Inspection·December 29, 2023

F 0600 if the situation again presented itself, he would talk to staff instead. Level of Harm - Minimal harm or potential for actual harm On 12/27/23 at 2:20pm V7, Housekeeper, stated on 12/17/23 at about 10am, she was walking toward the short hall entranceway to the dining room. V7 could hear R2 talking loud about being tired of people in his way, and he was going to start stepping on peoples toes. V7 then heard R1 say ouch. R2 then rolled out of the dining room mumbling under his breath, and R1 had a shocked look on her face. V7 stated she finished cleaning the dining room and then reported the incident to V10, Registered Nurse. Residents Affected - Few On 12/27/23 at 2:30pm, V11, Activity Aid/Former Housekeeper, stated she also witnessed the altercation between R1 and R2. V11 stated R1 was in the short hallway leading into the dining room, sleeping in her wheelchair. V11 stated she saw R2 tell R1 to move. V11 stated she told R2 that R1 was asleep. R2 stated he was going to start running over people's toes. V11 heard R1 say, Ouch, my toe. V11 stated R2 said, I'm tired of people getting in my way. V11 stated she and V7 finished putting the cleaning cart up and went and reported the incident to V10. V10 told them to call V1. On 12/28/23 at 10:20am, V1 stated staff are to report abuse immediately to her, and she is the facility's Abuse Coordinator. V1 stated V1's understanding is that V7 and V11 reported the incident immediately to V10. V1 stated she began an immediate investigation after she was notified and she notified law enforcement, the facility's Ombudsman representative, R1 and R2's Physicians and [NAME] of Attorney, and IDPH. The Facility's Abuse Prevention Policy dated 8/16/21 stated, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. The facility therefore prohibits mistreatment, neglect, or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145890 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 145890 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eldorado Rehab & Healthcare 1001 A Jefferson Street Eldorado, IL 62930 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on interview, observation, and record review the facility failed to ensure preventative cleaning measures were implemented to promote pest control and maintain an environment free of insects. This failure has the ability to affect all 62 residents living at the facility. Residents Affected - Many Findings include: On 12/27/23 at 11:40am, R4 was alert and oriented to person, place, time and purpose. R4 stated she has seen roaches in the facility dining room on her table within the past few weeks. On 12/28/23 at 8:50am, a roach was observed crawling on the floor of the Activity/Alternate Dining Room. On 12/28/23 at 9:00am, the facility kitchen was toured. V4, Cook, stated for past 2 to 3 weeks he has seen roaches in the dish room. The floor of the dish room was flooded with food debris under the garbage disposal. The dish room smelled of rotting food. V4 stated V5, Dietary Manager, and V1, Administrator, are aware of this issue. V4 stated it is his understanding is they are trying to get an exterminator to come to the facility. V4 stated the roaches are probably due to the disposal leaking and attracting them. V4 stated the disposal got fixed 3 to 4 weeks ago but is broken again and has been leaking for the past week. V4 stated V6, Maintenance Director, has looked at it several times. V4 stated all shifts are to clean and he hasn't had a chance to clean yet today. A shelf by the service window containing a tray of clean cups was noted to have a roach crawling on the tray, with food debris and grime on the tray. Shelving over the food preparation (prep) area held a container, covered with grime, which held brown sugar, cheese puffs, and vanilla wafers which were open to air. A sign over the prep area stated, Everything must be sealed, labeled, and dated. A food prep table in the center of the room under which there was shelving, and this shelving was heavy with grime and food crumbs. Clean sheet pans were being stored on this shelf. Utensils such as spatulas were stored on the prep table in a grimy container in which there was food debris. Also on the prep table were roach adhesive traps containing dead roaches. A grimy container with oven mitts was observed to contain food particles. Gnats were flying around and landing on the utensils. A toaster oven was soiled with grime and crumbs. A flat top grill's grease trap was full of congealed oil and chunks of food. A deep fryer was full of dark oil with food debris and heavy grime on its surfaces. The freezer area contained a laundry basket of dirty rags with gnats flying around it. Bins of flour and sugar being stored on the floor were heavily soiled with grime. An empty steam table was noted to have food particles in the compartments. The dining room had built in drawers with various items such as drinking straws, and was noted to have dead roaches in all the drawers. On 12/28/23 at 9:40am, V7, Housekeeping staff, stated she has been employed at the facility for about a year and has observed roaches in the building on a daily basis since then. V7 stated she has observed roaches crawling on trays and food during meal service. V7 stated while standing at the service window, she has observed roaches crawling on the walls in the kitchen. V7 stated it is dietary staff's responsibility to clean the kitchen. V7 stated a pest control company comes and sprays periodically but it never seems to help. On 12/28/23 at 10:00am V5 stated there have been roaches since about 11/27/23, and V1 is aware. V5 stated a pest control contractor comes and sprays every few weeks, and was last here about 3 weeks ago. V5 stated as far as V5 knows, he hasn't been back and nobody has called him. V5 stated the disposal was fixed a few weeks ago but has been leaking again for about a week. V5 stated he not sure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145890 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 145890 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eldorado Rehab & Healthcare 1001 A Jefferson Street Eldorado, IL 62930 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many what is wrong with it but he thinks it may be due to kitchen staff getting it too full without flushing it with water. On 12/28/23 at 10:20am, V1 stated she was not aware of roaches or disposal issues in the kitchen, but a family member told her yesterday there was a roach in a resident room. V1 stated the facility's pest control contractor is scheduled to come monthly and if there is a problem between appointments, the facility can notify them and they will come out. V1 stated the pest control vendor was last at the facility on 12/10/23. On 12/28/2023 at 10:45am, V6 stated the garbage disposal has been having problems for about a month. V6 stated the unit was fixed but began acting up again on 12/26/23. V6 stated he examined it and found the collar on the unit had failed. V6 stated he called his corporate Maintenance Director who then ordered a new collar, which has not yet arrived. V6 denied ever seeing roaches in the kitchen but acknowledged that residents have complained about roaches. V6 stated he believes the pest control contractor sprayed a couple of weeks ago. V6 stated he does not accompany the contractor when he visits. On 12/28/23 at 11:11am, V6 reported a garbage disposal had been located at a sister facility and it would be delivered on 12/28/23 and the project would be completed by the morning of 12/29/2023. An undated Pest Control and Prevention Policy stated, It is the policy of this facility to control pests and vermin and provide a clean, safe environment for its residents and staff and to establish procedures that ensure those conditions are maintained on a continuous basis. Procedure step 4 of the same policy documents The facility shall enforce rules and regulations related to the storage of perishable items from meals to prevent opportunistic pestilence such as gnats and rodents. At each facility, residents will be assisted to ensure all food items are kept in sealed containers or contained in original sealed packages. Under the section titled Control step 1 documents Each facility's daily sanitation inspection of the facility shall include checking for presence of pests or vermin. It will also include proper disposal of trash and food waste, properly stored food items and lids on dumpsters are closed. Supplies will be removed from cardboard boxes where possible upon receipt. According to terminex.com/roachcontrol, the following things attract roaches: Food, Water, Shelter. Recommendations include to eliminate access to food by throwing away food that has been left out on counters .throw garbage away every night. Clean by wiping surface of food prep areas and remove any crumbs from the floor. Deep cleaning is important .clean under appliances and wipe down appliances on the counter .clean underneath and behind refrigerator, stove and check drawers for leftover food debris. Store food in airtight containers .or in airtight bags that are stored off the floor, ideally in a cabinet or pantry. Remove standing water by checking pipes and repairing any leaks . A Room Roster dated 12/27/23 documented a total of 62 residents living at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145890 If continuation sheet Page 4 of 4