Health inspection·November 29, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. On 11/20/23 at 09:54 AM, R35 was alert sitting in a shower chair in his bathroom, following a shower. R35 had an indwelling urinary catheter with cloudy yellow urine present in the tubing and the drainage bag. R35's Physician's orders document that R35 has an order for Humalog per a sliding scale subcutaneously two times a day and Insulin Glargine 20 units subcutaneously two times a day for R35's diagnosis of Diabetes Mellitus. R35's Physician's orders also document an order for a 16 French 10 milliliter indwelling urinary catheter. R35's Current Care plan, printed 11/20/23, has no documentation of a comprehensive care plan addressing R35's use of Insulin for his diagnosis of Diabetes Mellitus nor his indwelling urinary catheter. On 11/22/23 at 10:17 AM, V7 (Care Plan Coordinator) confirmed there is no comprehensive care plans for R35's use of insulin nor his indwelling urinary catheter. 4. R6's current POS (Physician Order Sheet) documents R6 has a diagnosis of Type Two Diabetes Mellitus with Hyperglycemia and Depression. R6's MDS (Minimum Data Set) dated 9-1-23 documents R6 had a diagnosis of Diabetes Mellitus and Depression. This same MDS identifies R6 was administered insulin and antidepressant medications. R6's Care Plan revised 9-19-23 did not document a care plan for the use of an antidepressant medication. This same plan did not document a care plan for diabetic management. 5. R36's current POS (Physician Order Sheet) documents R36 had a diagnosis of Diabetes and Depression. R36's MDS dated [DATE] documents R36 had a diagnosis of Diabetes Mellitus and Depression. This same MDS documents R36 receives insulin and antidepressant medications. R36's Care Plan revised on 9-18-23 does not document a care plan for the use of an antidepressant medication. This same plan of care does not document a care plan for diabetic management. On 11/21/23 at 2:35 PM V7 Care Plan/MDS coordinator confirmed R6's and R36's current plan of care does not include a behavioral care plan with use of antidepressant medications or a diabetic management care plan. V7 states, Those should have been on R6 and R36's care plan. I must have missed it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146057 If continuation sheet Page 2 of 20 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 146057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monmouth Rehab and Nursing 117 South I Street Monmouth, IL 61462 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 - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide Active and Passive Range of Motion programming for residents with limited range of motion for two of two residents (R3, R6) reviewed for functional limitations in range of motion in the sample of 45. Findings include: The facility's Resident Mobility and Range of Motion policy dated 07/2017 documents, Resident with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in range of motion. Residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. 1. R3's MDS (Minimum Data Set) assessment dated [DATE] documents R3 has a limitation in ROM (Range of Motion) to one lower extremity. This same MDS documents R3 has not received any ROM exercises, restorative treatment, or therapy for this limitation. R3's current Plan of Care revised 11-20-23 documents, (R3) is at risk for immobility. She sits in a recliner, and she sleeps in her recliner. She is incontinent. Transfers per aid. Wheelchair for mobility or ambulate with staff and gait belt. This same plan of care documents interventions for AROM (Active Range of Motion) to all extremities during cares 10-15 reps (repetitions). R3's Restorative Nursing Program forms dated 10-1-23 to 11-20-23 documents R3 will maintain current level of joint mobility with an approach of AROM to all extremities during cares 10 to 15 reps each. These same forms document R3 has not received any AROM exercises for 12 out of 50 days. On 11-20-23 at 10:32AM R3 was sitting in R3's recliner. R3 was unable to lift her left leg. R3 states she is not receiving therapy services currently. R3 stated, I would like them (the facility) to do some exercises or ROM to my left leg every day. R3 verified staff have not been performing any exercises or ROM exercises to R3's left leg. 2. R6's Current POS (Physician Order Sheet) documents R6 has a diagnosis of Personal History of Transient Ischemic Attack (TIA), Cerebral Infarction, Parkinson's Disease, and Restless Leg Syndrome. R6's MDS assessment dated [DATE] documents R6 is cognitively intact. This same MDS documents R6 has a limitation in range of motion to one side of the upper extremity and has not received range of motion exercises, restorative treatment, or therapy for this limitation. R6's Current Plan of Care revised on 9-19-23 documents, (R6) needs assistance with ADL's (Activities of Daily Living). She is paralyzed left upper/lower extremity. This same care plan documents interventions for AROM to right upper/lower extremities and PROM (Passive Range of Motion) to left upper/lower extremity 10 reps during cares. R6's Restorative Nursing Program forms dated 10-1-23 to 11-20-23 documents R6 will improve or maintain current functional ROM with an approach of AROM to right extremities and PROM to left (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146057 If continuation sheet Page 3 of 20 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 146057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monmouth Rehab and Nursing 117 South I Street Monmouth, IL 61462 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 - Few extremities with group exercises or with cares 10 reps each. These same forms document R6 has not received any AROM or PROM exercises for 15 out of 50 days. On 11/20/23 at 10:10AM R6 was laying in R6's bed with the HOB (Head of Bed) slightly elevated. R6's left hand was in a closed position with fingers curled downward. R6 was unable to open her fingers to her left hand. R6 was able to slightly lift her left arm. R6 stated, They never offer to perform ROM exercises to my left arm or hand. I would like them to everyday because it would help me. On 11/20/23 at 12:40PM V5 (Assistant Director of Nursing/Restorative Nurse) verified R3 and R6's restorative programs for the month of October and November 2023 have not been done at least 15 minutes daily. V5 stated, Any resident who is on a restorative program should be receiving those programs at least 15 minutes daily. On 11/20/23 at 1:00PM V6 CNA (Certified Nursing Assistant) stated, We don't have time to do the restorative programs most of the time. We are short staffed. I have not performed any PROM or AROM exercises on R3 or R6. On 11/22/23 at 10:12AM V16 CNA stated, We are not able to get restorative programs done. We sometimes have to sign off that we do them, even if we don't get to them. V16 confirmed she has not performed any PROM or AROM exercises on R3 or R6. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146057 If continuation sheet Page 4 of 20 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 146057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monmouth Rehab and Nursing 117 South I Street Monmouth, IL 61462 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. Based on observation, interview, and record review, the facility failed to ensure an indwelling urinary catheter drainage bag was kept below the level of the bladder and off the floor for one of two residents (R35) reviewed for indwelling urinary catheters in the sample of 45. Findings include: The facility's Urinary Catheter Care, dated 2014, documents, The purpose of this procedure is to prevent catheter associated urinary tract infections. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Be sure the catheter tubing and drainage bag are kept off the floor. R35's Physician's orders, dated 11/20/23, document that R35 has an order for a 16 French 10 milliliter indwelling urinary catheter. On 11/20/23 at 09:54 AM, R35 was sitting up on a shower chair in his bathroom following a shower. V6 and V10 (Both CNAs-Certified Nursing Assistants) were dressing R35. R35's indwelling urinary catheter drainage bag was lying on the floor next to R35's shower chair. Then, V6 picked up the drainage bag and put it through R35's pant leg, prior to putting the pants on R35, and then laid the drainage bag back down on the floor. V6 and V10 positioned R35 into the stand aid lift. V10 hooked the drainage bag onto the lift, and both proceeded to transfer R35 to his bed. V6 unhooked the drainage bag from the lift aid laying it on the floor, and then V6 and V10 positioned R35 into a lying position in his bed. V6 picked up the drainage bag from the floor and held it above R35 in order to place it into a privacy bag. Cloudy yellow urine was observed in the tubing refluxing towards R35 with the drainage bag being above R35's bladder. On 11/20/23 at 10:10 AM, V6 stated, The catheter bag should not be on the floor, and the bag should always be below the level of the bladder. I shouldn't have done that. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146057 If continuation sheet Page 5 of 20 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 146057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monmouth Rehab and Nursing 117 South I Street Monmouth, IL 61462 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Based on observation, interview, and record review, the facility failed to attempt less restrictive interventions, obtain an informed consent, obtain a physician order, and perform a risk of entrapment assessment for the use of side rails for one of one resident (R11) reviewed for side rails in the sample of 45. Findings include: The facility's Proper Use of Side Rails policy, dated 1/2017, documents, The use of side rails as an assistive device will be addressed in the resident care plan. Less restrictive interventions that will be incorporated in care planning. Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails. The risks and benefits of side rails will be considered for each resident. Consent for side rail will be obtained from the resident or representative. On 11/20/23 at 11:28 AM, R11 was alert sitting up in her recliner. R11's 1/2 side rail was in an upright position on the right side of R11's bed. R11 stated, They just put that on my bed. I didn't ask for it. I don't use it for anything but to clip my call light on when I go to bed. The facility's Quarterly Bed Entrapment Prevention Checklist, dated October to December 2023, documents that R11 has one side rail. R11's current medical record has no documentation of a physician's order or consent for the use of a side rail. The medical record also has no documentation of less restrictive interventions prior to the initiation of the side rails or a risk of entrapment assessment. On 11/21/23 at 10:26 AM, V2 (Director of Nursing) stated, (R11) does not use a side rail therefore there is no risk of entrapment assessment or consent. V2 confirmed that R11 did not have a physician's order or less restrictive interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146057 If continuation sheet Page 6 of 20 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 146057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monmouth Rehab and Nursing 117 South I Street Monmouth, IL 61462 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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to develop a Dementia plan of care for one of two residents (R35) reviewed for Dementia care in the sample of 45. Residents Affected - Few Findings include: R35's electronic diagnoses, dated 11/21/23, documents that R35 has the diagnosis of Vascular Dementia. R35's Current Care plan, printed 11/20/23, has no documentation of a comprehensive care plan addressing R35's diagnosis of Vascular Dementia. On 11/22/23 at 10:17 AM, V7 (Care plan Coordinator) confirmed there is no Dementia plan of care for R35. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146057 If continuation sheet Page 7 of 20 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 146057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monmouth Rehab and Nursing 117 South I Street Monmouth, IL 61462 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R35's Physician's orders, dated 11/20/23, document that R35 has an order to receive Seroquel (antipsychotic) 50 mg (milligrams) by gastrostomy tube daily for Major Depressive Disorder. R35's Psychotropic Assessment, dated 7/24/23, documents that R35 uses Seroquel for the diagnosis of Adjustment Disorder with anxiety and the behavior of agitation. R35's Behavioral Care Solutions evaluation, dated 11/7/23, documents, Today's visit reviewed Depression, Dementia. Behaviors due to psychiatric condition increased anger, anxiety, and decreased appetite. Patient denies a history of bipolar, schizophrenia. R35's Care Plan, dated 11/8/23, documents, R35 has diagnosis of agitation and receives an antipsychotic medication. He does become agitated at times, but usually is easily calmed down. R35's current electronic record has no documentation of behavior monitoring for R35's use of an antipsychotic. On 11/21/23 at 10:33 AM, V7 (Care Plan coordinator) stated, (R35) has not had any behavior tracking done since he returned from the hospital on 9/19/23. On 11/22/23 at 10:34 AM, V5 (Registered Nurse/Assistant Director of Nursing) stated, (R35's) diagnosis and behaviors for his Seroquel are Vascular Dementia & Adjustment Disorder with Anxiety Major Depressive Disorder. He has anger issues and increased agitation. None of his behaviors are psychotic or put him or others at risk for harm. Behavior tracking should be done every shift. I wasn't aware that he didn't have behavior tracking in place. It should have been reinstated when he was readmitted on [DATE]. Based on observation, interview, and record review, the facility failed to document a diagnosis and target behaviors to warrant the use of an antipsychotic and perform behavior monitoring for two of two residents (R4, R35) reviewed for antipsychotics in the sample of 45. Findings include: The facility's Psychotropic Medication Use policy, dated 1/2017, documents, Residents will only receive psychotropic medications when necessary to treat specific conditions for which they are indicated and effective. Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record, consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders (current or subsequent editions): a. Schizophrenia; b. Schizo-affective disorder; c. Schizophreniform disorder; d. Tourette's Disorder; e. Huntington Disease. Diagnoses alone do not warrant the use of psychotropic medication. The staff will observe, document, regarding the effectiveness of any interventions, including psychotropic medications. Nursing staff shall monitor for side effects and adverse consequences of psychotropic medication. 1. On 11/20/23 at 10:00 AM, R4 was sitting in her room in a chair. R4 stated she is doing well and denied any concerns. R4 was not displaying any behaviors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146057 If continuation sheet Page 8 of 20 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 146057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monmouth Rehab and Nursing 117 South I Street Monmouth, IL 61462 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 11/21/23 at 9:00 AM, R4 was in her room putting a blanket on her chair and preparing to eat breakfast. R4 was smiling and was not displaying any behaviors. R4's current Physician Order Sheet, dated 11/21/23, documents R4 has an order for Seroquel (antipsychotic medication)12.5 milligrams by mouth every bedtime on Monday, Tuesday, Thursday, and Saturday. R4's current care plan, dated 10/4/23, documents R4 has diagnoses including Dementia, Alzheimer's Disease and Anxiety. This same care plan does not document that R4 receives the antipsychotic medication Seroquel. R4's Medication Administration Records, dated 9/1/23-9/30/23, 10/1/23-10/31/23 and 11/1/23-11/20/23, all document R4 has behavior monitoring of Monitor for the following: (Depression & Psychosis) crying, self isolation, pacing, wandering without purpose, itching, picking at skin, restlessness (agitation), hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucination, psychosis, aggression, refusing care. These same sheets document that R4 did not display any behaviors for the entire month of September, October, and November as of 11/20/23. On 11/21/23 at 11:09 AM, V7 (Care Plan/Minimum Data Set Coordinator) confirmed that R4's behavior tracking listed a large quantity of generic behaviors that are not specific to R4. V7 stated (R4) does not have any targeted, resident specific behaviors that we monitor. On 11/21/23 at 11:30 AM, V11 (Registered Nurse) stated (R4) can be feisty and irritable at times. She usually gets more confused and irritable, and it almost always means she has a Urinary Tract Infection (UTI), so we order her a urine. She doesn't have behaviors that are psychotic in nature. (R4) isn't a threat to herself of other residents. On 11/22/23 at 10:08 AM, V7 confirmed R4's Seroquel is not on her Care Plan. V7 stated I didn't realize that it (Seroquel) should be on there. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146057 If continuation sheet Page 9 of 20 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 146057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monmouth Rehab and Nursing 117 South I Street Monmouth, IL 61462 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure staff hair was covered during the plating of food, while in the kitchen, and failed to date opened food items, to ensure use before expiration. These failures have the potential to affect all 39 residents currently residing in the facility. FINDINGS INCLUDE: The facility policy, Personal Hygiene and Appearance Nutrition Services, dated (revised) January 2018, directs staff, To support food safety practices and to maintain compliance with Federal, State and Local regulations governing food safety. Hair nets or hair coverings shall be worn while in the kitchen or storage areas. The facility policy, Dietary Food Storage, dated November 2007, directs staff, All food shall be stored according to regulatory guidelines governing food safety and sanitation and within established facility guidelines, as follows: Leftovers shall be labeled and dated. On 11/20/23 at 9:34 A.M., during a tour of the facility kitchen, with V3/Dietary Manager a five-pound plastic container of opened potato salad (approximately 1/2 full and an undated) and an opened plastic bag of shredded cheddar cheese was present in the facility refrigerator. At that time, V3/Dietary Manager confirmed the presence of the opened, undated food and stated dietary staff should date and label all opened food products. On 11/20/23 at 12:10 P.M., V10/Certified Nursing Assistant was in the facility kitchen leaning on the counter while V3/DM plated the noon meal on the same counter with no hair restraint in place. On 11/20/23 at 2:10 P.M., V3/Dietary Manager verified that V10/Certified Nursing Assistant did not have a hair covering on while in the facility kitchen during the plating of food. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146057 If continuation sheet Page 10 of 20 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 146057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monmouth Rehab and Nursing 117 South I Street Monmouth, IL 61462 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 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide speech therapy services to one of one resident (R35) reviewed for specialized therapy services in the sample of 45. Residents Affected - Few Findings include: The Facility Assessment, dated 8/31/23, documents, Services and Care Offered: Therapy-PT (Physical Therapy), OT (Occupational Therapy), Speech/Language, Respiratory, Music, Art, management of braces, splints. On 11/20/23 at 10:08 AM, R35 was alert sitting up in his bed. R35 had a gastrostomy tube capped off coming from his stomach. R35 stated, I don't like the ground meat or the thickened liquids. They are awful! I'm supposed to be getting speech therapy, but the lady is never here. So how am I supposed to get better. R35's Swallow Study, dated 7/7/23, documents, Today R35 reports that he has had a g-tube for about a year following a CVA (Cerebrovascular Accident). Patient/caregiver concerns: Patient would like for his diet to be upgraded. Therapy Diagnosis: Oropharyngeal Dysphagia. Medical Diagnosis: Dysphagia. R35 referred to Speech Therapy with deficits noted including impairments of swallowing which contribute to the following areas of functional restriction or limitation. Clinical impression at this time: Patient will benefit from ongoing skilled Speech Therapy intervention. Recommend patient continue with pudding thick liquids and pureed solids. Plan of care and diet recommendations to be determined by treating speech language pathologist. R35's Speech Therapy Plan of Care, dated 9/24/23, documents, Reason for referral: R35 referred by facility physician for skilled ST (Speech Therapy) evaluation/treatment as indicated to address dysphagia. R35 recently admitted to hospital with diagnosis of upper GI (Gastrointestinal) bleed. Past medical history of stroke, dysphagia, Diabetes Mellitus type II. Therapy necessity: Skilled ST indicated to address Oropharyngeal dysphagia. Without skilled ST, patient at risk for further decline in function, increased reliance on caregivers, choking/aspiration, malnutrition/dehydration. Frequency/Duration: Four times in four weeks. R35's Physician's orders, dated 11/20/23, document that R35 has an order for regular texture food and honey consistency liquids, and that R35 has a PEG (percutaneous endoscopies gastrostomy) tube for the diagnosis of dysphagia. The orders also document that effective 9/24/23, R35 was to receive speech therapy four times in four weeks to address Oropharyngeal dysphagia. On 11/21/23 at 10:45 a.m., V1 (Administrator in Training) stated, (R35) should still be receiving Speech Therapy services. However, he hasn't been getting them because the Speech Therapist has not been able to make it here. His last Speech Therapy visit was on 10/9/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146057 If continuation sheet Page 11 of 20 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 146057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monmouth Rehab and Nursing 117 South I Street Monmouth, IL 61462 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Immediate jeopardy to resident health or safety Based on observation, interview and record review, the facility systemically failed to implement facility wide protocols to address respiratory symptoms as evidenced by: failed to recognize respiratory symptoms of facility staff and residents as a possible contagious illness (RSV, COVID 19 Influenza); failed to perform the required COVID-19 testing on staff and residents actively demonstrating signs and symptoms of a possible infectious respiratory illness, or after close contact with a resident or staff member that had tested positive for COVID-19; failed to test for other infectious respiratory illnesses when a COVID 19 test was negative and the resident was symptomatic; failed to immediately implement the required transmission based precautions for residents with suspected respiratory illness; and, failed to wear proper PPE (Personal Protective Equipment) when caring for a COVID-19 positive resident. These failures have the potential to affect all 39 residents currently residing in the facility. Residents Affected - Many These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 9/21/23 when R34 became symptomatic with congestion, chest discomfort, and a cough. The facility failed to identify that R34's symptoms were potential signs/symptoms of COVID-19 and did not test nor isolate R34 while he was symptomatic. While the immediacy was removed on 11/29/23, the facility remains out of compliance at a Severity Level two as additional time is needed to evaluate the implementation and effectiveness of the removal plan including their Inservice training and Quality Assessment oversite. Findings include: On 11/20/2023 at 9:05 AM, Upon entrance to facility, multiple staff were wearing surgical face masks. V2 (DON/Director of Nursing/Infection Preventionist) stated that some staff were not feeling well. V2 also stated there were no positive COVID-19 residents in the facility, and no residents were currently in transmission based precautions. The CDC (Centers for Disease Control and Prevention) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 5/8/23, documents, NIOSH Approved particulate respirators with N95 filters or higher used for: NIOSH Approved particulate respirators with N95 filters or higher can also be used by HCP (Healthcare Professionals) working in other situations where additional risk factors for transmission are present, such as when the patient is unable to use source control and the area is poorly ventilated. They may also be considered if healthcare-associated SARS-CoV-2 transmission is identified and universal respirator use by HCP (Health Care Personnel) working in affected areas is not already in place. Anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for SARS-CoV-2 as soon as possible. Asymptomatic patients with close contact with someone with SARS-CoV-2 infection should have a series of three viral tests for SARS-CoV-2 infection. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. Healthcare facilities should have a plan for how SARS-CoV-2 exposures in a healthcare facility will be investigated and managed and how contact tracing will be performed. The decision to discontinue empiric Transmission-Based Precautions by excluding the diagnosis of current SARS-CoV-2 infection for a patient with symptoms of COVID-19 can be made based upon having negative results from at least one viral test. If (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146057 If continuation sheet Page 12 of 20 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 146057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monmouth Rehab and Nursing 117 South I Street Monmouth, IL 61462 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many using NAAT (molecular), a single negative test is sufficient in most circumstances. If a higher level of clinical suspicion for SARS-CoV-2 infection exists, consider maintaining Transmission-Based Precautions and confirming with a second negative NAAT. If using an antigen test, a negative result should be confirmed by either a negative NAAT (molecular) or second negative antigen test taken 48 hours after the first negative test. HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Responding to a newly identified SARS-CoV-2-infected HCP or resident: When performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction's public health authority. A single new case of SARS-CoV-2 infection in any HCP or resident should be evaluated to determine if others in the facility could have been exposed. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. If additional cases are identified, strong consideration should be given to shifting to the broad-based approach if not already being performed and implementing quarantine for residents in affected areas of the facility. As part of the broad-based approach, testing should continue on affected unit(s) or facility-wide every 3-7 days until there are no new cases for 14 days. If antigen testing is used, more frequent testing (every 3 days), should be considered. R34's Nurses' notes, dated 9/21/23 at 12:36 a.m., document, Resident states that he thinks he has Pneumonia. R34's Nurses' notes, dated 9/21/23 at 12:46 a.m., document, Lungs clear states he feels congested and has some discomfort in chest. R34's current electronic record has no documentation of R34 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) until 10/24/23 or being placed in transmission based precautions. R28's Nurses' notes, dated 9/22/23 at 9:22 a.m., document, Resident complains of cough and chest congestion. Doctor notified and orders received to offer Geri-tussin as directed PRN (as needed). R28's current electronic record has no documentation of R28 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions. R28's Nurses' notes, dated 9/26/23 at 8:11 a.m., document, Resident had a large emesis this a.m. R28's Nurses' notes, dated 9/26/23 at 12:30 p.m., document, Resident had no further emesis this shift. COVID test done, and it was negative. R28's current electronic record has no documentation of R28 being tested for potentially contagious illnesses (RSV, Influenza) other than COVID-19 or being placed in transmission based precautions; nor was there any follow-up COVID-19 testing until 10/24/23. R28's Nurses' notes, dated 10/4/23 at 10:26 a.m., document, Resident voicing concerns related to continuous cough. Resident states that Mucinex and Geri-tussin are not providing enough relief. Doctor was notified and assessed resident and gave orders for Keflex (antibiotic) 500 mg (milligrams) twice a day for seven days. As R28's respiratory symptoms continued, R28's current electronic record has (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146057 If continuation sheet Page 13 of 20 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 146057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monmouth Rehab and Nursing 117 South I Street Monmouth, IL 61462 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many no documentation of R28 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) until 10/24/23 or being placed in transmission based precautions. R38's Nurses' notes, dated 10/5/23 at 2:18 p.m., document, This nurse has noted increased cough. Cough producing yellow sputum. Resident also has congestion in the nasal area. R38's current electronic record has no documentation of R38 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions. R34's Nurses' notes, dated 10/10/23 at 3:49 p.m., document, Resident noted to have a cough this a.m. Cough is occasional and non-productive. As R34's respiratory symptoms continue, R34's current electronic record has no documentation of R34 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) until 10/24/23 or being placed in transmission based precautions. R38's Nurses' notes, dated 10/11/23 at 1:55 p.m., document, Started antibiotic for URI. Resident has a productive cough with yellow phlegm. Lung sounds are congested. As R38's respiratory symptoms continue, R38's current electronic record has no documentation of R34 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions. R7's Nurses' notes, dated 10/16/23 at 1:20 p.m., document, Resident noted to have increased productive cough with purulent sputum. Lung sounds crackles in bilateral lower lobes. Doctor notified. New orders for Levaquin (antibiotic) 500 mg (milligrams) by mouth daily for 10 days and guaifenesin 400 mg by mouth twice a day for 10 days. R7's current electronic record has no documentation of R7 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) until 10/24/23 or being placed in transmission based precautions. R26's Nurses' notes, dated 10/19/23 at 8:24 a.m., document, New order for Mucinex 400 mg one tablet by mouth twice a day for seven days for cough/congestion per doctor. R26's current electronic record has no documentation of R26 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) until 10/24/23 or being placed in transmission based precautions. R34's Nurses' notes, dated 10/19/23 at 10:33 a.m., document, Fax sent to doctor in regards to resident having an occasional cough and some congestion, waiting for reply. As R34's respiratory symptoms continued, R34's current electronic record has no documentation of R34 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) until 10/24/23 or being placed in transmission based precautions. R21's Medication Administration note, dated 10/22/23 at 8:30 a.m. and 1:13 p.m., document that R21 received PRN doses of guaifenesin 400 mg for sinus drainage. R21's current electronic record has no documentation of R21 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions. R16's Nurses' notes, dated 10/22/23 at 10:51 a.m., document, Resident noted to have a non-productive cough and nasal congestion. Doctor notified and gave orders for Tylenol 650 mg by mouth every six hours PRN, guaifenesin 400 mg every twelve hours PRN, and Geri-tussin every eight hours PRN. R16's current electronic record has no documentation of R16 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) until 10/24/23 or being placed in transmission based precautions. On 11/21/2023 at 1:35 P.M., a review of the required facility COVID-19 positive report documents on 10/22/23 at 12:09 P.M., V14 (Housekeeping Supervisor) tested positive for COVID-19 and at 12:10 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146057 If continuation sheet Page 14 of 20 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 146057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monmouth Rehab and Nursing 117 South I Street Monmouth, IL 61462 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many P.M., R3 tested positive for COVID-19. This same report documents that V15 (Dietary Aide) tested positive for COVID-19 on 11/1/23. At that time, V2 (Director of Nurses/Infection Preventionist) confirmed that no contact tracing was done to determine which facility residents or staff that would have been directly exposed to V14, V15, or R3 in the previous 48 hours in order to begin the day 1, day 3 and day 5 COVID-19 testing. On 11/21/2023 at 1:50 P.M., V2 stated, I have just been testing (COVID-19 testing) when someone has symptoms, that's it. I don't keep a record of any of the tests, only the positive ones. I thought that was the new guidance. V2 verified that she didn't have any policies specific to COVID-19, influenza, or RSV. The facility's Daily Assignment Sheets, dated 10/20-10/22/23, document that the following staff would have had direct exposure to R3: V11 (Registered Nurse-RN), V16 (Certified Nursing Assistant-CNA), V6 (CNA), V10 (CNA), V17 (Hydration Aide), V18 (RN), V19 (CNA), V8 (LPN-Licensed Practical Nurse), V13 (CNA), V20 (CNA), V21 (CNA), V22 (RN), V23 (CNA), V24 (CNA), V25 (LPN), V26 (CNA), and V27 (CNA). R26's Nurses' notes, dated 10/23/23 at 8:40 a.m., document, Doctor assessed resident this a.m. and new order received for Keflex 500 mg by mouth three times a day for 10 days. R26's current electronic record has no documentation of R26 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) until 10/24/23 or being placed in transmission based precautions. R14's Nurses' notes, dated 10/24/23 at 9:15 a.m., document, Resident presents with signs and symptoms of common cold COVID test negative. As R14's respiratory symptoms continue, R14's current electronic record has no documentation of R14 being tested for other potentially contagious illnesses (RSV, Influenza) or being placed in transmission based precautions; nor was there any follow-up COVID-19 testing. R10's Nurses' notes, dated 10/24/23 at 9:16 a.m., document, Resident presents with signs and symptoms of common cold COVID test negative. As R10's respiratory symptoms continue, R10's current electronic record has no documentation of R10 being tested for other potentially contagious illnesses (RSV, Influenza) or being placed in transmission based precautions; nor was there any follow-up COVID-19 testing. R26's Nurses' notes, dated 10/24/23 at 9:54 a.m., document, Resident presents with signs/symptoms of common cold and is COVID negatives. As R10's respiratory symptoms continue, R10's current electronic record has no documentation of R10 being tested for other potentially contagious illnesses (RSV, Influenza) or being placed in transmission based precautions; nor was there any follow-up COVID-19 testing. R34's Nurses' notes, dated 10/24/23 at 9:56 a.m., document, Resident presents with signs/symptoms of common cold and is COVID negative. As R34's respiratory symptoms continue, R34's current electronic record has no documentation of R34 being tested for other potentially contagious illnesses (RSV, Influenza) or being placed in transmission based precautions; nor was there any follow-up COVID-19 testing. R7's Nurses' notes, dated 10/24/23 at 9:57 a.m., document, Resident presents with signs/symptoms of common cold and is COVID negative. As R7's respiratory symptoms continue, R7's current electronic record has no documentation of R7 being tested for other potentially contagious illnesses (RSV, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146057 If continuation sheet Page 15 of 20 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 146057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monmouth Rehab and Nursing 117 South I Street Monmouth, IL 61462 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Influenza) or being placed in transmission based precautions; nor was there any follow-up COVID-19 testing. R28's Nurses' notes, dated 10/24/23 at 9:57 a.m., document, Resident presents with signs/symptoms of common cold and is COVID negative. As R28's respiratory symptoms continue, R28's current electronic record has no documentation of R28 being tested for other potentially contagious illnesses (RSV, Influenza) or being placed in transmission based precautions; nor was there any follow-up COVID-19 testing. R16's Nurses' notes, dated 10/24/23 at 9:58 p.m., document, Resident presents with signs and symptoms of common cold and is COVID-negative. As R16's respiratory symptoms continue, R16's current electronic record has no documentation of R16 being tested for other potentially contagious illnesses (RSV, Influenza) or being placed in transmission based precautions; nor was there any follow-up COVID-19 testing. R14's Nurses' notes, dated 10/25/23 at 1:54 p.m., document, Resident's lung sounds assessed due to signs and symptoms of a cold. As R14's respiratory symptoms continue, R14's current electronic record has no documentation of R14 having follow-up testing for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions. R34's Nurses' notes, dated 10/25/23 at 2:07 p.m., documents, Resident's lung sounds assessed related to signs and symptoms of a cold. As R34's respiratory symptoms continue, R34's current electronic record has no documentation of R34 having follow-up testing for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions. R14's Nurses' notes, dated 11/1/23 at 2:21 p.m., document, Resident refused shower times two. Resident stated he was too tired and cold and just did not want to. As R14's respiratory symptoms continue, R14's current electronic record has no documentation of R14 being tested for potentially contagious illnesses (COVID-19, RSV, Influenza) or being placed in transmission based precautions. R5's Nurses' notes, dated 11/15/23 at 7:50 p.m., documents, Resident lying in bed with 2-3 blankets on her up to her chin also wearing flannel pajamas. Warm to touch. Temperature 101.5 face flushed. Blankets removed and given Tylenol. R5's current electronic record has no documentation of R5 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions. R5's Nurses' notes, dated 11/16/23 at 10:52 a.m., document, Temperature 101. Appears Lethargic. As R5's respiratory symptoms continue, R5's current electronic record has no documentation of R5 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions. R26's Medication Administration Note, dated 11/16/23 at 1:06 p.m. and 11/17/23 at 7:21 a.m., document that R26 was administered Tylenol 650 mg by mouth as needed for complaints of a headache. As R26's respiratory symptoms continued, R26's current electronic record has no documentation of R26 being tested for potentially contagious illnesses (COVID-19, RSV, Influenza) or being placed in transmission based precautions. R8's Nurses' notes, dated 11/16/23 at 6:39 p.m., document, Resident nauseated and has a headache. Given Tylenol other medications held. R8's current electronic record has no documentation of R8 being (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146057 If continuation sheet Page 16 of 20 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 146057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monmouth Rehab and Nursing 117 South I Street Monmouth, IL 61462 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions. R8's Nurses' notes, dated 11/17/23 at 7:00 a.m., document, Resident complains of not feeling well. Stomach upset. Temperature 100.9 degrees. R8's Nurses' notes, dated 11/17/23 at 8:15 a.m., document, Doctor seen resident. States it's viral. No new orders. As R8's respiratory symptoms continue, R8's current electronic record has no documentation of R8 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions. R18's Nurses' notes, dated 11/17/23 at 1:51 p.m., document, Refused shower times three attempts. Stated he didn't feel well. Came out for both meals. R18's current electronic record has no documentation of R18 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions. R1's Nurses' notes, dated 11/18/23 at 10:24 a.m., document, Resident has mucous in the base of her throat. Resident encouraged to try and cough it up. R1's current electronic record has no documentation of R1 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions. R18's Nurses' notes dated 11/18/23 at 12:45 p.m., document, Resident refused to come out for lunch stated he doesn't feel well. As R18 continues to feel ill, R18's current electronic record has no documentation of R18 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions. R1's Nurses' notes, dated 11/19/23 at 11:30 a.m., document, Resident sleeping most of this morning. Lung sounds congested. As R1's respiratory symptoms continued, R1's current electronic record has no documentation of R1 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions. R36's Nurses' notes, dated 11/19/23 at 2:09 p.m., document, Resident has no voice. Resident states other than being generally blah. R36's current electronic record has no documentation of R36 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions. R26's Nurses' note, dated 11/20/23 at 7:46 a.m. document, Doctor here to see resident. New order for Cephalexin (antibiotic) 500 mg by mouth three times a day for URI (upper respiratory infection.) As R26's respiratory symptoms continue, R26's current electronic record has no documentation of R26 being tested for potentially contagious illnesses (COVID-19, RSV, Influenza) or being placed in transmission based precautions. R1's Nurses' notes, dated 11/20/23 at 8:05 a.m., document, COVID tested as resident not feeling well with negative results. Doctor saw this am with new orders to start antibiotic for Bronchitis. As R1's respiratory symptoms continued, R1's current electronic record has no documentation of R1 being tested for other potentially contagious illnesses (RSV, Influenza) or being placed in transmission based precautions; nor was there any follow-up COVID-19 testing. R5's Nurses' notes, dated 11/20/23 at 8:09 a.m., document, Resident COVID tested due to reports of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146057 If continuation sheet Page 17 of 20 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 146057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monmouth Rehab and Nursing 117 South I Street Monmouth, IL 61462 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many resident not feeling well and results are Negative. As R5's respiratory symptoms continued, R5's current electronic record has no documentation of R5 being tested for other potentially contagious illnesses (RSV, Influenza) or being placed in transmission based precautions; nor was there any follow-up COVID-19 testing. R25's Nurses' notes, dated 11/20/23 at 8:15 a.m., document, Resident not feeling well COVID test negative. R25's current electronic record has no documentation of R25 being tested for other potentially contagious illnesses (RSV, Influenza) or being placed in transmission based precautions; nor was there any follow-up COVID-19 testing. R28's Nurses' notes, dated 11/20/23 at 8:24 a.m., document, Doctor seen resident who is complaining of a cough. New order for Robitussin 10 ml (milliliters) by mouth twice a day for five days. R28's current electronic record has no documentation of R28 being tested for potentially contagious illnesses (COVID-19, RSV, Influenza) until 11/22/23 or being placed in transmission based precautions. R36's Nurses' notes, dated 11/20/23 at 11:43 a.m., document, Resident complains of sore throat and afebrile raspy voice COVID tested for symptoms and due to roommate not feeling well with negative results. As R36's continued to feel ill, R36's current electronic record has no documentation of R36 being tested for other potentially contagious illnesses (RSV, Influenza) or being placed in transmission based precautions; nor was there any follow-up COVID-19 testing. R1's Nurses' notes, dated 11/21/23 at 10:33 a.m., document, Continues on antibiotic for URI (Upper Respiratory Infection). Has productive cough. Has difficulty coughing it up and out. As R1's respiratory symptoms continued, R1's current electronic record has no documentation of R1 being placed in transmission based precautions. On 11/21/2023 at 11:30 AM, frequent coughing was heard across the hall from facility Family Room coming from R9's room. V2 (DON/Infection Preventionist) verified that it was R9 coughing. V2 stated that R9 was not feeling well and had spiked a temperature during the night with a persistent cough. V2 confirmed that transmission based precautions were not implemented nor was R9 tested for COVID-19 with R9 exhibiting symptoms of an upper respiratory illness. On 11/21/23 at 12:50 p.m., R9 had droplet isolation precaution signage on his door. V6 (CNA) applied a surgical mask, face shield, gown, and gloves. V6 entered R9 room with R9's meal tray. At 12:58 p.m., V6 exited R9's room. V6 stated, (R9's) hospice nurse just told us that we need to wear isolation stuff for (R9). I think he has COVID, but I'm not totally for sure. When I went into the room, I was wearing a surgical mask, a face shield, a gown, and gloves. I haven't had COVID for over two years now. I can't tell you the last time I was tested here. It's been a while. On 11/21/2023 at 1:15 P.M., a review of the facility Staff Call-In log from March 2023 through November 2023 documents most recent COVID-19 positive staff member as V13 (Certified Nursing Assistant) on 11/18/2023. At that time, V2 stated, (V13) came into work on 11/18/23 at 6:00 A.M. stating she didn't feel well. She was assigned the residents in rooms 24-36 (R3, R7, R10, R14, R20-R22, R27, R29). About halfway through her shift she began complaining of cough, fatigue, shortness of breath and a fever. (V5 Registered Nurse/ Assistant Director of Nursing) called me and told me what was going on. I told her to test her (COVID-19). Her test came back positive, and we sent her home. I only test people (residents or staff) if they are not feeling well. At that time, V2 confirmed that V13 was not tested prior to working with the residents, despite V13 stating she didn't feel well. V2 also stated that no contact tracing was done to determine which facility residents or staff that would have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146057 If continuation sheet Page 18 of 20 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 146057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monmouth Rehab and Nursing 117 South I Street Monmouth, IL 61462 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many been directly exposed to V13 in the previous 48 hours in order to begin the day 1, day 3 and day 5 testing for COVID-19. During the survey on 11/20/23 and 11/21/23, V7 (Care Plan Coordinator/Infection Preventionist) was observed wearing a surgical mask while in the facility. On 11/21/23 at 2:30 p.m., V7 (Care Plan Coordinator) had a raspy voice. V7 stated, These symptoms started a week ago with a sore throat and a headache. I tested and it was negative. I'm still having symptoms, but it's laryngitis. I haven't tested for COVID again since the first one was negative. V7 confirmed that she has not been required to stay home while exhibiting these symptoms. The facility's COVID-19 testing (Residents) log, dated 11/22/23, documents that R9 tested positive on 11/22/23 with symptoms starting on 11/21/23. On 11/22/23 at 08:27 AM, a tour of the facility determined only one resident (R9) was currently in transmission based precautions. On 11/22/23 at 09:29 AM, V14 stated, I can't remember if I tested on (October) 20th or 22nd. But it was that weekend (October 21-22, 2023). I had been to the doctor on Friday because I wasn't feeling well. I came into work late on Friday. I tested myself at home and I was off work the following week (October 23-27, 2023). I am a working supervisor. I am all over the building, helping my staff. On 11/22/23 at 09:11 AM, V7 stated, I submit the (COVID-19) Testing Log. The dates recorded are the dates I was informed that the COVID Test was done on that date and was positive. I don't keep any testing logs of tests done, that are not positive. Since the pandemic ended, we quit keeping any logs except for positive staff or residents. On 11/22/2023 at 9:15 AM, the facility was unable to provide documentation of COVID-19 testing of staff or residents. V2 stated, I don't keep a (COVID-19) testing log of negative tests. I tell (V7) when someone tests positive. I tell her the date and time the test was done, and she submits the information. I didn't know I was supposed to keep logs. On 11/22/23 at 09:32 AM, V5 (RN/Assistant Director of Nursing) stated, Right now I have (R1 & R26) who are symptomatic of an upper respiratory infection. COVID-19 symptoms are cough, congestion, headache, fever, nausea and vomiting. If a resident has symptoms, I notify the doctor and then COVID-19 test them. If they are negative, I just treat them as having an upper respiratory infection. The residents are not put in isolation unless they are actually COVID-19 positive. We don't retest them if they continue to be sick. If a staff member is symptomatic, we immediately test them. If they are negative, they can continue to work. They are not retested. I have only tested on ce, but it was because I tested myself. The facility has not tested me in the last two months. On 11/22/23 at 09:46 AM, V14 stated, That Friday (10/20/23) at work, I started having symptoms of a head cold. I had a headache and congestion. I didn't think it was COVID. I worked that day, but I didn't test. Over the weekend, my daughter told me that I should really consider testing. I didn't test until after the weekend. R26's Nurses' notes, dated 11/22/23 at 10:43 a.m., documents, Continues on antibiotic for URI coughing noted. As R26's respiratory symptoms continue, R26's current electronic record has no documentation of R26 being tested for potentially contagious illnesses (COVID-19, RSV, Influenza) or being placed in transmission based precautions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146057 If continuation sheet Page 19 of 20 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 146057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monmouth Rehab and Nursing 117 South I Street Monmouth, IL 61462 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many R28's Nurses' notes, dated 11/22/23 at 11:38 a.m., document, Resident tested for COVID at 11:20 am due to fever of 100.0 resident states that he just feels like he has cold. Results Negative. R28's current electronic record has no documentation of R28 being tested for other potentially contagious illnesses (RSV, Influenza) or being placed in transmission based precautions. On 11/28/23 at 12:47 p.m., V9 (Licensed Practical Nurse/LPN) stated, If a staff member is sick no fever and negative, they can work as long as they are wearing a mask. My symptoms started on 11/19/23, I was hot then cold with the chills and aching all over. I tested after my shift was over on 11/19/23 and I was (COVID-19) positive. The facility's Staff Call Ins Report, dated 11/18-11/29/23, documents that V9 (LPN) tested positive for COVID-19 on 11/20/23 and that she was symptomatic starting 11/19/23. On 11/22/23 at 3:05 P.M., V1 (Administrator in Training) was notified of the Immediate Jeopardy. On 11/27/23, V1 submitted the facility's abatement plan for review. 1. V2 (Director of Nursing/Infection Preventionist) and V7 (Care Plan Coordinator/Infection Preventionist) were educated by V28 (Regional Nurse) on the signs and symptoms of COVID-19 infection and other respiratory illness, when COVID-19 testing is required, facility contact tracing and the implementation of transmission-based precautions for any resident experiencing respiratory symptoms, prior to testing on 11/22/23. 2. V2 and V5 (RN/Assistant Director of Nursing) tested all residents and staff for COVID-19 on 11/22/23, 11/24/23, 11/26/23, and they will continue to test every 3-7 days until no more COVID-19 positives for 14 days. 3. V1 and V2 were educated by V28 on initial outbreak and broad-based/contact tracing testing on 11/22/23. 4. V1 and V2 educated all facility staff on the required PPE when they are caring for a COVID-19 positive resident on 11/23/23. 5. V1 and V2 educated all nursing staff on identification of signs and symptoms of COVID-19 and other contagious respiratory illness, in order to implement physician notification, testing, and transmission-based precautions on 11/22/23. 6. V1 began Quality Assurance monitoring daily of all residents and staff with respiratory symptoms and a implemented a system to determine facility testing and isolation on 11/22/23. 7. On 12/4/23, V1 will be meeting with V31 (IDPH Infection Preventionist) for infection control guidance. Through observation, interview, and record review, it was found[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146057 If continuation sheet Page 20 of 20