Health inspection·December 12, 2023

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to complete a restraint/enabler assessment for two residents (R12, R21) and failed to release a restraint during lunch for one resident (R12) of two residents reviewed for restraints in a sample list of 26. Residents Affected - Few Findings include: The facility's policy Physical Restraint/Enabler Policy revised 7/24/18 documents Policy: To allow residents to be free of physical restraints which are not required to treat the resident's medical symptoms or as a therapeutic intervention. Physical restraints shall not be used for the purpose of discipline or convenience. Definition of Physical Restraint: Physical restraints is any manual method, or physical or mechanical device, equipment, or material attached or adjacent to the resident's body, which the individual cannot remove easily, and which restrict freedom of movement or normal access to his or her body. This definition also states, Also Physical restraint may include a device which prevents the resident from rising, such as placement of a chair or bed so close to a wall that prevent a resident from rising out of the chair or voluntarily getting out of bed. This policy also states Procedure: Complete physical enabler/restraint use/reduction evaluation. Obtain verbal and/or written consent from resident/legally responsible party (may obtain verbal consent until able to receive written consent). Document in the nurse's notes the date, time, and which type of consent obtained prior to physical restraint being applied. Obtain (Physician's) order for restraint or adaptive device/enabler. The order must include specific medical/physical reason, type of restraint or enabler, 'release and reposition every two hours and when to be used. The policy also states 'After initial documentation, all physical restraints require quarterly documentation regarding the type of physical restraint used, resident's response to the physical restraint, and if reduction plan has been attempted. Initiate restraint Elimination/reduction Program ninety days after application. 1. R21's Medical Diagnoses list printed 12/12/23 includes the following diagnoses: Severe Dementia with Agitation, Depression, and Repeated falls. R21's Current Physician's Orders Sheet documents R21 has a physician's order dated 12/7/23 May use lap positioning device on chair while up to enhance positioning because of leaning forward and weakness related to safety awareness due to cognitive deficit. Release and reposition resident (every) 2 hrs while device is in place, remove during meals. On 12/10/23 at 10:00AM R21 was in a common area in the wheelchair with the lap cushion in place. R21 was leaning forward and appeared to be sleeping. R21's weight was causing pressure to the lap cushion to the point the notches holding the cushion in place to the wheelchair arms were starting to come loose. There were no staff close to R21 at this time. R21's medical record does not document a restraint assessment was completed for R21. There is no documentation of less restrictive interventions being attempted prior to implementing the lap cushion. On 12/11/23 at 10:00AM V3, MDS (minimum data set) Coordinator stated, We have not done a restraint/enabler assessment for (R21). 2. R12's Medical Diagnoses list printed 12/12/23 includes the following diagnoses: Unspecified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146113 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 146113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenup Rehab and Nursing 300 North Marietta Street Greenup, IL 62428 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 0604 Dementia Severe with mood disturbance and Depression. Level of Harm - Minimal harm or potential for actual harm R12's Current Physician's Orders Sheet documents R12 has a physician's order dated 1/4/23 for a seat belt and alarm. Residents Affected - Few On 12/11/23 at 12:30PM R12 was seated with her wheelchair up to the dining table. R12's seatbelt is fastened in place. V4, Certified Nurse's Aide (CNA) stated We should have released (R12's) seatbelt during her meal V5 Certified Nurse's Aide (CNA) stated we are supposed to remove all restraints during meals. R12's medical record does not document a restraint assessment was completed for R12. There is no documentation of less restrictive interventions being attempted prior to implementing the lap cushion. On 12/11/23 at 10:00AM V3, MDS Coordinator stated, We have not done a restraint/enabler assessment for (R12). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146113 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 146113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenup Rehab and Nursing 300 North Marietta Street Greenup, IL 62428 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to have RN (Registered Nurse) coverage for 8 hours/day, 7 days/week for one day, 12/3/23 of 15 days reviewed for nursing coverage. This failure has the potential to affect all 36 residents residing in the facility. Findings include: The nursing schedule provided by V1 Administrator dated 11/26/23 through 12/10/23 documents no RN coverage on 12/3/23. On 12/11/23 at 10:29 AM V1 confirmed there was no RN coverage on 12/3/23. On 12/11/23 at 2:43 PM, V2 Director of Nursing stated they do not have a staffing policy. The facility's Long Term Care Facility Application for Medicare and Medicaid dated 12/10/23 documents 36 residents reside in the building. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146113 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 146113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenup Rehab and Nursing 300 North Marietta Street Greenup, IL 62428 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review the facility failed to ensure that controlled substances were accounted and reconciled for seven (R2, R3, R4, R10, R15, R16, and R23) of seven residents reviewed for controlled substance accounting and reconciliation from a total sample list of 26 residents. Findings include: The facility provided Controlled Substance Policy revised date 11/16/2018 documents that the Schedule II drugs and those in other schedules which have been restricted and stored in the Controlled Substance cabinet will be counted and reconciled by the nurse coming on duty with the nurse that is going off duty. On 12/11/23 at 10:00AM, the long hall medication cart was reviewed with V7 Licensed Practical Nurse. 1. The controlled substance box contained R2's Oxycodone (narcotic) 100 milligrams/5 milliliters with a remaining 20.75milliliters (ml) of medication. Additionally, R2's Lorazepam (controlled sedative) 1mg was in the controlled substance box with 10 remaining tablets. 2. The controlled substance box contained R3's Lorazepam 0.5mg, with a remaining 24 tablets. 3. The controlled substance box contained R4's Lorazepam 0.5mg, with a remaining 30 tablets. 4. The controlled substance box contained R10's Morphine (narcotic) 20mg/ml, with 8.75 ml of remaining medication. Additionally, 2 unopened bottles of Morphine 20mg/ml containing 30mls were in the drawer. Finally, the unlocked refrigerator contained R10's Lorazepam oral solution 2mg/ml with 27.5 ml's remaining. 5. The controlled substance box contained R15's Tramadol (narcotic) 50mg with 19 tablets remaining. 6. The controlled substance box contained R16's Tramadol 50mg with 24 tablets remaining. 7. The controlled substance box contained R23's Guaifenesin with Codeine (narcotic) liquid 100mg/5ml with 35 ml's remaining. The facility provided Controlled Drug Count Record dated December 2023 documents that the outgoing and incoming nurse did not count, nor sign the controlled substances record on December 3, 4, 5, 7, 9, 10 and 11, 2023. On 12/12/23 at 1:00PM, V2 Director of Nursing stated that the expectation of the nursing staff is to count at each change of shift with the off-going and on-coming nurses. Failure to do so could result in medication errors, discrepancies and the potential for drug diversion. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146113 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 146113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenup Rehab and Nursing 300 North Marietta Street Greenup, IL 62428 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.) R27 Order Summary Report dated 12/12/23 documents diagnoses including Unspecified Dementia with Agitation and Depression. This Order Summary documents an order for Citalopram HBR (Hydrobromide) (antidepressant) 20 mg (milligrams) one tablet one time a day related to Depression. R27's Care Plan dated 3/24/23 documents R27 has a history of signs and symptoms of depression and is currently being treated. This Care Plan documents interventions of administering medications as ordered. R27's medical record documents one Psychotropic medication assessment dated [DATE]. R27's medical record does not document any other Psychotropic medication assessments for 2023. On 12/11/23 at 12:22 PM, V3 Minimum Data Set Nurse confirmed V3 is responsible to complete the Psychotropic medication assessments. On 12/11/23 at 2:43 PM, V3 confirmed that R27's quarterly Psychotropic medication assessments were not completed like they should have been. The facility's Psychotropic Medication Policy with a revised date of 11/28/17 documents, Any resident receiving psychotropic medication will have the Psychotropic Medication Assessment done at a minimum of every quarter. Based on interview and record review the facility failed to complete quarterly Psychotropic medications assessments/Abnormal Involuntary Movement Scale (AIMS) assessments for three (R36, R22, R27) of seven residents reviewed for psychotropic medication in a sample list of 26. Findings Include: The facility's policy Psychotropic Medication Policy revised 11/28/17 states 17. Any resident receiving psychotropic medications will have an AIMS assessment done at a minimum of every six months. This policy also states Quarterly documentation will be done on a progress note of any resident that currently receives psychotropic medications. This is to include, but not limited to, individual resident response and/or progress, psychotropic medication assessment, behaviors exhibited, problems or issues which the resident may be having, current medications, recent medication changes, and tolerance of the medication regimen. 1.) R36's Medical Diagnosis List printed 12/12/23 documents the following diagnoses: Dementia Without Behavioral Disturbances, Anxiety Disorder, and Senile Degeneration of the Brain. R36's Medication Administration Record (MAR) for 12/1/23 through 12/31/23 includes physician's orders for: 1. Seroquel (Antipsychotic) 100 Milligrams (MG) twice daily,2. Lorazepam (antianxiety) 0.5 MG every six hours and 0.5 MG every six hours as needed and One MG. at bedtime as needed. 3. Diazepam (antianxiety) Rectal Suppositories 5 MG every six hours as needed for anxiety. There are no documented psychotropic assessments documented for R36 for any of these medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146113 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 146113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenup Rehab and Nursing 300 North Marietta Street Greenup, IL 62428 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 There is no AIMS assessment documented for the use of antipsychotic medications. Level of Harm - Minimal harm or potential for actual harm On 12/11/23 at 10:00AM V3, MDS Coordinator stated I can see the psychotropic assessments and the AIMS assessments were not done for (R36). (R36) is not using the Diazepam and it probably should have been discontinued. Residents Affected - Few 3.) The facility provided Psychotropic Medication Policy revised date November 2001 documents that any resident receiving psychotropic medication will be reviewed at a minimum of every quarter by the interdisciplinary team. Additionally, any resident receiving psychotropic medications will have an (Abnormal Involuntary Movement Scale) AIMS assessment done, at a minimum, every six months. R22's August 2023 medication administration record documents an order for Seroquel 50 milligrams (antipsychotic) twice daily with a start date of 4/16/23. R22's April through October 2023 medication administration records document continued administration of Seroquel 50 milligrams (mg) twice daily. On October 5, 2023 Seroquel 25mg was ordered to be given in the morning and Seroquel 50mg was ordered to be given before bed, continuing through the survey date. R22's medical record does not document quarterly assessments for psychotropic drug usage, nor does it document an Abnormal Involuntary Movement Scale (AIMS). On 12/11/23 at 12:04PM, V2 Director of Nursing said she could not find where quarterly assessments or an AIMS scale was completed for (R22 and that it was supposed to have been done. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146113 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 146113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenup Rehab and Nursing 300 North Marietta Street Greenup, IL 62428 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to administer an anticoagulant medication as ordered for one resident. This failure resulted in a significant medication error for one of one resident (R38) reviewed for medication errors in the sample list of 26. Residents Affected - Few Findings include: The facility's Medication Administration policy with a revised date of 11/18/17 documents, If the medication is not available for a resident, call the pharmacy and notify the physician when the drug is expected to be available. R38's Order Summary Report dated 12/12/23 documents a diagnosis of Paroxysmal Atrial Fibrillation (A-fib) and an order for Apixaban (anticoagulant) Oral Tablet 2.5 mg (milligrams), give one tablet by mouth two times a day for A-fib with a start date of 9/2/23. R38's Medication Administration Record dated 9/1/23 through 9/30/23 documents the Apixaban 8:00 AM dose was not administered on 9/22/23 and 9/23/23 and the 5:00 PM dose was not administered on 9/23/23 for a total of three doses not administered. R38's Nurse's Progress Notes dated 9/22/23 at 7:41 AM documents the Apixaban was not administered because the medication was out of stock. R38's Nurse's Progress Notes dated 9/23/23 at 7:46 AM documents the Apixaban was not administered because it was on order. R38's Nurse's Progress Notes dated 9/23/23 at 4:18 PM documents the Apixaban was not administered because the medication was not available at this time. On 12/12/23 at 12:05 PM, V2 Director of Nursing confirmed that R38 missed three doses of Apixaban on 9/22/23 and 9/23/23 and if the medication was available in the back up supply it should have been taken from there and administered. The facility's Ekit (Emergency kit) Contents list provided by V2 on 12/12/23 at 1:15 PM documents the Ekit contains six tablets of Eliquis (Apixaban) 2.5 mg and six tablets of Eliquis 5 mg. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146113 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 146113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenup Rehab and Nursing 300 North Marietta Street Greenup, IL 62428 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review the facility failed to store and secure controlled medications behind a separately locked compartment for four (R10, R22, R36 and R193) of four residents reviewed for medication storage from a total sample list of 26 residents. Findings include: The facility provided Procurement and Storage of Medications Policy date reviewed November 2018, documents that Schedule II drugs are to be stored under a double-lock subject to a different key and that medication bottles are to be kept clean and orderly. On 12/11/23 at 9:31AM R10's Lorazepam 2 milligrams (mg) per milliliter (ml) (a schedule 4 controlled, antianxiety medication) bottle and paper packaging was saturated with Lorazepam. Additionally, the refrigerator containing Lorazepam 2mg per ml for R10, R22, R36 and R193 was unlocked. On 12/11/23 at 9:35AM, V7 Licensed Practical Nurse stated that the medication room refrigerator was supposed to be locked and that R10's Lorazepam should be disposed of because the bottle and box were saturated with Lorazepam, subjecting anyone who picked up the box to accidental drug exposure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146113 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 146113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenup Rehab and Nursing 300 North Marietta Street Greenup, IL 62428 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 prevent the potential for cross-contamination of disposable plates and failed to maintain sanitary kitchen and pantry floor areas. These failures have the potential to affect all 36 residents in the facility. Findings include: 1. On 12/10/2023 at 9:12AM, kitchen supplies including disposable plates and cups were stored on a shelf below exposed pipes in the kitchen basement. One pipe was actively leaking onto a box of disposable plates located on the shelf. The box was wet and discolored and the water drip had leaked onto the plates stored inside, leaving a leaving a yellow residue on the plates. 2. On 12/10/2023 at 8:55AM, the entire flooring surface throughout the kitchen and pantry areas was discolored with soiling and also had accumulations of debris including onion peels, tree leaves, binder clips, dried pasta, and single serve condiment packets. V6 (Dietary Manager) was present and reported the dietary staff are responsible for routine floor maintenance in the dietary areas, but they have been waiting on maintenance staff to assist with cleaning and sealing the unsealed floor surface, but the maintenance staff haven't had time yet to assist with the floors. The facility Long-Term Care Facility Application for Medicare and Medicaid (12/10/2023) documents 36 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146113 If continuation sheet Page 10 of 10