Health inspection·August 16, 2024

F 0567 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many resident trust account was reconciled by (V4) with no concerns noted. (V3) has been terminated from employment effective immediately. The investigation has been turned over to the Local Police Department. The facility will fully cooperate with any requests made by the Police Department. This letter was signed by V1, Former Administrator. A List of Resident Trust Accounts from 2/1/24 through 5/24/24 documented R1 through R50 as having a resident trust account during that time period. On 8/7/24 at 9:05am, V10 (Transportation) stated she was hired on 2/1/24. V10 stated from the beginning of her employment, twice a month she would take R1 to R1's bank with a check written for cash, R1 would get the cash and V10 would take R1 to a liquor store to buy a carton of cigarettes. When they returned to the facility, she or R1 would give V3 the remainder of the money, which V3 had stated was being put toward R1's room and board. V10 stated V3 never gave R1 a receipt. V10 stated the checks were never written for the same amount, and the checks written on the first of the month would be written for anywhere from $2000 to $2500, with the checks written toward the middle of the month between $300 to $700. V10 stated she found this situation confusing and felt something was off about it. V10 stated she went to V1 about it on the morning of 5/23/24 and told her to look into this money thing with R1. V10 stated, I made myself clear that I thought something was not right about it. (V1) was rustling papers around on her desk and not listening to me. She said I don't deal with that, that's the business office take it up with (V3). V10 stated she then approached V16 (Corporate Regional Director of Marketing) and talked to her about it. V10 stated the next day, she was interviewed by V11 (Regional Director of Clinical and Operations) who said an investigation had begun. On 8/7/24 at 9:55am, V3 stated she was hired as Business Office Manager on 4/22/21. V3 stated, I have never taken or stolen money from any resident, from their account, or cash, or their belongings, or petty cash. V3 stated twice a month, R1 would tell V3 to write out a check on R1's checking account, and R1 would tell V3 how much to write the check for. V3 stated R1 spent all her money but didn't have anything to show for it and V3 doesn't know what she spent it on. V3 stated V10 nor R1 ever brought V3 any cash. V3 stated the last time she was aware, R1 owed the facility around $20,000 for room and board. V3 stated she tried to talk to R1 about R1's bill, but she ignored V3. V3 stated she could not remember any specific check amounts. V3 stated R1 did not have a POA (Power of Attorney) or guardian and was capable of handling her own financial affairs. V3 stated she does think she discussed R1's outstanding bill with somebody from the corporate office, but is not sure who or when. V3 stated in October of 2023, a cyberattack took out the program used for resident trust accounts, and she did not have any way to find out what resident balances were. V3 stated she would call the corporate office, but they would never get back to her. V3 stated within a few weeks after the corporation went into receivership in early February of 2024, all the trust information was forwarded to V3 but the accounts hadn't been balanced since October 2023. V3 stated she did not then balance them because she did not have time, as she was overwhelmed from all the administrative changes that were going on. V3 stated the receivership organization set up a new system for accounting, but she had not taken the training required to use it. On 8/8/24 at 10:15am, V4 (Corporate Business Office Manager) stated she first entered the facility on 5/31/24 to audit the accounts as part of the misappropriation investigation. V4 stated that audits of resident trust fund petty cash showed checks written and signed by V3 documented that at one point, the facility would have had about $3000 in petty cash, whereas a facility of its size should only keep a few hundred dollars worth of cash. V4 stated the resident trusts are commingled in one account with separate record keeping for each individual resident. V4 stated when a resident takes money out of petty cash, it is to be deducted form that resident's trust account amount. V4 stated V3 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146121 If continuation sheet Page 2 of 24 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 08/16/2024 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 0567 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many kept meticulous records which when audited, balanced correctly, up until November 2023, at which point V3 stopped balancing the accounts. V4 stated the previous corporation who managed the facility has refused to provide any resident trust documentation to the current receivership corporation, which took over on 2/8/24. V4 stated a total of fifty current and former residents had resident trust accounts for the period of 12/1/23 to 6/1/24, all of whom would be affected by misappropriation from the pooled account. V4 stated R1 should never have had large checks written for cash and then brought back to the facility, but instead written a check to the facility for the room and board with the remaining Medicaid $60 individual allowance put in R1's resident trust account. V4 stated her audits documented a total of $9857 outstanding balance on R1's room and board, $10650 of checks written out to cash from R1's account. V4 stated the pooled resident trust account, on which V3 had written checks for cash, was missing $5515.19, although the checks V3 had written totaled less than that amount, indicating V3 may have written checks earlier than 2/1/24, although there is no documentation. V4 stated the facility has reimbursed all the missing money. V4 stated an audit of R2's trust account balance showed no suspicious activity, but since R2 reported items had been paid for by her and not received, these items were ordered for R2 and paid for by the facility. V4 further stated Business Office Managers are not to keep resident checkbooks unless the resident specifically signs a written consent, which none of the residents including R1 have done. V4 stated R1 keeps her checkbook in her room. V4 stated during the investigation, V3 came to the facility and was asked to provide receipts for the petty cash and for the cash R1 brought in, but V3 was unable to do so. V4 stated there were no other staff members found to be involved as the checks were all written and signed by V3. V4 stated since the investigation has concluded, it is to be noted that R1 has not requested any checks to be written or to be given cash, and the only thing R1 has requested is cigarettes. Copies of checks written to cash provided with R1's bank statements were reviewed. The checks were signed by R1 and were written on the following dates with amounts as follows: 12/21/23: $250 12/29/23: $200 1/3/24: $1,800 1/22/24: $200 2/2/24: $1,500 2/14/24: $300 3/1/24: $2,000 3/13/24: $250 4/3/24: $1,900 4/17/24: $250 5/3/24: $2,000 Copies of checks to written to cash, written on the pooled resident trust account were written on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146121 If continuation sheet Page 3 of 24 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 08/16/2024 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 0567 the following dates and signed by V3 with amounts as follows: Level of Harm - Minimal harm or potential for actual harm 2/1/24: $500 3/14/24: $500 Residents Affected - Many 4/19/24: $1000 5/16/24: $1000 5/21/24: $600 The facility was unable to provide documentation as to what the cash was used for, such as receipts given to residents. R1's [NAME] Statement documented that between 2/29/24 through 6/1/24, nothing was applied to R1's room and board, and the outstanding balance as of 6/1/24 was $9857. An undated Resident Funds Policy and Procedure stated, (The facility) recognizes the resident's right to manage his/her own financial affairs and does not require the resident to deposit their personal funds with facility. However, upon written authorization of a competent resident the facility will hold, safeguard, manage and account for personal monies deposited with the facility. If the resident has been determined to be incompetent, the written authorization may be signed by the resident's fiduciary guardian, legal representative, or immediate family. In all cases the authorization must be witnessed by a disinterested party in an interest bearing, pooled Resident Monies Account. All accrued interest paid to the Resident Monies Account is prorated among those residents having personal funds in the account. In this manner, the resident will have access to his/her monies within the same day. At least quarterly, the facility will provide the resident or his/her representative a written, itemized statement of all transactions to his/her account which occurred in the last quarter. A review of the resident's account status is available to the resident upon request and in a reasonable amount of time. The facility will institute security measures to insure that resident funds managed by the facility are safeguarded from theft or mismanagement and shall include; signed vouchers for all resident transactions, computerized tracking of account activity, monthly oversight by the facility Administrator, and signed quarterly statements. Further, the facility will require dual signatures on all banking transactions requiring signatures as well as require receipts for all purchases made from residents' personal monies that shall include date of purchase, amount of purchase, and detail of all items or services purchased. If a resident is incapable of handling his/her own funds and does not have a fiduciary guardian, legal representative, or an immediate family member, the facility shall notify the Office of the State Guardian. Procedure: 1. The facility shall appoint a qualified designee who will be responsible for maintaining resident funds upon written authorization. The facility Administrator will have ultimate oversight over all aspects of the handling of the resident trust and resident funds. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146121 If continuation sheet Page 4 of 24 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 08/16/2024 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 0567 2. Level of Harm - Minimal harm or potential for actual harm The facility has adopted the Answers on Demand computerized Resident Trust Program to assure a full, complete and separate accounting for each resident. The Resident Trust Program shall be maintained according to generally accepted accounting principles. Residents Affected - Many 3. Resident funds will not be commingled with facility funds, or any other funds, except that all resident personal funds shall be maintained in a single interest bearing Resident Monies Account. 4. The Resident account maintained in the Resident Trust Program for each participating resident shall be updated in a timely manner. This personal account detail shall be available to the resident and/or his/her legal representative to review upon request within a reasonable time-frame. 5. Receipts for purchases from resident's personal monies shall be obtained for every purchase and maintained to verify: date of purchase, amount of purchase, and items purchased. The facility shall require that the Resident Trust Account be a dual signatory account requiring the signature of the Administrator or Corporate designee and the appointed qualified facility designee for all account transactions requiring a signature, where allowed by the financial institution. 6. Interest earned on the account shall be prorated to individual accounts within two working days of notification of interest earned from the financial institution. 7. The facility Administrator will complete, or require the facility designee to complete, a Resident Trust Reconciliation form on a monthly basis. The Administrator will compare and review the Resident Trust Reconciliation and Resident Trust Account banking Statement to insure the secure handling of resident funds. Prior to the survey date, the facility took the following actions to correct the noncompliance: 1. The resident trust cash box was reconciled and assured of accuracy on 5/30/24 by V4. 2. The resident trust account was balanced and the missing funds were deposited into the account on 6/5/24 by V4. 3. V3 was suspended on 5/24/24 and terminated on 6/10/24 by V1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146121 If continuation sheet Page 5 of 24 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 08/16/2024 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 0567 4. V3 was removed from as an authorized user of the resident trust account on 5/31/24 by V4. Level of Harm - Minimal harm or potential for actual harm 5. The results of the above audits will be discussed in the Quality Assurance meeting with any discrepancies/patterns/trends discussed by V5 (Administrator/Current BOM). The Committee will make recommendations as indicated. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146121 If continuation sheet Page 6 of 24 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 08/16/2024 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 0568 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Based on interview and record review, the facility failed to maintain accurate records for residents trust funds and personal checking accounts for 50 residents (R1-R50) reviewed for resident trust fund accounts in the sample of 52. This past noncompliance occurred from 12/21/23 to 6/10/24. Findings include: A letter dated 6/10/24 addressed to IDPH (Illinois Department of Public Health) stated in part, This letter will serve as a follow up and final report to the initial report submitted on 05/24/2024 regarding an allegation of misappropriation of resident property. The facility was unable to identify a specific resident involved at the time of the initial allegation. On 05/24/2024 at approximately 9:30 am, Housekeeper (V6) reported an allegation of misappropriation of resident property. The alleged perpetrator was Business Office Manager (BOM), V3. V6 voiced some vague concerns regarding V3 and the resident trust fund. (V3) was immediately suspended pending the results of the investigation. The Medical Director, Ombudsman, and local Police Department were made aware, and investigation initiated . (V6) was interviewed and revealed that (V7) Housekeeping Supervisor, had communicated this information during a conversation. (V6) voices (V7) made the comment to Keep an eye on your brother's (R3) money. (V6) brother, (R3) is a resident of the facility) . (V3) was interviewed and denies using resident monies an any way other than for the residents. In subsequent interviews (V3) was asked to explain her bookkeeping process, obtaining receipts and regarding recent checks written from the resident trust account. (V3) was unable to locate some receipts and unable to answer some specific questions related to checks written from the resident accounts and the resident trust account . (R2) was interviewed and voices she would have (V3) order items from a catalog for her. (R2) voices she requested some items to be ordered and never received them. The items (R2) requested for order have since been ordered .(V4), Regional Admissions/BOM reconciled the resident trust petty cash box. Based on that reconciliation, the facility is unable to account for $2728.59. The facility has replaced this amount for the resident trust petty cash box. (V10) Transportation (Staff), was interviewed and voices since February 2024, (V3) would have her take (R1) to her (R1's) bank to cash a check written to cash for (R1's) rent. (V10) voices (V3) would write a check out at the beginning of the month and about mid-month. (V10) voices she would take (R1) to the bank, cash the check, and then purchase (R1) a carton of cigarettes. (V10) voices they would return to the facility and (R1) would give (V3) the remaining cash. (V10) voices she doesn't know what (V3) did with the cash. (R1's) account was reviewed, and it was noted R1 owes $9857.00 for Room and Board. (R1's) checking account was reviewed and reveals $10,650 in checks written to cash. (R1) was re-imbursed the amount written out of her account. (R1's) room and board invoices was paid in full . The actual resident trust bank account was reconciled with bank statements by (V4). Based on that reconciliation, the facility was unable to account for $5515.19. The facility has replaced the above amounts that were unaccounted for. (R3's) resident trust account was reconciled by (V4) with no concerns noted. (V3) has been terminated from employment effective immediately. The investigation has been turned over to the Local Police Department. The facility will fully cooperate with any requests made by the Police Department. This letter was signed by V1, Former Administrator. A List of Resident Trust Accounts from 2/1/24 through 5/24/24 documented R1 through R50 as having a resident trust account during that time period. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146121 If continuation sheet Page 7 of 24 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 08/16/2024 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 0568 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 8/7/24 at 9:05am, V10 (Transportation) stated she was hired on 2/1/24. V10 stated from the beginning of her employment, twice a month she would take R1 to R1's bank with a check written for cash, R1 would get the cash and V10 would take R1 to a liquor store to buy a carton of cigarettes. When they returned to the facility, she or R1 would give V3 the remainder of the money, which V3 had stated was being put toward R1's room and board. V10 stated V3 never gave R1 a receipt. V10 stated the checks were never written for the same amount, and the checks written on the first of the month would be written for anywhere from $2000 to $2500, with the checks written toward the middle of the month between $300 to $700. V10 stated she found this situation confusing and felt something was off about it. V10 stated she went to V1 about it on the morning of 5/23/24 and told her to look into this money thing with R1. V10 stated, I made myself clear that I thought something was not right about it. (V1) was rustling papers around on her desk and not listening to me. She said I don't deal with that, that's the business office take it up with (V3). V10 stated she then approached V16 (Corporate Regional Director of Marketing) and talked to her about it. V10 stated the next day, she was interviewed by V11 (Regional Director of Clinical and Operations) who said an investigation had begun. On 8/7/24 at 9:55am, V3 stated she was hired as Business Office Manager on 4/22/21. V3 stated twice a month, R1 would tell V3 to write out a check on R1's checking account, and R1 would tell V3 how much to write the check for. V3 stated R1 spent all her money but didn't have anything to show for it and V3 doesn't know what she spent it on. V3 stated V10 nor R1 ever brought V3 any cash. V3 stated the last time she was aware, R1 owed the facility around $20,000 for room and board. V3 stated she tried to talk to R1 about R1's bill, but she ignored V3. V3 stated she could not remember any specific check amounts. V3 stated R1 did not have a POA (Power of Attorney) or guardian and was capable of handling her own financial affairs. V3 stated she does think she discussed R1's outstanding bill with somebody from the corporate office, but is not sure who or when. V3 stated in October of 2023, a cyberattack took out the program used for resident trust accounts, and she did not have any way to find out what resident balances were. V3 stated she would call the corporate office, but they would never get back to her. V3 stated within a few weeks after the corporation went into receivership in early February of 2024, all the trust information was forwarded to V3 but the accounts hadn't been balanced since October 2023. V3 stated she did not then balance them because she did not have time, as she was overwhelmed from all the administrative changes that were going on. V3 stated the receivership organization set up a new system for accounting, but she had not taken the training required to use it. On 8/8/24 at 10:15am, V4 (Corporate Business Office Manager) stated she first entered the facility on 5/31/24 to audit the accounts as part of the misappropriation investigation. V4 stated that audits of resident trust fund petty cash showed checks written and signed by V3 documented that at one point, the facility would have had about $3000 in petty cash, whereas a facility of its size should only keep a few hundred dollars worth of cash. V4 stated the resident trusts are commingled in one account with separate recordkeeping for each individual resident. V4 stated when a resident takes money out of petty cash, it is to be deducted form that resident's trust account amount. V4 stated V3 kept meticulous records which when audited, balanced correctly, up until November 2023, at which point V3 stopped balancing the accounts. V4 stated the previous corporation who managed the facility has refused to provide any resident trust documentation to the current receivership corporation, which took over on 2/8/24. V4 stated a total of fifty current and former residents had resident trust accounts for the period of 12/1/23 to 6/1/24, all of whom would be affected by misappropriation from the pooled account. V4 stated R1 should never have had large checks written for cash and then brought back to the facility, but instead written a check to the facility for the room and board with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146121 If continuation sheet Page 8 of 24 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 08/16/2024 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 0568 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many the remaining Medicaid $60 individual allowance put in R1's resident trust account. V4 stated her audits documented a total of $9857 outstanding balance on R1's room and board, $10650 of checks written out to cash from R1's account. V4 stated the pooled resident trust account, on which V3 had written checks for cash, was missing $5515.19, although the checks V3 had written totaled less than that amount, indicating V3 may have written checks earlier than 2/1/24, although there is no documentation. V4 stated the facility has reimbursed all the missing money. V4 stated an audit of R2's trust account balance showed no suspicious activity, but since R2 reported items had been paid for by her and not received, these items were ordered for R2 and paid for by the facility. V4 further stated Business Office Managers are not to keep resident checkbooks unless the resident specifically signs a written consent, which none of the residents including R1 have done. V4 stated R1 keeps her checkbook in her room. V4 stated during the investigation, V3 came to the facility and was asked to provide receipts for the petty cash and for the cash R1 brought in, but V3 was unable to do so. V4 stated there were no other staff members found to be involved as the checks were all written and signed by V3. V4 stated since the investigation has concluded, it is to be noted that R1 has not requested any checks to be written or to be given cash, and the only thing R1 has requested is cigarettes. Copies of checks written to cash were signed by R1 and were written on the following dates with amounts as follows: 12/21/23: $250 12/29/23: $200 1/3/24: $1800 1/22/24: $200 2/2/24: $1500 2/14/24: $300 3/1/24: $2000 3/13/24: $250 4/3/24: $1900 4/17/24: $250 5/3/24: $2000 Copies of checks to written to cash, written on the pooled resident trust account were written on the following dates and signed by V3 with amounts as follows: 2/1/24: $500 3/14/24: $500 4/19/24: $1000 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146121 If continuation sheet Page 9 of 24 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 08/16/2024 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 0568 5/16/24: $1000 Level of Harm - Minimal harm or potential for actual harm 5/21/24: $600 Residents Affected - Many The facility was unable to provide documentation as to what the cash was used for, such as receipts given to residents. R1's [NAME] Statement documented that between 2/29/24 through 6/1/24, nothing was applied to R1's room and board, and the outstanding balance as of 6/1/24 was $9857. An undated Resident Funds Policy and Procedure stated, (The facility) recognizes the resident's right to manage his/her own financial affairs and does not require the resident to deposit their personal funds with facility. However, upon written authorization of a competent resident the facility will hold, safeguard, manage and account for personal monies deposited with the facility. If the resident has been determined to be incompetent, the written authorization may be signed by the resident's fiduciary guardian, legal representative, or immediate family. In all cases the authorization must be witnessed by a disinterested party in an interest bearing, pooled Resident Monies Account. All accrued interest paid to the Resident Monies Account is prorated among those residents having personal funds in the account. In this manner, the resident will have access to his/her monies within the same day. At least quarterly, the facility will provide the resident or his/her representative a written, itemized statement of all transactions to his/her account which occurred in the last quarter. A review of the resident's account status is available to the resident upon request and in a reasonable amount of time. The facility will institute security measures to insure that resident funds managed by the facility are safeguarded from theft or mismanagement and shall include; signed vouchers for all resident transactions, computerized tracking of account activity, monthly oversight by the facility Administrator, and signed quarterly statements. Further, the facility will require dual signatures on all banking transactions requiring signatures as well as require receipts for all purchases made from residents' personal monies that shall include date of purchase, amount of purchase, and detail of all items or services purchased. If a resident is incapable of handling his/her own funds and does not have a fiduciary guardian, legal representative, or an immediate family member, the facility shall notify the Office of the State Guardian. Procedure: 1. The facility shall appoint a qualified designee who will be responsible for maintaining resident funds upon written authorization. The facility Administrator will have ultimate oversight over all aspects of the handling of the resident trust and resident funds. 2. The facility has adopted the Answers on Demand computerized Resident Trust Program to assure a full, complete and separate accounting for each resident. The Resident Trust Program shall be maintained according to generally accepted accounting principles. 3. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146121 If continuation sheet Page 10 of 24 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 08/16/2024 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 0568 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Resident funds will not be commingled with facility funds, or any other funds, except that all resident personal funds shall be maintained in a single interest bearing Resident Monies Account. 4. The Resident account maintained in the Resident Trust Program for each participating resident shall be updated in a timely manner. This personal account detail shall be available to the resident and/or his/her legal representative to review upon request within a reasonable time-frame. 5. Receipts for purchases from resident's personal monies shall be obtained for every purchase and maintained to verify: date of purchase, amount of purchase, and items purchased. The facility shall require that the Resident Trust Account be a dual signatory account requiring the signature of the Administrator or Corporate designee and the appointed qualified facility designee for all account transactions requiring a signature, where allowed by the financial institution. 6. Interest earned on the account shall be prorated to individual accounts within two working days of notification of interest earned from the financial institution. 7. The facility Administrator will complete, or require the facility designee to complete, a Resident Trust Reconciliation form on a monthly basis. The Administrator will compare and review the Resident Trust Reconciliation and Resident Trust Account banking Statement to insure the secure handling of resident funds. Prior to the survey date, the facility took the following actions to correct the noncompliance: 1. The resident trust cash box was reconciled and assured of accuracy on 5/30/24 by V4. 2. The resident trust account was balanced and the missing funds were deposited into the account on 6/5/24 by V4. 3. V3 was suspended on 5/24/24 and terminated on 6/10/24 by V1. 4. V3 was removed from as an authorized user of the resident trust account on 5/31/24 by V4. 5. The results of the above audits will be discussed in the Quality Assurance meeting with any discrepancies/patterns/trends discussed by V5 (Administrator/Current BOM). The Committee will make recommendations as indicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146121 If continuation sheet Page 11 of 24 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 08/16/2024 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 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent the misappropriation of resident trust funds and private checking accounts from V3, former Business Office Manager for 50 of 50 residents (R1-R50) reviewed for theft in a sample of 52. This failure resulted in checks written for cash on R1 through R50's pooled resident trust account, totaling $5515.19 and checks written from R1's individual checking account totaling $10,650. These actions would cause a reasonable person to have feelings of sadness, worry, stress and anguish while residing in a home where monetary theft occurred. Residents Affected - Many The Immediate Jeopardy began on 12/21/23 when V3 wrote a $250 check for cash on R1's personal checking account, with no documentation as to what happened to the money. V11, Regional Director of Clinical Operations, was notified of the Immediate Jeopardy on 8/13/24 at 3:28pm. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed, and the deficient practice corrected, on 6/10/24, prior to the start of the survey and was therefore past noncompliance. Findings include: A letter dated 6/10/24 addressed to IDPH (Illinois Department of Public Health) stated in part, This letter will serve as a follow up and final report to the initial report submitted on 05/24/2024 regarding an allegation of misappropriation of resident property. The facility was unable to identify a specific resident involved at the time of the initial allegation. On 05/24/2024 at approximately 9:30 am, Housekeeper (V6) reported an allegation of misappropriation of resident property. The alleged perpetrator was Business Office Manager (BOM), V3. V6 voiced some vague concerns regarding V3 and the resident trust fund. (V3) was immediately suspended pending the results of the investigation. The Medical Director, Ombudsman, and local Police Department were made aware, and investigation initiated . (V6) was interviewed and revealed that (V7) Housekeeping Supervisor, had communicated this information during a conversation. (V6) voices (V7) made the comment to 'Keep an eye on your brother's (R3) money'. (V6) brother, (R3) is a resident of the facility) . (V3) was interviewed and denies using resident monies an any way other than for the residents. In subsequent interviews (V3) was asked to explain her bookkeeping process, obtaining receipts and regarding recent checks written from the resident trust account. (V3) was unable to locate some receipts and unable to answer some specific questions related to checks written from the resident accounts and the resident trust account . (R2) was interviewed and voices she would have (V3) order items from a catalog for her. (R2) voices she requested some items to be ordered and never received them. The items (R2) requested for order have since been ordered .(V4), Regional Admissions/BOM reconciled the resident trust petty cash box. Based on that reconciliation, the facility is unable to account for $2728.59. The facility has replaced this amount for the resident trust petty cash box. (V10) Transportation (Staff), was interviewed and voices since February 2024, (V3) would have her take (R1) to her (R1's) bank to cash a check written to cash for (R1's) rent. (V10) voices (V3) would write a check out at the beginning of the month and about mid-month. (V10) voices she would take (R1) to the bank, cash the check, and then purchase (R1) a carton of cigarettes. (V10) voices they would return to the facility and (R1) would give (V3) the remaining cash. (V10) voices she doesn't know what (V3) did with the cash. (R1's) account was reviewed, and it was noted R1 owes $9857.00 for Room and Board. (R1's) checking account was reviewed and reveals $10,650 in checks written to cash. (R1) was re-imbursed the amount written out of her account. (R1's) room and board invoices was paid in full . The actual resident trust bank account was reconciled with bank statements by (V4). Based on that reconciliation, the facility was unable to account for $5515.19. The facility has replaced the above amounts that were unaccounted for .(V3) has (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146121 If continuation sheet Page 12 of 24 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 08/16/2024 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 0602 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many been terminated from employment effective immediately. The investigation has been turned over to the Local Police Department. The facility will fully cooperate with any requests made by the Police Department. This letter was signed by V1, Former Administrator. R1's Face Sheet documented an admission Date of 1/1/24 and listed diagnoses including Diabetes Type 2, Anxiety Disorder, Depression, and Chronic Obstructive Pulmonary Disease. R1 is listed as being her own responsible party. R1's Care Plan dated 6/5/24 documented problem areas, Resident has diagnosis and takes medication for anxiety, and Impaired cognition as related to confusion at times. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11, indicating R1 has moderate impairment in cognitive functioning. R2's Face Sheet documented an admission Date of 2/1/24 and listed diagnoses including Major Depressive Disorder, Unspecified Psychosis, Chronic Kidney Disease, and Hypertension. The Face Sheet also listed V23 from OSG (The Office of State Guardian) as R2's Power of Attorney (POA). R2's Care Plan dated 7/2/24 documented a problem area, Resident displays impaired cognition. R2's 6/25/24 Minimum Data Set (MDS) documented a BIMS score of 12, indicating R2 has moderate deficits in cognitive functioning. A List of Resident Trust Accounts from 2/1/24 through 5/24/24 documented R1 through R50 as having a resident trust account during that time period. On 8/2/24 at 1:10pm, R1 who was alert and oriented to person and place, but not time stated that, The lady who took care of the money took some from my account. R1 stated she was not sure how much money she got every month, and did not know how much her checking account had in it or how much it should have in it. R1 stated she had never previously had any suspicions about staff taking her money. R1 stated she would go out twice a month to buy a carton of cigarettes, and that R1 would make out a check for cash and take it to the bank, and bring all the change back to, The lady who took care of that stuff, and she was supposed to be putting it toward my bill here, but I guess she wasn't. R1 stated she is not sure how much she wrote the checks for cash out for or how much change she was bringing back. R1 stated she was not really upset by any of this as R1, Doesn't let stuff like that get to her. R1 stated she does not recall ever getting any notification from the facility that her bill was not being paid. R1 stated she keeps her checkbook in her room. On 8/7/24 at 1:45pm, R2 was alert and oriented to person and place but not time. R2 stated in the spring of this year, V3 was supposed to be taking money out of R2's trust account and loading it onto a prepaid credit card and ordering items for R2 from a catalog. R2 stated the items never came and when she asked V3 about it, she would put R2 off. R2 stated she did not know how much money was taken out of her account, how much money she has in it, or how much money she should have in it. R2 stated the facility went ahead and ordered and paid for the items, and she is satisfied with this outcome. R2 stated she got her items, and that was all she had wanted. On 8/2/24 at 11:10am, V11 (Regional Director of Clinical Operations), stated she had assisted V1 (Former Administrator), in the above referenced investigation. V11 stated when she went to pull V3's background check from her hire date of 4/22/21, there wasn't one on file. V11 stated she ran a background check on V3 on 5/31/24, and it came back with a disqualifying offense, but it did not show what the offense was. V11 stated all employee background checks were then audited with no other disqualifying offenses found. On 8/7/24 at 8:20am, V6 (Housekeeper) stated in April 2024, a couple weeks after the Easter egg (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146121 If continuation sheet Page 13 of 24 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 08/16/2024 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 0602 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many hunt for kids in the community, V7 (Housekeeping Supervisor) told V6 that eggs with cash in them had been left in V3's office, but when the kids opened them later, there was no cash in them. V7 stated she believed V3 had taken the cash. V7 told V6, I better keep an eye on (R3's) trust account. V6 stated she is R3's POA (Power of Attorney), and he is unable to read or write. V6 stated she did not inform V1 of this immediately because she didn't want to accuse V3 if it wasn't true. V6 stated later in May, date unknown, V6 wrote out a letter to V1 outlining her concerns and took it to V1. V6 stated she believed this happened on a Thursday, and V6 stated V3 was here the remainder of that day at least until 1:30pm when V6 gets off. V6 stated she returned to work the following Tuesday and heard V3 had been walked out and an investigation started. An undated letter provided to this surveyor by V1, that is addressed to V1 and signed by V6, stated, (V7) said (V3) is always so poor and always broke, (R3)'s money should be monitored closely. On 8/7/24 at 9:05am, V10 (Transportation) stated she was hired on 2/1/24. V10 stated from the beginning of her employment, twice a month she would take R1 to R1's bank with a check written for cash, R1 would get the cash and V10 would take R1 to a liquor store to buy a carton of cigarettes. When they returned to the facility, she or R1 would give V3 the remainder of the money, which V3 had stated was being put toward R1's room and board. V10 stated V3 never gave R1 a receipt. V10 stated the checks were never written for the same amount, and the checks written on the first of the month would be written for anywhere from $2000 to $2500, with the checks written toward the middle of the month between $300 to $700. V10 stated she found this situation confusing and felt something was off about it. V10 stated she went to V1 about it on the morning of 5/23/24 and told her to look into this money thing with R1. V10 stated, I made myself clear that I thought something was not right about it. (V1) was rustling papers around on her desk and not listening to me. She said I don't deal with that, that's the business office take it up with (V3). V10 stated she then approached V16 (Corporate Regional Director of Marketing) and talked to her about it. V10 stated the next day, she was interviewed by V11 who said an investigation had begun. V10 stated, I don't think (R1) really understands really what happened. On 8/7/24 at 9:55am, V3 stated she was hired as Business Office Manager on 4/22/21. V3 stated she assumed the facility had done a background check on her at that time. V3 stated years ago she had a forgery conviction for writing bad checks in her husband's name. V3 stated, I have never taken or stolen money from any resident, from their account, or cash, or their belongings, or petty cash. V3 stated on 5/24/24 she was informed by V1 that a facility employee had written a letter to V1 stating that V7 had told the employee to watch her brother R3's resident trust account carefully because V3 couldn't be trusted. V3 stated she does not know why V7 would say that. V3 said she was told to gather her belongings and was walked out. V3 stated V1 called V3 around 6/1/24 and stated they were terminating V3 due to her background check showing she was ineligible to work due to a criminal conviction. V3 denied she confessed to V1 that she had misappropriated funds. V3 stated twice a month, R1 would tell V3 to write out a check on R1's checking account, and R1 would tell V3 how much to write the check for. V3 stated R1 spent all her money but didn't have anything to show for it and V3 doesn't know what she spent it on. V3 stated V10 nor R1 ever brought V3 any cash. V3 stated the last time she was aware, R1 owed the facility around $20,000 for room and board. V3 stated she tried to talk to R1 about R1's bill, but she ignored V3. V3 stated she could not remember any specific check amounts. V3 stated R1 did not have a POA or guardian and was capable of handling her own financial affairs. V3 stated she does think she discussed R1's outstanding bill with somebody from the corporate office, but is not sure who or when. V3 stated in October of 2023, a cyberattack took out the program used for resident trust accounts, and she did not have any way to find out what resident balances were. V3 stated she would call (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146121 If continuation sheet Page 14 of 24 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 08/16/2024 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 0602 Level of Harm - Immediate jeopardy to resident health or safety the corporate office, but they would never get back to her. V3 stated within a few weeks after the corporation went into receivership in early February of 2024, all the trust information was forwarded to V3 but the accounts hadn't been balanced since October 2023. V3 stated she did not then balance them because she did not have time, as she was overwhelmed from all the administrative changes that were going on. V3 stated the receivership organization set up a new system for accounting, but she had not taken the training required to use it. Residents Affected - Many On 8/8/24 at 9:00am, V2 (Director of Nurses) stated there have been no changes in R1's level of functioning since the misappropriation was discovered. V2 stated R1 has not had an increase in behaviors, remains confused a lot of the time, has not required any medication changes, and R1's level of cognition has remained at baseline. V2 stated the most recent training about abuse she has had was on 5/24/24. V2 stated abuse is to be reported immediately to the Administrator. V2 stated she was unaware of any problems with resident accounts until 5/24/24. On 8/8/24 at 10:15am, V4 (Corporate Business Office Manager) stated she first entered the facility on 5/31/24 to audit the accounts as part of the misappropriation investigation. V4 stated that audits of resident trust fund petty cash showed checks written and signed by V3 documented that at one point, the facility would have had about $3000 in petty cash, whereas a facility of its size should only keep a few hundred dollars worth of cash. V4 stated the resident trusts are comingled in one account with separate recordkeeping for each individual resident. V4 stated when a resident takes money out of petty cash, it is to be deducted form that resident's trust account amount. V4 stated V3 kept meticulous records which when audited, balanced correctly, up until November 2023, at which point V3 stopped balancing the accounts. V4 stated the previous corporation who managed the facility has refused to provide any resident trust documentation to the current receivership corporation, which took over on 2/8/24. V4 stated a total of fifty current and former residents had resident trust accounts for the period of 12/1/23 to 6/1/24, all of whom would be affected by misappropriation from the pooled account. V4 stated R1 should never have had large checks written for cash and then brought back to the facility, but instead written a check to the facility for the room and board with the remaining Medicaid $60 individual allowance put in R1's resident trust account. V4 stated her audits documented a total of $9,857 outstanding balance on R1's room and board, $10,650 of checks written out to cash from R1's account. V4 stated the pooled resident trust account, on which V3 had written checks for cash, was missing $5,515.19, although the checks V3 had written totaled less than that amount, indicating V3 may have written checks earlier than 2/1/24, although there is no documentation. V4 stated the facility has reimbursed all the missing money. V4 stated an audit of R2's trust account balance showed no suspicious activity, but since R2 reported items had been paid for by her and not received, these items were ordered for R2 and paid for by the facility. V4 further stated Business Office Managers are not to keep resident checkbooks unless the resident specifically signs a written consent, which none of the residents, including R1, have done. V4 stated R1 keeps her checkbook in her room. V4 stated during the investigation, V3 came to the facility and was asked to provide receipts for the petty cash and for the cash R1 brought in, but V3 was unable to do so. V4 stated there were no other staff members found to be involved as the checks were all written and signed by V3. V4 stated since the investigation has concluded, it is to be noted that R1 has not requested any checks to be written or to be given cash, and the only thing R1 has requested is cigarettes. On 8/8/24 at 1:45pm, V1 stated she considered V6 (Housekeeper) to be a disgruntled employee, and when V6 approached her with the letter on 5/23/24, she considered it to be about, Staff drama. V1 did state the letter said that according to V7, V6 should keep a close eye on R3's money. V1 stated she discussed the letter with V16 (Corporate Marketing Director), Who must have notified (V11- Regional (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146121 If continuation sheet Page 15 of 24 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 08/16/2024 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 0602 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Director of Clinical Operations). V1 stated she then gave the letter to V11 and the investigation was started. V1 stated as far as she knew, V3 was doing her job, and V1 did not suspect V3 of misappropriating resident funds. V1 stated at some point, not sure when, V10 approached V1 with a check written on R1's checking account, and V1 stated she did not realize V10 was reporting potential misappropriation. V1 stated she was hired in 2023 and V3 was already employed at the facility. V1 stated she was not aware the previous Administrator had not completed a background check. V1 stated in retrospect, she did recall on one occasion R1 had not felt well and had not wanted to go to the bank that day, and V3 became upset and said no, she has to go to the bank today. V1 stated she spoke with V3 privately during the investigation, and that V3 confessed to V1 that she had misappropriated the money as outlined above. V1 stated for Easter 2024, the previous corporation gave the facility $500 for a community easter egg hunt, and there was a rumor going around that V3 stole $5 bills out of three or four eggs for the kids. V1 stated at that time she asked V3 about it, which V3 denied. On 8/8/24 at 2:50pm, V17 (Police Officer/Patrolman) stated he was called by the facility on 5/24/24 sometime in the morning by V1 to report that V3 was suspected of misappropriating resident funds. V17 stated he interviewed multiple staff members. V17 stated he did not interview R1 as she was asleep. V17 stated all staff were very forthcoming during interview. V17 stated V3 had not yet been interviewed as V3 is avoiding law enforcement. V17 stated the investigation at this time is still ongoing, and as such a Police Report cannot be released. V17 stated after V3 is interviewed, the investigation will be sent to the States Attorney where charges may be filed at the States Attorney's discretion. On 8/13/24 at 8:50am, V16 (Regional Director of Marketing and Development) stated V1 showed her a letter on 5/23/24 written by V6 stating V6 was told by V7 not to trust V3 with R3's trust account. V16 stated she advised V1 to immediately notify V11 and to start an investigation. V16 stated the following day, V16 asked V11 if V1 had contacted her about the letter, which she hadn't. V16 stated she informed V11 about the contents of the letter, and V11 started an immediate investigation. V16 stated she was present during an interview with V3 during the investigation in which V3 was unable to produce receipts for the missing money as outlined above. V16 stated when the investigation was initiated, V16 retrained all facility staff about reporting abuse and misappropriation and provided staff with a copy of the current Abuse Policy. V16 stated staff are to report any knowledge or suspicion of abuse, neglect, or financial misappropriation to the Administrator immediately. On 8/14/24 at 9:10am, V6 stated if R3 was cognitively intact and found out that staff may have stolen his money, His heart would be hurt, like mine was when I found out (V3) took other resident's money. He wouldn't be mad, he would be hurt. On 8/16/24 at 9:15am, R47 was alert and oriented to person, place, and time. R47 stated he has a resident trust account. R47 stated he was not aware of anybody misappropriating his resident trust money. R47 stated if this happened he would, Be agitated, he would not have access to cigarettes and he is addicted to nicotine. A Grievance Complaint Report dated 5/31/24 documented,(R2) reported clothing and DVDs (Digital Video Disc) she ordered have not been delivered. Resident reported these items should have been delivered 5/4/24-5/7/24. Resident reported she had assistance from (V3) when ordering these items. Method of correction: Replaced all her DVD's and clothes that she had ordered and purchased items for resident. Copies of checks written to cash provided with R1's bank statements were reviewed. The checks were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146121 If continuation sheet Page 16 of 24 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 08/16/2024 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 0602 signed by R1 and were written on the following dates with amounts as follows: Level of Harm - Immediate jeopardy to resident health or safety 12/21/23: $250 Residents Affected - Many 1/3/24: $1,800 12/29/23: $200 1/22/24: $200 2/2/24: $1,500 2/14/24: $300 3/1/24: $2,000 3/13/24: $250 4/3/24: $1,900 4/17/24: $250 5/3/24: $2,000 Copies of checks to written to cash, written on the pooled resident trust account were written on the following dates and signed by V3 with amounts as follows: 2/1/24: $500 3/14/24: $500 4/19/24: $1000 5/16/24: $1000 5/21/24: $600 The facility was unable to provide documentation as to what the cash was used for, such as receipts given to residents. R1's [NAME] Statement documented that between 2/29/24 through 6/1/24, nothing was applied to R1's room and board, and the outstanding balance as of 6/1/24 was $9,857. A Checking Account Activity Report dated 8/15/24 documented that $10,650 was deposited into R1's account on 6/6/24. A Resident Trust Checking Account Statement dated 6/27/24 documented that on 6/7/24, $5,515.19 was deposited into that account. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146121 If continuation sheet Page 17 of 24 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 08/16/2024 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 0602 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many An IDPH Healthcare Worker Registry Background Check dated 5/31/24 documented, (V3): Work Eligibility: Ineligible: Disqualifying Criminal Offenses. Date: 10/22/07. No waivers on record. The facility policy titled Abuse Prevention Program dated 11/28/16 documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below . This facility is committed to protecting our residents from abuse by anyone including; but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals . Under the section titled Definitions it documents Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. The Immediate Jeopardy that began on 12/21/23 was removed prior to the survey date on 6/10/24 when the facility took the following actions to remove the immediacy and correct the deficient practice as confirmed through observation, interview, and record review: 1. The resident trust cash box was reconciled and assured of accuracy on 5/30/24 by V4. 2. The resident trust account was balanced and the missing funds were deposited into the account on 6/5/24 by V4. 2. V3 was suspended on 5/24/24 and terminated on 6/10/24 by V1. 3. V3 was removed as an authorized user of the resident trust account on 5/31/24 by V4. 4. The former Administrator was inserviced on employee background checks on 5/31/24 by V11. 5. Facility staff were inserviced on the Abuse policy with a focus on misappropriation of resident property on 5/31/24 by V16. 6. 100% of employee background checks were audited on 5/31/24 by V1. 7. V11 will review abuse reports weekly for four weeks to ensure thorough investigations are being completed. 8. V5, Current Administrator/BOM, will review all employee new hires for complete background checks as indicated. 9. The results of the above audits will be discussed in the Quality Assurance meeting with any discrepancies/patterns/trends discussed by V5. The Committee will make recommendations as indicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146121 If continuation sheet Page 18 of 24 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 08/16/2024 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 0606 Not hire anyone with a finding of abuse, neglect, exploitation, or theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to perform a pre-employment background checks on the business office manager. This has the potential to affect all 46 residents living at the facility. Residents Affected - Many This past noncompliance occurred from 4/22/21 to 6/10/24. Findings include: An IDPH (Illinois Department of Public Health) Notification Form dated 5/24/24 at 9:40am documented, Staff reported an allegation of misappropriation of resident property. Staff member immediately suspending pending the results of investigation. POA (Power of Attorney), MD (Medical Doctor), and Police notified. Final (Report) to follow. A letter dated 6/10/24 addressed to IDPH stated, This letter will serve as a follow up and final report to the initial report submitted on 05/24/2024 regarding an allegation of misappropriation of resident property. The facility was unable to identify a specific resident involved at the time of the initial allegation. On 05/24/2024 at approximately 9:30 am, Housekeeper (V6) reported an allegation of misappropriation of resident property. The alleged perpetrator was Business Office Manager (BOM), (V3). A List of Resident Trust Accounts from 2/1/24 through 5/24/24 documented R1 through R50 having had resident trust accounts within that period of time. On 8/2/24 at 11:10am V11, Regional Director of Clinical Operations, stated she had assisted V1, Former Administrator, in the above referenced investigation. V11 stated when she went to pull V3's background check from her hire date of 4/22/21, there wasn't one on file. V11 stated she ran a background check on V3 on 5/31/24, and it came back with a 'disqualifying offense', but it did not show what the offense was. V11 stated all employee background checks were then audited with no other disqualifying offenses found. V11 stated V3 was suspended and walked out on 5/24/24 pending the results of the misappropriation investigation, and was subsequently terminated after it was determined she had misappropriated resident's funds. An IDPH Healthcare Worker Registry Background Check dated 5/31/24 documented, (V3): Work Eligibility: Ineligible. Disqualifying Criminal Offenses: Date: 10/22/07. No waivers on record. On 8/7/24 at 9:55am, V3 stated she was hired as Business Office Manager on 4/22/21. V3 stated she assumed the facility had done a background check on her at that time. V3 stated, Years ago, she had a forgery conviction for, writing bad checks in her husband's name. On 8/8/24 at 10:15am, V4, Corporate Business Office Manager, stated she first entered the facility on 5/31/24 to audit the accounts as part of the misappropriation investigation. V4 stated that audits of resident trust fund petty cash showed checks written and signed by V3 documented that at one point, the facility would have had about $3000 in petty cash, whereas a facility of its size should only keep a few hundred dollars' worth of cash. V4 stated the resident trusts are commingled in one account with separate record keeping for each individual resident. V4 stated when a resident takes money out of petty cash, it is to be deducted from that resident's trust account amount. V4 stated V3 kept meticulous records which when audited, balanced correctly, up until November 2023, at which point V3 stopped balancing the accounts. V4 stated a total of fifty current and former residents had resident trust accounts for the period of 11/1/23 to 6/1/24, all of whom would be affected by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146121 If continuation sheet Page 19 of 24 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 08/16/2024 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 0606 misappropriation from the pooled account. Level of Harm - Minimal harm or potential for actual harm On 8/8/24 at 1:45pm, V1 stated she was hired in 2023 and V3 was already employed at the facility. V1 stated she was not aware the previous Administrator had not completed a background check on V3. Residents Affected - Many The facility's Abuse Prevention Program Policy dated 11/28/16 stated, The facility will not knowingly employ any staff convicted of any crimes listed in the Healthcare Worker Background Check Act (unless waivered under the provision of the act), or with findings of abuse listed on the Illinois Healthcare Worker Registry. A Facility Matrix dated 8/1/24 documented a total of 46 residents living at the facility. Prior to the survey date, the facility took the following actions to correct the noncompliance: 1. V3 was suspended on 5/24/24 and terminated on 6/10/24 by V1. 2. The former Administrator was inserviced on employee background checks on 5/31/24 by V11. 3. Facility staff were inserviced on the Abuse policy with a focus on misappropriation of resident property on 5/31/24 by V16. 4. 100% of employee background checks were audited on 5/31/24 by V1. 5. V5, Current Administrator/BOM, will review all employee new hires for complete background checks as indicated. 6. The results of the above audits will be discussed in the Quality Assurance meeting with any discrepancies/patterns/trends discussed by V5. The Committee will make recommendations as indicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146121 If continuation sheet Page 20 of 24 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 08/16/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, facility staff failed to immediately report to the Administrator an allegation of potential staff to resident misappropriation of funds. This has the potential to affect all 46 residents living at the facility. This past noncompliance occurred from 4/1/24 to 6/10/24. Findings include: On 8/7/24 at 8:20am, V6 (Housekeeper) stated in April 2024, a couple weeks after the Easter egg hunt for kids in the community, V7 (Housekeeping Supervisor) told V6 that eggs with cash in them had been left in V3's (Former Business Office Manager) office, but when the kids opened them later, there was no cash in them. V7 stated she believed V3 had taken the cash. V7 told V6, I better keep an eye on (R3's) trust account. V6 stated she is R3's POA (Power of Attorney), and he is unable to read or write. V6 stated she did not inform V1 (Former Administrator) of this immediately because she didn't want to accuse V3 if it wasn't true. V6 stated later in May date unknown, V6 wrote out a letter to V1 outlining her concerns and took it to V1. V6 stated she believed this happened on a Thursday, and V6 stated V3 was here the remainder of that day at least until 1:30pm when V6 gets off. V6 stated she returned to work the following Tuesday and heard V3 had been walked out and an investigation started. An undated letter to V1, signed by V6, stated, (V7) said (V3) is always so poor and always broke, (R3)'s money should be monitored closely. On 8/7/24 at 9:05am, V10 (Transportation) stated she was hired on 2/1/24. V10 stated from the beginning of her employment, twice a month she would take R1 to R1's bank with a check written for cash, R1 would get the cash and V10 would take R1 to a liquor store to buy a carton of cigarettes. When they returned to the facility, she or R1 would give V3 the remainder of the money, which V3 had stated was being put toward R1's room and board. V10 stated V3 never gave R1 a receipt. V10 stated the checks were never written for the same amount, and the checks written on the first of the month would be written for anywhere from $2000 to $2500, with the checks written toward the middle of the month between $300 to $700. V10 stated she found this situation confusing and felt something was off about it. V10 stated she went to V1 about it on the morning of 5/23/24 and told her to look into this money thing with R1. V10 stated, I made myself clear that I thought something was not right about it. (V1) was rustling papers around on her desk and not listening to me. She said I don't deal with that, that's the business office take it up with (V3). V10 stated she then approached V16 (Corporate Regional Director of Marketing) and talked to her about it. V10 stated the next day, she was interviewed by V11 (Regional Director of Clinical Operations) who said an investigation had begun. V10 stated, I don't think (R1) really understands really what happened. On 8/8/24 at 1:45pm, V1 stated she considered V6 to be a disgruntled employee, and when V6 approached her with the letter on 5/23/24, she considered it to be about, Staff drama. V1 did state the letter said that according to V7, V6 should keep a close eye on R3's money. V1 stated she discussed the letter with V16 (Corporate Marketing Director), Who must have notified (V11). V1 stated she then gave the letter to V11 and the investigation was started. V1 stated as far as she knew, V3 was doing her job, and V1 did not suspect V3 of misappropriating resident funds. V1 stated at some point not sure when V10 approached V1 with a check written on R1's checking account, and V1 stated she did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146121 If continuation sheet Page 21 of 24 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 08/16/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many realize V10 was reporting potential misappropriation. V1 stated for Easter 2024, the previous corporation gave the facility $500 for a community easter egg hunt, and there was a rumor going around that V3 stole $5 bills out of three or four eggs for the kids. V1 stated at that time she asked V3 about it, which V3 denied. On 8/13/24 at 8:50am, V16 stated V1 showed her a letter on 5/23/24 written by V6 stating V6 was told by V7 not to trust V3 with R3's trust account. V16 stated she advised V1 to immediately notify V11 and to start an investigation. V16 stated the following day, V16 asked V11 if V1 had contacted her about the letter, which she hadn't. V16 stated she informed V11 about the contents of the letter, and V11 started an immediate investigation. V16 stated she was present during an interview with V3 during the investigation in which V3 was unable to produce receipts for the missing money as outlined above. V16 stated when the investigation was initiated, V16 retrained all facility staff about reporting abuse and misappropriation and provided staff with a copy of the current Abuse Policy. V16 stated staff are to report any knowledge or suspicion of abuse, neglect, or financial misappropriation to the Administrator immediately. A Facility Matrix dated 8/1/24 documented a total of 46 residents living at the facility. A List of Resident Trust Accounts from 2/1/24 through 5/24/24 documented R1 through R50 as having a resident trust account during that time period. An Abuse Prevention Policy dated 11/28/16 documented in part, Employees are required to immediately report any occurrences of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property they observe, hear about, or suspect to a supervisor and the Administrator. Upon learning of the report, the Administrator or designee shall initiate an investigation. Prior to the survey date, the facility took the following actions to correct the noncompliance: 1. V3 was suspended on 5/24/24 and terminated on 6/10/24 by V1. 2. V3 was removed from as an authorized user of the resident trust account on 5/31/24 by V4. 3. Facility staff were inserviced on the Abuse policy with a focus on misappropriation of resident property on 5/31/24 by V16. 4. V11 will review abuse reports weekly for four weeks to ensure thorough investigations are being completed. 5. The results of the above audits will be discussed in the Quality Assurance meeting with any discrepancies/patterns/trends discussed by V5 (Administrator/Current Business Office Manger). The Committee will make recommendations as indicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146121 If continuation sheet Page 22 of 24 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 08/16/2024 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 begin an immediate investigation into an allegation of staff to resident misappropriation. This has the potential to affect all 46 residents living at the facility. Residents Affected - Many This past noncompliance occurred from 5/23/24 to 6/10/24. Findings include: On 8/7/24 at 8:20am, V6 (Housekeeper) stated in April 2024, a couple weeks after the Easter egg hunt for kids in the community, V7 (Housekeeping Supervisor) told V6 that eggs with cash in them had been left in V3's (Former Business Office Manager) office, but when the kids opened them later, there was no cash in them. V7 stated she believed V3 had taken the cash. V7 told V6, I better keep an eye on (R3's) trust account. V6 stated she is R3's POA (Power of Attorney), and he is unable to read or write. V6 stated she did not inform V1 (Former Administrator) of this immediately because she didn't want to accuse V3 if it wasn't true. V6 stated later in May date unknown, V6 wrote out a letter to V1 outlining her concerns and took it to V1. V6 stated she believed this happened on a Thursday, and V6 stated V3 was here the remainder of that day at least until 1:30pm when V6 gets off. V6 stated she returned to work the following Tuesday and heard V3 had been walked out and an investigation started. On 8/7/24 at 9:05am, V10 (Transportation) stated she was hired on 2/1/24. V10 stated from the beginning of her employment, twice a month she would take R1 to R1's bank with a check written for cash, R1 would get the cash and V10 would take R1 to a liquor store to buy a carton of cigarettes. When they returned to the facility, she or R1 would give V3 the remainder of the money, which V3 had stated was being put toward R1's room and board. V10 stated V3 never gave R1 a receipt. V10 stated the checks were never written for the same amount, and the checks written on the first of the month would be written for anywhere from $2000 to $2500, with the checks written toward the middle of the month between $300 to $700. V10 stated she found this situation confusing and felt something was off about it. V10 stated she went to V1 about it on the morning of 5/23/24 and told her to look into this money thing with R1. V10 stated, I made myself clear that I thought something was not right about it. (V1) was rustling papers around on her desk and not listening to me. She said I don't deal with that, that's the business office take it up with (V3). V10 stated she then approached V16 (Corporate Regional Director of Marketing) and talked to her about it. V10 stated the next day, she was interviewed by V11 who said an investigation had begun. V10 stated, I don't think (R1) really understands really what happened. An undated letter to V1, signed by V6, stated, (V7) said (V3) is always so poor and always broke, (R3)'s money should be monitored closely. On 8/8/24 at 1:45pm, V1 stated she considered V6 to be a disgruntled employee, and when V6 approached her with the letter on 5/23/24, she considered it to be about, Staff drama. V1 did state the letter said that according to V7, V6 should keep a close eye on R3's money. V1 stated she discussed the letter with V16 (Corporate Marketing Director), Who must have notified (V11) (Regional Director of Clinical Operations). V1 stated she then gave the letter to V11 and the investigation was started. V1 stated as far as she knew, V3 was doing her job, and V1 did not suspect V3 of misappropriating resident funds. V1 stated at some point not sure when V10 approached V1 with a check written on R1's checking account, and V1 stated she did not realize V10 was reporting potential misappropriation. V1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146121 If continuation sheet Page 23 of 24 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 08/16/2024 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 Residents Affected - Many stated for Easter 2024, the previous corporation gave the facility $500 for a community easter egg hunt, and there was a rumor going around that V3 stole $5 bills out of three or four eggs for the kids. V1 stated at that time she asked V3 about it, which V3 denied. On 8/13/24 at 8:50am, V16 stated V1 showed her a letter on 5/23/24 written by V6 stating V6 was told by V7 not to trust V3 with R3's trust account. V16 stated she advised V1 to immediately notify V11 and to start an investigation. V16 stated the following day, V16 asked V11 if V1 had contacted her about the letter, which she hadn't V16 stated she informed V11 about the contents of the letter, and V11 started an immediate investigation. V16 stated she was present during an interview with V3 during the investigation in which V3 was unable to produce receipts for the missing money as outlined above. V16 stated when the investigation was initiated, V16 retrained all facility staff about reporting abuse and misappropriation and provided staff with a copy of the current Abuse Policy. V16 stated staff are to report any knowledge or suspicion of abuse, neglect, or financial misappropriation to the Administrator immediately. An IDPH (Illinois Department of Public Health) Notification Form dated 5/24/24 at 9:40am documented, Staff reported an allegation of misappropriation of resident property. Staff member immediately suspending pending the results of investigation. POA (Power of Attorney), MD (Medical Doctor), and Police notified. Final (Report) to follow. A List of Resident Trust Accounts from 2/1/24 through 5/24/24 documented R1 through R50 as having a resident trust account during that time period. A Facility Matrix dated 8/1/24 documented a total of 46 residents living at the facility. An Abuse Prevention Policy dated 11/28/16 documented in part, Employees are required to immediately report any occurrences of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property they observe, hear about, or suspect to a supervisor and the Administrator. Upon learning of the report, the Administrator or designee shall initiate an investigation. Prior to the survey date, the facility took the following actions to correct the noncompliance: 1. V3 was suspended on 5/24/24 and terminated on 6/10/24 by V1. 2. V3 was removed from as an authorized user of the resident trust account on 5/31/24 by V4. 3. Facility staff were inserviced on the Abuse policy with a focus on misappropriation of resident property on 5/31/24 by V16. 4. V11 will review abuse reports weekly for four weeks to ensure thorough investigations are being completed. 5. The results of the above audits will be discussed in the Quality Assurance meeting with any discrepancies/patterns/trends discussed by V5 (Administrator/Current Business Office Manager). The Committee will make recommendations as indicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146121 If continuation sheet Page 24 of 24