Health inspection·December 8, 2023

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to timely complete the Preadmission Screening and Resident Review (PASARR) Level-1 screening and failed to complete the recommended Level-2 screening for one of one residents (R47) reviewed for required screenings on the sample list of 27. Residents Affected - Few Findings Include: R47's Physician Order Sheet (POS), dated December 2023, documents R47 was admitted into the facility on 4/26/23 and has medical diagnoses of Sever Bipolar Disorder with Psychotic Features and Dementia with Behavioral Disturbances. The undated Maximus computer screen-shot documents R47's Level-1 PASARR screen was submitted on 8/9/23. R47's Notice of PASARR Level-1 Screen Outcome documents R47's Level-1 Screening results were received by the facility on 12/6/23 and recommended R47 be referred for a Level-2 screening due to Mental Health Disability. On 12/07/23 at 10:45 AM V1 Administrator stated R47 was first admitted on [DATE]. The Level 1 PASARR was not submitted to be completed until 8/9/23 and those results, showing a Level 2 screening should be completed, were not received by the facility until 12/6/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146117 If continuation sheet Page 2 of 15 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 146117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casey Rehab and Nursing 100 N.E. 15th Casey, IL 62420 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to implement physician ordered fall prevention interventions. This failure affects one resident (R8) out of six reviewed for falls on the sample list of 27. Findings Include: R8's current Physician Order Sheet, dated for December 2023 documents a physician order for R8 to have a bed and chair pressure alarm. On 12/5/23 at 10:31 AM, R8 was seated in a wheelchair in the facility Family Room. There was not any alarm on R8's wheelchair. V2 Assistant Director of Nursing stated, We are using a pommel cushion in (R8's) wheelchair so we don't have a double restraint. I think the chair alarm maybe refers to a recliner. On 12/5/23 at 10:58 AM, R8's room did not contain any kind of a chair, including a recliner. On 12/6/23 at 3:38 PM V2 stated, The pommel cushion does not prevent (R8) from standing up (not a restraint), she does it all the time. V2 further stated, The pressure alarm did not prevent (R8) from standing up (also not a restraint), she will stand up regardless. R8's Care Plan for Falls dated from 12/12/19 documents R8 experienced 16 falls in the four year period of residency at the facility. A fall intervention dated 7/30/23 documents, Fall from wheelchair without injury, staff to replace pressure alarm batteries. This intervention is documented as D/C (discontinue) to indicate the staff had changed the batteries. This same Care Plan for Falls has an intervention dated 12/14/22 Pommel cushion to wheelchair indicating R8 had the pommel cushion and the pressure alarm simultaneously in the recent past. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146117 If continuation sheet Page 3 of 15 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 146117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casey Rehab and Nursing 100 N.E. 15th Casey, IL 62420 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to properly clean and maintain a Continuous Positive Airway Pressure (CPAP) machine and mask for one of one residents (R43) reviewed for respiratory care on the sample list of 27. Residents Affected - Few Findings Include: The facility's Bilevel Positive Airway Pressure/Continuous Positive Airway Pressure (BiPAP/CPAP) policy dated 3/8/13 documents CPAP machines provide continuous positive pressure to the airways of spontaneously breathing residents. Machine circuits are to be cleaned every week and as needed. External filters should be cleaned once a week and as needed. R43's Physician Order Sheet (POS) dated December 2023 documents R43 is diagnosed with Aspiration Pneumonia, Quadriplegia, Seizures, Altered Mental Status, and Mild Cognitive Impairment. R43 has an order to use a Continuous Positive Airway Pressure (CPAP) machine at bedtime. On 12/5/23 at 11:40 AM R43's Continuous Positive Airway Pressure (CPAP) mask was stored in a plastic bag however the mask was visibly soiled and had white debris all over the inside of the mask. The CPAP machine's water reservoir was dry and the entire bottom and sides of the reservoir had thick, dried, white, scaly residue. On 12/5/23 at 11:40 AM V2 Assistant Director of Nursing (ADON) confirmed R43's Continuous Positive Airway Pressure (CPAP) mask was dirty and appeared to have not been cleaned in a while. V2 also confirmed the CPAP water reservoir was dry and appeared to have mineral deposits (hard, scaly white residue) coating the bottom and sides of the reservoir. V2 ADON confirmed the mask should have been cleaned and should be cleaned after every use especially since R43 produces a lot of sputum and saliva. V2 also confirmed staff should be cleaning the reservoir weekly and or as needed and staff should be using distilled water to fill the water reservoir. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146117 If continuation sheet Page 4 of 15 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 146117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casey Rehab and Nursing 100 N.E. 15th Casey, IL 62420 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to employ a Registered Nurse to serve as full time Director of Nursing. This failure has the potential to affect all 51 residents in the facility. Findings Include: On 12/5/2023 at 10:19 AM V1 Administrator confirmed the facility does not currently employ a Registered Nurse to serve as full time Director of Nursing. Upon survey entrance and throughout the survey (12/5/23- 12/8/23) there was no Director of Nursing present and employed by the facility. The facility's Facility assessment dated [DATE] documents a full time Director of Nursing is required in order to meet the resident's needs and provide competent support and care for the facility's resident population. The facility Long-Term Care Facility Application for Medicare and Medicaid dated 12/5/2023 documents 51 residents currently reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146117 If continuation sheet Page 5 of 15 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 146117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casey Rehab and Nursing 100 N.E. 15th Casey, IL 62420 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interview and record review, the facility failed to obtain a physician's rationale for declining a Registered Pharmacist recommendation to reduce the dosage of an Anti-depressant/ sedative (Trazodone). This failure affects one resident (R35) out of five reviewed for psychotropic and unnecessary medications on the sample list of 27. Findings Include: R35's Pharmacist Consultation Report dated 7/26/23 documents the facility's Registered Pharmacist gave the facility a reminder that V13, Nurse Practitioner, had declined to accept the Pharmacist recommendation to decrease Trazodone on 6/22/23, but had not provided a rationale as a basis for disagreeing with the recommendation. On 12/7/23 at 2:09 PM, V1 Administrator stated, Here is the return form from V13. This return form with a rationale was dated 8/11/23, 46 days after the initial recommendation from the Pharmacist. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146117 If continuation sheet Page 6 of 15 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 146117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casey Rehab and Nursing 100 N.E. 15th Casey, IL 62420 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services and failed to employ a person-in-charge (PIC) with the required Food Protection Manager Certification. These failures have the potential to affect all 51 residents in the facility. Findings Include: On 12/07/2023 at 11:45 AM V6 (Dietary Manager) was actively supervising dietary operations in the facility kitchen. V6 reported being the full-time manager of the facility food service (person in charge) and reported not being a clinically qualified Certified Dietary Manager or having equivalent training. V6 denied meeting the State of Illinois standards to be a food service manager or dietary manager. V6 reported the facility dietician only works in the facility one day per month. V6 also denied being a certified Food Protection Manager, as required, for every person in charge of a food service. V6 denied: -being a dietician; -being a certified dietary manager; -having an associate's or higher degree in food service management or in hospitality; -having 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting; -being a graduate of a dietetic and nutrition school or program authorized by the Accreditation Council for Education in Nutrition and Dietetics, the Academy of Nutrition and Dietetics, or the American Board of Nutrition; -being a graduate, prior to July 1, 1990, of a Department (Illinois Department of Public Health) approved course that provided 90 or more hours of classroom instruction in food service supervision and having experience as a supervisor in a health care institution which included consultation from a dietician; -or having completed an Association of Nutrition & Food Service Professionals approved Certified Dietary Manager or Certified Food Protection Professional course. The Food and Drug Administration Food Code (2022) documents a dietary service Person in Charge (PIC) shall be a Certified Food Protection Manager. On 12/7/2023 at 1:40 PM V1 (Administrator) reported V6 (Dietary Manager) did not meet the qualifications of a Certified Dietary Manager. Throughout the duration of the survey, the kitchen failed to prevent the potential for physical cross-contamination of food, failed to ensure all dietary staff donned hair restraints, and failed to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146117 If continuation sheet Page 7 of 15 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 146117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casey Rehab and Nursing 100 N.E. 15th Casey, IL 62420 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 0801 exclude flying insects from the kitchen areas. Level of Harm - Minimal harm or potential for actual harm The Facility assessment dated [DATE] documents a full-time dietician or other clinically qualified nutrition professional is needed to provide competent support and care for the facility's resident population every day and during emergencies. Residents Affected - Many On 12/7/2023 at 2:30 PM V6 reported food from the kitchen is available for all residents in the facility to eat. The facility Long-Term Care Facility Application for Medicare and Medicaid (12/5/2023) documents 51 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146117 If continuation sheet Page 8 of 15 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 146117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casey Rehab and Nursing 100 N.E. 15th Casey, IL 62420 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 physical cross-contamination of food and failed to ensure dietary staff donned required hair restraints. These failures have the potential to affect all 51 residents in the facility. Findings Include: 1. On 12/5/2023 at 10:16 AM V7 (Dietary Aide) was working in the food preparation area of the facility kitchen without any required hair restraint. 2. On 12/7/2023 at 11:32 AM a can opener was mounted on a food prep table in the kitchen. The opener was soiled with accumulations of metal shavings where the cutting blade contacts canned food items being opened. The cutting surfaces of the opener blade felt dull when touched. On 12/7/2023 at 11:50 AM V6 (Dietary Manager) observed the above can opener and stated the opener definitely needs cleaned. On 12/7/2023 at 2:30 PM V6 reported food from the kitchen is available for all residents in the facility to eat. The facility Long-Term Care Facility Application for Medicare and Medicaid (12/5/2023) documents 51 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146117 If continuation sheet Page 9 of 15 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 146117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casey Rehab and Nursing 100 N.E. 15th Casey, IL 62420 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure required personnel attended the required quarterly Quality Assessment and Assurance (QAA) committee meetings. This failure has the potential to affect all 51 residents in the facility. Residents Affected - Many Findings include: The undated Quality Assurance Plan documents the facility Quality Assessment & Assurance (QAA) Committee should identify opportunities for improvement should be used to keep all QAA members, including the Administrator and Director of Nurses, up to date on what is going on within the facility. On 12/8/2022 V1 Administrator provided five QAA Meeting Sign-In Sheets (1/16/23, 4/10/23, 7/17/23, and 10/16/23) for the previous year's QAA meetings. The January, April, July, and October 2023 QAA Meeting Sign-In Sheets do not document the facility's Director of Nursing was present at any of the meetings. On 12/5/23 at 4:00 PM V1 Administrator confirmed the facility has not employed a Director of Nurses (DON) and therefor the facility has not had a DON at the last four Quality Assurance Committee Meetings held on 10/16/23, 7/17/23, 4/10/23, and 1/16/23. V1 Administrator confirmed all required members of the QAA committee, including the Director of Nurses, should be present at all quarterly QAA meetings. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 12/5/23 documents 51 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146117 If continuation sheet Page 10 of 15 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 146117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casey Rehab and Nursing 100 N.E. 15th Casey, IL 62420 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 - Minimal harm or potential for actual harm Based on interview and record review the facility failed to map and identify high risk areas for Legionella growth, failed to formulate a prevention plan, failed to formulate a plan for any identified cases of Legionella, and failed to identify facility water outlets for testing samples. This failure has the potential to affect all 51 residents residing in the facility. Residents Affected - Many Findings Include: On 12/7/23 at 1:53 PM V1 Administrator provided an undated Legionella Environmental Assessment Form. At 2:54 PM V12 Maintenance Director provided an undated floor plan map. The facility's floor plan map (undated) was a fire safety map showing the locations of fire walls, egress routes, smoke detectors, fire extinguishers, and sprinkler heads. V12 stated, I don't have a mapping to show the water distribution or high-risk areas for Legionella, I know where the city water comes into the building. The Legionella Environmental Assessment Form (undated) documented the facility characteristics, such as city water supply, number of buildings on the property, number of rooms, average length of stay, emergency water systems such as sprinklers and eye wash stations, and ice machines. This Form did not identify any areas or fixtures as high risk for the growth of Legionella. This Form did not contain any measures to prevent the growth of Legionella. This form did not identify a response plan in the event of a positive case of Legionella. This Form did not document when the facility should initiate testing for Legionella, nor a plan for remediation if Legionella was discovered in the facility water fixtures. On 12/8/23 at 10:04 AM V1 Administrator acknowledged the lack of required components in the Environmental Form and stated, I think it sounds like I need an action plan. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 12/5/23 documents 51 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146117 If continuation sheet Page 11 of 15 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 146117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casey Rehab and Nursing 100 N.E. 15th Casey, IL 62420 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 0909 Level of Harm - Minimal harm or potential for actual harm Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. Based on observation, interview, and record review the facility failed to maintain resident bed side rails in a safe condition. This failure affects one resident (R2) of 12 reviewed for bed side rails in the sample list of 27. Residents Affected - Few Findings include: On 12/5/2023 at 11:52 AM R2 was resting in bed with the left (room side) half-length side rail raised in the upward position. The rail vertical supports were spaced 7.5-8.5 apart. R2 reported using the rail for bed mobility and positioning. On 12/8/2023 at 10:02 AM R2 remained in bed with the side rail in the raised position. V11 (Licensed Practical Nurse) was present and observed the spacing on the vertical supports on the rail and confirmed the spacing of the supports was a hazard. R2's undated medical diagnosis list documents R2's medical diagnoses include Physical Debility and Sleep Apnea. R2's comprehensive assessment (9/19/2023) documents R2 has impaired range of motion in bilateral upper and lower extremities. R2's Physician Orders (December 2023) documents R2 uses oxygen via nasal cannula tubing. This creates an additional entanglement risk when used with side rails. R2's Bed Rail Evaluation (9/23/2023) documents R2 has Weakness and Musculoskeletal Disorder. The Food and Drug Administration Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment (3/10/2006) documents to reduce the risk of entrapment, injury, and death, the maximum safe spacing in a bed side rail system should not exceed 4 3/4. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146117 If continuation sheet Page 12 of 15 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 146117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casey Rehab and Nursing 100 N.E. 15th Casey, IL 62420 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 0924 Put firmly secured handrails on each side of hallways. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain corridor handrails in sound and stable condition. This failure has the potential to affect all 51 residents in the facility. Residents Affected - Many Findings Include: On 12/7/23 at 2:54 PM there was a one-foot section of handrail at the intersection of the two 200 halls which was loose and easily moveable up and down as well as rotating. There was a section of handrail between resident rooms [ROOM NUMBERS] which moved up and both directions sideways one and one-half inches, being unscrewed from the mounting bracket, and having screws protruding from the brackets. There was a section of handrail between resident rooms [ROOM NUMBERS] which had a loose mounting bracket that could be pushed one half inch recessed into the wall, allowing the handrail to move a commensurate amount, as well as having loose screws the length of the rail allowing the rail to be rotated. Between resident room [ROOM NUMBER] and the end of the corridor, the was a section of handrail with loose screws, allowing the rail to move and rotate over one-half inch. Between the therapy room and the end of the 200 corridor there was a section of handrail with loose screws, allowing the rail to move and rotate three-quarters of an inch. There was a section of handrail between the therapy room and resident room [ROOM NUMBER] with loose screws, allowing the rail to rotate one-half inch. Next to a storage room on the 200 hall, after resident room [ROOM NUMBER], there was a section of handrail with loose screws, allowing the rail to rotate one-half inch. Between the janitor room and the Minimum Data Set office on the back 200 hall, there was a section of handrail with loose screws, allowing the rail to rotate one-half inch. Between resident room [ROOM NUMBER] and the exit door, there was a section of handrail with loose screws, allowing the rail to rotate one-half inch. There was a section of handrail between resident room [ROOM NUMBER] and a storage room with loose screws, allowing the rail to rotate one-half inch. Between resident rooms [ROOM NUMBERS] there was a section of handrail which was not properly mounted on the wall bracket, being mounted to the downward curved portion of the bracket, causing the rail to be tight directly up against the wall at the end next to resident room [ROOM NUMBER]. The remainder of the rail slowly tapered away from the wall, creating an entrapment hazard for any resident using the handrail to get their hand caught as the rail tapered down to no clearance. There was a section of handrail between resident room [ROOM NUMBER] and the nursing station with loose screws that rotated one-half inch. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146117 If continuation sheet Page 13 of 15 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 146117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casey Rehab and Nursing 100 N.E. 15th Casey, IL 62420 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 0924 Level of Harm - Minimal harm or potential for actual harm There was a section of handrail between resident room [ROOM NUMBER] and the dining room with loose screws, allowing the rail to rotate three-quarters of an inch. There was a section of handrail between resident rooms [ROOM NUMBERS] with loose screws, allowing the rail to rotate three-quarters of an inch. Residents Affected - Many Between the corner of the 100 hall and the exit door there was a rail with loose and missing screws allowing the rail to move one and one-half inches. Between resident room [ROOM NUMBER] and the hallway entrance there was a section of handrail with loose and protruding mounting screws, allowing the brackets to move and recede into the wall one-half inch. There was a section of handrail between resident rooms [ROOM NUMBERS] with loose screws, allowing the rail to rotate one-half inch. There was a section of handrail between resident rooms [ROOM NUMBERS] with loose screws, allowing the rail to move and rotate three-quarters of an inch. Between the janitor room and the shower room on the 100 hall there was a section of handrail with loose mounting screws, allowing the mounting brackets to move and recede into the wall one-half inch. On the facility's 100 hall there was a section of handrail between the two shower rooms with loose screws, allowing the rail to move and rotate one-half inch. Between resident rooms [ROOM NUMBERS], the section of handrail had loose screws, allowing the rail to rotate three-quarters of an inch. Between resident room [ROOM NUMBER] and the hallway fire door, a section of handrail with loose screws could move and rotate three-quarters of an inch. There was a section of handrail between resident rooms [ROOM NUMBERS] with loose screws that could move and rotate one-half inch. Between a storage room and the end of the 200 hall, there was a section of handrail with loose screws which moved and rotated one-half inch. During this tour of the facility handrails V12 Maintenance Supervisor made statements such as, Oh, I didn't know that was like that. Oh man that's loose. Oh yeah that needs fixed and I usually keep an eye on these things. When referring to the handrail between resident rooms [ROOM NUMBERS] with the entrapment hazard, V12 stated, I think someone must have hit that with the (full body mechanical lift). The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 12/5/23 documents 51 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146117 If continuation sheet Page 14 of 15 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 146117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casey Rehab and Nursing 100 N.E. 15th Casey, IL 62420 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to maintain an effective pest control program by failing to exclude and prevent flying insects throughout the facility kitchen areas. This failure had the potential to affect all 51 residents in the facility. Residents Affected - Many Findings Include: On 12/5/2023 at 10:28 AM three or more flies resembling fruit flies were flying around and resting on the kitchen dishwasher drainboard areas. On 12/7/2023 at 11:45 AM five or more flies resembling fruit flies were flying around and resting on the kitchen dishwasher drainboard areas. An additional fly surfaced and flew out of a nearby floor drain. The floor drain contained standing water and the interior pipe surface above the water was soiled with dark colored accumulations of debris. V6 (Dietary Manager) was present and stated the kitchen floor drains are the problem (causing the flies in the kitchen areas) and they (the flies) are so bad. Facility pest control contractor treatment reports (September-November 2023) document flies were present in the facility kitchen during each month from September-November 2023. On 12/7/2023 at 2:30 PM V6 (Dietary Manager) reported food from the kitchen is available for all residents in the facility to eat. The facility Long-Term Care Facility Application for Medicare and Medicaid (12/5/2023) documents 51 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146117 If continuation sheet Page 15 of 15