Health inspection·March 2, 2023

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Facility failures resulted in two deficient practices. Residents Affected - Few A. Based on interview, observation, and record review, the facility failed to ensure fall prevention interventions were in place and new fall prevention interventions were implemented following a fall for one of one resident (R31) reviewed for falls in the sample of 26. As a result, on 09/13/22, R31 was witnessed ambulating barefoot, and subsequently slipping and falling. R31 was transported to a local hospital for evaluation where she was diagnosed with sustaining a left clavicle fracture and a fracture of the left distal radius during the fall. B. Based on interview, observation and record review, the facility failed to prevent a resident identified as an elopement risk from eloping the building unsupervised. The facility also failed to conduct an investigation and notify the state agency as directed by their policy after an elopement occurred for one of two residents (R31) reviewed for elopement in the sample of 26. Findings include: A. R31's current Fall Risk Assessment (dated 02/16/23) documents a score of 70, indicating R31 is at high risk for falling. R31's current Fall Prevention Care Plan documents the following: I have a history of falls related to poor safety awareness, impaired gait. This same care plan documents the following interventions: Ensure that I am in the eyesight while awake (date initiated 05/04/22); Ensure that I am wearing shoes or non-skid socks when ambulating and at HS (bedtime) (date initiated 10/11/19); Please keep the door to my room open so that staff can check on me (date initiated 05/06/22); Staff to ensure area at bedside free of clutter (date initiated 04/29/20). On 02/27/23 at 12:10 PM, R31 was utilizing her walker near the front entry to the building. R31 was confused and approached this surveyor asking about the bathroom near the front entrance. An (elopement deterrent bracelet) was in place on R31's left ankle, and the facility's (elopement deterrent) alarm system was sounding while R31 was in close proximity to the front door. V3 (Licensed Practical Nurse) approached R31 at this time, and redirected her away from the door, and R31 began wandering down the facility's 200 hall. R31's Fall Investigation (dated 09/13/22) documents the following: CNA (Certified Nursing Assistant) called this nurse to resident's room at 5:40 AM. Resident was lying on the floor with walker in front of her. Assessed resident and observed skin tear. Cleaned area with wound cleaner and two steri-strips applied. Just below elbow, a puffy area that looks like fatty tissue, resident denies pain there. Resident is complaining of pain to left clavicle, she can only raise her arm part way up. Called (V11, R31's Physician) and received order to have portable x-ray done stat (immediately). Called (local x-ray company) and ordered x-ray. Resident was barefoot, staff needs to be sure she has on slipper socks at all times when in bed. R31's Follow-up Reportable (dated 09/16/22) documents the following: On 09/13/22 (R31) was in her room, the CNA (Certified Nursing Assistant) was in the room assisting roommate and observed resident fall, resident had book and dropped and appeared to try and pick it up and slipped on the book. CNA got nurse and nurse to room to assess resident. Assessment revealed skin tear left elbow and pain to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146151 If continuation sheet Page 2 of 8 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 146151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clayberg, The 625 East Monroe Street Cuba, IL 61427 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few left shoulder area and left lower arm area. Physician notified and resident sent to emergency room due to pain in shoulder area. In emergency room X-rays obtained left hip, pelvis, left elbow, left shoulder and left clavicle and a CT (computed tomography) of the clavicle related to not seen well on x-ray. CT showed left clavicle fracture. Resident returned to facility with sling. On 09/14/22 resident observed with darker bruising and warm to touch area to left wrist area. Physician notified and nurse requested x-ray of wrist area related to not being done in emergency room, Physician wanted resident sent back to emergency room for x-ray. X-ray showed a fracture of distal radius. Resident again returned with splint in place and follow up with orthopedic physician. R31's Progress Note (dated 09/13/22) documents the following: It was reported to this nurse this morning that (R31) had fallen early this morning and had increase difficulty raising her Lt (left) arm, this nurse and ADON (Assistant Director of Nursing) was assisting resident to restroom at this time and noticed that resident was c/o (complaining of) increase pain and having increase difficulty walking to restroom, upon assessment it was noted that resident had bump to Lt (left) shoulder with increase edema and bluish/purple discoloration to collar and neck on the Lt (left) side, resident sent to (local emergency department) for evaluation per nursing judgement to rule out possible fx (fracture), report called to (local emergency department) and HCPOA (Health Care Power of Attorney), and DON (Director of Nursing) notified of transport. (Local emergency department) called at this time to get update on resident, ER (emergency room) reported that resident had left clavicle fx (fracture) and was going to be discharged back to facility, HCPOA and DON notified of fx. Received call at this time from (local emergency department) with report on resident, she has left clavicle fx and UTI (urinary tract infection), start Keflex 500mg TID (three times per day) x 3 days awaiting culture, resident is to wear sling and apply ice off and on, and PT/OT (physical therapy/occupational therapy) to evaluate and treat, orders read back and verified. R31's Progress Note Text (dated 09/14/22): Resident recently had fall which resulted in fracture to left clavicle. Bruising noted to left shoulder down to breast on left side. Resident also noted to have bruising down left arm. Some swelling and warmth noted to left hand/wrist. This nurse placed call to physician on call. Message left on voicemail regarding resident's hand. No x-ray of hand or wrist done in ER (emergency room) on 09/13/22. This nurse requested order for x-ray. Resident has sling in place all of this shift. Will continue to monitor resident for any changes. R31's Progress Note (dated 09/14/22) document the following: Data: Resident had recent fall and was taken to the (local emergency department) yesterday and was diagnosed with a left fractured clavicle. No x-ray was obtained of her left wrist and hand at that time. Today it was noted that her left wrist and hand were red, swollen, and warm to the touch. Action: Doctor was notified, and new order was received to send resident to either Emergency Department or Convenient Care. Due to the time the order was received at 5:00 PM, resident was taken by transport to (local emergency department) to be evaluated. Response: X-Ray to left wrist was completed and resident has a left distal radius fracture. Her arm was placed in a velcro brace. Order to follow-up was received. R31's (Local Hospital) medical records (dated 09/13/22) document the following: Radiology Report. CT (Computed tomography) Cervical Spine. Impression: Displaced left clavicular head fracture with overlying soft tissue hematoma/contusion. R31's (Local Hospital) medical records (dated 09/14/22) document the following: Exam: X-ray left Wrist 4 Views. Impression: Nondisplaced fracture of the left wrist. R31's Progress Note (dated 09/16/22) documents the following: IDT (interdisciplinary team) reviewed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146151 If continuation sheet Page 3 of 8 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 146151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clayberg, The 625 East Monroe Street Cuba, IL 61427 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 incident and agree with intervention: slipper socks on while in bed. Staff re-educated about necessity for floor mats, frequent checks, and ensuring a safe environment for resident. Level of Harm - Actual harm Residents Affected - Few On 03/02/23 at 11:20 AM, V7 (Care Plan Coordinator) stated, (R31) should not have been barefoot at the time of her fall. She already had the intervention in place for non-skid socks when ambulating and at bedtime. She should have had non-skid socks on. I am not sure why the IDT note agreed with the new intervention of slipper socks, as it was already in place at the time of (R31's) fall. V7 then confirmed that in addition to no new fall intervention implemented after R31's 09/13/22 fall, R31's care plan was never updated with R31's 09/13/22 fall or any new interventions following the fall. B. The facility's Wandering, Unsafe Resident policy (revised August 2014) documents, The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. This policy also documents, When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall: Examine the resident for injuries; Contact the Attending Physician and report findings and conditions of the resident; Notify the resident's legal representative; Notify search teams that the resident has been located; Complete and file an incident report; Document relevant information in the resident's medical record. The facility's Policy Regarding Missing Residents and Elopements (undated) documents the following: Definition- Elopement: Elopement occurs when a facility resident that has been properly identified as a wanderer and requires supervision leaves the building without the staff's awareness/supervision for any period of time. This policy also documents, Elopement Procedure. Missing Resident and Elopement: Elopement occurs when a resident that has been properly identified as a wanderer and requires supervision leaves the building without staff's awareness/supervision for any period of time; When a resident that has been properly identified as a wanderer, and requires supervision, leaves the building without the staff's awareness/supervision for any period of time, the charge nurse will be notified immediately. The charge nurse will notify the working staff, call the Administrator and the Director of Nurses, and then assign staff to call non-scheduled employees to come in and assist in searching for the resident. (Facility) will follow Disaster Plan regarding missing resident; If the resident is not found during a preliminary check of the property, the charge nurse will call 911 and report the resident missing to the authorities; The resident's Physician shall be notified; The resident's Power of Attorney, Guardian, or representative shall be notified; The charge nurse will stay in the building to manage incoming calls, and direct non-scheduled employees and volunteers to the command post set up by Fire and Rescue; Administrator or Designee will notify the (State Agency). This same policy documents the following: Following the Recovery of the Missing Resident. Immediately following the recovery, the missing resident will be evaluated objectively and subjectively for any injuries by available nursing staff or emergency personnel. Any injuries shall be treated and/or the resident shall be transported by ambulance if needed. If the resident does not have (elopement deterrent alert device), one shall be obtained from maintenance personnel and placed on resident's wrist or ankle as appropriate. Immediate evaluation of the door alarms shall be done by the maintenance supervisor/staff and the alarm system contractor shall be notified to check for any malfunction and correct any deficiency which may have enable the resident to leave the facility unescorted. R31's Wandering Risk Scale (dated 01/11/23) documents a score of 13, indicating R31 is a high risk of wandering. This same form also documents, (R31) has been assessed to be a high risk for wandering/exit-seeking behaviors. (Elopement deterrent alert device) is in place. R31's current Physician's Orders document the following order: Check (elopement deterrent alert device) placement every shift for exit seeking. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146151 If continuation sheet Page 4 of 8 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 146151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clayberg, The 625 East Monroe Street Cuba, IL 61427 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few R31's current care plan documents the following: I am a high risk for leaving the facility unattended related to a diagnosis of Alzheimer's/Dementia. My Wandering Risk Assessment score is 13 (high risk). My BIMS (Brief Interview for Mental Status) is 3 (severely cognitively impaired). On 02/27/23 at 12:10 PM, R31 was utilizing her walker near the front entry to the building. R31 was confused and approached this surveyor asking about the bathroom near the front entrance. An (elopement deterrent bracelet) was in place on R31's left ankle, and the facility's (elopement deterrent) alarm system was sounding while R31 was in close proximity to the front door. V3 (Licensed Practical Nurse) approached R31 at this time and redirected her away from the door. R31's Progress Note (dated 09/10/22) documents the following: Data: While this nurse was at lunch, it was reported to this nurse that resident noted to be outside walking on sidewalk. Action: Staff noticed resident by themselves and helped resident back in facility. (V9, R31's Power of Attorney) was notified of resident being outside. Response: (V9) will be in to have lunch with resident tomorrow. On 03/01/23 at 10:10 AM, V5 (Licensed Practical Nurse) stated she was the nurse working when R31 exited the building on 09/10/22. V5 verified writing the above progress note, and indicated that, One of the CNAs (Certified Nursing Assistant) reported this to me once I returned from lunch. I guess she was found walking alone outside the building. I reported this to the former DON (Director of Nursing) after it occurred and notified (V9, R31's Power of Attorney). On 03/01/23 at 11:30 AM, V6 (Certified Nursing Assistant) stated that she was the staff member that discovered R31 walking alone outside the building on 09/10/22. V6 stated, During the end of my lunch, I was outside with one of the activity girls and saw (R31) walking alone down the sidewalk. I don't know how she got out there, or how long she had been out there. I just know she was out there alone and that should never happen. I am guessing that she walked down the 200 hall and went out of the therapy doors because I don't think that door locks when someone wearing the (elopement deterrent device) approaches it like the other doors in the building do. I took (R31) back inside and told the nurses what had happened. I do remember this incident quite clearly. It stands out because this is not something you'd expect to see. On 03/01/23 from 1:20 PM - 1:40 PM, a tour through the facility to each exit door was conducted with V2 (Director of Nursing) and V12 (Maintenance). An (elopement deterrent device) was taken in close proximity to each exit door of the building, and the following doors secured and alarmed when approached with the (elopement determent device): the front entry door, the back door near the kitchen, and the door at the end of the 100 hall. The exit door at the end of the 200 hall did not alarm when approached with the (elopement deterrent device). On the 200 hall door, a large sticker was adhered in an area of high visibility above the push bar. This sticker stated the following: Push until alarm sounds. Door can be opened in 15 seconds. With the (elopement deterrent device) in close proximity, V2 pushed the push bar on the door, and the door began alarming, continued to alarm for 15 seconds, and then the alarm ceased, the door unlocked and was able to be opened. V12 stated the 200 hall door does not remain secured after the 15 second alarm sounds and it unlocks. V12 stated, The (elopement deterrent device) will not lock that door since you have to hold the push bar for 15 seconds to open it. R31's current care plan has no mention of R31 exiting the building on 09/10/22, or any new interventions implemented after the elopement occurred. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146151 If continuation sheet Page 5 of 8 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 146151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clayberg, The 625 East Monroe Street Cuba, IL 61427 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 On 03/02/23 at 10:40 AM, V2 (Director of Nursing) stated an investigation regarding R31's elopement from the building on 09/10/22 cannot be provided because, an investigation was not conducted. Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 03/02/23 09:15 AM, V1 (Administrator) stated an investigation was not completed when R31 exited the building on 09/10/22, because (R31) never left the grounds. V1 stated the facility has cameras for video surveillance to access, but they cannot be accessed beyond 30 days. V1 then stated the facility did not notify the State Agency of the R31's 09/10/22 elopement. Event ID: Facility ID: 146151 If continuation sheet Page 6 of 8 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 146151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clayberg, The 625 East Monroe Street Cuba, IL 61427 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. Based on interview, observation, and record review, the facility failed to attempt a gradual dose reduction of a psychotropic medication as ordered by the physician for one of three residents (R31) reviewed for psychotropic medications in the sample of 26. Findings include: The facility's Psychopharmacologic Drug Usage policy (revised 09/08) documents, Purpose: To provide appropriate assessment and monitoring of residents receiving these medications. To ensure residents receive gradual dose reductions and behavioral interventions in an effort to discontinue these medications and minimize adverse consequences. This policy also documents, Gradual Dose Reductions (GDR) must be attempted. For Sedatives/Hypnotics, a reduction should be attempted at least quarterly, unless clinically contraindicated. All other psychopharmacologic drugs must have a reduction attempt at least in two separate quarters during the first year (with at least one month between attempts) and then annually, unless clinically contraindicated. Reduction of medication must be done per physician's order. This same policy documents, Unsuccessful reduction of medication must be substantiated by documentation, including rationale from the physician as to why the medication cannot be reduced further. The ultimate goal of successful gradual dose reduction is to discontinue the medication, or to utilize the lowest possible dose of medication necessary for the benefit of the resident and to minimize adverse consequences. R31's current Physician's Orders document the following medication orders: Abilify (antipsychotic) 2 milligrams by mouth one time a day every Monday, Tuesday, Thursday, Saturday related to Persistent Mood Disorder; Ativan (anti-anxiety) 2 milligrams by mouth two times per day related to General Anxiety Disorder. R31's Behavior Monitoring Sheet (dated 01/31/23 - 03/01/23) documents R31 frequently displays the following behaviors: Anxious/Restless, Elopement/Exit Seeking, Sad/Tearful, and Wandering. On 02/27/23 at 12:10 PM, R31 was utilizing her walker near the front entry to the building. R31 was confused and approached this surveyor asking about the bathroom near the front entrance. An (elopement deterrent bracelet) was in place on R31's left ankle, and the facility's (elopement deterrent) alarm system was sounding while R31 was in close proximity to the front door. V3 (Licensed Practical Nurse) approached R31 at this time and redirected her away from the door. R31 began wandering towards the facility's 200 hall. R31's Psychiatry Note (dated 01/31/23) documents R31 was evaluated by (V8, Psychiatric Physician), and the following medication change was ordered: Lower Ativan to 1 milligram three times per day for gradual dose reduction. R31's Progress Note (dated 2/3/23) documents the following: (R31) was seen by (V8, Psychiatric Physician) and received new order to decrease Ativan order from 2 milligrams BID (twice daily) to 1 milligram TID (three times daily). (V9, R31's Power of Attorney) does not want medication changed. Facility will notify (V8). R31's Note to Attending Physician/Provider (dated 09/13/22) documents the following: Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146151 If continuation sheet Page 7 of 8 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 146151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clayberg, The 625 East Monroe Street Cuba, IL 61427 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 receives the following medication: Abilify 2 milligrams daily, omitting Sundays and Wednesdays. Pharmacist recommended dose reduction to: Abilify 2 milligrams at bedtime on Monday and Thursday, and 1 milligram all other days. This same form documents (V11, R31's Attending Physician) agreed and approved the gradual dose reduction that was suggested. A note written on the bottom of this form (dated 09/19/22) that documents, Received telephone order to continue current dose before the gradual dose reduction due to (V9, R31's Power of Attorney) request. R31's Progress Note (dated 01/23/23) documents the following: Pharmacy recommendation came through to do a GDR (gradual dose reduction) on (R31's) Abilify. (V9, R31's Power of Attorney) does not want (R31's) medication changed. (R31) has had GDR in the past and not successful. This nurse placed call to (V11, R31's Physician) and reported this. (V11) was ok with leaving medication as is. (V9) was notified. On 03/02/23 at 09:35 AM, V10 (Registered Nurse/Minimum Data Set Coordinator) stated the physician-ordered gradual dose reductions on R31's Abilify and Ativan were not completed due to (V9, R31's Power of Attorney) refusing the changes. V10 stated R31 frequently displays the following behaviors: Anxiety, Wandering, Exit Seeking, and Tearfulness. V10 stated R31 is not a harm to herself or others, and Most of the time she is easily redirected. (V9, R31's Power of Attorney) stated she would not sign the consent to change the medication dosages. We have tried to educate (V9), but she just refuses to allow us to make any changes to (R31's) medications. We have even explained that if the changes made do not work out, we can always increase the dose back to where it was. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146151 If continuation sheet Page 8 of 8