Health inspection·March 8, 2024

F 0657 Level of Harm - Minimal harm or potential for actual harm 3.) Current Physician's Order Summary Report indicates R53 was admitted to the facility on [DATE] with diagnoses that include Unspecified Dementia with Behavioral Disturbance. Order Summary includes an order for Seroquel (antipsychotic) 25mg twice daily for Anxiety related to Dementia (date initiated 2/22/24). Residents Affected - Few Current Care Plan indicates R53 is on Anti-psychotic therapy. Care plan does not identify target behaviors for use of an antipsychotic medication. On 3/8/24 at 11:20am V1 (Administrator) stated A fall should automatically get pulled over into the care plan from the incident report. On 3/8/24 at 2:30pm V1 and V2 (Director of Nursing) stated it's been difficult to keep up with the care plans, so the plan is to have the MDS (Minimum Data Set)/Care Plan Coordinator take over the care plans. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146138 If continuation sheet Page 2 of 5 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 146138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mercer Manor Rehabilitation 309 N W 9th Avenue Aledo, IL 61231 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide an appropriate indication for use of an antipsychotic medication for two residents (R13, R53) with a diagnosis of Dementia of five residents reviewed for unnecessary medications in the sample of 25. Findings include: Facility Policy/Psychotropic Medication Management dated 12/4/19 documents: An assessment must be conducted to identify specific behaviors/symptoms, potential causative factors, and recommendations for managing identified behaviors. The physician should evaluate the use of antipsychotic medication use if one or more of the following are the only indication: Wandering, poor self-care, restlessness, impaired memory, anxiety, depression (without psychotic features), insomnia, unsociability, indifference to surroundings, fidgeting, nervousness, uncooperativeness, or agitated behaviors which do not represent danger to the resident or others. The resident or (resident representative)/responsible party will be advised on the non-pharmacological interventions attempted and the response. The need for psychotropic medication, indication for use and any potential side effects will be presented to assist them in making an informed decision. 1. On 3/5/24 at 10:15am R13 was sitting in her room with the lights off and did not want the light turned on. R13 appeared confused and was unable to answer simple questions appropriately. On 3/8/25 at 10:20am V9 (Certified Nurse Assistant/CNA) stated that R13 Sometimes talks to people who aren't there and/or sometimes wants to cover her baby up, but there is no baby. V9 stated that R13 did not appear to be distressed when talking to people who aren't there or when she wanted to cover up her baby. V9 stated R13 can be resistive to care at times Last night she slapped away the night CNA's hands. Psychiatric Evaluation and Consultation (obtained via tele-medicine) Note dated 2/6/24 indicates R13 is [AGE] years old is alert, cooperative and of broad affect. R13's mood is okay but looks confused. Note recommends obtaining a urinalysis to rule out a UTI (Urinary Tract Infection). Behavior Monitoring dated 2/1/24 to 3/5/24 indicates R13 is monitored for agitation/restlessness, delusions, exit-seeking, and refusal of care. Monitoring indicates there were five occurrences of refusal of care - all other behaviors did not occur. Current Physician Order Summary Report indicates R13 has orders for Risperidone (antipsychotic) 0.25mg (milligrams) twice daily for Delusional Disorder (date initiated 10/26/23). Psychotropic Medication Consent indicates consent was signed by R13's representative on 8/2/23 for R13 to receive Risperdal 0.25mg for Depressive Disorder. Consent does not include how often Risperdal should be given or specific behaviors exhibited by R13 requiring the use of an antipsychotic medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146138 If continuation sheet Page 3 of 5 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 146138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mercer Manor Rehabilitation 309 N W 9th Avenue Aledo, IL 61231 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm R13's Care Plan dated 3/5/24 indicates R13 is currently on Anti-psychotic therapy for Delusional Disorder. Care Plan does not include specific target behaviors. On 3/8/24 at 11:45am V2 (Director of Nursing/DON) stated that R13 has less behaviors than in the past, but still can be resistive to care. Residents Affected - Few 2. On 3/5/24 at various times of the day, R53 was seen in his room and complained of not feeling well. Later during the day R53 asked for some cookies. R53 did present guarded, confused with disorganized thinking. On 3/8/24 at 10:20am V9 (CNA) stated that R53 used to be always trying to go through the exit doors and verbally aggressive toward staff. On 3/8/24 at 11:45am V2 (DON) stated that R53 used to be delusional about being in the war but was never in a war. V2 stated R53 has been aggressive toward staff but not toward residents. Psychiatric Evaluation and Consultation (obtained via tele-medicine) Note dated 2/20/24 indicates R53 is [AGE] years old who was alert and cooperative. Note indicates per nurse R13 yells and tries to throw stuff at the staff before now. Note recommends to Increase Seroquel to 25mg twice daily. Note indicates R53 denies Suicidal Ideation, Homicidal Ideation and Audio-Visual Hallucinations. Behavior Monitoring dated 21/24 to 3/5/24 indicates R53 exhibited yelling, screaming, wandering (8 occurrences), and was also monitored for agitation/restlessness (10 occurrences), delusions (7 occurrences), exit-seeking (12 occurrences), hallucinations (2 occurrences) and physical/verbal aggression (10 occurrences). Monitoring does not include nature/content of delusions or hallucinations. Current Physician's Order Summary Report indicates R53 was admitted to the facility on [DATE] with diagnoses that include Unspecified Dementia with Behavioral Disturbance. Order Summary includes an order for Seroquel (antipsychotic) 25mg twice daily for Anxiety related to Dementia (date initiated 2/22/24). Psychotropic Medication Consent indicates R53's representative signed a consent for R53 to receive Seroquel 25mg by mouth twice daily for Agitation. Consent does not indicate specific behaviors R53 was exhibiting requiring the use on an antipsychotic medication. Current Care Plan indicates R53 is on Anti-psychotic therapy. Care plan does not identify target behaviors for use of an antipsychotic medication. On 3/8/24 at 2:30pm V1 (Administrator) and V2 (Director of Nursing) stated they have been auditing the psychotropics during care plan meetings, but were unaware of the consent discrepancies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146138 If continuation sheet Page 4 of 5 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 146138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mercer Manor Rehabilitation 309 N W 9th Avenue Aledo, IL 61231 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow its policy for the Antibiotic Stewardship Program. This failure has the potential to affect all 57 residents who currently reside in the facility. Residents Affected - Many Findings Include: Facility Room Resident Room Roster dated 3/5/24 documents 57 residents in the facility. The Facility's Infection Control with Antibiotic Stewardship Policy dated 11/01/2015 documents this policy establishes directives for antibiotic stewardship at this facility in order to develop antibiotic use protocols and a system to monitor antibiotic use. The Facility's Infection Control with Antibiotic Stewardship Policy dated 11/01/2015 documents The Antibiotic Stewardship Committee will: support and promote antibiotic use protocols which include Assessment of residents for infection using standardized tools and criteria. The criteria used by this facility are Mc [NAME] Criteria-see policy. The McGeer Criteria for Long Term Care is defined by the CDC (Center for Disease Control) website as an assessment of infections that considers fever, leukocytosis (high white blood cell count), acute change in mental status or acute functional decline. The Facility's Infection Control Monitoring Logs for December 2023, January and February 2024 did not include any documentation of the use of the standardized tool (McGreer Criteria) for any of the infections listed. On 03/06/2024 V2 (Director of Nursing/Infection Preventionist) confirmed there was no documentation of any standardized assessment for any of the facility's known infections. V2 stated I keep telling the nurses they need to fill out the McGreer Data Tool for all of the infections because it gives a bigger picture, I guess I will be telling them again. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146138 If continuation sheet Page 5 of 5