Inspection·April 19, 2023

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few notified on 04/06/23 at 8:00am, The POA (Power of Attorney) was notified on 04/06/23 at 8:10am. Additional follow up: (R1's Physician) has been notified and the facility has received a verbal temporary order for a restraint if the resident's behaviors are causing harm to herself or others. After review of all statements, (V1/Administrator) believes, and according to (V15's) statement, she did willfully (she acted based on situation at the time to help protect (R1) from falling or attacking other peer, not that (V15) intended to use as a restraint), she did drape a sheet across the dining room chair, flowing to (R1) midsection a loosely tied the sheet around the back of the chair .Although the resident would have been able to remove the sheet .by definition it would still be considered a restraint. Restraint Policy: Restraints shall only be used for the safety and well-being of the resident(s), and only after other alternatives have been tried successfully. Restraint Assessment completed, order received from PCP (Primary Care Provider) for temporary use of restraint when all interventions have been exhausted, and she is presenting a danger to herself or others. Reassess in ten days for planned D/C (Discontinuation) of order. On 4/11/23 at 3:10pm V15 (RN) was interviewed by phone. V15 stated on 4/5/23 she worked from 6:00am to 6:00pm on the North Hall. V15 stated about ten minutes before her shift ended at 6:00pm, V15 saw R1 ambulating up the hall. V15 stated R1 is not to ambulate unassisted as R1 is, confused, a huge fall risk, and blind. V15 stated she went to R1, who was very wobbly, and R1 almost fell twice but V15 kept her from falling. V15 stated she sat R1 down at a table by the nurses' station in a chair by a peer. V15 stated she got R1 a snack, a drink, and an activity book, but R1 kept trying to get up. V15 stated R1 then started picking up the peer's activity book and pencils and started throwing them, and then started shaking the table. V15 stated she ambulated R1 to a dining room chair right by the nurses' station and sat her in it. V15 stated she tried distracting R1 by talking softly and holding her hand, but R1 was still trying to get up. V15 stated she then got a sheet from the linen closet and placed it across R1's lap and tied it loosely behind the chair. V15 stated the sheet was so loosely fastened R1 could have easily gotten up had she tried. V15 stated she placed an activity blanket in R1's lap. V15 stated R1 calmed right down and there were no further issues. V15 stated V14 (LPN) relieved V15 at 6:00pm, and V14 and V15 removed the sheet from R1, got her wheelchair, which had been in her room, they transferred R1 into it, and V15 went home. V15 stated the next morning, on 4/6/23 at about 4:30am, V15 was called by V1 who stated V15 failed to follow the restraint policy and was being written up and suspended until V15 could be in serviced, which was to be 4/12/23. V15 stated, I wasn't even thinking about the sheet being a restraint. And I was not trying to abuse R1, I love all my residents and would never do that. On 4/18/23 at 9:30am, the Surveyor asked V15 (RN) to recreate the sheet restraint with V8 (Certified Nursing Assistant/CNA) taking the place of R1. V15 demonstrated moving a dining room chair from around the table and moving it closer to the North Hall nurses' station, about six feet away from the nurses seat at the computer. V15 went to the linen closet and came back with a flat sheet, placing the sheet loosely on V8's lap and tying the back once over, not knotted, very loosely, leaving V8's hands and arms free. V15 stated there were no staff who witnessed her place the sheet around R1. V15 stated she did not contact R1's Physician or POA, did not check the chart for a Physician's Order or a Restraint Consent signed by the POA, or a Restraint Assessment. V15 stated she did not contact V2 (DON) stating V2 was already gone for the day. On 4/18/22 at 10:10am, R1 was observed in the facility dining room. R1 had no restraint devices in use. On 4/18/23 at 1:00pm, V2 (DON) stated per the facility policy V2 could temporarily authorize a restraint in emergency situations with a physician's order but acknowledged V15 on 4/5/23 did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145323 If continuation sheet Page 2 of 4 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 145323 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carrier Mills Nsg & Rehab Ctr 6789 US Rt 45 Carrier Mills, IL 62917 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few contact V2 nor obtain a physician's order. V2 stated when she arrived at the facility about 7:00am on 4/6/23, she immediately assessed R1 for injuries from the restraint and there were none. V2 stated on that day she completed a Restraint Assessment, obtained verbal consent from R1's POA and a physician's order for a least restrictive soft restraint. V2 was unable to explain what that meant exactly but acknowledged it wouldn't include tying R1 with a sheet to a chair. V2 stated she would need to contact V16 (R1's Physician) to clarify the order. An undated Restraint Consent Form listed R1's name at the top, and the Resident Representative Signature and Date line were blank. There was no documentation in the April 2023 Nursing Progress Notes to indicate V2 had obtained verbal consent from R1's POA for any restraint. A Physicians Telephone Order Sheet dated 4/8/23 documented, May use less resistant restraint for resident when behaviors could cause harm to self or others when other interventions exhausted. There was no medical diagnosis on this order to indicate what it was being used to treat or the specific type of restraint to be used. On 4/18/23 at 1:40pm, V14 (LPN) stated she entered the North Hall at about 5:55pm on 4/5/23 to begin her shift. V14 stated she saw R1 sitting in a dining room chair with a flat sheet around her middle, which was tied loosely behind the chair. V14 stated V15 said R1 had been having a lot of behaviors that day and V15 had been trying to calm her down. V14 stated she was Flabbergasted to see R1 restrained in this manner. V14 stated, I knew right then it was wrong, and I should have said something to her (V15) about it, but she is a good nurse and a good person, and I didn't want to get her into trouble. I think she was just frustrated and made a bad choice. V14 stated they removed the sheet, transferred R1 into her wheelchair, and R1 didn't have further behaviors. V14 stated she did not physically assess R1 as the sheet had not been tight enough to injure R1. V14 stated between 11:00pm to 12:00am that evening, V14 decided she needed to report the incident, so she called V2 (DON), who instructed her to notify V1 (Administrator). V14 stated she was told by V1 she should have immediately reported it, and V14 stated she was written up by administration Because they said I violated the abuse policy by not immediately reporting it. On 4/18/23 at 2:10pm, V1 (Administrator) stated she was called at about midnight on 4/6/23 to report R1 having been restrained as referenced above. V1 stated she asked V14 why she had not reported it earlier. V1 stated she began an immediate investigation, calling other staff who had been present on both the 6am to 6pm and 6pm to 6am shifts, and then called V15 (RN) and left V15 a voicemail. V1 stated V15 returned her call at about 4:20am on 4/6/23. V1 stated she told V15 about V14's report. V15 stated she had tried snacks, drinks, coloring books and pencils for redirection, which were not effective. V1 stated V15 told V1 she laid a sheet over R1's lap and loosely tied it behind the chair, placing an activity blanket in R1's lap, which was effective in calming R1 down. V1 stated V15 was written up for violating the facility's restraint policy due to not having a physician's order and the method of the restraint used. On 4/19/23 at 9:24am, V1 provided what she stated was an updated Physicians Telephone Order, undated, which stated, Least restrictive restraint possible when other interventions have been exhausted (soft fabric, loosely tied) in chair no more than one hour at a time. There was no diagnosis on this order. On 4/19/23 at 10:05am, V16 (R1's Physician) stated he was not contacted about R1 being restrained until V17 (Regional Director of Operations) called him on 4/7/23 in the late afternoon or early evening. V16 stated tying a resident to a chair using a sheet is not an appropriate form of restraint. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145323 If continuation sheet Page 3 of 4 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 145323 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carrier Mills Nsg & Rehab Ctr 6789 US Rt 45 Carrier Mills, IL 62917 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete V16 stated one to one supervision should have been utilized if other interventions were not working. V16 stated R1 has had several falls and gait instability. V16 stated going forward, if R1 requires a restraint he will probably order a weighted lap cushion. A Use of Restraints Policy with a revision date of April 2017 documented, The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove the device in the same manner in which the staff applied it .and this restricts his/her typical ability to change positions or place, that device is considered a restraint. Restraints shall only be used to treat the residents medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls .Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including Tucking sheets so tightly that a bed bound resident cannot move .(and) placing the resident in a chair that prevents the resident from rising .Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention and a restraint is required to: A) Treat the medical symptom. B) Protect the resident's safety, and C) Help the resident attain the highest level of his/her physical or psychological well-being .Prior to placing a resident in restraints, there shall be a pre restraining assessment and review to determine the need for restraints. Emergency use of restraints is permitted if their use is immediately necessary to prevent the resident from injuring himself/herself or others and/or to prevent the resident from interfering with life-sustaining treatment, and no other less restrictive interventions are feasible .The Director of Nurses has the authority to order the use of emergency restraints. The attending Physician must be notified of such and the reason for the order .Restraints shall be used upon written order of the physician and after obtaining consent from the resident and/or representative. Event ID: Facility ID: 145323 If continuation sheet Page 4 of 4