented the bruise (R12) sustained on her right forearm occurred during a transfer but V16 documented the incident wasn't witnessed so she was confused by this documentation. V2 stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145851 If continuation sheet Page 7 of 10 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 06/06/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm if (R12) was restless and hitting her arms against her wheelchair arms an appropriate intervention would be to pad the wheelchair arms to prevent further bruising/injuries. On 6/6/2025 at 10:10 AM V1, Administrator stated she isn't sure the facility has an accident/incident policy, and she will look. Residents Affected - Few On 6/6/2025 at 1:00 PM no facility accident/incident policy received. 3. R46's Undated Face Sheet documents R46 was admitted to the facility on [DATE] and has a diagnosis of Dementia, Major Depressive Disorder, Adjustment Disorder with Depressed Mood, Anxiety Disorder, Type 2 Diabetes Mellitus, Hypertension, Lack of Coordination, and Muscle Wasting and Atrophy. R46's Care Plan with an initiation date of 6/14/2024, documents R46 has risk factors that require monitoring and intervention to reduce potential for self-injury. R46 has weakness, unsteady gait, takes psych meds, history of falls, confusion & gets up without assist. R46's Care Plan does not document new progressive interventions for R46's falls that occurred on 3/8/2025, 3/21/2025, 4/7/2025, and 5/1/2025. R46's Minimum Data Set (MDS) dated [DATE] documents R46 is mildly cognitively impaired and is dependent on the assistance of staff with toileting hygiene, getting from a sitting to a standing position, lying to sitting on the side of the bed, transferring from a chair to bed/bed to chair, and toilet transfers. The Facility's Monthly Fall Analysis Report documents R46 experienced a fall on 11/28/2024, 2/20/2025, 3/8/2025, 3/21/2025, 4/7/2025, and 5/1/2025. R46's Quality Care Reporting Form dated 11/18/2024 documents R46 sustained a fall with no injuries. R46 was getting up without assistance to go to the bathroom, no call light in use. Sign placed on bathroom door to remind resident to use call light and wait for assistance. Interventions implemented to prevent another fall includes sign on bathroom door- Call don't fall. Progress Note dated 2/20/2025 at 1:45 AM documents resident pressure alarm sounding. Resident sitting on the floor in front of her recliner, the footrest to the recliner still up. Resident says that she was trying to get up and the chair tipped forward and she slid to the floor. No injuries noted. Range of motion (ROM) within normal limits (wnl). Neuro checks started and wnl. Resident denies pain or discomfort. Resident assisted up per mechanical lift. Resident placed on 30 min checks for 24 hours. Progress Note dated 3/9/2025 at 5:15 AM documents residents pressure alarm sounding. Resident sitting on floor in front of toilet in resident bathroom. Resident had adult diaper down and floor was wet with urine. Resident also had bare feet, no shoes or slipper socks on. Resident just says that she slipped. Resident denies hitting head, but Neuro checks started due to (d/t) fall not witnessed. Neuros wnl. ROM wnl. Resident denies pain or discomfort. Resident got up from floor per mechanical lift. Attempted to notify Power of Attorney (POA), but no answer. Resident placed on 30 min checks for 24 hours. Progress Note dated 3/24/2025 at 10:34 AM documents Interdisciplinary Team (IDT) met to review fall from 3/21/25. Resident was in bathroom by self and was self-transferring from toilet, attempting to pull pants up by self and lost balance causing resident to fall onto buttocks in front of toilet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145851 If continuation sheet Page 8 of 10 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 06/06/2025 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 0689 Fall intervention: Staff education to not leave resident on toilet by self. Level of Harm - Minimal harm or potential for actual harm Progress Note dated 4/7/2025 at 3:29 AM documents residents alarm was sounding. Resident observed laying on the floor on her right side. Resident had got up without assist and without her walker and lost her balance and fell. No injuries noted. Resident denies hitting her head, but neuro checks started d/t unwitnessed fall. Neuro checks wnl. ROM wnl. Resident denies pain or discomfort. Resident got up off the floor per mechanical lift. Resident bought to recliner at nurses' station to be in view of staff. Resident placed on 30 min checks for 24 hours. Medical Doctor (MD) made aware. Attempted to call POA, but no answer. Residents Affected - Few Progress Note dated 5/1/2025 at 9:55 AM documents Resident was sliding out of recliner at nurses' station and was lowered to the floor by staff. Resident was attempting to self-transfer. Pressure alarm was in place and functioning properly. MD and POA aware. No injuries voiced. Resident denies pain or discomfort. On 6/6/2025 at 9:49 AM V2, Director of Nursing (DON), stated a new intervention should be implemented on a resident's Care Plan after each fall. V2 stated new interventions can get tricky to come up with depending on the resident and how many falls they have experienced, but the goal is for a new intervention to be put in place with each fall. The Facility's Fall Prevention Policy revised 11/10/2018, documents policy to provide for resident safety and to minimize injuries related to fall; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. Procedure: a fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. The unit nurse will place any new intervention on the CNA assignment worksheet. All falls will be discussed in the Morning Quality Assurance meeting and any new interventions will be written on the care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145851 If continuation sheet Page 9 of 10 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 06/06/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on interview, observation, and record review, the Facility failed to ensure food was stored in a manner that prevents foodborne illness. This has the potential to affect all 55 residents living in the Facility. Residents Affected - Many Findings include: On 6/4/25 at 9:15 AM, in the standing freezer there was a plastic bag with uncooked steak that was not labeled or dated. The bag was previously opened and was not resealed, leaving the meat open to air. There was a bag of uncooked chicken that was not labeled or dated. The steak and chicken were both stored on the top shelf next to a sponge cake and directly above a box of dinner rolls. V4, Dietary Manager, stated, We can probably get rid of those. They have been in there for a while. On 6/4/25 at 9:20 AM, in the resident refrigerator there was a carton of ham salad with R50's name on the label. The sell by date was 5/28/25. There was a plastic bag of deli meat that was not dated. The bag had been opened and was not resealed, leaving contents open to air. V4 stated that should have a label on it. On 6/4/25 at 9:23 AM, in the standing refrigerator there were two pitchers labeled sweet tea with use by dates of 5/9. There were two pitchers labeled lemonade with use by dates of 5/9. There was a pitcher containing a clear liquid with no label or date. There were 26 individual cups of assorted colored liquids on a tray that were not labeled or dated. There was a plastic container labeled turkey with use by date of 5/9. V4 stated, We will throw that out. On 6/6/25 at 9:48 AM, V1, Administrator, stated she expects staff to follow the Facility's food storage guidelines. The Facility's Undated Food Storage Policy documents, Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration. Leftover contents of cans and prepared food will be stored in covered, labeled and dated containers in refrigerators and/or freezers. Store raw animal foods such as eggs, meat, poultry, and fish separately from cooked and ready-to-eat food. If they cannot be stored separately, place raw meat, poultry and fish items on shelves beneath cooked and ready-to-eat items. It multiple shelves are available, the raw animal food with the highest final cooking temperature shall be stored on the lowest level, i.e. poultry and stuffed foods. The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 6/4/25 documents there are 55 residents living in the Facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145851 If continuation sheet Page 10 of 10