Health inspection·February 4, 2025

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 1/30/25 at 8:30 AM, V1 (Administrator) stated that they get rescreened after 30 days after discharge off therapy. They are not necessarily all receiving a restorative programs, other than group exercise activities and ADL's. On 1/30/25 at 8:32 AM, V3 (Therapy Director) stated that the residents are screened 30 days post discharge off therapy services and then at minimum every quarter on the MDS schedule. V3 went on to state that if there is a decline noticed by any nursing staff they can refer to therapy for a screening at any time. 4. R52's admission record documents an admission date of 8/24/24. This same documents includes the following diagnoses: spondylopathies cervical region, alcohol dependence, and PTSD. Review of R52's current Care Plan has a focus area for self-care deficit as evidence by: R52 needs assistance with ADL's related to complex medical factors. The goal for this focus area is: R52 will participate with ADL's daily and ADL status will improve by target date. Interventions for this focus area include: PT (Physical Therapy) and OT (Occupational Therapy) evaluation and treatment as per physician orders, with an initiations date of 9/16/24. R52's admission MDS dated [DATE] documents in section GG that no impairment on upper extremities and impairment on both sides for lower extremities. R52's Quarterly MDS dated [DATE] Section GG documents no impairment on upper extremities and impairment on both sides on lower extremity. The same MDS Section O0500 documents that he is not receiving any restorative nursing programs active or passive range of motion. R52's PT Evaluation with a certification period of 8/27/24-10/16/24 documents under musculoskeletal system assessment that bilateral lower extremities ROM and strength impaired. R52's Notice of Discharge From Therapy dated 11/4/24 documents a discharge date from therapy of 11/7/24 and that R52 should continue with restorative measures of bilateral upper/lower extremities with therapy exercises and active range of motion written in on the discharge form. Review of R52's current month physician orders does not include any restorative orders. On 1/28/24 at 10:30 AM, R52 who is alert to person, place, and time stated that since he has finished therapy he does not receive any types of exercises. R52 replied no when asked if the staff move his arms/legs/hands daily to ensure his joints are exercised and do not get stiff. R52 stated that he cannot stand, is in bed all the time, and chooses to not attend group activities or eat in the dining room. The facility policy titled Range of Motion with a date of 01/02/2022 documented range of motion exercises is critical to improve and maintain function in the joint and prevent contracture deformity. 1. Verify that there is a physician's order for this procedure. If there is no order for treatment, contact the attending physician to obtain treatment orders .4. Move each joint through its range of motion three times unless otherwise instructed . 3. R3's document titled admission Record documents an admission date 10/5/2005 with diagnoses including Intracranial Injury without loss of consciousness subsequent encounter, Chronic Obstructive Pulmonary Disease, Aphasia, Dysphagia, GERD, Paraplegia, Hypertension, and Contractures of the Right (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146021 If continuation sheet Page 2 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2025 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 0688 Knee, Left Ankle, Right Ankle, and Right Hip. Level of Harm - Minimal harm or potential for actual harm R3's MDS dated [DATE] documents R3's cognition is severely impaired. Section GG documents under Functional Limited Range of Motion documents that R3 has impairment on both sides for upper and lower extremities and R3 is dependent for toilet hygiene, showers, upper body, and lower body dressing, putting on and taking off footwear, personal hygiene, rolling left to right, lying to sitting on side of bed, chair- chair transfer and toilet/shower transfer. R3's Care Plan documents a Focus area of R3 requires assistance with ADL's (Activity of Daily Living) related to paraplegia contractures, aphasia, pain, enteral feeding, TBI (Traumatic Brain Injury). R3's Goals document R3 will have ADL needs identified and met with staff assistance and interventions while maintaining highest level of independent function possible to review date every 90 days. Documented Interventions include: Head of Bed elevated 30 degrees always except brief ADL care, oral care every shift, provide assistance with required completion of ADL task, and up in specialized wheelchair as tolerated. Residents Affected - Some R3's Occupational Therapy OT Evaluation and Plan of Treatment, authored by V3 (Therapy Director) documents a discharge date from therapy of 12/31/2024 with reason noted of Resident reached maximum potential. Under objective progress/short term goals R3 has a baseline date of 10/25/2024 with a target date of 11/7/2024, the patient will improve right upper extremity elbow hypertonicity with application of elbow extension split to reduce further progressing/development of contracture. On 1/30/2025 at 11:10 AM, V13 (Restorative Certified Nurse Assistant) stated she was the one that does all the restorative programs. V13 stated she does not have written programs and she just does what is needed for the residents. V13 was asked if she follows any guidelines as to how many reps are done on the affected joints, V13 stated no we do not have any guidelines like that. V13 stated she does see R3 on a regular basis for range of motion. V13 stated that R3 loves to be stretched out and by Friday he is usually much looser where he has contractures but then on Monday, we must start the process all over again. V13 was asked how she knew who to see for restorative purposes, V13 stated I usually see who needs to be seen and sometimes physical therapy will tell me to pick someone up after they complete therapy. V13 was asked if therapy gave her a plan of care to follow and she said they will tell me what needs to be done. V13 stated she sees R3 everyday Monday through Friday usually, but she has been off sick, and she doesn't think it was done while she was off sick. V13 stated R3 does not have splints. On 1/28/2025, 1/29/2025, and 1/30/2025, R3 was noted to be up in specialized wheelchair with noted contractures to right upper extremity, right lower extremity, right and left ankles. On 1/31/2025 at 9:45AM, V12 (Certified Nurse Assistant/CNA) stated she does not do PROM for R3, V12 stated the restorative duties are done by the restorative aid. On 1/31/2025 at 9:48AM, V10 (Certified Nurse Assistant/CNA) stated she care for R3 and is not responsible for any type of ROM because the restorative aid does all of that and the restorative CNA is V13. On 1/31/2025 at 2:22PM, V14 (Regional Clinical Director) stated he was not familiar with the Restorative Program and was unsure about the MDS. V14 stated he was not sure about the programs and who wrote the programs. V14 stated he was aware that a lot of companies are moving away from restorative programs due to financial issues. V14 stated there really were not programs written for the residents and most of the residents are on walk to dine programs. V14 stated there are only 2 contractures in the facility that she is aware of. V14 stated there are other residents with splints and devices (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146021 If continuation sheet Page 3 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2025 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 0688 like that. Level of Harm - Minimal harm or potential for actual harm On 1/31/2025 at 10:15 AM, V13 (Restorative Certified Nurse Assistant) was observed doing PROM on R3 while R3 was in bed. V13 had placed warm compress to right shoulder and right knee. V13 did not do range of motion to right shoulder or right upper extremity. V13 did 5 reps of knee extension to right knee and 5 reps of rotation to right ankle were done. No PROM was completed to left ankle. Residents Affected - Some Based on observation, interview, and record review the facility failed to provide services to increase and/or prevent further decrease of range of motion (ROM) for 5 (R23, R28, R3, R37, and R52) of 5 residents reviewed for decreased range of motion in the sample of 55. Findings Include: 1. R23's admission Record documented R23 as a [AGE] year-old with an admission date to the facility of 03/16/2024. Diagnoses listed are hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, other immunodeficiencies, type 2 diabetes mellitus, essential hypertension, lymphedema, generalized anxiety disorder, hyperlipidemia, and embolism and thrombosis of superficial veins of left lower extremity. R23's Order Summary Report with a print date of 01/31/2025 does not document an order for any range of motion or restorative nursing program. R23's Quarterly Minimum Data Set (MDS) dated [DATE] noted that R23's Brief Interview for Mental Status (BIMS) score is 15 which indicates R23 is cognitively intact. Section GG documents for functional limitation in range of motion that R23 has impairment on one side for both upper and lower extremities. Section GG for self-care documents that R23 is dependent for shower/bathing, upper body dressing, lower body dressing, and putting on and taking off footwear. Section O of the same MDS documents R23 received 0 days of range of motion and 0 days of passive range of motion (with a look back period of 7 days.) R23's Care Plan, with a start date of 03/18/2023, documents a focus area of R23's Self-Care Deficit as evidenced by needs assistance with activities of daily living related to left sided weakness. Interventions listed include: encourage the resident to participate to the fullest extent with each interaction and encourage resident to discuss feelings about self-care deficit. The Focus area documents that R23 has hemiplegia/hemiparesis with interventions listed as bowel / bladder program, discuss the residents' concerns and fear, and give medications as ordered. R23's document titled Occupational Therapy (OT) Evaluation and Plan of Treatment dated 09/05/2024 under Musculoskeletal System Assessment documented right upper extremity range of motion within functional limits, left upper extremity impaired, left upper extremity hemiplegia - patient unable to perform active range of motion, but passive range of motion within functional limits for shoulder/elbow/forearm. Increased tone noted in left hand / wrist but 50% gross passive range of motion achieved in digits. Functional limitations as result of contracture left upper extremity hemiplegia contributing to left hand contracture risk and reduced ability to utilize left hand. R23's document titled Notice of Discharge From Therapy dated 10/2/24 documents that resident is to continue with restorative measures with a date of discharge from therapy of 10/4/24. On the bottom of this same form, it documents for R23 to do AROM (Active range of Motion) bilateral upper and lower extremities and utilize the bike for lower extremities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146021 If continuation sheet Page 4 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2025 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 01/28/2024 at 10:50 A.M., R23 stated he does not receive any therapy or range of motion from the facility. R23 stated he was supposed to get therapy 3 times a week and he stated he doesn't get it at all. R23 stated he would like to go to therapy to lift weights and ride the bike, but the staff tell him he can't. R23 stated he would like to attempt to walk. R23 stated he feels like he is stiff as a robot. On 01/29/2025 at 1:23 P.M.V15 (Certified Nurse Assistant/CNA) was observed performing AROM to R23's right side. V15 asked resident to open and close hands, asked resident to move his foot up and down, asked resident to open and close his hand, asked resident to open and close arm at the elbow, and asked resident to move his head. There was no range of motion completed to the left side of R23's body. This observation ended at 1:27 P.M. 2. R28's admission Record documented R28 as a [AGE] year-old with an admission date to the facility of 03/16/2024. Diagnoses listed are Parkinson's disease, unspecified dementia, chronic obstructive pulmonary disease, essential hypertension, major depressive disorder, and anxiety. R28's Order Summary Report with a print date of 01/31/2025 does not document an order for any range of motion or restorative nursing program. R28's Quarterly MDS with a date of 01/06/2025 noted that R28's BIMS score is 09 which indicates R28 has moderate cognitive impairment. Section GG documents for functional limitation in range of motion that R28 has impairment on one side for both upper and lower extremities. Section GG for self-care documents that R28 is dependent for oral hygiene, toileting hygiene, shower/bathing, upper body dressing, lower body dressing, and putting on and taking off footwear. Section O of the same MDS documents R28 received 0 days of range of motion and 0 days of passive range of motion (with a look back period of 7 days.) R28's Care Plan documents a focus area of R28 has an activity of daily living self-care performance deficit related to deconditioning. Interventions listed for the focus area include: R28 requires extensive assistance of one staff for bathing, extensive assist of one for turning and repositioning in bed, extensive assist of one for dressing, the resident required mechanical lift with two staff assistance for transfers and physical therapy (PT) / occupational therapy (OT) evaluation and treatment as per physician orders. R28's Occupational Therapy (OT) Evaluation and Plan of Treatment with a start date of 10/12/2023 documented under musculoskeletal system assessment upper extremity range of motion impairment on the right and left. On 01/29/2025 at 1:27 P.M. V15 performed AROM to R28. V15 asked resident to move both feet back and forth, asked resident to wiggle his toes, asked resident to move his legs up and down, asked resident to move his hand up and down, asked resident to move his arms up and down, and asked resident to move his head. Observation ended at 1:31 P.M. with CNA leaving room to go get R28 hot chocolate. On 01/30/2025 at 9:00 A.M., V3 (Physical Therapy Assistant) stated that after the resident is off therapy they leave the facility a restorative plan . V16 stated that the facility does not do PROM (Passive Range of Motion) as restorative therapy. She stated that the facility considers dressing a resident passive range of motion. V16 stated that dressing a resident may not prevent the decline in mobility in some residents. She stated that it all would depend on the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146021 If continuation sheet Page 5 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2025 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 0688 Level of Harm - Minimal harm or potential for actual harm On 01/30/2025 at 9:42 A.M., V16 (Licensed Practical Nurse / MDS Nurse) stated that when she was trained to do MDS she was told that she cannot code section O0500 as anything but a 0 because they do not have a structured restorative program. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146021 If continuation sheet Page 6 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2025 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement interventions to prevent falls for 1 of 6 (R122) residents reviewed for falls in a sample of 55. This failure resulted in R122 falling and sustaining a left intertrochanteric fracture and subsequent hospitalization. The Findings Include: R122's admission Record documents an admission date of 1/8/25 with diagnoses including unspecified dementia, weakness, and atrial fibrillation. R122's admission Record documents a date of discharge og 1/14/25 to a local acute care hospital. R122's Order Summary Report with a print date of 1/31/25 documents an order for a bed alarm and chair alarm every shift with an order date of 1/8/25. R122's Care Plan has a focus area of being at risk for falls and injuries related to weakness, CVA (cerebral vascular accident), and Atrial Fibrillation. The goal for this focus area is to decrease risk of fall and/or minimize injuries form falls for 90 days. The interventions for the focus area include: assist to toilet prior to laying down with an initiation date of 1/13/25, bed and chair alarms in place with an initiation date of 1/8/25, and mat at bedside when in bed date with an initiation date of 1/13/25. R122's Minimum Data Set (MDS) 5 day assessment dated [DATE] Section J documents that R122 did not have a fall prior to admission. This same section documents R122 had one fall with a minor injury and one fall with a major injury after admission. The same MDS Section C documents a Brief Interview of Mental Status (BIMS) score of 11, indicating that he has moderately impaired cognition. R122's Progress Note dated 1/8/25 documents Resident is a high fall risk. New orders received for bed/chair alarm. Alarms in place at this time and functioning properly. R122's Progress Notes dated 1/11/25 document the following: 6:57 PM: notified POA (Power of Attorney), MD (Medical Doctor), and V2 (Director of Nursing/DON) of situation and R122 was being transferred to the local emergency room via EMS (Emergency Management Services) for evaluation. 7:04 PM: Resident had an unwitnessed fall while eating dinner in his room. Resident had small red mark on head back of head, roommate stated he witnessed him hit his head when he fell. Family called, DON notified, MD notified. Report called into (name of local hospital), and EMS notified. Report given to (name of nurse at local hospital), all information passed along and questions answered. EMS arrived as report to (name of local hospital) was finishing up. Resident was transferred via one assist on to gurney. Paperwork given to EMS, all information passed along and questions answered. Resident was secured and loaded into ambulance. R122's Unwitnessed Fall report dated 1/11/25 documents under the incident description: CNA's (Certified Nurse's Assistant) reported to nurse (self) that resident had fallen on the floor. Fall was not witnessed. Roommate stated resident hit head when he fell. Resident stated he was trying to get up (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146021 If continuation sheet Page 7 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few but could not state why he was getting up. Resident was hoyered (used a mechanical lift) from floor 3x assist. Resident denied pain, but had a small red bump on head. Sent to hospital due to resident being on blood thinners for precautionary measures due to inability to judge confusion level due to resident's normal cognitive state. Resident stated he was trying to get up but could not remember why. Resident is unsure if he hit his head or not. This same document lists the root cause of the incident: R122 attempted to stand up out of bed unassisted and fell, hitting his head. Intervention is to assist R122 to toilet before assisting to bed. R122's Progress Note dated 1/13/25 at 5:34 PM it is documents: Resident slid out of his bed onto his bedroom floor at 0630 (6:30 AM) this morning. Resident received a head-to-toe assessment. VS (vital signs) and neuro (neurological checks) started per facility protocol. Resident was assisted back into his wheelchair with 2 staff. Resident denied any pain or discomfort at this time. Resident expressed pain and discomfort at approximately 1100 (11:00 AM) of L (left) hip. (MD) was notified and received orders for L hip and pelvic X-ray. Notified (name of mobile X-ray company) and waiting for call back. Resident c/o (complains of) pain to L should while doing PT (Physical Therapy). (MD) notified again, and received orders to add L shoulder to x-ray. Resident had x-ray completed at 1651 (4:51 PM). Awaiting results. Resident is currently resting in his room. R122's Progress Note dated 1/14/25 at 1:01 AM documents that a call was received with x-ray results indicating a left intertrochanteric fracture. A facility Incident Report dated 1/13/25 at 6:30 AM documents that R122 was oriented x1 and had no injury to report. The investigative statement on this report documents that R122 stated he was ready to get in his wheelchair. R122 stated then that he thought he could do it himself, and before he knew it he had slid onto the floor, sitting on his bottom. This report documents under actions: a fall assessment, skin assessment, a pain assessment were completed and diagnostic services ordered. On 1/30/25 at 2:31 PM, V4 (Certified Nurse Assistant/CNA) stated that she was the staff member who found R122 on the fall that occurred on 1/11/25. V4 stated that she heard a loud noise and ran to his room and found him on the floor. V4 stated that there was no fall mat observed in the room and R122 did not have an alarm sounding. V4 went on to state that he would not ever stay still and did not listen to reminders of not getting up to walk alone. V4 stated that she found him close to the doorway, and thinks he was likely getting up to go to the bathroom. V4 stated that he was refusing to want to use a mechanical lift to get up from the floor and did not want to go to the hospital, but she got help from the staff to assess him properly and R11 did go to the emergency room since they were unsure of whether he hit his head. On 1/30/25 at 2:38PM, V7 (CNA) stated on a telephone interview that she was the staff that found R122 on his fall that occurred on 1/13/25. V7 stated that she has just clocked out for the shift but was waiting to let her car warm up when she came back in the facility and walked by R122's room and saw him on the floor. V7 stated that she got staff to assist her with getting him assessed by the nurse and back in his chair. On 1/30/25 at 2:45PM, R44 who is alert to person, place and time stated that he was R122's roommate and the alarm did not sound for either of the falls. R44 stated that he remembers R122 getting up and being all wobbly and that he couldn't do anything to help him because he is unable to walk. On 1/30/25 at 2:55PM, V2 (Director of Nursing) stated that the CNA's check placement and function at the start of each shift of resident's bed/chair alarms. V2 stated that she is unsure why the alarm (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146021 If continuation sheet Page 8 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2025 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 0689 did not sound after each of the falls. V2 stated that all the alarms at the current time are working. V2 went on to state that the alarm should have been placed both in the chair and in the bed. Level of Harm - Actual harm Residents Affected - Few On 1/30/25 at 2:55 PM, V1 (Administrator) stated that R122 was here a very short time and had a couple of falls. R122 stated that after the second fall he never returned to the facility as planned due to going on hospice and expiring at the hospital. On 1/20/25 at 3:38 PM, V5 (CNA) and V6 (CNA) stated that they check placement and function every shift for alarms. On 01/31/2025 at 12:44 PM, V17 (Licensed Practical Nurse) stated she was the nurse the night of 01/11/2025. V17 stated that she had just started her shift at 6:00 P.M. V17 stated that it had been reported to her that R122 had been restless for day shift and had gotten up and down all day from his bed and chair. V17 stated it was her understanding that R122's baseline is that he is confused. V17 stated that she was alerted by the CNA that R122 had fallen. R122's emergency room provider notes, dated 1/14/24 at 3:37 AM from the local hospital, documents under chief complaint that R122 is from the nursing home and presents with complaint of left hip pain. Per nursing home report patient had a fall this morning x-ray report this evening showing left hip fracture. History is limited by patient's mental status. It is unclear if he had any associated head or neck injury. Differential diagnosis includes likely hip fracture, less likely head or cervical spine injury. The hospital records document CT (Computed Tomography) results for the head and cervical spine dated 1/14/25 are negative for fractures. An Orthopedic Consult dated 1/14/25 documents a recommendation of surgical repair. A Brief Op (Operative) Note dated 1/15/25 documents that R122 had an Open Reduction Internal Fixation of the left hip/ trochanteric (fixation nail) performed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146021 If continuation sheet Page 9 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2025 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide the required 80 square feet of floor space per resident for 38 of 38 (R2, R16, R55, R8, R19, R5, R35, R20, R17, R50, R51, R26, R12, R43, R30, R31, R14, R1, R62, R56, R3, R48, R25, R41, R11, R24, R60, R40, R59, R61, R23, R46, R28, R18, R58, R47, R52, and R54) residents reviewed for room size in a sample of 55. The findings include: On 01/31/2025 at 9:28 A.M., V1 (Administrator) stated the waived rooms are 100-109, 111, 201-209 and 211, are certified 2 bed rooms, and measure less that 80 square feet per resident. On 01/31/2025 at 9:05 A.M., V9 (Maintenance) measured rooms [ROOM NUMBERS]. rooms [ROOM NUMBERS] measured 12 feet by 12 feet equaling 144 square feet which is approximately 72 square feet per resident bed. V9 stated that 100-109,111 and 201-209, and 211 are all the same size. Each room contained 2 beds, 2 dressers, and 2 nightstands. On 01/31/2025 at 9:10 A.M. R50 and R51 stated they both have no concerns with the room size. R50 and R51 are both alert and orientated to person, place, and time. On 1/31/2025 at 9:15 A.M. R56 stated he has no concerns with the room size. R56 is alert and orientated to person, place, and time. On 1/31/2025 at 9:18 A.M. R11 stated he has no concerns with the room size. R11 is alert and orientated to person, place and time. On 1/31/2025 at 9:20 A.M. R35 stated she has no concerns with the room size. R35 is alert and oriented to person, place and time. The facility daily rooster dated 01/27/2025 documents R2, R16, R55, R8, R19, R5, R35, R20, R17, R50, R51, R26, R12, R43, R30, R31, R14, R1, R62, R56, R3, R48, R25, R41, R11, R24, R60, R40, R59, R61, R23, R46, R28, R18, R58, R47, R52, and R54 reside in rooms 100-109, 111, and 200-209, and 211. Observations of the waived rooms were made from 01/28/2025 - 01/31/2025, showing these rooms provide adequate space to meet the medical and personal needs of these residents. The Resident Council Meeting Minutes from July 2024 through January 2025 documents no concerns regarding the size of resident rooms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146021 If continuation sheet Page 10 of 10