Health inspection·December 9, 2024

F 0550 On 12/9/24 at 3:10PM, V2, Corporate Director of Nursing, stated the expectation of the facility is that dignity should be provided to all residents with all care. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146162 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 146162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide bathing, oral care, and nail care to three (R1, R3, R4) of three dependent care residents reviewed for activities of daily living from a total sample list of eight residents reviewed. Residents Affected - Some Findings includes: 1.) R1's undated care plan documents admission to the facility on 5/24/24, with diagnoses including: sepsis with septic shock, encephalopathy, dysphagia, depression, morbid obesity, rheumatoid arthritis, weakness, and a need for assistance with personal care. R1's Minimum Data Set, dated [DATE], documents R1 as cognitively intact. R1's care plan, dated 5/28/24, documents R1 is dependent on bathing twice weekly, and on bathing days, staff are to check, clean, and trim nails as needed. On 12/9/24 at 3:03PM, R1's nails appeared long, more than 1/2 inch past the toe, with white and yellow matter on and between the toes. On 12/9/24 at 3:00PM, R1 stated her toenails are too long. I have asked the nurse's to cut my toenails and they just don't do it. I'm not a diabetic or anything, but I have stuff between my toes and my toenails and I just don't feel clean but I can't do it, I can't reach them. 2.) R3's undated care plan documents diagnoses that include: history of intellectual disability, hematuria, hydronephrosis, genitourinary surgery, depression, chronic leukemia, spondylosis, osteoarthritis, persistent atrial fibrillation, and need for assistance with personal care. R3's undated census sheet documents R3 was readmitted to the facility from the hospital on [DATE]. On 12/3/24 at 9:15AM, R3 was laying on a dried, bloody, bedsheet. R3's beard and hair were greasy. R3's had an odor of feces and body fluids. R3's teeth were black and brown, some teeth rotten with mucous covering them. R3's fingernails had a thick brown substance under them. R3's toenails were 1/2 inch beyond the end of the toe, with a yellow substance covering and between the toes. On 12/3/24 at 9:16AM, V7 and V11, Certified Nursing Assistants (CNA), were cleaning under R3's fingernails. V7, CNA, confirmed they were cleaning feces from underneath R3's fingernails and could not say how long it had been there. R3's Minimum Data Set, dated [DATE], documents R3 is severely cognitively impaired. R3's care plan, dated 8/20/24, documents R3 requires assistance for oral care and bathing. R3's task documentation for showers, dated 12/9/24, documents R3 is to have a shower twice weekly and as needed. R3's task documentation for oral care and bathing, dated 12/9/24, has no documentation for R3 for the last 28 days. 3.) R4's undated diagnosis sheet documents diagnoses that include: amyotrophic lateral sclerosis, low back pain, depression, weakness, dysphagia, speech disturbance, and need for personal care. R4's Minimum Data Set, dated [DATE], documents R4 is cognitively intact. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146162 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 146162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2024 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 12/4/24 at 11:23AM, R4 was sitting in a wheelchair in her private resident room. R4's hair appeared greasy (surrounding the edges) while wearing a hat. R4's teeth appeared to have a layer of mucus covering them. On 12/9/24 at 2:45PM, R4's teeth appeared to have mucous covering them. R4 stated she had not had her teeth brushed that day, and she does not always get a shower every week. R4's Minimum Data Set, dated [DATE], documents R4 is dependent for oral care and requires maximum assistance for showering/bathing. R4's task documentation for oral care, dated 12/9/24, does not document any oral care for the past 28 days. R4's task documentation for bathing, dated 12/9/24, documents R4 is to get showers twice weekly and as needed. The facility provided shower sheets documenting that R4 received a shower on 11/27/24 and then again on 12/8/24, eleven days later. On 12/9/24 at 3:10PM, V2, Corporate Director of Nursing, stated dependent residents should be assisted with bathing and nail care as often as scheduled or requested, and oral care should be provided at the beginning and end of each day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146162 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 146162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2024 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm Based on observation, interview, and record review, the facility failed to provide a residents' dietary recommendations to the physician, notify the Registered Dietician and physician of continued weight loss, obtain weights as ordered, follow dietary orders, and failed to report a residents' peg tube (gastric tube) placement to the Registered Dietician upon readmission to the facility. These failures affect one (R3) of three residents reviewed for nutrition on a total sample list of eight residents. These failures resulted in R3 losing 13.5% of his body weight in three and a half months, resulting in malnutrition, dehydration, and peg tube placement due to nutritional insufficiency. Residents Affected - Few Findings include: The facility weight assessment and intervention policy, dated 12/2024, documents the nursing staff will measure residents weight on admission, weekly for four weeks thereafter, and then monthly, if no weight concerns are noted. R3's progress notes, dated 8/16/24, document R3 was admitted to the facility with a history of intellectual disability, hematuria, hydronephrosis, genitourinary surgery, depression, chronic leukemia, spondylosis, osteoarthritis, persistent atrial fibrillation and a need for assistance with personal care. R3's weight summary, dated 8/16/24, documents: R3 weighed 149 pounds on 8/16/24, 131.6 pounds on 10/2/24, 130 pounds on 11/27/24 and 128.9 pounds on 12/2/24. No weight was documented in September 2024. R3's progress notes, dated 10/2/24, document R3 weighed 131 pounds, having lost l2% of his body weight. At this time, recommendations for weight gain were made by V4, Registered Dietician, to provide twice daily supplements and an appetite stimulant, neither of which were implemented. On 10/31/24, R3 was sent to the hospital for blood in the urine and a penile abcess. R3's hospital notes, dated 11/3/24, document a potassium level of 3.3milligrams (mg) compared to R3's potassium level, dated 7/18/24, of 3.8mg and R3's magnesium level dated 11/3/24 of 1.8mg, indicative of malnourishment, dehydration, and weakness to the degree that a feeding tube was placed for supplemental nutrition and fluids. R3's body mass index was documented on this date at 17.3, severely malnourished. On 11/3/24, hospital physician progress notes document a gastric tube placement will be discussed with the guardian given severe malnutrition which appears to have been going on for some time. R3's hospital discharge records, dated 11/27/24, document R3 returned to the facility with orders for oral intake of soft and bite sized food on a dysphagia three diet, with supplemental peg tube feedings. The formula included Osmolite 1.5 at 90 milliliters ml per hour, starting at 6:00PM and stopping at 8:00AM, and 50ml flushes with tap water every four hours. R3's intake records document the facility failed to provide R3 with the Osmolite 1.5 at 90 ml per hour for 14 hours, and instead provided it for 12 hours. Additionally, they did not provide R3 with oral nutrition from 11/27/24 until 11/30/24, when they obtained a nothing by mouth order until a speech consultation is obtained, due to weakness and inability for R3 to eat. R3's intake summary, dated 11/28/24 to 12/7/24, documents the first time oral nutrition is provided (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146162 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 146162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2024 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 0692 to R3 was on 12/5/24. Level of Harm - Actual harm R3's weight summary, dated 12/2/24, documents R3's weight measured 128 pounds, a loss of 13.5 percent of R3's total body weight in 3.5 months. Residents Affected - Few On 12/3/24 at 9:15AM, R3 was laying in bed, with blood and feces covering his sheets. R3's left arm was covered with a bandage, and his fingernails were caked with dark, thick, dough-like matter. R3's teeth were black and brown, with some teeth missing. R3 appeared severely underweight, with bones protruding from his translucent skin, and both legs contracted. On 12/3/24 at 9:17AM, V7 and V11, Certified Nursing Assistants, were cleaning R3's fingernails and body. V7, CNA, stated they were cleaning feces from underneath R3's nails. Both stated when R3 came to the facility in August of 2024, R3 was able to feed himself, they only supervised, and was able to wheel himself throughout the facility in a wheelchair, but now he is too weak to do anything for himself. R3's medical record does not document an attempt to obtain dental services for R3. On 12/4/24 at 10:45AM, V2, Corporate Nurse, stated R3 should have been offered dental services in light of his rotting teeth and weight loss. On 12/3/24 at 11:15AM, V3, Nurse Practitioner (NP), stated R3's tube feeding order from the hospital was intended to be a supplement to oral feedings, and did not contain enough calories to help with weight gain, which is why an additional oral feeding was ordered. V3, NP, stated R3 is malnourished and needs more calories, and the failure on the part of the facility to feed R3 and to notify V4, Registered Dietician, of R3's new tube placement and feeding order, as well as the failure to notify V5, MD, of the recommendations for weight gain by V4, RD, all contributed to R3's increased weight loss. On 12/3/24 at 2:51PM, V5, Medical Doctor (MD), stated he was not made aware of R3's significant weight loss or of V4, RD's, recommendations. V5, MD, stated he was called on 11/30/24 and told R3 was so weak that he couldn't eat. He said he told them not to feed R3 until a speech consult was obtained to make sure he was safe to eat. V5, MD, said he would have utilized the recommendations of (V4, RD), had he known about them, and he was accustomed to collaborating in other facilities with Dieticians. On 12/3/24 at 12:06PM, V4, Registered Dietician (RD), stated she was not aware the facility didn't implement the supplements and other recommendations she made on 10/10/24, and she wasn't notified R3 returned to the facility on a tube feeding until today. V4, RD, stated, I should have been notified of a new resident with a tube feed. (R3's) weight loss was preventable had they implemented supplements, provided me with regular weights, let me know what his oral intake looked like, and communicated with me so that I might have been able to help. He should have had an assessment when he returned. He just continues to lose weight and hyponatremia and hypomagnesemia are indicative of malnutrition and dehydration. On 12/4/24 at 10:15AM, V4, Registered Dietician (RD), stated she calculated R3's current tube feeding order, and it is insufficient to meet R3's caloric needs. (R3) is currently only receiving 990 calories and 42 grams of protein. This is why we have to be involved in all tube feedings from the start so that they get the nutritional support that they need and don't continue to lose weight. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146162 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 146162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2024 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 0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Level of Harm - Actual harm Residents Affected - Few Based on interview and record review, the facility failed to monitor and document a residents' tube feeding administration amounts, gastric tube placement, residuals, feeding complications, and consultation to ensure adequate nutritional intake was being administered via the tube feeding. These failures affect one (R3) of one resident reviewed for tube feedings from a total sample list of eight residents reviewed. These failures resulted in R3 having nausea and vomiting with tube feeding administration, the tube feeding being shut off without a physician order/consultation, and R3 experiencing continued significant weight loss. Findings include: The undated facility tube feeding skills checklist documents to monitor resident for feeding intolerance, document the verification of tube placement, amount and time of enteral feeding and amount of flush and report complications to the supervisor and medical practitioner. R3's progress notes, dated 8/16/24, document R3 was admitted to the facility with a history of intellectual disability, hematuria, hydronephrosis, genitourinary surgery, depression, chronic leukemia, spondylosis, osteoarthritis, persistent atrial fibrillation, and a need for assistance with personal care. R3's admission nutritional assessment, dated 8/29/24, documents an order for R3 to have regular, soft, bite sized foods. R3's weight summary, dated 8/16/24, documents R3's admission weight at 149 pounds. R3's weight summary, dated 10/2/24, documents R3's weight at 131.6 pounds, a 12% weight loss in 17 days. R3's medical record does not document the implementation of any Dietician recommendations or physician notifications of Dietician recommendations from admission throughout R3's entire facility stay. On 10/31/24, R3 was sent to the hospital for blood in the urine and a penile abscess. R3's hospital notes, dated 11/3/24, document a potassium level of 3.3milligrams (mg), compared to R3's potassium level, dated 7/18/24 of 3.8mg, and R3's magnesium level, dated 11/3/24 of 1.8mg, indicative of malnourishment, dehydration, and weakness to the degree that a feeding tube was placed for supplemental nutrition and fluids. R3's body mass index was documented on this date at 17.3, severely malnourished. R3's hospital discharge notes document on 11/27/24, R3 returned to the facility with a peg tube and an order for Osmolite 1.5 at 90cubic centimeter (cc) per hour for 14 hours with a 50cc tapwater flush every four hours, in addition to an oral diet of soft, bite sized food, dysphagia level three. R3's physician orders, dated 11/27/24, document the facility was administering R3's Osmolite 1.5 at 90cc for 12 hours, instead of the 14 hours as ordered upon discharge. R3's weight summary, dated 11/27/24, documents R3's weight as 130 pounds. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146162 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 146162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2024 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 0693 R3's weight summary, dated 12/2/24, documents R3's weight as 128.9 pounds. Level of Harm - Actual harm R3's physician progress notes, dated 12/3/24, documents V5, Physician, was asked to review R3's situation regarding poor oral intake, deconditioning, and weight loss. R3's notes document that the peg tube feeding is running from 6:00PM to 6:00AM, 12 hours at a time, and another two pound weight loss has occurred. Residents Affected - Few R3's physician orders, dated 12/3/24, document a change in tube feeding formula from Osmolite 1.5 at 90cc per hour to Jevity 1.5 at 50cc per hour to increase in 10 cc increments until reaching 70cc per hours for twelve hours, from 6:00PM to 6:00AM. R3's progress notes document R3 vomiting once on 12/4/24 and three times on 12/7/24 with feedings stopped on 12/4/24 and 12/7/24. R3's physician orders do not document an order to stop feedings, nor any consultation with the Dietician. R3's medical record does not contain documentation of verification of tube placement, amount of enteral feeding administered, or that all episodes of vomiting were reported to the physician and supervisor. On 12/9/24 at 10:20AM, V22, Registered Nurse/RN stated on 12/6/24 at 2:00AM, R3 vomited after dinner, and after his tube feeding was started, he vomited twice more. V22 stated she turned off R3's tube feeding and did not notify anyone. On December 7, 2024, I saw that he ate about 25% of his meal and then threw it up. The on call physician was then notified by the other nurse. At one point, we discussed talking with the Dietician, but it just didn't go anywhere. On 12/9/24 at 10:06AM, V4, Registered Dietician (RD), stated she was unaware the MD did not accept her recommendations for the tube feeding formula amounts and she was not made aware of R3 vomiting, so that another type of formula could be tried. Stopping the feedings was not the right choice in someone with malnourishment, we could have tried different formulas. On 12/9/24 at 12:00PM, V3, Nurse Practitioner stated she was never provided V4's, RD, recommendations. If I had gotten them, I would have communicated them to the doctor and definitely considered them, but neither I nor the physician were made aware of them. On 12/9/24 at 12:15PM, V2, Corporate Director of Nursing, stated when caring for residents with tube feedings, staff should be documenting intake and output incuding flushes and tube feedings, verification of placement and any complications. If they don't (document), you don't know if they are receiving all of the nutrition that they need. I would expect the Dietician would be involved at admission, weekly, and when there is a change of condition. Certainly the physician and Director of Nursing should be notified with any complications related to the feeding. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146162 If continuation sheet Page 8 of 8