Health inspection·March 3, 2022

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The facility's initial report to State Agency, dated 2/27/22, documents that on 2/26/22 at 12:50 p.m., R41 was involved in a resident to resident altercation (with R28). R28's Current Care plan dated 2/1/22 and R41's Current Care plan dated 2/21/22, have no documentation of revisions to implement new interventions following the resident to resident altercations that occurred on 2/21/22 and 2/26/22 between R28 and R41. On 03/01/22 at 03:54 PM, V14 (Social Services Director) confirmed that neither R28 nor R41's Care Plans were updated following their resident to resident altercations on 2/21/22 and 2/26/22. On 03/02/22 at 10:09 AM, R28 stated, (R41) is just a rude mean lady. One day she was asking me to take her home or to let her out the door, and I told her no I couldn't do that. She wasn't too happy with that response and hit me. Then a few days later, after lunch I was sitting in my room, and (R41) came to my door to come in. I told her this wasn't her room and for her to leave. Then, I heard a commotion next door, and knew she went into my neighbors room who wasn't in there. So, I went into the hallway and told (R41) she needed to get out of that room because it wasn't her room. No staff were out in the hallway because everyone was still in the dining room. I had my grabber on my lap, and she came at me and grabbed it. Then, she hit me on the arms, on the head, and on my back. She hits hard. It really hurt. (V12-Certified Nursing Assistant/CNA) was in a room and heard the commotion and came out getting the grabber from (R41). I was so upset and crying. It hurt when she hit me and I was just angry. I shouldn't have to worry about another resident hitting me. On 03/02/22 at 12:52 PM, V12 (CNA) stated, I was taking another resident to the bathroom on 200 hall. When I heard (R41) screaming on the 100 Hall. When I got to (R28 and R41), they were yanking the grabber/reacher back and forth. Then, (R28) ripped it out of her hands. I brought (R41) up here to the common room across from the nurses' desk to separate them. (R28) told me that (R41) hit her with the grabber/reacher, and that she was sore. If (R41) was up walking around one of us should be with her. After the 2nd incident (2/26/22), we started the 15 minute checks on (R41). After the first incident, we would try to keep (R41) in the common room. When we are busy, we can't keep an eye on her at all times. On 03/02/22 at 01:00 PM, V13 (Licensed Practical Nurse) stated, On 2/21/22, (R28) was reading the newspaper near the front door and (R41) was standing at the door. (R41) was repeatedly asking everyone to take her home. Then according to (R28), she asked (R28) to take her home. (R28) told her she couldn't take her home, and (R41) hit (R28) in back of her head with her palm. After that incident, we did not have (R41) on 15 minute checks. All we did after the incident was kept them away from each other. We did not keep (R41) in the common room. (R41) prefers to be in her room. (R41) won't stay in the common room unless an activity is going on or its meal time/snacks. (R41) could still move around independently throughout the facility, she wasn't' restricted. The 2nd incident occurred with (V12) around the corner. (R28) got emotional and was crying afterwards saying she didn't have to deal with being hit, and that she isn't going to put up with it. On 3/1/22 at 3:00 p.m., V1 (Administrator) stated, On 2/21/22 the residents were separated, and (R41) was put on a 1:1 until behavior subsided that day. We did a urine dip on (R41) in house that was clear. When we contacted her Physician there were no new orders. However, the Physician stated to us to keep (R41) by the nurses' station. So, we put her in the common area across from the nurse's station to increase her supervision. We continued to keep her in the common area when she wasn't in the dining room. That was working fine until this incident (2/26/22). (V12) came out of another resident's room when she heard (R28 & R41) yelling. According to (R28), (R41) was coming out of a resident room. Everyone was still in the dining room during this time. (R28) had the grabber and was waving (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145952 If continuation sheet Page 2 of 12 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 145952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beardstown Health & Rehab Ctr 8306 St Lukes Drive Beardstown, IL 62618 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 it at her telling her to stay out of other peoples rooms. (R41) took the grabber from (R28) and struck (R28) with it. (R41) said (R28) struck her on the back, back of the head and arms. (R28) claims she was hit three times. Yes, (R41) was unsupervised when the (2/26/22) incident occurred. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145952 If continuation sheet Page 3 of 12 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 145952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beardstown Health & Rehab Ctr 8306 St Lukes Drive Beardstown, IL 62618 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to follow operational policies and procedures regarding developing new interventions to prevent further physical abuse following an allegation of physical abuse for two of two residents (R28, R41) reviewed for abuse in the sample of 24. Residents Affected - Few Findings include: The facility's Abuse Prohibition Policy, dated 3/15/18, documents, Prevention of Abuse: Appropriate interventions to address identified behaviors will be included on resident Care Plans, and reviewed as/when change occurs. These interactions will be communicated to the direct caregivers. The facility Report to the State Agency, dated 2/25/22, documents, This resident (R41) was involved in a resident to resident altercation with no injuries. On February 21, 2022, (R41) was at the nurses station asking staff to taker her home and stating her address repeatedly. (R41) is alert and oriented times one with confusion and requires staff intervention and frequent reminders of the date, year, and where the facility is located. (R41) also requires staff assistance for ADLs (Activities of Daily Living) and she ambulates throughout the facility frequently on a daily basis. On this day, (R41) asked another resident (R28) to take (R41) home as (R28) approached the nurses' station in her electric scooter. (R28) is alert and oriented times three and did not respond to (R41's) request. (R41) then restated to (R28), I need you to take me home, and (R28) responded, 'No, I can't drive.' (R41) then used the inner palm of her right hand to make contact on the back of (R28's) posterior side of her head and then (R41) stated, 'You drive that thing fine. R28's Nurses' notes, dated 2/26/2022 at 12:50 p.m., document, This alert and oriented times three resident (R28) saw another resident (R41) in someone else's room and went into the room to tell (R41) to leave. R41 grabbed the grabber/reacher from (R28) and began to hit (R28) with it. The facility's initial report to State Agency, dated 2/27/22, documents that on 2/26/22 at 12:50 p.m., R41 was involved in a resident to resident altercation (with R28). R28's Current Care plan dated 2/1/22 and R41's Current Care plan dated 2/21/22, have no documentation of revisions to implement new interventions following the resident to resident altercations that occurred on 2/21/22 and 2/26/22 between R28 and R41. On 03/01/22 at 03:54 PM, V14 (Social Services Director) confirmed that neither R28 nor R41's Care Plans were updated following their resident to resident altercations on 2/21/22 and 2/26/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145952 If continuation sheet Page 4 of 12 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 145952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beardstown Health & Rehab Ctr 8306 St Lukes Drive Beardstown, IL 62618 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 - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on observation, interview, and record review, the facility failed to revise a Care Plan with the development of a pressure ulcer, resident to resident altercation, significant weight loss, and ROM (Range of Motion) limitations for four of 15 residents (R17, R28, R40, R41) reviewed for Care Plans in the sample of 24. Findings include: The facility's Care Plan Process policy, dated 11/2017, documents, A comprehensive person-centered Care Plan shall be developed and implemented to meet the resident's preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs, while honoring resident rights to choice. This Care Plan shall include goals, measurable objectives, and interventions to meet identified resident needs. 1. The facility's Wound and Ulcer Policy and Procedure policy, dated 1/10/18, documents, When a resident is found to have a wound, a licensed nurse will complete ulcer, either on admission or during their stay, the following care interventions for staff involved in the resident's care are communicated via the resident Care Plan . On 03/02/22 at 09:59 AM, R17 had oval shaped shallow open area to R17's left lower buttock. R17's Braden Scale for Predicting Pressure Ulcer Risk assessment, dated 2/28/22, documents a score of 7 putting R17 at a very high risk for developing pressure ulcers. R17's Ulcer/Wound Documentation, dated 2/28/22, documents that R17 has an in house Stage two pressure ulcer to R17's left buttock that was discovered on 2/12/22. The Wound documentation also documents the current measurements of 2 cm (centimeters) x 1 cm x 1 mm (millimeter). R17's Skin Care plan, dated 2/1/22, documents, I have pressure ulcers and I am at risk for skin breakdown related to fragile skin, Dementia, and colostomy. R17's Care Plan has no documentation of a revision with new interventions following the development of R17's pressure ulcer on 2/12/22. On 3/3/22 at 11:05 a.m., V7 (Care plan Coordinator) confirmed that R17's Care Plan was not revised with new interventions following the development of R17's pressure ulcer. 2 On 02/28/22 at 11:01 AM, R40 stated that she's limited with what she can do because of her shoulders. R40 attempted to raise bilateral arms and was unable to go past her shoulder level. R40's OT (Occupational Therapy) Evaluation, dated 5/13/21, documents, ROM Measurements: RUE (Right Upper Extremity) ROM=Impaired; LUE (Left Upper Extremity) ROM=Impaired; Joints: Shoulder=Impaired. R40's PT (Physical Therapy) Evaluation, dated 10/19/21, documents, ROM measurements: RUE ROM impaired; LUE ROM impaired. R40's Care Plan, dated 2/21/22, documents, I am at risk for an ADL (Activities of Daily Living) Self Care Performance Deficit related to Osteoarthritis, HTN (Hypertension) and frequent falls. R40's Care Plan has no documentation to include R40's ROM limitations to R40's bilateral shoulder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145952 If continuation sheet Page 5 of 12 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 145952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beardstown Health & Rehab Ctr 8306 St Lukes Drive Beardstown, IL 62618 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 - Some On 3/3/22 at 11:05 a.m., V7 confirmed that R40's Care Plan was not revised to include R40's ROM limitations. 3. The facility Report to the State Agency, dated 2/25/22, documents, This resident (R41) was involved in a resident to resident altercation with no injuries. On February 21, 2022, (R41) was at the nurses' station asking staff to take her home and stating her address repeatedly. (R41) is alert and oriented times one with confusion and requires staff intervention and frequent reminders of the date, year, and where the facility is located. (R41) also requires staff assistance for ADLs (Activities of Daily Living) and she ambulates throughout the facility frequently on a daily basis. On this day, (R41) asked another resident (R28) to take (R41) home as (R28) approached the nurses' station in her electric scooter. R28 is alert and oriented times three and did not respond to (R41's) request. (R41) then restated to (R28), I need you to take me home, and (R28) responded, 'No, I can't drive.' (R41) then used the inner palm of her right hand to make contact on the back of (R28's) posterior side of her head and then (R41) stated, 'You drive that thing fine. The facility's initial report to State Agency, dated 2/27/22, documents that on 2/26/22 at 12:50 p.m., R41 was involved in a resident to resident altercation (with R28). R41's Nurses' note, dated 2/26/2022 at 12:50 p.m., documents, (R41) had an altercation with an alert resident (R28) at this time. (R41) was in another resident's room when (R28) saw her and was telling (R41) to get out. (R41) grabbed (R28's) grabber/reacher and hit (R28) on the head, across the top of her back, and on both shoulders. R28's Current Care plan dated 2/1/22 and R41's Current Care plan dated 2/21/22, have no documentation of revisions following the resident to resident altercations that occurred on 2/21/22 and 2/26/22 between R28 and R41. On 03/01/22 at 03:54 PM, V14 (Social Services Director) confirmed that neither R28 nor R41's Care Plans were updated following the incidents on 2/21/22 and 2/26/22. 4. R41's Electronic weights document that R41's current weight on 2/28/22 was 113.5 lbs (pounds) and six months ago she weighed 127.8 lbs (11.19% loss). R41's Nutrition note, dated 1/26/2022 at 3:23 p.m., documents, Registered Dietician Weight Observation note: (R41's) weight reflects a 6 lb/5.2% weight loss in one month; and a 17 lb/13.6% weight loss in five months. R41's Care plan, dated 1/28/22, documents, I have/am at risk for nutritional problems related to the diagnoses of Lymphoma, Cancer, and Dementia. R41's Care Plan has no documentation of revisions following R41's significant weight loss. On 03/03/22 at 09:32 AM, V5 (Dietary Manager) stated, I have not updated her Care Plan regarding (R41's) significant weight loss or the interventions I've put into place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145952 If continuation sheet Page 6 of 12 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 145952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beardstown Health & Rehab Ctr 8306 St Lukes Drive Beardstown, IL 62618 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide assistance with shaving for one of three residents (R40) reviewed for ADLs (Activities of Daily Living) in the sample of 24. Residents Affected - Few Findings include: The facility's A.M. (Morning) Care policy, dated 4/2009, documents, Objective: To provide personal hygiene in the morning. Provide assist with shaving (both male and female). R40's MDS (Minimum Data Set) assessment, dated 2/8/22, documents, Functional Status: requires extensive assistance by one person for personal hygiene. On 02/28/22 at 11:01 AM, R40 was alert lying in bed. R40 had multiple long white hairs above R40's lip and on R40's chin and neck. R40 stated, I've been asking them for days to shave me. They keep saying they are going to do it, but they haven't. I don't like having long whiskers. On 03/01/22 at 12:11 PM, R40 was alert sitting up in her motorized wheel chair at the dining room table eating lunch. R40 stated, I still haven't gotten my whiskers trimmed. On 03/01/22 at 01:50 PM, V12 and V15 (Both CNAs-Certified Nursing Assistants) exited R40's room. V12 and V15 stated trimming of facial hairs is done with morning cares and showers. R40 self propelled her wheel chair up to V12 and V15. R40 stated, It doesn't get done very often. V12 stated, We should have trimmed her facial hair this morning when we got her up. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145952 If continuation sheet Page 7 of 12 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 145952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beardstown Health & Rehab Ctr 8306 St Lukes Drive Beardstown, IL 62618 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to act upon a significant weight loss, notify the Physician and implement further weight loss prevention interventions in a timely manner, for one of two residents (R36) reviewed for weight loss, in a sample of 24. Residents Affected - Few Findings include: The facility Policy, titled Weight Management Policy and Procedure (Revised 2/2016), documents, Each resident will be weighed at least once per month on a predetermined schedule. All residents will be monitored for significant weight changes to assure maintenance of acceptable parameters of body weight. The Policy further documents, At least monthly, resident weights will be compared to prior weights to identify any significant, severe or insidious weight changes. The Weight and Vitals Exception Report will be reviewed weekly by dietary staff to determine significant weight changes. Parameters of a significant weight change per OBRA (Omnibus Budget Reconciliation Act) guidelines will be used. Weight loss that occurs quicker than OBRA guideline parameters will be addressed as they occur. (Example: If a 10% weight loss occurs in four months, the weight loss will be addressed at that time.) Any resident with a significant or insidious weight change will be referred to the dietitian for assessment of the residents' condition. The dietitian will implement any necessary clinical interventions or make recommendations regarding diet and supplementation to the Physician. The Physician will be notified of any significant weight change and be made aware of any recommendations made by the dietitian. The policy defines a significant weight change as 5% or more in 30 days and 10% or more in 180 days. The Electronic Medical Record documents R36 was admitted to the facility on [DATE], with the diagnosis of Parkinson's Disease and Muscle Wasting and Atrophy, weighing 195.2 pounds. Weight Records document R36 weighed 192.0 pounds on 1/03/22 and then 171.0 pounds on 1/24/22, which is a decrease of 10.94% in three weeks. On 1/26/2022, Dietary Notes document, (Dietary Manager) has asked for a reweigh for (R36). Current weight noted at 171 (pounds), (Interdisciplinary Team) will continue to monitor and no new dietary interventions were implemented. There is no documented evidence in R36's medical record that the Physician was notified of R36's 10.94% weight loss at that time. On 1/31/22, R36's Plan of Care was revised, documenting R36 as At risk for nutritional problems (related to the diagnosis) of Parkinson's. (R36) will maintain adequate nutritional status as evidenced by maintaining weight within 2%, no (signs/symptoms) of malnutrition, and consuming at least 75% of at least (all) meals daily through review date. Monitor/document/report to (Physician as needed signs) of Dysphagia: Pocketing, Choking, Coughing, Drooling, Holding Food in mouth, Several Attempts at swallowing, Refusing to eat, Appears concerned during meals. Monitor/record/report to (Physician as needed, symptoms) of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3 lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. The Weight Records document R36 next weight as 164.4 pounds on 2/07/22, which is an overall weight decrease of 13.33% since 1/03/22. Two days later, on 2/09/22, a Dietary Note documents, Weight and wound meeting was held today. (R36) has had a 12.4 (pound) loss. Current weight is 171 (pounds). (Interdisciplinary Team) has recommended to add 60 cc (cubic centimeters) Med Pass (three times per day). (Dietary Manager) will fax doctor for request. (Interdisciplinary Team) will continue to monitor with the weekly weight program. (Physician, Power of Attorney and Registered Dietitian) notified. Physician's orders document R36's Med Pass Dietary Supplement 60 cc three times per day was started on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145952 If continuation sheet Page 8 of 12 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 145952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beardstown Health & Rehab Ctr 8306 St Lukes Drive Beardstown, IL 62618 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 0692 2/10/22, 17 days after the significant weight loss was originally identified. Level of Harm - Minimal harm or potential for actual harm On 3/03/22 at 09:21 AM, V4 (Dietary Manager) stated the facility is to respond with dietary interventions as soon as a significant weight loss is identified. V4 stated R36 was started on Super Cereal, but not until approximately 2/03/22, and the following week they started R36 on Med Pass supplement. V4 was unable to provide documented evidence of exactly when R36 was started on the Super Cereal, only that Super Cereal was part of R36's current diet. V4 confirmed that there was a delay in the facility's response to R36's weight loss, which was noted on 1/24/22. V4 stated she had been out of the facility due to medical issues, but other individuals are able to make needed dietary changes if she is gone. V4 concluded, As soon as I'm aware of a significant weight loss, an intervention is to be implemented. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145952 If continuation sheet Page 9 of 12 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 145952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beardstown Health & Rehab Ctr 8306 St Lukes Drive Beardstown, IL 62618 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 Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to label food items, dispose of outdated foods and wash hands when coming into the kitchen and after handling dirty dishes and before handling clean dishes. This has the potential to affect all 45 residents living in the facility. Findings: The document Food Labeling and Dating, dated 2/22 documents, Labeling and dating food is important to assure foods are used in a timely manner. Proper food labeling includes: Name of product, date stored and in some cases, the time of the day; the food must be labeled and dated if it is removed from its original container. The document Food Storage Chart, dated 2/22, documents, Use by dates printed on label by the manufacturer applies until the product is opened. Once opened, use the following time limits. After a food item is opened, it will be covered, labeled, the 'use by date' will be put on, initiated and stored. The day of opening/preparation counts as Day 1. Meats, Cottage Cheese, Salads - seven days;. On 2/28/22 at 9:55 AM, the refrigerator held one pan containing two pounds of diced ham, one package of three pounds of sliced white American cheese, both without labels/dates; one pan containing six cups of cottage cheese, one pan containing six cups diced beets, four pans of gelatin (one yellow gelatin, three red gelatin, ) all were dated 2/10/22. Both the cottage cheese and beets had a foul smell. V4, Certified Dietary Manager, confirmed the items that did not have labels and confirmed that the foods dated 2/10/22 should have been discarded on 2/17/22. V4 stated, I prefer to have items such as these discarded after three days. The document Hand Washing and Glove Use, dated 2/22, documents, Proper hand washing is cleaning hands and exposed arms by applying soap and warm water, rubbing them together vigorously, rinsing them with clean water and drying them thoroughly. Hand washing is important to get rid of dirt and reduce germs that can cause illness. Hands should be washed when entering the kitchen; after handling soiled dishes and utensils. On 2/28/22 at 9:40 AM, V11, Dietary Aide, entered into the department from an outside door, removed his outer clothing, pulled his hair back and put a hairnet onto his head. Without washing his hands, V11 immediately began handling food containers which were in the reach-in refrigerator. At 10:05 AM, V10, Dietary Aide, working in the dish room, was handling soiled resident dishes from the breakfast meal and emptying pans of discarded foods into the garbage disposal. Without washing her hands, V10 pulled clean baskets of clean dishes, pans and other items from the dishwasher. V10 removed the clean items and stacked them onto a cart. V4, Certified Dietary Manager, confirmed that hands should be washed. V4 stated, (V11) should have washed his hands before beginning work and (V10) should have washed her hands after handling dirty dishes and before touching any of the clean dishes/pans. The Centers for Medicare and Medicaid Services (CMS) Resident's Census and Conditions of Residents Report, form 672, dated 2/28/22 and signed by V5, Minimum Data Set Assessment Coordinator, documents that at the time of the survey, 45 residents resided in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145952 If continuation sheet Page 10 of 12 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 145952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beardstown Health & Rehab Ctr 8306 St Lukes Drive Beardstown, IL 62618 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 observations, record review and interview, the facility failed to ensure a indwelling catheter bag and tubing remained off the floor for one of one residents (R36) reviewed with an indwelling catheter, in a sample of 24. Residents Affected - Few Findings include: The facility policy, titled Catheter Protocol (dated 2/01/10), documents 7. The collection bag for catheters shall be emptied at least every shift. Care shall be taken to avoid contact of the drainage tube with anything that could contaminate it. On 02/28/22 at 11:37 AM, R36 was lying in bed, with his suprapubic catheter bag connected to the bottom of the bed frame. R36's bed was in the lowest position, close to the floor, and the catheter bag was resting on the floor. On 03/01/22 at 09:38 AM, R36 had been returned to the nurses' station from the Therapy Department, as R36 was propelled in his wheelchair down the hall, his catheter bag and tubing was dragging on the floor. On 03/02/22 at 12:14 PM, R36 was propelling himself from the dining room back to his room after lunch. R36's catheter tubing was coiled and dragging under his wheelchair, along with his collection bag, which was secured to the bottom of the wheelchair in a cloth pouch. At that time, V9 (Certified Nursing Assistant) approached R36 to assist him into his room. V9 was questioned as to why the catheter tubing and the bag was dragging on the floor. V9 stated the tubing should be coiled up into the cloth pouch holding the drainage bag and the drainage bag should have been hung from a higher point on the back of the wheelchair to keep it off the floor. On 03/03/22 at 09:49 AM, V2 (Director of Nursing) stated a indwelling catheter bag should always hang below the the level of the bladder, but never touching the floor. V2 concluded that catheter tubing should never be on the floor and is to be placed in the pouch under the wheelchair, for infection control purposes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145952 If continuation sheet Page 11 of 12 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 145952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beardstown Health & Rehab Ctr 8306 St Lukes Drive Beardstown, IL 62618 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation and interview, the facility failed to empty a personal commode in a resident room that was causing odors for one of three residents (R28) reviewed for ADLs (Activities of Daily Living) in the sample of 24. Findings include: On 03/01/22 at 12:41 PM, R28 was alert sitting up in her recliner in her room. R28 had a commode located immediately to R28's left side. A foul urine like smell was noted in R28's room. R28 stated, I don't use the restroom to go to the restroom, I use this commode. The staff hardly ever dump it for me. Can you smell it? It's like this all the time. No one from third shift dumped it and no one has dumped it this shift either. R28 lifted the commode lid. The commode container was filled half the way up with a dark brown green liquid, and more odor was let out at that time. R28 stated, It gets so full that when I wipe myself, my hands end up touching what's in the commode. It's disgusting. On 03/01/22 at 01:39 PM, R28 was lying back in her recliner. R28's room continued to have a foul urine odor. R28 stated, The commode was just emptied. On 03/01/22 at 01:50 PM, V15 (Certified Nursing Assistant) confirmed that R28's commode had just been emptied. On 03/01/22, V15 (Certified Nursing Assistant) stated that R28's bedside commode should be emptied at the beginning and end of the CNAs shift. On 03/02/22 at 10:09 AM, R28's room had a foul urine like odor. R28 was alert sitting up in her recliner with her commode directly to her left side. R28 stated, They haven't emptied that thing since the end of 2nd shift last night. You just wait its going to get super stinky in here if I have to wait until 2:00 p.m. to get it emptied. It smells bad enough now. All I ask for the staff is to empty my commode. I do everything else on my own, but they can't even empty this. R28's commode contained a large amount of brown stool and yellow urine. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145952 If continuation sheet Page 12 of 12