Inspection·December 13, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few from V12 (former Activity Director) saying that allegedly a CNA (V12) had said she hated our resident (R4) refusing to change her. As I was off Friday (12/1/23), on Monday the 4th of December, I called V10 into my office to discuss the matter. V10 claimed that V12 was lying, and this did not happen, nor did she say she hated R4. She (V10) was in my office crying over the situation, as she was positive V12 was lying, and she was able to tell me info about what V12 was saying to her during their conversation together. As V12's behavior was erratic over the course of her employment with this, I believed her accusation against V10 to be false. Additionally, V12 stated a strong dislike towards R4 and wanted to put up a baby gate to keep her out of the activity room. R4's face sheet documents an admission date of 8/29/23. R4's Physician's Orders dated 12/1/23 to 12/31/23 document diagnoses including DM II (diabetes mellitus, type II), anxiety, dementia, depression, and right distal humerus fracture. R4's MDS (Minimum Data Set) dated 9/5/23, Section C, documents a BIMS (Brief Interview for Mental Status) score of 99 which indicates R4 was unable to complete the cognitive interview. Section GG of the same MDS documents that R4's self-care performance for toilet hygiene as Dependent-Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. The facility policy titled Abuse Prevention Program (revised 11/28/16) documents that a written report shall be sent to the Department of Public Health. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146121 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 146121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Benton Rehabilitation and Health Care Center 1409 North Main Street Benton, IL 62812 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to conduct a thorough investigation of an allegation of abuse for 1 of 3 residents (R4) reviewed for abuse in the sample of 11. Residents Affected - Few The findings include: On 12/8/23 at 1:00pm, V9 (Certified Nurse Assistant/ CNA) said on 11/30/23 she did hear V10 (Certified Nurse Assistant) say that she hated R4 and refuse to change her one time when she was asked by V12 (former Activity Director). V9 said she reported it to the nurse on duty at that time. On 12/8/23 at 1:51pm, V12 said that V10 told her that she hated R4 and refused to change her when she asked her to. On 12/8/23 at 2:00pm, V1 (Administrator) said on or around 11/30/23, she did speak to V12 (former Activity Director) on the phone. V1 said that V12 was going on and on about policies and procedures and budgets and said she thinks V12 did tell her that V10 said she hated R4 and had refused to change her. V1 said that due to V12's erratic behavior, she did not believe it to be true. V1 said that she felt that V12 did not like R4 as she was wanting to put a baby gate up to keep R4 out of the activity room. V1 then said that she did get a call from V2 (ADON/Assistant Director of Nurses, ICP/Infection Control Preventionist, LPN/Licensed Practical Nurse) she thinks on or around Monday, 12/4/23 regarding V12's behavior that occurred on 11/30/23 and that V12 said that allegedly V10 had said she hated one of their residents (R4) and was refusing to change her. V1 said she was off Friday, 12/1/23, but on Monday, 12/4/23, V1 said she called V10 into her office to discuss the matter. V10 claimed that V12 was lying, and this did not happen, nor did she say she hated R4. V1 said that V10 was in her office crying over the situation, as she was positive V12 was lying, and she was able to tell me info about what V12 was saying to her during their conversation together. V1 said she did not do a complete investigation since she was told R4 was nowhere a round when the statement was allegedly made. V1 said that V10 said that V12 was telling a lie and she did not say that she hated R4. V1 also said that V12 was terminated due to her erratic behavior and felt that V10 was telling the truth. V1 said she did not conduct a thorough investigation since she was told R4 was not around when the incident occurred and did not report the incident to the Department of Public Health until 12/8/23 when she began an investigation when it was brought to her attention by the state surveyor. A facility Incident Investigation Form for the incident that occurred on 11/30/23 and signed by V1 on 12/8/23, documents on Thursday (11/30/23) or Friday (12/1/23) afternoon, I (V1) received a call from V12 (former Activity Director) saying that allegedly a CNA (V12) had said she hated our resident (R4) refusing to change her. As I was off Friday (12/1/23), on Monday the 4th of December, I called V10 into my office to discuss the matter. V10 claimed that V12 was lying, and this did not happen, nor did she say she hated R4. She (V10) was in my office crying over the situation, as she was positive V12 was lying, and she was able to tell me info about what V12 was saying to her during their conversation together. As V12's behavior was erratic over the course of her employment with this, I believed her accusation against V10 to be false. Additionally, V12 stated a strong dislike towards R4 and wanted to put up a baby gate to keep her out of the activity room. R4's face sheet documents an admission date of 8/29/23. R4's Physician's Orders dated 12/1/23 to 12/31/23 document diagnoses including DM II (diabetes mellitus, type II), anxiety, dementia, depression, and right distal humerus fracture. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146121 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 146121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Benton Rehabilitation and Health Care Center 1409 North Main Street Benton, IL 62812 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 0610 Level of Harm - Minimal harm or potential for actual harm R4's MDS (Minimum Data Set) dated 9/5/23, Section C, documents a BIMS (Brief Interview for Mental Status) score of 99 which indicates R4 was unable to complete the cognitive interview. Section GG of the same MDS documents that R4's self-care performance for toilet hygiene as Dependent-Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. Residents Affected - Few The facility policy titled Abuse Prevention Program (revised 11/28/16) documents The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our residents. This will be done by: .Implementing systems to investigate all reports and allegations of mistreatment, exploitation, neglect, abuse of residents and misappropriation of resident property; promptly and aggressively, and making the necessary changes to prevent future occurrences; . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146121 If continuation sheet Page 4 of 4