Health inspection·July 13, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R2's progress notes document on 5/3/23 that R2 was admitted to the facility. R2's progress notes document assessments with no documentation of physically aggressive behaviors until 5/28/23 when R2's progress notes document, patient observed hitting another patient (R7) that entered his room. Patient (R2) hit the other patient (R7) in the face 3 times with right hand closed fist. Patient (R2) reported he woke me up and it made me mad. Patient (R2) was redirected, and he prepared for bed, he (R2) did not sustain any injuries. R2's progress notes continue to document assessments with no other documentation related to physical aggression until 7/5/2023 when R2's progress notes document, This resident got into an altercation with a staff member, (name of physician) here for rounds and ordered STAT CMP (comprehensive metabolic panel) and CBC (complete blood count). Will monitor resident. On 7/6/23 R2's progress notes document R2 was evaluated by a local psychiatric Physician Assistant. R7's progress notes document on 5/27/23 at 8:36 PM, .patient was observed entering room of another patient, while in his wheelchair and chair alarm on and in place, anti-skid footwear on, observed patient reach toward other patient and the other patient struck him in the face with closed fist 3 times, swelling immediately to patient upper lip and complaints of pain. Patients separated .and assessments completed, family, MD (physician), police and administration notified. R7's progress notes document on 5/28/23 at 5:43 AM, patient has swelling noted to nose and left maxillae region, swelling is same to upper lip, will continue to monitor, per patient pain is 4 out of 10, pain with palpation to area. On 7/12/23 at 8:43 AM, V4 (CNA/Certified Nursing Assistant) stated one day last week (specific day unknown) R2 was in the dining room and was choking. V4 checked on R2 and R2 asked for a drink of water. V4 stated she got R2 a drink of water and R2 then asked for more food. V4 stated R2 was still coughing and had puked. V4 stated she asked R2 to wait a little bit to ensure he was ok before eating more food. V4 stated she sat down by the door and R2 came up to her and was staring at her and then began choking her. V4 stated R2 said I am going to kill this fu**ing bi**h. V4 stated she reported it to V1 (Administrator) and V1 sent V4 home for the rest of the day. V4 stated she was afraid of R2, and she wasn't aware of any other intervention that was implemented after the incident. When asked if that was the first time R2 had been physically aggressive V4 stated R2 had also hit V5 (CNA). On 7/12/23 at 9:36 AM, V5 (CNA) stated she was working during nurse's week and the facility had put food in the staff break room for the staff. V5 stated R2 entered the break room to get food and V5 told R2 he couldn't go in there. V5 stated R2 left the break room and V5 left to answer a call light. V5 stated after responding to the call light she went to the nurse's station to look at the schedule and R2 was at the nurse's station. V5 stated she turned away from the wall where the schedule was located and R2 began to hit her. V5 stated she yelled for help and turned so R2 would hit her back instead of her face. V5 stated all the other staff were assisting residents down the halls and didn't hear her yelling. After R2 stopped hitting her, V5 reported the incident to V21 (RN/Registered Nurse) who stated, Oh, well. V5 stated she then called V1 (Administrator) and reported the incident to her. V5 stated she reported the incident to V17 (LPN/Licensed Practical Nurse) and V17 had her fill out an incident report. V5 stated she had bruises on her arm, jaw, and back. According to https://www.nursingworld.org/ana-enterprise/nurses-month/ nurses' week was 5/8-5/14/23. On 7/12/23 at 2:15 PM, when asked for the incident report V21 filled out, V1 (Administrator) stated she got a call from V5 and was told R2 had come after V5 but didn't know R2 had hit her and didn't receive an incident report from V21. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146021 If continuation sheet Page 2 of 11 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 146021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nature Trail Health and Rehab 1001 South 34th Street Mount Vernon, IL 62864 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 Residents Affected - Few On 7/12/23 2:43 PM, V17 (LPN) stated V5 reported to her she was by the nurse's station and R2 grabbed a hold of her, and it hurt her shoulder. V17 stated V5 asked her opinion on it, and she instructed V5 to call V1 and write a statement. When asked if she assessed V5 for injuries, V17 stated V5 didn't point any injuries out to her. V17 stated she didn't know the date of the incident. On 7/13/23 at 12:52 PM, V21 (RN) stated she was working on the night of the incident with R2 and V5. V21 stated she didn't witness it but V5 reported to her, R2 had knocked her on her arm or pushed her or something. V21 stated she went to R2's room and R2 was laying in his bed, and she asked him if had bothered V5 and he stated he hadn't. V21 stated she told R2 he wasn't supposed to bother them, hit them, or push them, and R2 said, ok. V21 stated V5 reported R2 had pushed her on her arm but V5 didn't appear to have any injuries. When asked if she had V5 fill out an incident report, V21 stated she thought V5 filled out a behavior tracking sheet. When asked if R2 had behavior tracking or a care plan for physical aggression in place at the time of the incident, V21 stated she didn't think so. When asked how V5 appeared that night, V21 stated V5 was upset R2 would do that. On 7/12/23 at 10:45 AM, V13 (MDS Coordinator) stated she was responsible for implementing resident care plans. V13 stated if there was a risk management, she implemented new interventions for behaviors. V13 stated she was aware of R2's physically aggressive behaviors with R7 and with V4 and V5. When asked if she tracked/trended behaviors of physical aggression against staff, V13 stated no one had told her she had to. When asked if there were any new interventions implemented after R2's physical aggression with staff, V13 stated R2 was easily redirected, the incident was discussed in morning meeting and that was where they left it. This indicates R2 had physical aggression during the week of 5/8-5/14/23 with no care plan, interventions, or behavior tracking implemented to prevent further acts of physical aggression. On 7/13/23 at 11:03 AM, V2 (DON/Director of Nurse) stated she was not aware of the incident between V5 (CNA) and R2. V2 stated she was not able to find any documentation related to the incident in R2's medical record. V2 stated she didn't know when behavior tracking started for R2. V2 stated the first time she was aware R2 had behaviors of physical aggression was when R2 hit R7. When asked if R2 had a care plan in place and/or behavior tracking for physical aggression prior to the incident between R2 and R7, V2 stated he did not. When asked what she would have done had she been aware of the incident between V5 and R2, V2 stated she would have spoken with social services, had a meeting with R2's family, put a care plan with interventions in place, had a medication review, called the physician, and obtained lab work. On 7/13/2023 at 11:55 AM, when asked if there were two incidents of R2 having physical aggression with staff, V1 (Administrator) stated she was still questioning the incident with V5. V1 stated when V5 called her she couldn't understand her. V1 stated she told V5 she would call V21 and have her check on R2. V1 stated V21 checked on R2 and R2 was lying in bed, and she was told by V21 there was no incident. V1 stated V5 has been caught in lies and no other staff member heard it or witnessed it, and according to staff, V5 didn't have any marks on her. V1 stated she didn't believe the incident between V5 and R2 occurred. V1 stated she talked with other staff that worked the night of the incident and they didn't see anything. When asked if that was documented anywhere, V1 stated only in her personal notes. When asked who she spoke with V1 stated V21 and she wasn't sure who else. V1 stated it was just odd they didn't have confirmation of the incident. V1 stated, What I believe personally shouldn't hinder the investigation or checking on his (R2) behaviors to make sure he was safe, she was safe, or other team members or residents. When asked what her expectation would be, V1 stated, she would expect there to be some kind of follow up. V1 stated R2 didn't have any behavior tracking, care plan, or interventions in place for physical aggression prior to the peer-to-peer physical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146021 If continuation sheet Page 3 of 11 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 146021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nature Trail Health and Rehab 1001 South 34th Street Mount Vernon, IL 62864 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 aggression between R2 and R7 on 5/27/2023. Level of Harm - Minimal harm or potential for actual harm R2's current undated Care Plan documents a Focus Area of, R2 has potential to be physically aggressive r/t (related to) observed hitting another resident with right hand closed fist. Date Initiated: 5/30/23. This focus area includes the following interventions initiated on 5/30/23, 5/27/23 2036 (8:36 PM) patient observed hitting another patient in the face 3 times with right hand closed fist, he reported the other patient woke him up and it made him mad. Intervention: Residents were separated by a CNA (Certified Nursing Assistant) and assessed .Analyze times of day, places, circumstances, triggers, and what de-escalates .Asses and address for contributing sensory deficits .Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain etc .Communication: Provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated .Give the resident as many choices as possible about care and activities . Residents Affected - Few R2's current undated Care Plan documents a Focus Area of (R2) is/has potential to be Physically abusive r/t Dementia, Mental/Emotional illness. Date Initiated: 7/12/2023. This focus area includes the following interventions dated 7/12/2023, Administer medications as ordered. Monitor/document for side effects and effectiveness. Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc. Assess resident's coping skills and support system. Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Give the resident as many choices as possible about care and activities. Monitor for behavior of physical aggression with peers/staff and document if behavior seen. 7/5/2023 Resident seen by staff standing over team member (V4) with an angry appearance on his face and then he lounged (sic) forward and grabbing her around the neck and choking her with a shake. Intervention: Nurse at nurses station immediately came to aid and assist able to easily redirect W/ (with) verbal cueing. Monitor for pain and provide meds as appropriate. Monitor significant side effects of antipsychotic medications and notify MD (physician) as appropriate . The undated facility Abuse policy documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, mistreatment, misappropriation of resident property, and a crime against a resident in the facility. This facility will not tolerate resident abuse or mistreatment or crimes against a resident by anyone including staff members, family members, legal guardians, friends, or other individuals. Definition: Abuse- willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, mental anguish or deprivation of goods or services that are necessary to attain and/or maintain physical, mental, and psychosocial wellbeing. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Under Establishing a Resident Sensitive Environment, the policy documents, Offenders are identified and appropriately managed to reduce risk . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146021 If continuation sheet Page 4 of 11 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 146021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nature Trail Health and Rehab 1001 South 34th Street Mount Vernon, IL 62864 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure incontinence care was provided timely for 1 of 3 (R1) residents reviewed for incontinence care in the sample of 15. Findings Include: R1's admission Record with a print date of 7/13/23 documents R1 was admitted to the facility on [DATE] with diagnoses that include Parkinson's Disease, diabetes, heart failure, dementia, major depressive disorder, weakness, and Alzheimer's disease. R1's MDS (Minimum Data Set) dated 5/30/23 documents R1 has a BIMS (Brief Interview for Mental Status) score of 01, which indicates a severe cognitive deficit. This same MDS documents under Section G that R1 requires one person physical assist for toileting. R1's current undated Care Plan documents a Focus Area of .Self-Care Deficit: As evidenced by: Needs Assistance with ADL's (activities of daily living) related to weakness. Date Initiated: 4/18/2023. The interventions for this focus area include, PT/OT (physical therapy/occupational therapy) evaluation and treatment as ordered per MD (physician) orders. Praise all efforts at self care. Discuss with resident/family/POA (power of attorney) any concerns related to loss of independence,decline, in function. Encourage the resident to use bell to call for assistance. Encourage the resident to participate to the fullest extent possible with each interaction. Encourage the resident to discuss feelings about self-care deficit . On 7/12/23 at 10:45 AM, V13 (MDS Coordinator/LPN-Licensed Practical Nurse) stated V11 (family member) had a care plan meeting at 2:30 PM on 7/11/23 and voiced concerns related to finding R1 with feces on him. V13 stated she was working on the day of the incident. V13 stated she heard V11 ask who R1's CNA (Certified Nursing Assistant) was and heard V9 (CNA) respond that she was. V13 stated she was then asked by an unknown CNA to speak with V11 because V11 was upset. V13 stated V11 reported to her R1 had been incontinent and had feces on him and when she asked who his CNA was, V9 stated she was and kept walking. V13 stated she spoke with V9 (CNA) and told her she needed to make it right with R1 and V11 and to ensure V9 was providing appropriate care. V13 stated she reported the incident to V1 (Administrator) in morning meeting the next day. On 7/12/23 at 11:30 AM, V9 (CNA) stated she was providing care for R1 one day (unknown date) and R1 was extremely tired. V9 stated R1 was already in his chair when she arrived to the facility and she was unable to change him due to a risk of him falling. V9 stated she didn't have another staff member help her with R1 because they were busy on other halls. V9 stated incontinence care should be provided every two hours. When asked how long it had been before R1 was provided incontinence care, V9 stated about 3-4 hours. When asked if she provided incontinence care for R1 at that time, V9 responded, No, R1's wife did. On 7/13/23 at 11:03 AM, V2 (DON/Director of Nurses) stated she was made aware on 7/12/23 of R1 not being provided incontinence care by V9 (CNA). V2 stated she would expect residents would be checked every two hours and assistance provided as needed. On 7/13/2023 at 11:55 AM, V1 (Administrator) stated she hadn't had any complaints/concerns that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146021 If continuation sheet Page 5 of 11 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 146021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nature Trail Health and Rehab 1001 South 34th Street Mount Vernon, IL 62864 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete residents weren't getting provided with incontinence care timely. After this surveyor reviewed, V13 and V9's interviews, V1 stated she was not aware V9 (CNA) was R1's CNA and was supposed to assist R1 with his care. V1 stated she believed V9 should have provided R1 with incontinence care and V11 (family member) should not have had to walk in on R1 like that. The facility Incontinence Care Policy dated 5/16/2022 documents, Purpose: To provide guidelines to all nursing staff for providing proper incontinence care in order to clean (sic) skin clean, dry, free of irritation and odor. Policy: All incontinent residents will receive incontinence care in order to keep skin clean, dry and free of irritation and/or odor. Incontinence care will be provided as required Event ID: Facility ID: 146021 If continuation sheet Page 6 of 11 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 146021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nature Trail Health and Rehab 1001 South 34th Street Mount Vernon, IL 62864 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a care plan was initiated, interventions were implemented, and behaviors were tracked and trended for 1 of 3 (R2) residents reviewed for behaviors of physical aggression in the sample of 15. Findings Include: R2's facility admission Record with a print date of 7/13/23 documents R2 was admitted to the facility on [DATE] with diagnoses that include diabetes, kidney failure, peripheral vascular disease, hypertension, dementia, and unspecified lack of expected normal physiological development in childhood. R2's MDS (Minimum Data Set) dated 5/10/23 documents R2 has a BIMS (Brief Interview for Mental Status) score of 12, which indicates a moderate cognitive impairment. R7's admission Record with a print date of 7/13/23 documents R7 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease, repeated falls, hypertension, post traumatic stress disorder, and Parkinson's Disease. R7's MDS dated [DATE] documents a BIMS score of 05, which indicates a severe cognitive impairment. On 7/12/23 at 8:43 AM, V4 (CNA/Certified Nursing Assistant) stated one day last week (specific day unknown) R2 was in the dining room and was choking. V4 checked on R2 and R2 asked for a drink of water. V4 stated she got R2 a drink of water and R2 then asked for more food. V4 stated R2 was still coughing and had puked. V4 stated she asked R2 to wait a little bit to ensure he was ok before eating more food. V4 stated she sat down by the door and R2 came up to her and was staring at her and then began choking her. V4 stated R2 said I am going to kill this fu**ing bi**h. V4 stated she reported it to V1 (Administrator) and V1 sent V4 home for the rest of the day. V4 stated she was afraid of R2, and she wasn't aware of any other intervention that were implemented after the incident. When asked if that was the first time R2 had been physically aggressive V4 stated R2 had also hit V5 (CNA). The facility Supervisor Accident Investigation dated 7/5/2023 documents, (V4 -CNA) sitting at front door. Resident (R2) was coughing, looking for drink, got water and drank it, still coughing and started throwing up. (R2) Started staring at her (V4), scared her (V4), (R2) grabbed both hands and choked her (V4) with both hands. The report documents V20 (CNA) as a witness to the event. On 7/12/23 at 3:29 PM, V20 (CNA/Restorative Aid) stated she was in the Human Resource office and V4 was sitting in a chair watching the front door. V20 stated she saw R2 hovering over and giving V4 a weird glare. V20 stated she asked V4 why R2 was looking at her that way and V4 stated she didn't know but she was scared. V20 stated R2 lunged at V4 and used both hands to choke V4. V20 stated she ran towards them and V4's face was turning purple and V4's hands were up in the air. V20 stated she asked R2 what he was doing and R2 stated he was going to kill this fu**ing bi**h. V20 stated she had heard V4 asking R2 if he was choking prior to the incident and then R2 hollering that he wanted more food and V4 told R2 to wait a minute because he was choking. On 7/13/2023 at 11:55 AM, V1 (Administrator) stated on the day of the incident with V4, R2 went up to V4 and was coughing. V1 stated V4 got R2 a drink. V1 stated R2 was still coughing and asked for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146021 If continuation sheet Page 7 of 11 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 146021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nature Trail Health and Rehab 1001 South 34th Street Mount Vernon, IL 62864 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few something to eat and V4 told R2 he didn't need something to eat. V1 stated, V4 proceeded to get bread and bacon from the kitchen and made herself a bacon sandwich. V1 stated that was when R2 reached out and put his hands on her (V4's) neck. V1 stated V4 didn't have any scratches, red marks, bruising on her neck. On 7/12/23 at 9:36 AM, V5 (CNA) stated she was working during nurse's week and the facility had put food in the staff break room for the staff. V5 stated R2 entered the break room to get food and V5 told R2 he couldn't go in the staff break room. V5 stated R2 left the break room and V5 left to answer a call light. V5 stated after responding to the call light she went to the nurse's station to look at the schedule and R2 was at the nurse's station. V5 stated she turned away from the wall where the schedule was located and R2 began to hit her. V5 stated she yelled for help and turned so R2 would hit her back instead of her face. V5 stated all the other staff were assisting residents down the halls and didn't hear her yelling. After R2 stopped hitting her V5 reported the incident to V21 (RN/Registered Nurse) who stated, Oh, well. V5 stated she then called V1 (Administrator) and reported the incident to her. V5 stated she reported the incident to V17 (LPN/Licensed Practical Nurse) and V17 had her fill out an incident report. V5 stated she had bruises on her arm, jaw, and back. According to https://www.nursingworld.org/ana-enterprise/nurses-month/ nurses' week was 5/8-5/14/23. On 7/12/23 at 2:15 PM, when asked for the incident report V21 filled out, V1 (Administrator) stated she got a call from V21 and was told R2 had come after V5 but didn't know R2 had hit her and didn't receive an incident report from V5. On 7/12/23 2:43 PM, V17 (LPN) stated V5 reported to her she was by the nurse's station and R2 grabbed a hold of her, and it hurt her shoulder. V17 stated V5 asked her opinion on it, and she instructed V5 to call V1 and write a statement. When asked if she assessed V5 for injuries, V17 stated V5 didn't point any injuries out to her. V17 stated she didn't know the date of the incident. On 7/13/23 at 12:52 PM, V21 (RN) stated she was working on the night of the incident with R2 and V5. V21 stated she didn't witness it but V5 reported to her, R2 had knocked her on her arm or pushed her or something. V21 stated she went to R2's room and R2 was laying in his bed, and she asked him if had bothered V5 and he stated he hadn't. V21 stated she told R2 he wasn't supposed to bother them, hit them, or push them, and R2 said, ok. V21 stated V5 reported R2 had pushed her on her arm but V5 didn't appear to have any injuries. When asked if she had V5 fill out an incident report, V21 stated she thought V5 filled out a behavior tracking sheet. When asked if R2 had behavior tracking or a care plan for physical aggression in place at the time of the incident, V21 stated she didn't think so. When asked how V5 appeared that night, V21 stated V5 was upset R2 would do that. The facility Report Form- Illinois Department of Public Health (IDPH) Notification dated 5/27/23 documents a physical altercation between R2 and R7. This same form documents the local police, ombudsman, physician, and families were notified of the altercation. The facility Verification of Incident Investigation/Administrative Summary dated 6/1/23 documents under Immediate Action Taken: Investigation immediately implemented .(V1) Abuse Coordinator notified. Risk assessments completed. Trauma/Skin assessments completed on both residents. 15-minute checks for each resident immediately implemented for a minimum of 72 hours. (Name of physician) to see both residents next scheduled rounds The report documents under, Follow Up Actions Taken: Review of resident's medications, treatments, labs. Continued behavioral assessments and contact to physician as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146021 If continuation sheet Page 8 of 11 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 146021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nature Trail Health and Rehab 1001 South 34th Street Mount Vernon, IL 62864 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few needed. Resident Risk and Quality Assurance Committee reviews for tracking and trends, with recommendations as indicated. Resident care plans updated with interventions to address. Through thorough investigation the allegation of resident-to-resident altercation is founded as staff witnessed. (R2) vaguely remembers the altercation and (R7) has no recollection of event at all. Will continue to monitor residents ongoing for any changes in behavior. Both residents were seen by (name of physician) assistant at scheduled rounding. Labs ordered. Residents now on separate halls and remain at baseline with no ill effects from allegation. R2's progress notes document on 5/3/23 R2 was admitted to the facility. R2's progress notes document assessments with no documentation of physically aggressive behaviors until 5/28/23 when R2's progress notes document, patient observed hitting another patient (R7) that entered his room. Patient (R2) hit the other patient (R7) in the face 3 times with right hand closed fist. Patient (R2) reported he woke me up and it made me mad. Patient (R2) was redirected, and he prepared for bed, he (R2) did not sustain any injuries. R2's progress notes continue to document assessments with no other documentation related to physical aggression until 7/5/2023 when R2's progress notes document, This resident got into an altercation with a staff member, (name of physician) here for rounds and ordered STAT CMP (comprehensive metabolic panel) and CBC (complete blood count). Will monitor resident. On 7/6/23 R2's progress notes document R2 was evaluated by a local psychiatric Physician Assistant. R2's Detailed Behavior Tracking Form dated 5/27/23 documents that R2 sat snacks down on dresser and began to hit another resident in the face three times. R2's POC (Point of Care) Response History, Task: Behaviors, documents from 6/13/23 to 7/12/23, R2 had behaviors of grabbing and threatening on 7/5/23. There were no other behaviors documented on this report. There were no other reports prior to the Detailed Behavior Tracking Form dated 5/27/23 and no POC Response History reports prior to the report dated 6/13/23 to 7/12/23 to track R2's behavior . R2's current undated Care Plan documents a Focus Area of, R2 has potential to be physically aggressive r/t (related to) observed hitting another resident with right hand closed fist. Date Initiated: 5/30/23. This focus area includes the following interventions initiated on 5/30/23, 5/27/23 2036 (8:36 PM) patient observed hitting another patient in the face 3 times with right hand closed fist, he reported the other patient woke him up and it made him mad. Intervention: Residents were separated by a CNA (Certified Nursing Assistant) and assessed .Analyze times of day, places, circumstances, triggers, and what de-escalates .Asses and address for contributing sensory deficits .Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain etc .Communication: Provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated .Give the resident as many choices as possible about care and activities . R2's current undated Care Plan documents a Focus Area of (R2) is/has potential to be Physically abusive r/t Dementia, Mental/Emotional illness. Date Initiated: 7/12/2023. This focus area includes the following interventions dated 7/12/2023, Administer medications as ordered. Monitor/document for side effects and effectiveness. Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc. Assess resident's coping skills and support system. Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Give the resident as many choices as possible about care and activities. Monitor for behavior of Physical aggression with peers/staff and document if behavior seen. 7/5/2023 Resident seen by staff standing over team member (V4) with an angry appearance on his face and then he lounged (sic) forward and grabbing her around the neck and choking her with a shake. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146021 If continuation sheet Page 9 of 11 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 146021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nature Trail Health and Rehab 1001 South 34th Street Mount Vernon, IL 62864 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Intervention: Nurse at nurses station immediately came to aid and assist able to easily redirect W/ (with) verbal cueing. Monitor for pain and provide meds as appropriate. Monitor significant side effects of antipsychotic medications and notify MD (physician) as appropriate . This indicates R2 had a behavior of physical aggression with staff during the week of 5/8-5/14/23 and did not have a care plan, interventions, or behavior tracking implemented to prevent future physical aggression, until after a behavior of physical aggression with R7 on 5/27/23. On 7/12/2023 at 10:31AM, V12 (Social Services) stated she and V13 (MDS Coordinator) were responsible for tracking and trending behaviors. When asked if she had tracked R2's behaviors, V12 stated she had not. When asked how they monitored behaviors to determine if a new intervention needed to be implemented, V12 stated they review the nurse's notes. This surveyor reviewed the incidents of R2 being physically aggressive with staff and V12 stated she wasn't aware of those incidents. V12 stated if she wasn't aware of the behaviors then she couldn't implement new interventions. On 7/12/23 at 10:45 AM, V13 (MDS Coordinator) stated she was responsible for implementing resident care plans. V13 stated if there was a risk management, she implemented new interventions for behaviors. V13 stated she was aware of R2's physically aggressive behaviors with R7 and with V4 and V5. When asked if she tracked/trended behaviors of physical aggression against staff, V13 stated no one had told her she had to. When asked if there were any new interventions implemented after R2's physical aggression with staff, V13 stated R2 was easily redirected, the incident was discussed in morning meeting and that was where they left it. On 7/13/23 at 11:03 AM, V2 (DON/Director of Nurse) stated she was not aware of the incident between V5 (CNA) and R2. V2 stated she was not able to find any documentation related to the incident in R2's medical record. V2 stated she didn't know when behavior tracking started for R2. V2 stated the first time she was aware R2 had behaviors of physical aggression was when R2 hit R7. When asked if R2 had a care plan in place and/or behavior tracking for physical aggression, V2 stated he did not. When asked what she would have done had she been aware of the incident between V5 and R2, V2 stated she would have spoken with social services, had a meeting with R2's family, put a care plan with interventions in place, had a medication review, called the physician, and obtained lab work. On 7/13/2023 at 11:55 AM, when asked if there were two incidents of R2 having physical aggression with staff, V1 (Administrator) stated she was still questioning the incident with V5. V1 stated when V5 called her she couldn't understand her. V1 stated she told V5 she would call V21 and have her check on R2. V1 stated V21 checked on R2 and R2 was lying in bed, and she was told by V21 there was no incident. V1 stated V5 has been caught in lies and no other staff member heard it or witnessed it, and according to staff, V5 didn't have any marks on her. V1 stated she didn't believe the incident between V5 and R2 occurred. V1 stated she talked with other staff that worked the night of the incident and they didn't see anything. When asked if that was documented anywhere, V1 stated only in her personal notes. When asked who she spoke with, V1 stated V21 and she wasn't sure who else. V1 stated it was just odd they didn't have confirmation of the incident. V1 stated, What I believe personally shouldn't hinder the investigation or checking on his (R2) behaviors to make sure he was safe, she was safe, or other team members or residents. When asked what her expectation would be, V1 stated, she would expect there to be some kind of follow up. V1 stated R2 didn't have any behavior tracking, care plan, or interventions in place for physical aggression prior to the peer-to-peer physical aggression between R2 and R7 on 5/27/2023. The facility Behavioral Assessment, Intervention and Monitoring policy dated 3/2019 documents, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146021 If continuation sheet Page 10 of 11 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 146021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nature Trail Health and Rehab 1001 South 34th Street Mount Vernon, IL 62864 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Policy Statement, 1. The facility will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. 2. Behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment New onset or changes in behavior will be documented regardless of the degree of risk to the resident or others Cause Identification: 1. The interdisciplinary team will thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition Management: 1. The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm .7. Interventions will be individualized and part of an overall care environment that supports physical functional and psychosocial needs, and strives to understand, prevent, or relieve the resident's distress or loss of abilities. 8. Interventions and approaches will be based on a detailed assessment of physical, psychological, and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for the behavior Monitoring: 2. The IDT (Interdisciplinary Team) will monitor the progress of individuals with impaired cognition and behavior until stable. New or emergent symptoms will be documented and reported. Event ID: Facility ID: 146021 If continuation sheet Page 11 of 11