Inspection·September 29, 2025

F 0684 Level of Harm - Actual harm Residents Affected - Few treat and to be on pureed diet until that time. R2's Physician Order (PO) date 9/19/2025 documents Azithromycin 250mg 2 tabs today then 1-tab daily days 2-5. F/u chest x-ray 2 weeks.On 9/24/2025 at 10:39AM V5 (Licensed practical Nurse/LPN) stated she was on duty on 9/18 when R2 choked. R2 stated when she got to the dining room V3 (Registered Nurse/RN) was standing behind R2 and had performed the Heimlich on R2. V5 stated one of the CNAs had checked R2's mouth. V5 stated R2 was talking. V5 stated she had not known R2 to have difficulties with swallowing but eating problems were more related to her arthritis. V5 stated on 9/18 after her choking incident she notified the physician an order received for pureed diet and speech therapy evaluation. V5 stated R2 returned to the facility on 9/6 from a hospital stay in which R2 had a stroke. V5 stated she had a swallowing study while at the hospital and R2 returned to the facility on a regular diet with honey consistency liquids. V5 stated that had been upgraded to thin liquids by therapy.R2's Minimum Data Sheet (MDS) dated [DATE] documents R2 is cognitively intact with a Brief Interview of Mental Status (BIMS) of 14. R2's care plan dated 6/26/2025, documents R2 has a regular diet with thin liquids, k-cups with straws. Height 61 weight 134. Ideal Body Weight (IBW) rang 95-115#. Body Mass Index (BMI)I 25.3, weight trends July 132#, [DATE]# and [DATE]#. R2 has no known food allergies. Monthly weight. Diagnosis, major depression, anxiety insomnia, GERD, Alert and orientated able to voice her wants/needs, feeds/hydrates herself in the large dining room. Places her own order for all meals. not a very picky eater and likes most foods. Has her own teeth in good condition, her intake/appetite is good for most meals. Care plan documents the following interventions dated 6/26/2025 monitor monthly weight and intake, serve foods of choice, serve diet as ordered, notify physician of weight loss/gain of 5% in 30 days 7.5% in 90 days, 10% in 180 days, assist with tray set up and placement of clothing protector as needed, monitor for signs and symptoms of edema, diet-regular, thin liquids, k-cups with straw encourage intake at all meals. R2's care plan documents 9/18/2025 R2 had an incident in the dining room. R2 had trouble swallowing and Heimlich was performed. R2 had order for Speech Therapy to evaluate, and resident will be monitored by staff during all meals. On 9/24/2025 at 1:24PM R2 in recliner in area across from the nurse's station. R2 stated she did choke 2 times, and her diet has now been changed to pureed diet. R2 stated does not like the diet. R2 stated the meats are not good. R2 stated she did eat pureed carrots, potatoes and gravy and pureed apple crisp at lunch. R2 stated when she gets choked the food goes down but then feels like it gets stuck. R2 stated the second time she choked it was worse than the first time.On 9/24/2025 at 2:43PM, V1 (Administrator) stated she did not become aware of R2's choking incident on 9/13 until the choking episode on 9/18. V1 stated R2 remained on the same diet of regular diet with thin liquids after choking on 9/13 until choking episode on 9/18 and after that R2 was placed on pureed diet and thin liquids until could be evaluated by speech. V1 stated the physician should have been notified of choking incident on 9/13.R2's physician progress notes dated 9/24/2025 at 4:00PM. Progress notes R2 being seen due to 2 events of choking. 1 on 9/13 and 1 on 9/18. Documents Heimlich maneuver was performed during both episodes. Review of systems documents R2 is alert. Assessment and plan documents choking initial encounter, poor historian; please obtain speech eval, please downgrade to pureed diet, please monitor for further choking episodes and perform Heimlich maneuver if further choking episodes is witnessed manifested by signs of sever obstruction like weak or unable to cough, inability to speak, inability to breathe, of if the patient is witnessed clutching the throat, cyanosis is seen. Please do not perform the Heimlich maneuver if the patient is coughing forcibly, breathing or talking to avoid intervening with abdominal thrusts. Also order for Floroscopic Esophagram double contrast, Reason: swallowing problems, choking.On 9/25/2025 at 8:32AM, V10 (Speech Language Pathologist/SLP) stated she was not aware of R2's choking incident on 9/13/2025. V10 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146106 If continuation sheet Page 2 of 4 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 146106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Scott County Nursing Center Rural Route 2 Winchester, IL 62694 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 0684 Level of Harm - Actual harm Residents Affected - Few stated she became aware when the evaluation order came for the choking episode 9/18. V10 stated received order for evaluation on 9/19 and did come in and do on the 19th. V10 stated when R2 returned to the facility R2 was on a regular diet with moderate thick liquids. V10 stated she recommended change to thin liquids on 9/9. V10 stated R2 had no signs or symptoms of aspiration. V10 stated when looking at video swallow R2 had on 9/5 while in the hospital it documented penetration which means the food goes down to the level of the trachea and spontaneously comes back out. V10 stated she seen R2 on 9/9, 9/11 and 9/16. V10 stated she was seeing R2 to evaluate her liquids and discharged her on 9/16. V10 stated R2 was on a regular diet with thin liquids from 9/9-9/18 and diet changed after choking on 9/18. V10 asked surveyor if she had seen chest Xray results, V10 stated recent chest x-ray showed a moderate hiatal hernia which could lead to esophageal dysphagia which could be causing her problem. Surveyor referred V10 back to Xray regarding bilateral infiltrates in lungs with diagnosis of pneumonia and V10 agreed R2 could have possibly aspirated. V10 stated she should have been notified of choking incident on 9/13. V10 stated interview with R2's table mates they said R2 was still talking. V10 stated R2 reported she would swallow her food and then pointed to chest area below throat and stated feels like food is there. V10 stated would make sense if esophagus involved. V10 stated she had talked with R2 about a Barium swallow as last test on 9/5 was a modified Barium swallow. V10 stated the physician was at the facility last evening and did not know at this time if any new orders.On 9/25/2026 at 10:50AM R2 stated when she chokes, she is still getting air and can breathe. R2 stated she can talk and ask for help. R2 consistently points at chest below throat and states feel like food just sits there. R2 stated when staff intervene it is sure a relief because feels like food won't go down. R2 stated staff had spoken to her about another swallow study and she would not be against that. On 9/25/2025 at11:00AM V2 (Director of Nursing/DON) stated she was not aware of the first choking incident until after the second incident. V2 stated that she followed up to ensure there was a speech eval after the second episode. V2 stated staff are to be close by when R2 is eating. V2 stated would question if true choking episode as no documentation of any food being expelled and R2 can still talk. On 9/25/20025 at 11:15AM V10 (SLP) stated based on her evaluation on 9/19/2025 she will analyze diet, liquids, signs and symptoms of aspiration and choking, and different diet textures. V10 stated right now looking at minced and moist consistency. V10 stated R2 did well with a banana today. V10 stated she will be working with R2 twice a week. V10 did state she had spoken with R2 and the physician in regard to barium swallow. V10 stated will not increase diet consistency too much until a barium swallow. V10 stated would question if true choking incident because R2 can call for help. On 9/25/2025 at 11:15AM V11 (LPN) per phone interview stated on 9/13/2025 she was not in the dining room when R2 choked. V11 stated she was coming up the hall from passing medications and was told R2 got choked and CNA did Heimlich. V11 stated R2 was eating again when she seen her. V11 stated that R2 stated the pulled pork was stringy. V11 stated she did not do a lung assessment on R2 or notify the physician of a change in condition. On 9/25/2025 at 1:02PM per phone interview V12 (Physician), V12 stated he had been notified of both choking incidents on 9/18/2025. V12 stated R2 had remained on the same diet after choking on 9/13 and diet changed on 9/18 after informed of choking incidents. V12 stated he was at the facility last night to see R2. V12 stated may not be a true choking as speech stated R2 can clear food. V12 stated in regard to use of Heimlich maneuver if not really choking? V12 stated better safe than sorry. V12 stated the plan is to refer R2 to GI and have speech therapy continue to work with R2. On 9/25/2025 at 1:43PM per phone interview with V12 (Physician). V12 stated if he had been notified of choking incident on 9/13/2025 at that time V12 stated he would have downgraded R2's diet and ordered a speech eval. V12 stated the Heimlich maneuver irritation to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146106 If continuation sheet Page 3 of 4 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 146106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Scott County Nursing Center Rural Route 2 Winchester, IL 62694 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 0684 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete ribs. V12 stated performing Heimlich maneuver if not true choking, the benefits outweigh the risks. V12 stated the Heimlich maneuver can cause aspiration pneumonia if the resident vomits. On 9/25/2025 at 1:52 PM V3 (RN) stated she performed the Heimlich on R2 on 9/18/2025. V3 stated she did x2. V3 stated she was not nurse assigned to R2, but V3 stated she was pushing her med cart from dining room and said a resident told her R2 was choking. V3 stated R2 was not talking and had been eating chicken and noodles and after doing Heimlich was able to clear food. V3 stated R2 was drinking liquids when she left dining room. On 9/25/2025 at 2:25PM V1 (Administrator) stated the Heimlich maneuver should not be used if resident not actually choking. V1stated the Heimlich can cause rib fractures and choking.On 9/25/2025 at 3:01PM V8 (CNA) stated on 9/13 when R2 choking in dining room R2 was coughing, and table mate yelled and pointed to R2. V8 stated R2 was gasping when V8 did Heimlich.The facility policy Resident Condition Change/Policy on Contacting a Physician dated, revised 8/14/2018 documents when a change in condition (depending on severity) occurs in a resident, the resident's personal physician or the on-call physician will be contacted. The policy documents change may exist if the resident is beyond usual baseline/predicted or obvious acute changes in health. Event ID: Facility ID: 146106 If continuation sheet Page 4 of 4