Inspection·May 7, 2024

F 0600 Level of Harm - Actual harm Residents Affected - Few On 5/1/2024 2:32pm, V3 (Licensed Practical Nurse/LPN) stated she had abuse reported to her on 4/13/2024 by V4 (CNA). V3 stated V4 told her that V11 threatened R1 to stop scratching and then put hand sanitizer on her scratched areas. V3 stated she instructed V4 to report to V1 immediately. V3 stated she worked the next day and V1 came to the facility and V3 did a head-to-toe assessment on R1. V3 stated the assessment didn't reveal any new issues as R1 always has a red bottom with scratches. R1 did not show any signs of abuse. On 5/1/2024 2:10pm, V10 (family member) stated she was notified by V1 of the incident that involved R1 on 4/14/2024. V10 stated she has not seen any change in V10 since the reported incident. V10 stated R1 has had issues with her skin and scratching for many years and she has seen many doctors to find out what the cause is but the doctors, including dermatologist, do not know what the cause is. V10 stated after the investigation it seems as though the incident did occur, but she wasn't for sure. V10 stated she is surprised because she knew V11, but if he would treat anyone in this way then he doesn't need to work around residents. V10 stated she feels like R1 is safe here in the facility. On 5/1/2024 11:38am, V7 (CNA) stated she didn't report the abuse of R1 herself because she has issues at home with DCFS (Department of Children and Family Services) so she told V8 (CNA), who then told V4 (CNA), who was supposed to tell the LPN (Licensed Practical Nurse). V7 said she is unsure of who the LPN was that was told and is not sure if she was notified. V7 stated she was aware abuse is to be reported immediately but was afraid to do it herself. V7 stated she knows to report to V1 immediately. ON 5/1/2024 at 9:40am, R1 was observed receiving peri care per V4 (CNA) and V6 (CNA). R1 noted to have multiple scratch marks to her peri area, buttocks, and upper thighs, with many areas open with small amount of blood noted. The Abuse Investigation's provided by the facility were reviewed. A document titled Incident Investigation Form contained a phone interview with V11 dated 4/17/2024 at 1:47pm, and documented by V1, stating the resident was cleaned with sheer prep. V11 was asked if he had anything else to state add and V11 said, no I don't. The document was signed by V11. An undated and untimed document titled Incident Investigation Form documents that the Person Conducting Investigation as V1 and the person being interviewed as V7 (CNA). The form had a statement signed by V7 that states one night me (V7) and V11 was working together. After we did 1am bed checks, he (V11) put hand sanitizer on (R1's) legs because he (V11) thought it would be funny. I (V7) asked him why he (V11) did it and he (V11) just smiled. I (V7) didn't go into the room to check her, so I (V7) didn't see the incident happen. An Incident Investigation Form dated 4/14/2024 at 2:00pm, with an interview conducted by V1 with R1 documents Resident (R1) was asked by the investigator if she remembered ever being cleaned up and it burning? Resident (R1) stated, 'yeah it burnt like fire, I don't know why he done that.' Resident (R1) then rubbed upper thigh. This document signed by V1 and witnessed by V6 (CNA). An Incident Investigation Form with an interview conducted by V1 with V3 (LPN) document CNA (V4) reported to me that CNA (V8) had told her about (V11) abusing (R1). I (V3) asked what happened and (V8) told (V4) she was told that he (V11) was threatening (R1) with hand sanitizer if she (R1) would not stop itching so he (V11) rubbed hand sanitizer on her (R1) wounds on her (R1) coccyx. I (V3) told (V4) that is abuse and they need to report it asap to (V1) and or (V2-Director of Nursing ). Nothing can be done unless it is reported. This document has no date or time on it but is signed by V3. The facility policy titled Abuse Prevention Program, dated 11/28/2016, documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to corporal punishment, involuntary seclusion (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145964 If continuation sheet Page 2 of 8 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 145964 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE McLeansboro Rehab & Hlth C Ctr 405 West Carpenter McLeansboro, IL 62859 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 - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete and physical or chemical restraint not required to treat the resident's 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 control to prevent occurrences of mistreatment, exploitation, neglect, or abuse of our resident. Event ID: Facility ID: 145964 If continuation sheet Page 3 of 8 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 145964 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE McLeansboro Rehab & Hlth C Ctr 405 West Carpenter McLeansboro, IL 62859 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 0609 Level of Harm - Minimal harm or potential for actual harm Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to implement abuse policies by not reporting abuse within the designated time frames for 2 of 3 residents (R1 and R3) reviewed for abuse in a sample of 3. Residents Affected - Few Findings Include: 1. R1's face Sheet documents an admission date of 6/23/2017 with diagnoses including Alzheimer's Disease, Dementia, Chronic Pain, Excoriation (skin picking) Disorder, Anxiety, Hypertension, GERD, and Osteoporosis. R1's Minimum Data Set, dated for 4/17/2024, documents a Brief Interview for Mental Status (BIMS) score of 2, indicating that R1 has severe cognitive impairment. The same MDS documents that R1 is totally dependent of at least two persons for transfers, bed mobility, dressing, eating, and toileting needs. On 5/1/2024 at 10:26am, V1 (Administrator) stated she was notified on 4/14/2024 at approximately 9:00am by V3 (Licensed Practical Nurse/LPN) about an allegation of abuse. The allegation of abuse involved staff V11 (Certified Nurse's Assistant/CNA) to R1. V1 stated through the investigation process, it was discovered the actual incident occurred on 4/10/2024 during the evening/night shift. V1 stated V11 reported to her during the investigation, he (V11) had used Shear Prep Pads on R1's bottom and legs, to stop her from scratching. V1 stated Shear Prep pads are 2x 2 in size are kept locked up by the nurses and it would take a million of these to perform peri care. V1 stated, during the investigation her interviews with other CNA's revealed that V11 told them he applied hand sanitizer to R1's coccyx and legs to stop her from scratching. V1 stated she is the Abuse Coordinator. On 5/1/2024 at 2:32pm, V3 (LPN) stated she had abuse reported to her on 4/13/2024 by V4 (CNA). V3 stated V4 told her that V11 threatened R1 to stop scratching and then put hand sanitizer on her scratched areas. V3 stated she instructed V4 to report to V1 immediately. V3 stated she worked the next day and V1 came to the facility and V3 did a head-to-toe assessment on R1. V3 stated the assessment didn't reveal any new issues as R1 always has a red bottom with scratches. R1 did not show any signs of abuse. On 5/1/ at 2:10pm, V10 (family member) stated she was notified by V1 on 4/14/2024 of the incident that involved R1 on 4/10/2024. On 5/1/2024 at 11:38am, V7 (CNA) stated she didn't report it herself because she has issues at home with DCFS (Department of Children and Family Services) so she told V8 (CNA) who then told V4 (CNA) that she was supposed to tell the LPN (Licensed Practical Nurse). V7 said she is unsure of who the LPN was that was told and is not sure if she was notified. V7 stated she was aware abuse is to be reported immediately but was afraid to do it herself. V7 stated she knows to report to V1 immediately. The Final Investigation dated 4/17/2024 addressed to Illinois Department of Public Health documents Please accept this letter as the final report to the initial notification on 4/14/2024 regarding a resident abuse allegation. On 4/14/2024 at approximately 9:00am (V1) was given report of abuse to (R1). (name of city) police department, MD (Medical Director), and POA (Power of Attorney) were notified, and initial report filed, and investigation started immediately. Staff accused, (V11), was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145964 If continuation sheet Page 4 of 8 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 145964 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE McLeansboro Rehab & Hlth C Ctr 405 West Carpenter McLeansboro, IL 62859 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 0609 suspended upon investigation. Level of Harm - Minimal harm or potential for actual harm 2. R3 's Face Sheet documented an admission date of 2/4/2021 with diagnoses including Chronic Obstructive Pulmonary Disease and Anxiety. Residents Affected - Few R3's Minimum Data Set, dated for 4/23/2024, documented R3 has a BIMS score of 15, indicating R3 is cognitively intact . The same MDS documents that R3 requires set up assistance with showers/bathing and assistance of 1 to transfer in and out of shower chair for safety. On 5/2/2024 at 9:30am, R3 stated she was abused during a shower. R3 stated V12 (CNA) wadded up a washcloth and jabbed it in her stomach (belly button area). R3 stated it left a big red area and bothered her for a bit. R3 stated she reported it to V1 and things are better now because V1 changed R3's shower times so V12 will not be assisting her with showers anymore. R3 requires set up assistance with showers/bathing and assistance of 1 to transfer in and out of shower chair for safety. On 5/2/2024 at 9:45am, abuse investigation file for R3 was requested from V1. V1 stated it wasn't abuse and the Ombudsman (V13) was here, and she said it wasn't abuse, so I didn't do a reportable. V1 stated she didn't do an investigation. On 5/2/2024 12:33pm, V13 (Ombudsman) stated R3 came to her on 4/4/2024 and said V12 jabbed her in the abdomen with a washcloth during her shower. V13 stated she asked R3 if she reported this to V1, and she stated no. V13 stated she went to V1 a few minutes later and reported it to V1 and V1 stated that R3 had just told her. V13 was asked if she reported the incident with R3 as abuse to V1 and V13 stated, yes I did report it as abuse. V13 stated she returned on 4/10/24 and met with R3 and R3 stated the issue was resolved so she closed the case. V13 stated V1 told her that she took care of the issue. On 5/2/2024 at 12:50pm, V1 stated she was initiating an investigation on the allegation of abuse for R3. On 5/2/2024 at 4:05pm, V12 (CNA) stated she has assisted R3 with a few showers but R3 is mostly requires set up help with showers. V12 states she doesn't recall ever having any issues with R3 and she denied pushing a washcloth into her abdomen. V12 states she doesn't know why R3 would say that as that is abuse and she would never do that. On 5/2/2024 at 4:09pm, V14 (CNA) stated she has never witnessed abuse with R3 or by anyone. V14 states she does help with care for R3 but she has never had any issues and R3 has never reported any type of abuse to her. R3's progress notes from 4/1/2024 through 5/2/2024 were reviewed and no documentation was noted of complaints of abuse or discomfort. A document titled Ombudsman Complaint Form dated 4/4/24 at 1:00pm from V13 documents a reference title of Abuse. The intake description documents Resident (R3) approached (V13) on this visit to report that this past Monday, her shower day, she almost fell out of her shower chair, but didn't and prior to that the shower aid had taken a washcloth and jabbed it into the resident's (R3) stomach. Resident (R3) reported that this hurt, and she felt it was abuse. (R3) did not report this to anyone else. Resident (R3) gave (V13) permission to speak to (V1) and (V13) advised (R3) to report this to (V1). The same complaint form documents on 4/4/2024 at 1:20pm that V13 met with V1 to discuss R3's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145964 If continuation sheet Page 5 of 8 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 145964 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE McLeansboro Rehab & Hlth C Ctr 405 West Carpenter McLeansboro, IL 62859 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few complaint of a staff member stabbing a washcloth in R3's stomach, and she feels this is abuse. V1 was unaware of this until R3 told her today. V1 is confused about who R3 says had done this to her. V13 informed V1 that she would be following up on this next week. Case Notes by V13 dated 4/10/2024 at 2:05am documents that (V13) returned to the facility to speak with resident (R3). Resident (R3) stated that her showers have been okay and no conflict or aggression by the shower staff. (V13) is closing the case with the permission of (R3). On 5/3/2024 at 12:30pm, V1 provided R3's final investigation report to the initial investigation submitted on 5/2/24 regarding a resident abuse allegation. The report documents that V1 was notified of the allegation of abuse on 5/5/2024. The report documents the (name of city) Police came to the facility on 5/3/24 in connection with this investigation. On 5/3/2024 at 1:00pm, V1 stated that the allegation of abuse involving R3 was found to be unsubstantiated. The facility policy titled Abuse Prevention Program, dated 11/28/2016, documents under section IV titled Internal Reporting Requirements and Identification of Allegations that Employees are required to immediately report any occurrences of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property they observe, hear about, or suspect to a supervisor and the administrator. The same policy documents under section VII titled External Reporting of Potential Abuse that The facility must ensure that all alleged violations involving mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, misappropriation of resident property, and reasonable suspicion of a crime are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures. If the events that cause reasonable suspicion result in serious bodily injury or suspected criminal sexual abuse, the report shall be made to at least one law enforcement agency of jurisdiction and IDPH immediately after forming the suspicion (but no later than two hours after forming suspicion), Otherwise, the report must be made not later than 24 hours after forming suspicion. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145964 If continuation sheet Page 6 of 8 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 145964 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE McLeansboro Rehab & Hlth C Ctr 405 West Carpenter McLeansboro, IL 62859 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to initiate and thoroughly investigate an allegation of abuse for 1 of 3 residents (R3) reviewed for abuse in a sample of 3. Residents Affected - Few The Findings Include: R3 's Face Sheet documented an admission date of 2/4/2021 with diagnoses including Chronic Obstructive Pulmonary Disease and Anxiety. R3's Minimum Data Set, dated for 4/23/2024, documented R3 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R3 is cognitively intact. The same MDS documents that R3 requires set up assistance with showers/bathing and assistance of 1 to transfer in and out of shower chair for safety. On 5/2/2024 at 9:30am, R3 stated she was abused during a shower. R3 stated V12 (CNA) wadded up a washcloth and jabbed it in her stomach (belly button area). R3 stated it left a big red area and bothered her for a bit. R3 stated she wasn't sure of the date that it occurred, but it had been a little while, maybe a few weeks. R3 stated she reported it to V1 (Administrator) and things are better now because V1 changed R3's shower times so V12 will not be assisting her with showers anymore. On 5/2/2024 at 9:45am, abuse investigation file for R3 was requested from V1. V1 stated it wasn't abuse and the Ombudsman (V13) was here, and she said it wasn't abuse, so I didn't do a reportable. V1 stated she didn't do an investigation. On 5/2/2024 12:33pm, V13 (Ombudsman) stated R3 came to her on 4/4/2024 and said V12 jabbed her in the abdomen with a washcloth during her shower. V13 stated she asked R3 if she reported this to V1, and she stated no. V13 stated she went to V1 a few minutes later and reported it to V1 and V1 stated that R3 had just told her. V13 was asked if she reported the incident with R3 as abuse to V1 and V13 stated, yes I did report it as abuse. V13 stated she returned on 4/10/24 and met with R3 and R3 stated the issue was resolved so she closed the case. V13 stated V1 told her that she took care of the issue. On 5/2/2024 at 12:50pm, V1 stated she was initiating an investigation on the allegation of abuse for R3. A document titled Ombudsman Complaint Form dated 4/4/24 at 1:00pm from V13 documents a reference title of Abuse. The intake description documents Resident (R3) approached (V13) on this visit to report that this past Monday, her shower day, she almost fell out of her shower chair, but didn't and prior to that the shower aid had taken a washcloth and jabbed it into the resident's (R3) stomach. Resident (R3) reported that this hurt, and she felt it was abuse. (R3) did not report this to anyone else. Resident (R3) gave (V13) permission to speak to (V1) and (V13) advised (R3) to report this to (V1). The same complaint form documents on 4/4/2024 at 1:20pm that V13 met with V1 to discuss R3's complaint of a staff member stabbing a washcloth in R3's stomach, and she feels this is abuse. V1 was unaware of this until R3 told her today. V1 is confused about who R3 says had done this to her. V13 informed V1 that she would be following up on this next week. Case Notes by V13 dated 4/10/2024 at 2:05am documents that (V13) returned to the facility to speak with resident (R3). Resident (R3) stated that her showers have been okay and no conflict or aggression by the shower staff. (V13) is closing the case with the permission of (R3). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145964 If continuation sheet Page 7 of 8 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 145964 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE McLeansboro Rehab & Hlth C Ctr 405 West Carpenter McLeansboro, IL 62859 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 5/2/2024 at 4:22pm, V1 stated that according to her investigation earlier in the day that she believes this allegation occurred on 4/1/2024 as R3 told V13 on Thursday, 4/4/2024 the incident occurred the Monday prior to R3 reporting which would be 4/1/2024. V1 was unable to provide evidence of an investigation that was initiated on 4/4/2024 when V13 notified V1, who validated she is the Abuse Coordinator. The facility policy titled Abuse Prevention Program dated 11/28/2016, documents in Section VI titled Internal Investigation of Allegation and Response documents that 1. Once the administrator or designee receives an allegation of mistreatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property; the administrator will appoint a person to take charge of the investigation. The person in charge of the investigation will obtain a copy of any documentation relative to the incident and follow the Resident Protection Investigation Procedures. The Resident Protection Investigation Procedure documents Titles: Preparation, Confidentiality, Definitions of Abuse, Choosing an Investigation Path, Investigation Procedures, The Interview Process, and Final Investigation Report. Under the title of Investigation Procedures it documents Regardless of the specific nature of the allegation (physical, sexual, verbal/exploitation/mental, theft or neglect), the investigation shall consist of : Review of the initial written reports, completion of a written report of the status of the investigation of the occurrence, an interview with the person(s) reporting the incident, interviews with any witnesses to the incident, an interview wit the resident, where appropriate, an interview with the resident's attending physician or psychiatrist, a review of the medical records of any resident involved in the occurrence, if the accused individual is an employee, review the personnel file to check for references, background check, and documentation of orientation and training, an interview with staff members having contact wit the resident and accused individual during the period of the alleged incident, where appropriate, interviews with the resident's roommate, family members, visitors or others who were in the vicinity of the incident, interviews with other residents to which the accused individuals has regular contact, interview other employees to determine if they have ever witnessed other incidents of mistreatment involving the accused individual, obtain address, phone number and social security number of the accused individual, and interview with the accused individual or individuals and a review of all circumstances surrounding the incident. Event ID: Facility ID: 145964 If continuation sheet Page 8 of 8