Inspection visit

Health inspectionNovember 20, 2024

MOWEAQUA REHAB & HCCCMS #14616217 citations on this visit

17 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 17 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0561 Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Level of Harm - Actual harm Residents Affected - Few Based on observation, interview, and record review, the facility failed to honor repeated requests of a resident's (R263) choice of living arrangements. This failure affects one (R263) of six residents reviewed for self-determination in a sample list of 34. This failure resulted in R263 becoming anxious, angry, refusing to eat, drink, and receive care from staff. Findings Include: R263's admission progress note, dated 11/15/24, documents, (R263) arrived from (hospital) at approximately 5pm. Nurse to nurse report indicates advanced Amyotrophic Lateral Sclerosis, with Benign Prostatic Hypertrophy, and Osteoporosis cited as the only comorbidities. Resident is non-verbal. Resident is a Do Not Resuscitate. Regular diet with a Gluten Intolerance; requires maximum assistance. Resident takes pills crushed in applesauce/pudding/yogurt. Ambulance service stated the resident traveled to the area via plane from New York, and his family promptly admitted him to (hospital), where he's been since 11/7/24 awaiting placement. Skin check reveals some redness on the posterior, which was communicated by (hospital) who had been using a Zinc barrier cream. CNAs (Certified Nursing Assistants) advised to do the same. Resident would not permit writer to take vitals. Resident uses a sheet with letters to communicate but struggles significantly. An electronic tablet is available in his belongings, but he preferred to use the paper. Resident was also aggressive with CNAs when they were changing him. R263's Progress note, dated 11/15/24 at 11:00PM, by V23, Nurse Practitioner, documents, Reported by nurse that resident is not satisfied with cares that has been provided in facility and wants to go back to hospital. Stable condition. No acute medical issue at this time. Nurse will contact family members and social worker to talk to the (R263) and monitor. On 11/17/24 at 9:00AM, R263 was observed lying in bed leaning to the right side. R263 had severe contractures to all extremities and was unable to speak. R263 had a communication board and was able to express himself by pointing to letters or responses on the board. When asked if R263 was being cared for by facility staff, R263 laboriously spelled out No. I want to go to the hospital. I am afraid. I will die. I want to get up in my wheelchair. When asked if staff took time to listen to R263's wants or needs, R263 pointed to No on the board. R263 spelled out I need help. R263's full breakfast was on the over the bed tray untouched. When asked if R263 can feed self, R263 pointed to no. When asked if staff had offered to help, R263 pointed to no. There was a full cup of water on R263's over the bed tray. When asked if staff offer R263 drinks, R263 pointed to no. When asked if R263 refused care, R263 spelled out I don't trust. I am afraid. Nobody comes. On 11/20/24 at 11:00AM, V20, Licensed Practical Nurse (LPN), stated, I wanted to send (R263) to the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 28 Event ID: 146162 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 146162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Moweaqua Rehab & Hcc 525 South Macon Street Moweaqua, IL 62550 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 0561 Level of Harm - Actual harm hospital when he insisted. He is cognitively intact and can make his own decisions. He can communicate with the board, but it takes a very long time. We really do not have enough staff to meet (R263's) needs. (R263) is physically dependent and has contractures of both arms and legs. I know (R263) was very scared and frustrated because we do not have the staff to spend the time with (R263) that (R263) needs. Residents Affected - Few On 11/20/24 at 2:30PM, V21, Registered Nurse (RN), stated, I was the nurse who admitted (R263). (R263) is completely physically dependent and has contractures to both lower and upper extremities. (R263) in alert, oriented, and fully functional cognitively. (R263) is nonverbal but can communicate using the stroke board. (R263) makes his own decisions. (R263) wanted to go to the hospital. I contacted the Nurse Practitioner who advised me not to send (R263) to the hospital. This facility can not meet (R263's) needs. We have one CNA (Certified Nurse's Aide) for a hall and two nurses in the entire facility. There is not staff time even to effectively communicate with (R263). I knew he was angry and very fearful and honestly, I could see why. Several attempts were made to contact V23, Nurse Practitioner (who refused to send (R263) to the hospital). V1, Administrator, and other corporate staff reached out to V23, but V23 did not contact surveyor. V15, Corporate Nurse, denies the facility has a specific policy addressing resident self-determination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146162 If continuation sheet Page 2 of 28 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 146162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Moweaqua Rehab & Hcc 525 South Macon Street Moweaqua, IL 62550 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 0585 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on interview and record review, the facility failed to resolve grievances for four (R31, R33, R48 and R49) of five residents reviewed for grievances from a total sample list of 34 residents. Residents Affected - Some Findings include: The facility provided Resident Grievance Policy and Procedure, dated May 2018, documents it is the intent of the facility to encourage residents, their residents, or representatives to communicate any concerns, suggestions, complaints or opportunities for improvement in care or services. Each grievance will be investigated and addressed with a response. The Administrator/Executive Director will ensure grievances are addressed and resolved within a five-day time frame and final outcome communicated to the person originating the grievance. The resident council minutes, dated 1/3/24, document concerns including call lights taking too long and the food being cold. The facility resident council minutes, dated 11/4/24, document a grievance of late breakfast and late lunch was noted along with call lights not being address. The response to the grievance was that low staffing and missing ingredients cause the kitchen staff to be behind which causes late meals. The facility provided grievances, dated 9/23/24, document it took three hours for a call light to be answered when a catheter was leaking and that the food is cold. The facility provided grievances, dated 9/26/24, document staff did not provide timely care causing a resident to go in her pants. On 11/18/24 at 10:09AM, R31 stated, We have on going issue with staffing and food. The dining room is served is first. If you get a special order it is hot, but the regular food is cold. On 11/18/24 at 10:13AM, R33 stated, I didn't get my breakfast this morning until after 9:00AM. On 11/18/24 at 10:15AM, R48 stated she didn't' get her breakfast until after 9:00AM this morning, and that she often gets medications late. I have medicines that need to be given with food and lunch time is running into smoke time.We are not fed for an hour to two hours after. They need a plate warmer and more people to pass trays. On 11/18/24 at 10:20AM, R49 stated the hall trays are set out and left for hours to be given. On 11/18/24 at 10:22AM, R31 stated, Your insulin isn't given until after you eat and our medications that need to be given are given after we eat. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146162 If continuation sheet Page 3 of 28 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 146162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Moweaqua Rehab & Hcc 525 South Macon Street Moweaqua, IL 62550 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide fingernail care, bathing, and timely toileting/incontinence cares for three (R16, R21, R30) of 16 residents reviewed for Activities of Daily Living (ADLs) in the sample list of 34 residents. Residents Affected - Some Findings include: 1. The facility grievance log (January-November 18, 2024) documents 19 formal resident complaints related to call light response times. Facility Grievance Forms document the following recent grievances made during Resident Council meetings: -8/7/24: 3rd shift not cleaning up residents letting the resident in urine and not cleaning up the resident and Call lights aren't being answered in a timely manner -9/23/24: Took 3 hours for call light to be answered when (urinary) catheter was leaking -9/26/24: staff member didn't provide timely care resulting in her to go in her pants -10/9/24: Call lights not being answered in a timely manner. -11/4/24: Call lights not being answered in a timely manner. R30's diagnosis list (printed 11/19/2024) documents R30's diagnoses include: Hemiplegia/Hemiparesis (partial or total paralysis on one side of the body), Parkinson's Disease (brain disorder that causes unintended or uncontrollable movements), Anxiety Disorder, Major Depressive Disorder, and Muscle Weakness. R30's quarterly assessment (8/5/2024) documents R30 requires substantial or maximal assistance from facility staff for all activities of daily living. The same record documents R30 is frequently incontinent of bladder and always incontinent of bowel. R30's Care Plan (9/20/2024) documents R30 is incontinent of bladder and at risk of septicemia (life-threatening infection that occurs when bacteria, viruses, or fungi enter the bloodstream and spread) from urinary tract infections. The same record documents facility staff should check R30 every two hours for incontinence and also as-needed per R30's request. On 11/17/2024 at 10:23AM, R30 was in bed and reported facility staff do not answer call lights timely, and R30 has waited over an hour before to get an incontinence brief changed. R30 reported getting uncomfortable waiting on staff for care. 2. R21's diagnosis list (printed 11/20/2024) documents R21's diagnoses include: Multiple Sclerosis (chronic neurological disorder resulting in muscle weakness/spasms in the arms and legs, problems with walking/standing, tremors, dizziness, and speech problems), Feeding Difficulties, Muscle Weakness, Abnormal Posture, Lack of Coordination, and Muscle Wasting/Atrophy. R21's quarterly assessment (8/8/2024) documents R21 has both upper and lower extremity range of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146162 If continuation sheet Page 4 of 28 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 146162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Moweaqua Rehab & Hcc 525 South Macon Street Moweaqua, IL 62550 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 0677 motion impairment and requires substantial/maximal staff assistance for eating. Level of Harm - Minimal harm or potential for actual harm R21's Care Plan (11/9/2024) documents R21 has difficulty feeding R21's self and needs staff assistance. The same record documents R21 requires 1:1 staff assistance for meals. Residents Affected - Some On 11/17/2024 at 11:09AM, R21 reported eating meals in R21's room, and staff routinely drop a meal tray off in his room, but don't return for an hour to assist R21 with eating. R21 reported being the first resident to receive a hall tray, so staff pass all other trays before returning to help R21 eat R21's meals. 3. On 11/19/24 at 1:27PM, R16 was eating chicken with her fingers. R16's fingernails had copious quantities of feces (dark brown substance) between the nail and fingertip. On 11/19/24 at 1:28PM, V11, Certified Nursing Assistant, confirmed R16 had feces under her nails and that they would take care of it. On 11/20/24 at 10:56AM, V2 Director of Nursing, stated nail care should be provided on shower days to all dependent residents, especially anytime feces is found under the nails. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146162 If continuation sheet Page 5 of 28 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 146162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Moweaqua Rehab & Hcc 525 South Macon Street Moweaqua, IL 62550 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 physicians orders for treatment of a nonpressure wound for one resident (R54) of two residents reviewed for nonpressure wounds in a sample list of 34. Residents Affected - Few Findings Include: R54's Minimum Data Set (MDS), dated [DATE], documents R54 is cognitively intact. R54's Treatment Administration Record (TAR) for November documents a current physician's order to Change wound vac dressing day shift every day shift every Monday, Wednesday,and Friday. R54's Hospital discharge orders, dated 10/10/24, document, Left Medial Calf- Negative pressure therapy to be changed three times per week. Vac (vacuum) is continuous at 125mmHg. R54's TAR for November documents that treatment was not completed Monday 11/4/24, Friday 11/8/24, Monday 11/11/24, or Friday 11/15/24. On 11/17/24 at 10:00AM, R54 stated, I fell here (at the facility) and my surgical incision busted open and I bled all over the floor. That was when I got the wound vacuum. The nurse don't bother to change the dressing like the doctor ordered. On 11/19/24 at 12:30PM, V2, Director of Nursing, stated, I wasn't aware these treatments have been missed, but I do see that they were not signed off as ordered. On 11/20/24 at 10:00AM, V15, Corporate Nurse, stated the facility does not have a policy specific to wound vacuums. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146162 If continuation sheet Page 6 of 28 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 146162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Moweaqua Rehab & Hcc 525 South Macon Street Moweaqua, IL 62550 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to investigate, determine root cause, and implement resident centered fall interventions for one resident (R54) of one resident reviewed for falls in a sample list of 34. Findings Include: R54's Minimum Data Set (MDS), dated [DATE], documents R54 is cognitively intact. On 11/17/24 at 10:00AM, R54 stated, I fell here (at the facility) and my surgical incision busted open and I bled all over the floor. R54's hospital history and physical documents, (R54) presented to emergency room from Extended Care Facility where he had a mechanical fall in which his left lower extremity wound opened up and he was found to have bleeding. R54's progress Note, dated 10/1/24 at 2:45PM, documents, nurse was called to residents room due to resident falling. Resident's daughter was in his room with him when resident got up from his wheelchair to walk to his bed and fell. Resident was sitting on the floor next to his bed with his daughter sitting behind him holding him up. Noted a moderate amount of blood on the floor under his left leg. This nurse received permission from resident and daughter to cut residents right pant leg to expose where blood was coming from. Noted to residents left lower leg a large dehisced area from lower part of incision to left leg. A large amount of 4x4 gauze placed on open wound and secured with (stretch Gauze). Secured with Coban. Assessment completed and Vital Signs obtained. On 11/19/24 V1, Administrator, provided only a brief risk management reiterating the above Progress note. No fall investigation or root cause analysis were provided. V1 stated, We didn't do an in depth investigation because there were no injuries.z' When surveyor inquired about the wound dehiscence and referred to the hospital record, V1 stated, Well we thought since (R263) already had the incision it wasn't a new injury. On 11/20/24 at 10:00AM, V15, Corporate Nurse, stated the facility does not have a policy specific to Incident reporting and investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146162 If continuation sheet Page 7 of 28 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 146162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Moweaqua Rehab & Hcc 525 South Macon Street Moweaqua, IL 62550 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to administer oxygen as ordered, failed to correctly apply a nasal cannula, failed to provide oxygen humidification, and failed to maintain clean, dated, and labeled oxygen tubing for one (R160) of five residents reviewed for respiratory care from a total sample list of 34 residents reviewed. Residents Affected - Few Findings include: The facility provided Oxygen Administration Policy, dated 1/2017, documents there must be an order for oxygen administration and that the nasal cannula tube should be placed approximately one-half inch into the resident's nose, held in place by an elastic band placed around the resident's head. Equipment and supplies include a nasal cannula and humidifier bottle that should be replaced weekly and as needed. R160's physician orders, dated 10/23/24, documents oxygen to be administered at two liters per nasal cannula continuously to keep R160's oxygen saturation above 92%. R160's physician orders, dated 10/23/24, documents oxygen tubing to be changed weekly on Wednesday nights. On 11/17/24 at 11:09AM, R160 was laying in bed with a nasal cannula blowing into her cheek at 2.5 liters. R160's tubing was dated 11/7/24, and the humidification bottle was empty. On 11/18/24 at 9:14AM, R160 was wearing a nasal cannula blowing into her cheek at 2.5 liters. R160's tubing was dated 11/7/24, and the humidification bottle was empty and R160's oxygen continues at 2.5 liters per nasal cannula. On 11/18/24 1:16PM, V2, Director of Nursing, stated R160 should be receiving the ordered amount of oxygen (2 liters) and that the nurses and Certified Nursing Assistants are responsible for monitoring oxygenation to ensure that the proper amount of oxygen is being administered, the tubing is in place and dated, and that the oxygen is humidified. V2, Director of Nursing, stated the oxygen tubing and water should be replaced weekly and as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146162 If continuation sheet Page 8 of 28 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 146162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Moweaqua Rehab & Hcc 525 South Macon Street Moweaqua, IL 62550 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to provide sufficient Registered Nursing (RN) hours on two of sixteen days reviewed for RN staffing. This failure has the potential to affect all 54 residents in the facility. Findings include: The facility Nursing Schedule (January 8, 2025 through January 18, 2025) documents on Wednesday 1/8/25, Thursday 1/9/25, Sunday 1/12/25, Monday 1/13/25 and Tuesday 1/14/25, the facility scheduled zero (0) hours of RN coverage for a 24 hour period. On 1/27/25 at 1:45 PM, V16, Regional Consultant Administrator, provided a time card for V2 that documents V2 is employed as the Director of Nursing and is employed in supervisory role. The facility Resident Midnight Census, dated 1/21/25, documents 54 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146162 If continuation sheet Page 9 of 28 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 146162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Moweaqua Rehab & Hcc 525 South Macon Street Moweaqua, IL 62550 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 interview and record review, the facility failed to regularly assess residents, obtain informed consent, identify or track specific managed behaviors, and provide therapy rationale. This failure affects for three residents (R262, R30, R41) taking psychotropic medication of five residents reviewed for medications in a sample list of 34. Findings Include: The facility's policy Psychotropic Medication Use ,dated 09/2022, states, Staff will complete Psychoactive Medication Review assessment on admission, when any new psychotropic medication is ordered, with a change in condition, and quarterly. This assessment will be completed for any medication prescribed to manage behaviors i.e. Depakote, Nudexa, etc. Prior to starting psychotropic medications, informed consent will be obtained from residents/representative per state guidelines. Residents who are admitted from the community or transferred from a hospital and are already receiving psychotropic medication will be evaluated for appropriateness and indications for use. 1. R262's Current Physicians for November 2024 orders include the following active orders for psychotropic medications: Aripiprazole (antipsychotic) Oral Tablet 5 MG One daily, Duloxetine HCl (antidepressant) Oral Capsule Delayed Release Sprinkle 30 MG Daily, Doxepin HCl (antidepressant) Oral Tablet 3 MG at bed time, Amitriptyline HCl (antidepressant)Oral Tablet 25 MG at bed time. R262's Face Sheet, printed 11/20/24, documents R262 was admitted on [DATE]. R262's Care Plan, dated 11/2/24, does not address R262's use of psychotropic medication. R262's current electronic medical record for November 2024 does not document a psychotropic assessment or identification or tracking of targeted behaviors to justify the use of psychotropic medications. On 11/19/24 at 2:00PM, V15, Corporate Nurse, verified the facility did not complete a psychotropic medication assessment or identify targeted behaviors for R262. 2.) R30's physician order sheet (POS), dated 11/19/24, documents orders for alprazolam 0.125 milligrams (mg) daily for anxiety with a start date of 5/8/24, sertraline 100mg daily for major depressive disorder (MDD) start date 3/9/24, buspirone 5mg three times daily for MDD start date of 3/22/24, and abilify(antipsychotic) 2mg daily with start date of 3/30/24. R30's face sheet, dated 11/19/24, documents medical diagnosis including anxiety disorder (3/7/23), Parkinson's disease (10/1/23), and major depression disorder (1/12/24). R30's care plan (CP), dated 9/20/24, documents R30 has behavioral issues, anxiety, and major depressive disorder. These all indicate interventions to monitor behaviors and document interventions used. R30's medication administration record for month of November 2024 documents orders to monitor for signs of anxiety and depression behaviors including medication side effects, with a start date of 11/19/24. R30's medical record does not document behavior tracking with individualized non-pharmacological interventions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146162 If continuation sheet Page 10 of 28 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 146162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Moweaqua Rehab & Hcc 525 South Macon Street Moweaqua, IL 62550 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 R30's Pharmacy recommendations, dated 4/7/24, documents R30 is receiving duplicate therapies with multiple anxiolytic agents of alprazolam, buspirone, and abilify. Recommends physician change medications or respond with rationale for R30 requiring all three medications. Response marked disagree on document with no rationale provided on 4/9/24. R30's Pharmacy recommendations, dated 7/5/24, documents need for reduction of R30's sertraline dosage of 100mg or physican must provide rationale, box marked disagree with no rationale provided. On 11/19/24 at 2:45 PM, attempt made to contact physician listed on pharmacy recommendation document. Message left with office staff. No return call received. On 11/20/24 at 12:25 PM, V2, Director of Nursing (DON), stated there was no behavioral tracking documentation. 3. R41's medication administration record, dated November 2024, documents orders for Cymbalta(antideppressant,antianxiety) 60mg daily, mirtazapine (antidepressant) 7.5mg every night, Rexulti (antipsychotic) 3mg daily, trazadone (antidepressant) 25mg every night, and Austedo (involuntary movements) 12mg twice daily. R41's diagnosis sheet, dated 11/20/24, documents medical diagnosis including traumatic subdural hemorrhage 7/28/23, epilepsy 8/3/23, schizophrenia 8/3/23, alcohol abuse disorder 7/28/23, major depressive disorder (MDD) 8/15/23 and insomnia 12/11/23. R41's care plan, dated 10/31/24, documents the following diagnosis with interventions to monitor behaviors, psychosocial well-being problems, depression, insomnia, schizophrenia, and delirium related to traumatic subdural hemorrhage. R41's admission abnormal involuntary movement scale (AIMS), dated 9/20/23, documents severity of abnormal movements on a scale of 0-4. 0 equals none, 1 minimal, 2 mild, 3 moderate and 4 severe. Facial muscles including lip area rated at 2, tongue movement rated 3, and jaw movement at 0. Upper body movement rated 2, lower body rated 3, and trunk area 1. Overall global movement rated at 2 with incapacitation from abnormal movements at a 3. Also documents patient has awareness of abnormal movements. R41's AIMS, dated 4/9/24, documents same scores for all areas as documented in 9/20/23 AIMS, as well as adds jaw movement rated at 2. R41's pharmacy recommendation, dated 5/6/24, documents since Rexulti was added in August of 2023 R41's AIMS has increased which resulted in additional medication of Austedo in February 2024. AIMS continues to show increase in abnormal movements and recommends alternate antipsychotic. Physician response marked disagree with no rationale dated 5/7/24. R41's medication administration record (MAR) for month of November 2024 documents orders to monitor for signs of depression, suicidal thoughts and intentions, and psychotic behaviors including medication side effects, with a start date of 11/19/24. MAR does not document monitoring prior to 11/19/24. R41's medical record does not document behavior tracking with individualized non-pharmacological interventions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146162 If continuation sheet Page 11 of 28 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 146162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Moweaqua Rehab & Hcc 525 South Macon Street Moweaqua, IL 62550 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 On 11/20/24 at 9:45 AM, R41 noted to have facial movements around jaw that appear abnormal. Tongue protrusion with rapid movement and grimacing noted to face. Total body movement in a rocking motion appears uncontrollable to R41. R41 stated he can't stop doing it. On 11/20/24 at 12:25 PM, V2, DON, stated there was no behavioral tracking documentation. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146162 If continuation sheet Page 12 of 28 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 146162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Moweaqua Rehab & Hcc 525 South Macon Street Moweaqua, IL 62550 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide dental services for one (R16) of one residents reviewed for dental services from a total sample list of 34 residents. Residents Affected - Few Findings include: R16's nutritional assessment, dated 8/8/24, documents R16 is edentulous and requires nutritional supplements in addition to a regular pureed diet with snacks. On 11/17/24 at 10:48AM, R16 was edentulous and stated she would like to have dentures. On 11/19/24 at 9:38AM, V12, Social Services Director (SSD), stated she does not recall asking R16 if she needs dentures, and the resident has never asked them about it. V12 stated the facility does not have a dentist who will provide dentures. On 11/19/24 at 3:31PM, V18, Family Member, stated they had never been asked about R16's dental issues, and she has been in need of dentures for some time, and would like her to be seen. On 11/20/24 at 10:03AM, V2, Director of Nursing, stated R16 is provided nutritional supplements because she isn't a good eater and needs the calories. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146162 If continuation sheet Page 13 of 28 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 146162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Moweaqua Rehab & Hcc 525 South Macon Street Moweaqua, IL 62550 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services, and failed to employ a person-in-charge (PIC) with the required Food Protection Manager Certification. These failures have the potential to affect all 54 residents in the facility. Findings include: On 11/17/2024 at 9:58AM, V5 (Dietary Manager) was actively supervising Dietary operations in the facility kitchen. V5 reported being the full-time manager of the facility Food Service, and reported not being a clinically qualified Certified Dietary Manager or having equivalent training. V5 denied meeting the State of Illinois standards to be a Food Service Manager or Dietary Manager. V5 also denied being a certified Food Protection Manager, as required, for every person in charge of a food service. On 11/18/2024 at 12:43PM, V5 (Dietary Manager) reported being unaware if the facilty employed a Dietician. V5 reported never seeing or hearing of any Dietician working in the facility in the past several months. V5 denied: -being a Dietician; -being a Certified Dietary Manager; -having an associate's or higher degree in food service management or in hospitality; -having 2 or more years of experience in the position of Director of Food and Nutrition Services in a nursing facility setting; -being a graduate of a dietetic and nutrition school or program authorized by the Accreditation Council for Education in Nutrition and Dietetics, the Academy of Nutrition and Dietetics, or the American Board of Nutrition; -being a graduate, prior to July 1, 1990, of a Department (Illinois Department of Public Health) approved course that provided 90 or more hours of classroom instruction in food service supervision and having experience as a supervisor in a health care institution which included consultation from a dietician; -or having completed an Association of Nutrition & Foodservice Professionals approved Certified Dietary Manager or Certified Food Protection Professional course. The Food and Drug Administration Food Code (2022) documents a dietary service Person in Charge (PIC) shall be a Certified Food Protection Manager. Throughout the duration of the survey, from 11/17/2024-11/20/2024, the facility failed to effectively sanitize dishes, failed to prevent direct cross-contamination of ice, failed to prevent the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146162 If continuation sheet Page 14 of 28 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 146162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Moweaqua Rehab & Hcc 525 South Macon Street Moweaqua, IL 62550 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0801 Level of Harm - Minimal harm or potential for actual harm potential for biological cross-contamination of stored food, failed to prevent the potential for physical cross-contamination of food, failed to date and label TCS (time/temperature control for safety) food, failed to maintain sanitation test equipment supplies, and failed to maintain sanitary food service flooring areas. The following dietary service conditions were noted: Residents Affected - Many 1. On 11/17/2024 at 8:39AM, V3 (Cook) was working in the facility kitchen. When asked if the kitchen had dishwasher sanitizer test strips, V3 reported not being aware and stated, I have not been shown that yet, how to do that (how to use sanitizer test strips to test the dishwasher for adequate sanitizer concentration). On 11/17/2024 at 9:10AM, V4 (Dietary Aide) was washing resident dishes in the facility mechanical chlorine sanitizing dishwasher. When asked if the kitchen had sanitizer test strips to test the facility dishwasher to ensure the dishwasher was effectively sanitizing dishes, V4 proceeded to walk from the dishwashing room to the adjacent main kitchen area where the three-basin sink was located. V4 returned with a container of sanitizer test strips labeled to test quaternary ammonia sanitizer and not chlorine based sanitizer solutions. On 11/18/2024 at 12:45PM, V9 (Dietary Aide) was washing resident dishes in the above mechanical dishwasher. The dishwasher sanitizer solution concentration measured zero parts per million as measured by Illinois Department of Public Health chlorine sanitizer test strip. V9 observed the test strip and stated yes (the concentration of sanitizer in the dishwasher was zero parts per million). V9 reported thinking previously in the day something was wrong with the dishwasher because V9 had recently changed out the dishwasher's empty container of chlorine sanitizer for a full container and then tested the chlorine level with a sanitizer test strip from above, but still measured zero chlorine present in the dishwasher. V9 reported telling V5 (Dietary Manager) about the dishwasher problem, but V5 didn't respond to V9's concerns. A dishwasher log sheet (October 2024) was located on the wall beside the dishwasher, and did not have any log entries past October 3, 2024 documenting routine testing of the dishwasher sanitizer level to ensure effective dish sanitation. On 11/18/2024 at 12:38PM, the kitchen three-basin sink was in use with all three basins filled with solutions. The sanitize basin contained cooking pans and tested 100 parts per million sanitizer concentration by both a facility sanitizer test strip and Illinois Department of Public Health test strip. The container of sanitizer located immediately above the sanitize basin was empty. The manufacturer's label on the container documented a sanitizer concentration of 200-400 parts per million is required to effectively sanitize dishes. 2. On 11/17/2024 at 9:00AM, the kitchen ice machine was not operational and not producing ice. The storage bin on the machine was nearly empty, containing a layer of ice on the bottom of the bin appearing 3-4 in depth. V1 (Administrator) entered the kitchen and placed seven intact plastic bags of commercially prepared ice into the bin. The bags were randomly resting in direct contact with the existing ice located at the bottom of the bin. The exterior of several of the bags was visibly soiled with black-colored dirt and debris. V3 (Cook) was present and when asked if the ice in the bags would be emptied into the storage bin with the existing ice and then used for resident drinks, V3 stated yeah. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146162 If continuation sheet Page 15 of 28 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 146162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Moweaqua Rehab & Hcc 525 South Macon Street Moweaqua, IL 62550 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 11/17/2024 at 9:59AM, the above ice machine was operational and imminently ready to release ice into the storage bin. V3 was present and reported V3 was going to wait until the first batch of ice dropped down into the bin and then V3 was planning to empty the above bagged ice on top of the newly produced ice (effectively mixing together the ice in contact with the soiled plastic bags with newly formed ice). 3. On 11/17/2024 at 8:50AM, the reach-in cooler located by the kitchen two-basin sink had an open 48 ounce container of apple juice, an open 48 ounce container of orange juice, and an eight inch pie pan of quiche. None of the food items were labeled with the date opened or prepared or a use-by date. On 11/17/2024 at 8:52AM, the reach-in coolers located near the kitchen three-basin sink contained one-half of a deli ham roll wrapped in plastic, a gallon ziploc bag half full of hot dogs, a two liter plastic container full of a red liquid, a three liter plastic container filled with tuna salad, a gallon ziploc bag half full of ready to eat roast beef deli meat, a metal pan of cooked potatoes nested into a metal pan of cooked pasta (the bottom of the potato pan was in direct contact with the pasta), and a gallon ziploc bag half full of raw bacon. The exterior of the bacon bag was greasy when touched. None of the food packages were labeled with date opened or a use-by date. The raw bacon package was stored directly on top of the other stored food items, including the ready-to-eat deli meat. An adjacent reach-in cooler contained one-half of a sliced tomato wrapped in plastic, and two slices of tomato partially immersed in a white-colored opaque liquid in a ziploc bag. None of the packages were labeled with a use-by date. 4. On 11/172024 at 8:45AM, bulk sugar was stored in the manufacturer's bag in the kitchen pantry. A disposable plastic cup was located inside of the bag and all portions were in direct contact with the sugar. On 11/17/2024 at 8:52AM, the kitchen table-mounted can opener was soiled with sticky food accumulations and metal shavings. On 11/18/2024 at 12:38PM, the can opener remained in the same condition as above. 5. On 11/17/2024 at 8:45AM, floor surfaces throughout the kitchen, dishwashing room, and pantry areas were excessively soiled with accumulations of decomposing food debris, condiment packets, discarded hair nets, disposable utensils, drinking straws, and cardboard. On 11/18/2024 at 12:38PM, the floors remained as above. The Facility Assessment (undated) documents the facility will employ a Dietician and Certified Dietary Manager to provide care to residents in the facilty. On 11/17/2024 at 9:58AM, V5 reported food from the facility kitchen is available for all residents in the facility to eat. The facility Long-Term Care Facility Application for Medicare and Medicaid (11/17/2024) documents 54 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146162 If continuation sheet Page 16 of 28 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 146162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Moweaqua Rehab & Hcc 525 South Macon Street Moweaqua, IL 62550 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 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. 3. The facility Diet Report (11/18/2024) documents R14 receives a pureed diet. R14's Physician Orders (printed 11/20/2024) document R14 is ordered a pureed diet. Residents Affected - Some The facility menu (11/17/2024) documents residents receiving a pureed diet will receive pureed frosted cake during the lunch meal. On 11/17/2024 at 1:50PM, R14 was eating lunch in the facility dining room. R14's meal slip was present, with R14's menu selections circled including pureed frosted cake. No cake was present with R14's lunch meal. On 11/20/2024 at 9:17AM, V19 (Registered Dietician) reported the facility should be serving therapeutic diets as ordered. 4. R16's physician order, dated 5/10/24, documents an order for a regular diet with pureed texture including nectar thick fluids and low concentrated sweets with added fortified pudding with lunch and supper. R16's breakfast menu sheet, dated 11/19/24, documents pureed western scramble, oatmeal, wheat toast, sausage links, and crushed pineapple. On 11/19/24 at 9:15AM, R16 received pureed western scramble, sausage, and oatmeal. No pineapple or toast was provided as ordered. On 11/19/24 at 9:16AM, V11, Certified Nursing Assistant, stated R16 should have received pureed pineapple and toast. Based upon observation, interview, and record review, the facility failed to to ensure the resident's menus and/or the individual resident's food plan met her/his nutritional needs and preferences for four (R14, R16, R19, R43) of four residents reviewed from a total sample list of 34. 1.) R19's physician order, dated 2/5/24, documents diet order of regular diet mechanical soft texture with nectar thick fluids. On 11/17/24 at 1:10 PM, R19's plate of food includes carrots sliced, plain. [NAME] colored rice with brown orange cubes and green peas; fried breading piece mixed in; 1/2 cup red paste looking puree on side of plate. Side small plate has crumbled yellow cake substance with white frosting. Bowl contains plain macaroni noodles and brown lentil beans with clear liquid and thin red liquid as drink. V6, Resident family member, demonstrated carrots hard and unable to cut as well as cold when served. R19's Dietary slip, with meal dated 11/17/24 Lunch, documents diet as general, mechanical soft and nectar thick liquids. Meal to be served, pasta faggioli soup, white rice, grilled fried shrimp, glazed carrots and frosted yellow cake. 2.) On 11/17/24 at 9:45 AM, R43 stated her meals haven't been right since last week. They are not following menu, did not receive requested meal; specifically no biscuits gravy sausage, got eggs and oatmeal. When I don't like what is served for a meal, I'm only offered peanut butter and jam (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146162 If continuation sheet Page 17 of 28 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 146162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Moweaqua Rehab & Hcc 525 South Macon Street Moweaqua, IL 62550 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 0803 alternative. Level of Harm - Minimal harm or potential for actual harm On 11/17/24 at 9:50 AM, R43's breakfast plate on bedside table untouched. Meal ticket with plate documents biscuits and gravy and oatmeal circled as breakfast choices. Egg choice was scratched off ticket. Breakfast plate has scrambled eggs only, and small bowl contains oatmeal. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146162 If continuation sheet Page 18 of 28 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 146162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Moweaqua Rehab & Hcc 525 South Macon Street Moweaqua, IL 62550 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to serve timely and palatable meals to residents. These failures affect seven residents (R18, R19, R21, R25, R30, R31, R43) of 15 reviewed for meals in the sample list of 34. Residents Affected - Some Findings include: On 11/17/2024 at 8:39AM, V3 (Cook) reported facility meal times are 7:30AM, 12:00PM, and 5:30PM. On 11/19/2024 at 12:46PM, facility meal times were posted in the hallway outside of the dining room. The meals times posted were: breakfast at 7:30AM, lunch at 12:00PM, and supper at 5:30PM. The facility grievance log (January-November 18, 2024) documents 47 formal resident complaints related food. Facility Grievance Forms document the following recent grievances made during Resident Council meetings: --9/18/24: Cold food and Food is tasteless. --9/23/24: Food is cold and bad. Coffee is bad. --10/9/24: Cold food on hall trays and dining room. --10/9/24: Meals are not being served on time. --11/4/24: Breakfast on the hall 9:00/9:30AM Lunch on the hall 1:00/1:30PM. 1. On 11/17/2024 at 10:20AM, R30 reported supper meals have been late the last two weeks and should be served at 5:30-6PM, but have been served at late as 7:00PM. R30 stated it (the late meals) sucks, because I am hungry. 2. On 11/17/2024 at 11:09AM, R21 reported eating all meals in R21's room, and the meals are always late and cold. 3. On 11/19/2024 at 12:52PM, R31 reported hall meal trays do not arrive for breakfast until 9:15AM and lunch trays between 1:30-1:45PM and supper trays between 6:30-6:45PM. R31 reported the kitchen staff often get into verbal fights screaming at each other and have to shut the doors between the resident dining room and kitchen. She reported the staff fights make her feel not good. 4. On 11/19/2024 at the noon meal service, R18 did not receive lunch until 12:55PM. 5. On 11/19/2024 at 12:58PM, R25 was eating lunch in the facility dining room. R25 held up the dinner roll staff served for lunch and stated what do you think about that? The dinner roll was entirely black in coloration on the bottom and extremely hard when touched. 6. On 11/17/2024 at 12:45PM at the dining room designated for residents requiring feeding assistance, no lunch meals were present for residents. V8 (Certified Nurse Aide) was present and reported (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146162 If continuation sheet Page 19 of 28 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 146162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Moweaqua Rehab & Hcc 525 South Macon Street Moweaqua, IL 62550 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility staff transport residents to the dining room at noon and meals are late every day, and don't usually arrive until around 12:45PM, and hall trays don't arrive until 1:45PM. V8 reported lunch is supposed to be served to residents at 12:00PM. R19 was seated at the dining table waiting for lunch with V6, R19's family member. V6 reported being at the facility daily at noon with R19, and meals are always late and cold. Lunch meals were served at 12:55PM, and R19's meal temperature measured 90 degrees Fahrenheit by Illinois Department of Public Health thermometer. V6 stated, that's (R19's lunch meal) cold. On 11/17/24 at 10:55 AM, V6, R19's family member states she comes to feed R19 lunch everyday at noon scheduled time, but lunch is being served late everyday between 1:00pm and 2:00pm. On 11/17/24 at 12:04 PM resident in dining room, served red liquid in cup. No food in dining room. On 11/17/24 at 1:10 PM, R19 was served a plate. V6, family member, demonstrated carrots hard and unable to cut, as well as cold when served. On 11/18/24 at 1:25 PM, R19 was served a plate in dining room, V6, family member, stated the puree was ice cold. On 11/19/24 at 1:10 PM, R19 was served a lunch plate. Chicken temp was 98.2 degrees farenheit (F), soup temp 102.0 degrees F. 7. On 11/17/24 at 9:45 AM, R43 stated, Most of the time my food is cold and they never serve it on time. Sometimes I don't get lunch until 2:00 PM. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146162 If continuation sheet Page 20 of 28 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 146162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Moweaqua Rehab & Hcc 525 South Macon Street Moweaqua, IL 62550 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, and record review, the facility failed to provide the the correct food consistency for three residents (R263,R16, R19) of five residents reviewed for dietary consistency in a sample of 34 residents. Findings Include: 1. R263's Hospital History and physical, dated 11/8/24, documents, (R263) liquid/?pureed diet. This same history and Physical documents (R263) has been diagnosed with Advanced Amyotropic Lateral Sclerosis (AMS) for the past eight years. On 11/17/24 at 9:00AM, R263 was observed lying in bed leaning to the right side. R263 had severe contractures to all extremities and was unable to speak. R263 had a communication board and was able to express himself by pointing to letters or responses on the board. R263's full breakfast (ground consistency) was on the over the bed tray, untouched. When asked if R263 can feed self, R263 pointed to no. When asked if staff had offered to help, R263 pointed to no. There was a full cup of water on R263's over the bed tray. When asked if staff offer R263 drinks, R263 pointed to no. When asked if R263 refused care, R263 spelled out I don't trust. I am afraid. Nobody comes. When asked if R263 could swallow, R263 spelled out 'liquids' on his communication board. When asked if someone from Dietary had spoken with R263, he pointed to 'no'. When asked if R263 was in fear of choking, R263 pointed to 'yes'. On 11/20/24 at 9:12AM V19, Registered Dietitian, stated, I have not evaluated (R263). I was not aware (R263) has swallowing issues or was on a liquid or pureed consistency diet in the past. Given the history of AMS and swallowing problems, I would not think the ground meat appropriate for (R263). I would have hoped the facility would have alerted me of this when (R263) was admitted , but they didn't. I don't physically visit the facility. I am (out of state) and I do my consulting by telehealth. R263's Progress note by V2, Director of Nursing, dated 11/20/24 at 11:49AM, documents, Speech Therapy evaluated (R263) this AM and it was determined that resident is unsafe with pureed food and thickened liquids- recommendation was NPO. (Nothing by Mouth) Medical Doctor was notified and New Order received to send (R263) to emergency room for evaluation of Aspiration. 3. R16's physician order, dated 5/10/24, documents an order for a regular diet with pureed texture including nectar thick fluids and low concentrated sweets with added fortified pudding with lunch and supper. On 11/19/24 at 8:35AM, R16 was drinking regular chocolate milk, without thickener. On 11/19/24 at 8:36AM, V10, Certified Nursing Assistant, stated it was regular chocolate milk, not thickened, and she saw it poured directly from the container this morning. 2. R19's physician order, dated 2/5/24, documents diet order of regular diet mechanical soft texture with nectar thick fluids. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146162 If continuation sheet Page 21 of 28 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 146162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Moweaqua Rehab & Hcc 525 South Macon Street Moweaqua, IL 62550 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 11/17/24 at 10:55 AM, V6, R19's family member, states she comes to feed R19 lunch everyday, but feels that she doesn't get fed other meals. On 11/17/24 at 12:04, R19 was served red liquid in cup. Liquid thin, no label on pitcher. R19 was assisted with drink by V8, CNA. V8 states there are no thicked liquids on drink cart, and confirmed R19 recieved thin liquid. On 11/17/24 at 1:10 PM, R19's plate of food includes plain carrots sliced, brown colored rice with brown orange cubes, and green peas and fried breading pieces mixed in. 1/2 cup red paste looking puree on side of plate. Side small plate has crumbled yellow cake substance with white frosting. Smal side bowl contains plain macaroni noodles and brown lentil beans with clear, thin liquid. V6, R19's family member, demonstrated carrots hard and unable to cut. R19's meal ticket, dated 11/17/24 Lunch, indicates general mechanical soft diet with nectar thick liquids. On 11/18/24 at 1:25 PM, R19 was in dining room. R19 had pureed food, stating the served meal she was unable to eat. V6 states the puree was ice cold. Thin liquids, chocolate milk with served food. V6 confirmed chocolate milk was thin and poured from pitcher. R19 consumed 1/3 of meal. On 11/19/24 at 1:15 PM, R19 was served salad with chuncks of chicken and shredded cheese, no dressing, brownie square whole, and chocolate milk from kitchen pitcher. V6 stated it was not thickened and was the same milk all other residents served in dining room. R19's meal ticket, dated 11/19/24 Lunch, indicates general mechanical soft diet with nectar thick liquids. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146162 If continuation sheet Page 22 of 28 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 146162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Moweaqua Rehab & Hcc 525 South Macon Street Moweaqua, IL 62550 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to effectively sanitize dishes, failed to prevent direct cross-contamination of ice, failed to prevent the potential for biological cross-contamination of stored food, failed to prevent the potential for physical cross-contamination of food, failed to date and label TCS (time/temperature control for safety) food, failed to maintain sanitation test equipment supplies, and failed to maintain sanitary food service flooring areas. These failures have the potential to affect all 54 residents residing in the facility. Findings include: 1. On 11/17/2024 at 8:39AM, V3 (Cook) was working in the facility kitchen. When asked if the kitchen had dishwasher sanitizer test strips, V3 reported not being aware and stated, I have not been shown that yet, how to do that (how to use sanitizer test strips to test the dishwasher for adequate sanitizer concentration). On 11/17/2024 at 9:10AM, V4 (Dietary Aide) was washing resident dishes in the facility mechanical chlorine sanitizing dishwasher. When asked if the kitchen had sanitizer test strips to test the facility dishwasher to ensure the dishwasher was effectively sanitizing dishes, V4 proceeded to walk from the dishwashing room to the adjacent main kitchen area where the three-basin sink was located. V4 returned with a container of sanitizer test strips labeled to test quaternary ammonia sanitizer and not chlorine based sanitizer solutions. On 11/18/2024 at 12:45PM, V9 (Dietary Aide) was washing resident dishes in the above mechanical dishwasher. The dishwasher sanitizer solution concentration measured zero parts per million as measured by Illinois Department of Public Health chlorine sanitizer test strip. V9 observed the test strip and stated yes (the concentration of sanitizer in the dishwasher was zero parts per million). V9 reported thinking previously in the day something was wrong with the dishwasher because V9 had recently changed out the dishwasher's empty container of chlorine sanitizer for a full container and then tested the chlorine level with a sanitizer test strip from above, but still measured zero chlorine present in the dishwasher. V9 reported telling V5 (Dietary Manager) about the dishwasher problem, but V5 didn't respond to V9's concerns. A dishwasher log sheet (October 2024) was located on the wall beside the dishwasher, and did not have any log entries past October 3, 2024 documenting routine testing of the dishwasher sanitizer level to ensure effective dish sanitation. On 11/18/2024 at 12:38PM, the kitchen three-basin sink was in use with all three basins filled with solutions. The sanitize basin contained cooking pans and tested 100 parts per million sanitizer concentration by both a facility sanitizer test strip and Illinois Department of Public Health test strip. The container of sanitizer located immediately above the sanitize basin was empty. The manufacturer's label on the container documented a sanitizer concentration of 200-400 parts per million is required to effectively sanitize dishes. 2. On 11/17/2024 at 9:00AM, the kitchen ice machine was not operational and not producing ice. The storage bin on the machine was nearly empty, containing a layer of ice on the bottom of the bin appearing 3-4 in depth. V1 (Administrator) entered the kitchen and placed seven intact plastic bags of commercially prepared ice into the bin. The bags were randomly resting in direct contact with the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146162 If continuation sheet Page 23 of 28 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 146162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Moweaqua Rehab & Hcc 525 South Macon Street Moweaqua, IL 62550 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many existing ice located at the bottom of the bin. The exterior of several of the bags was visibly soiled with black-colored dirt and debris. V3 (Cook) was present and when asked if the ice in the bags would be emptied into the storage bin with the existing ice and then used for resident drinks, V3 stated yeah. On 11/17/2024 at 9:59AM, the above ice machine was operational and imminently ready to release ice into the storage bin. V3 was present and reported V3 was going to wait until the first batch of ice dropped down into the bin and then V3 was planning to empty the above bagged ice on top of the newly produced ice (effectively mixing together the ice in contact with the soiled plastic bags with newly formed ice). 3. On 11/17/2024 at 8:50AM, the reach-in cooler located by the kitchen two-basin sink had an open 48 ounce container of apple juice, an open 48 ounce container of orange juice, and an eight inch pie pan of quiche. None of the food items were labeled with the date opened or prepared or a use-by date. On 11/17/2024 at 8:52AM, the reach-in coolers located near the kitchen three-basin sink contained one-half of a deli ham roll wrapped in plastic, a gallon ziploc bag half full of hot dogs, a two liter plastic container full of a red liquid, a three liter plastic container filled with tuna salad, a gallon ziploc bag half full of ready to eat roast beef deli meat, a metal pan of cooked potatoes nested into a metal pan of cooked pasta (the bottom of the potato pan was in direct contact with the pasta), and a gallon ziploc bag half full of raw bacon. The exterior of the bacon bag was greasy when touched. None of the food packages were labeled with date opened or a use-by date. The raw bacon package was stored directly on top of the other stored food items, including the ready-to-eat deli meat. An adjacent reach-in cooler contained one-half of a sliced tomato wrapped in plastic, and two slices of tomato partially immersed in a white-colored opaque liquid in a ziploc bag. None of the packages were labeled with a use-by date. 4. On 11/172024 at 8:45AM, bulk sugar was stored in the manufacturer's bag in the kitchen pantry. A disposable plastic cup was located inside of the bag and all portions were in direct contact with the sugar. On 11/17/2024 at 8:52AM, the kitchen table-mounted can opener was soiled with sticky food accumulations and metal shavings. On 11/18/2024 at 12:38PM, the can opener remained in the same condition as above. 5. On 11/17/2024 at 8:45AM, floor surfaces throughout the kitchen, dishwashing room, and pantry areas were excessively soiled with accumulations of decomposing food debris, condiment packets, discarded hair nets, disposable utensils, drinking straws, and cardboard. On 11/18/2024 at 12:38PM, the floors remained as above. On 11/17/2024 at 9:58AM, V5 (Dietary Manager) reported food from the facility kitchen is available for all residents in the facility to eat. The facility Long-Term Care Facility Application for Medicare and Medicaid (11/17/2024) documents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146162 If continuation sheet Page 24 of 28 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 146162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Moweaqua Rehab & Hcc 525 South Macon Street Moweaqua, IL 62550 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 54 residents reside in the facility. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146162 If continuation sheet Page 25 of 28 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 146162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Moweaqua Rehab & Hcc 525 South Macon Street Moweaqua, IL 62550 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 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement a comprehensive quality program. This failure has the potential to affect all 54 residents who reside in the facility. Residents Affected - Many Findings include: The facility provided Long-Term Care Facility Application for Medicare and Medicaid, dated 11/18/24, documents 54 residents reside in the facility. The facility provided Quality Assurance Performance Improvement (QAPI) policy, dated January 2024, documents that the QAPI Program takes a systematic, comprehensive, and data-driven approach to maintaining and providing safety and quality while involving all caregivers in practical and creative problem solving. The community QAPI Program achieves the following: monitor quality/performance, find opportunities for improvement, improve performance, achieve resident/family desired outcomes, meet regulatory requirement, understand the CNA survey process and regulations, provide a QAPI path to correcting issues. The QAPI Program consist of monthly/quarterly meeetings, daily quality assurance activities, quality tasks and performance improvement plans. On 11/19/24 at 12:15PM, V1, Administrator, stated she was unaware of an active quality program functioning in the facility at this time, and that moving forward, she would be directing a comprehensive quality program. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146162 If continuation sheet Page 26 of 28 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 146162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Moweaqua Rehab & Hcc 525 South Macon Street Moweaqua, IL 62550 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and record review, the facility failed to develop quality based performance improvement projects including collecting and measuring data. This failure has the potential to affect all 54 residents in the facility. Findings include: The facility provided Long-Term Care Facility Application for Medicare and Medicaid, dated 11/18/24, documents 54 residents reside in the facility. The facility provided Quality Assurance Performance Improvement (QAPI) policy dated January 2024 documents that the QAPI Program takes a systematic, comprehensive, and data-driven approach to maintaining and providing safety and quality while involving all caregivers in practical and creative problem solving. The community QAPI Program achieves the following: monitor quality/performance, find opportunities for improvement, improve performance, achieve resident/family desired outcomes, meet regulatory requirement, understand the CNA survey process and regulations, provide a QAPI path to correcting issues. The QAPI Program consist of monthly/quarterly meeetings, daily quality assurance activities, quality tasks and performance improvement plans. On 11/19/24 at 12:15PM, V1, Administrator, and V17, Licensed Practical Nurse (LPN), were interviewed. V17, LPN, stated she had been an employee of the facility for several years, and she was unaware of any performance improvement projects or of quality measures being implemented by the facility. On 11/19/24 at 12:20PM, V1, Administrator, stated she was unable to locate any documentation of any performance improvement projects over the past year, and that moving forward quality improvement/performance improvement activities would be implemented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146162 If continuation sheet Page 27 of 28 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 146162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Moweaqua Rehab & Hcc 525 South Macon Street Moweaqua, IL 62550 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to hold quarterly quality improvement committee meetings, and failed to include the required members at these meetings. This failure has the potential to affect all 54 residents in the facility. Residents Affected - Many Findings include: The facility provided Long-Term Care Facility Application for Medicare and Medicaid, dated 11/18/24, documents 54 residents reside in the facility. The facility provided Quality Assurance Performance Improvement (QAPI) policy, dated January 2024, documents that the QAPI Program takes a systematic, comprehensive, and data-driven approach to maintaining and providing safety and quality while involving all caregivers in practical and creative problem solving. The community QAPI Program achieves the following: monitor quality/performance, find opportunities for improvement, improve performance, achieve resident/family desired outcomes, meet regulatory requirement, understand the CNA survey process and regulations, provide a QAPI path to correcting issues. The QAPI Program consist of monthly/quarterly meeetings, daily quality assurance activities, quality tasks and performance improvement plans. The facility provided one of four required sign in sheets for the last four quarterly quality meetings that did not include an Infection Preventionist in attendance. On 11/19/24 at 12:20PM, V1, Administrator, stated she would expect quarterly quality meetings to be held and that all required members of the quality committee should be in attendance including the Medical Director, Administrator, Director of Nursing, Infection Preventionist, and Pharmacist. At next year's annual, they will be done. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146162 If continuation sheet Page 28 of 28

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Citations

17 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0561SeriousS&S Gactual harm
F561 - Self-determination
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
0677GeneralS&S Epotential for harm
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
0758GeneralS&S Dpotential for harm
F758 - Medication Errors
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.
0803GeneralS&S Epotential for harm
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
0804GeneralS&S Epotential for harm
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
0805GeneralS&S Dpotential for harm
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
0812GeneralS&S Fpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0865GeneralS&S Fpotential for harm
F865 - Quality assurance and performance improvement (QAPI) program
Have a plan that describes the process for conducting QAPI and QAA activities.
0867GeneralS&S Fpotential for harm
F867 - Program feedback, data systems and monitoring
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
0868GeneralS&S Fpotential for harm
F868 - Quality assessment and assurance
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
0585GeneralS&S Epotential for harm
F585 - Grievances
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0689GeneralS&S Dpotential for harm
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0695GeneralS&S Dpotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0727GeneralS&S Fpotential for harm
F727 - Except when waived under paragraph (f) or (g) of this section, the
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
0791GeneralS&S Dpotential for harm
F791 - Dental Services
Provide or obtain dental services for each resident.
0801GeneralS&S Fpotential for harm
F801 - Staffing
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

FAQ · About this visit

Common questions about this visit

What happened during the November 20, 2024 survey of MOWEAQUA REHAB & HCC?

This was a inspection survey of MOWEAQUA REHAB & HCC on November 20, 2024. The surveyor cited 17 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at MOWEAQUA REHAB & HCC on November 20, 2024?

Yes, 17 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to and the facility must promote and facilitate resident self-determination through support o..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

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Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·November 20, 2024