Inspection·January 23, 2024

F 0686 Level of Harm - Minimal harm or potential for actual harm date. V3 said she then reported the change in R1's wound to V2 (DON) on 12/19/23 and was told that R1 would be seen in the facility by V9 (Wound Physician) on 12/21/23. V3 said that on 12/19/23, R1's wound did not have any odor or drainage. V3 said the afternoon of 12/19/23, R1 was transferred to the hospital for altered mental status and returned later on 12/19/23 with a diagnosis of Urinary Tract Infection (UTI) and was prescribed oral antibiotics. Residents Affected - Few R1's 12/19/23 hospital records documented in part . Sent from (facility) with possible UTI and increased confusion . Report of more confusion, history of UTI . Clinical Impression: Acute cystitis without hematuria . R1's progress notes documented R1 was sent to the hospital on [DATE] at 12:47 PM and returned to the facility on [DATE] at 5:40 PM. R1's hospital records documented a 12/21/23 at 2:13 PM note documented in part . Spoke with (Hospital Physician) regarding positive blood culture. (R1) given (intravenous antibiotics) in (Emergency Department) and prescribed (oral antibiotic) at discharge. (Hospital Physician) states treatment appropriate . On 1/16/24 at 1:42 PM, V2 (DON) said the last time she saw R1's wound it was just a small split at top of R1's gluteal fold. V2 initially stated she did not recall being notified by V3 that R1's wound had changed. On 1/18/24 at 3:24 PM, V2 (DON) clarified that she was notified of R1's wound change by V3 (LPN) over the phone on either 12/19/23 or 12/20/23. V2 said she was off work due to illness during that time. R1's Wound Healing Progress Report completed by V2 (Director of Nursing) documented a sacral wound with measurements (length x width x depth) as follows: 11/24/23 1 x 0.1 x 0.1 cm (centimeters), 11/30/23 1 x 0.1 x 0.1 cm, 12/7/23 1 x 0.1 x 0.1 cm, 12/14/23 1 x 0.1 x 0.1 cm. R1's Treatment Administration Record (TAR) documented the following orders: 9/25/23 through 12/15/23 cleanse area to sacrum with soap and water, pat dry, apply a thin layer of medihoney 100% paste, cover with calcium alginate and border dressing every shift; a 12/15/23 through 12/23/23 order to cleanse area to sacrum with soap and water, dry well, apply collagen and cover with calcium alginate and border dressing every shift, keep resident off sacrum as much as possible. On 1/16/24 at 3:00 PM, V9 (Wound Physician) said he was notified of R1's wound when he arrived at the facility on 12/21/23. V9 said R1's sacral wound prior to debridement was very large and open with black necrotic tissue and had a very strong odor. V9 said he debrided R1's sacral wound in the facility and changed the wound care treatment. V9 said he suspected R1 to have gas forming gangrene and was going to treat it with flagyl, dankins, and hydrogen peroxide. V9 said there was a second wound to R1's left buttock that did not appear to be infected. V9 said the second wound to R1's left buttock appeared to be a shear wound and could have happened just prior to V9 entering the facility. V9 said R1 was sent to the hospital on [DATE] after he had seen R1 in the facility where R1's wound was further debrided, and the sacral and buttock wounds became one. R1's 12/21/23 Wound Evaluation & Management Summary completed by V9 (Wound Physician) documented in part .Wound Sacrum Full Thickness .Etiology infection .Wound Size (Length x Width x Depth) 6 x 4 x 3 cm (centimeters) .Undermining 3 cm at 12 o'clock .Dressing Treatment Plan .Alginate calcium apply (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145323 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145323 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 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 0686 Level of Harm - Minimal harm or potential for actual harm twice daily for 30 days; Sodium hypochlorite solution (dakins) apply twice daily for 30 days: 1/2; Hydrogen peroxide apply twice daily for 30 days; Metronidazole sprinkle apply daily for 30 days .Wound of the Left Buttock Full Thickness .Etiology infection .Wound Size (Length x Width x Depth) 2 x 3 0.2 cm .Dressing Treatment Plan .Alginate calcium apply twice daily for 30 days; Sodium hypochlorite solution (dakins) apply twice daily for 30 days: 1/2 . Residents Affected - Few On 1/18/24 at 10:46 AM, V9 said he expected the facility to follow his orders. V9 said if the facility would have notified him on 12/19/23 with a picture of R1's wound, he would probably have changed R1's wound treatment orders to include dankins solution twice a day. V9 also stated however, if the facility would have notified him prior to 12/21/23, he did not think it would have changed R1's outcome. V9 said he had treated R1 for several years and R1 was very noncompliant with off loading pressure and the wound to R1's sacrum was unavoidable. R1's 1/14/24 Assessment for Clinically Unavoidable Pressure Sores documented in part . Clinical conditions that are the primary risk factors for developing pressure sores included, but are not limited to, resident immobility and: severe chronic pulmonary obstructive disease, chronic bowel incontinence, continuous urinary incontinence or chronic voiding dysfunction, sepsis, head of bed elevated the majority of the day due to medical necessity, serum albumin below 3.4 g/dl (grams per deciliter), weight loss of more than 10% during last month. On 1/18/24 at 1:09 PM, V14 (Attending Physician) said he could not recall if the facility had notified him of any changes to R1's wound on 12/19/23 or 12/20/23. V14 said if the facility had notified him, he would have ordered to continue the current wound treatment orders and to follow up with V9 on V9's next weekly visit. R1's December 2023 Electronic Medication Administration Record (EMAR) documented a 12/21/23 order for dakins wound solution to buttocks to be administered at 2:00 AM and 2:00 PM and was marked administered by V7 (Registered Nurse/ RN) on 12/21/23 at 2:00 PM. R1's Electronic Medical Record (EMR) documented the order for dakins wound solution to buttocks was entered on 12/21/23 at 1:29 PM by V7 (RN). R1's December 2023 Electronic Treatment Administration Record (ETAR) documented a 12/15/23 order for cleanse area to sacrum with soap and water dry well apply collagen and cover with calcium alginate and border dressing every shift. Keep resident off sacrum as much as possible at 2:00 AM and 2:00 PM and was marked administered by V7 on 12/21/23 at 2:00 PM. R1's December 2023 ETAR also documented a 12/21/23 order for apply dakins soak gauze with flagyl 250 mg (milligram) to wound bed cover with calcium alginate and border dressing at 2:00 AM and 2:00 PM, and was marked as administered by V7 on 12/21/23 at 2:00 PM. On 1/18/24 at 9:12 AM, V7 (RN) was asked which treatment he had completed for R1's wound care on 12/21/23 since there were three different wound care orders documented on the MAR and TAR, and V7 replied he did not know how to look up past charting on dressing changes. V2 (DON) assisted V7 with finding R1's December 2023 EMAR and ETAR. V7 said he did not recall which of R1's treatment orders he had completed on 12/21/23. V7 said he completed R1's wound treatments on 12/21/23 at 2:00 PM as they were charted. V7 was asked what R1's wound looked like on 12/21/23 and V7 replied he could not recall. V7 was asked if R1's wound was open on 12/21/23 and V7 replied he could not recall. V7 was asked who had given him the order to change R1's wound treatment on 12/21/23 and V7 replied he could not recall. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145323 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145323 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 1/18/23 at 9:21 AM, V2 (DON) said she expected staff would accurately chart any treatment they complete. On 1/18/23 at 9:58 AM, V11 (Certified Nursing Assistant/CNA) said R1's wound had gotten dark a few days prior to R1 being sent out to the hospital. V11 said R1's wound was open prior to V9 (Wound Physician) arriving on 12/21/23. During this interview, V7 (RN) interrupted V11 and told V11 she did not recall and instructed that she did not have to answer any of the surveyors' questions. R1's EMR progress notes from 12/8/23 through 12/21/23 did not document any change or new wounds to R1 or any complaints of pain to sacrum or buttocks. R1's 12/21/23 at 6:15 PM hospital record documented in part . arrived from (facility) with reports of altered mental status . (R1) has known UTI. (R1) was seen in the emergency department on 12/19/23 and diagnosed with UTI. (R1) was sent into the Emergency Department (ED) for worsening altered mental status today. Blood cultures review from ED stay on 12/19/23 revealed a positive culture in the aerobic bottle of Streptococcus dysgalactiae . (R1) does have history of frequent UTIs Differential Diagnosis: Cerebral Vascular Accident (CVA), Transient Ischemic Attack (TIA), UTI, encephalopathy, pneumonia . R1's hospital record documented a 1/5/24 Infections Disease Consultation in part .History of Present Illness: . patient is bed-bound, stage IV pressure ulcer sacral. Patient transferred from outside hospital earlier today for further treatment of suspected osteomyelitis of sacral area and recent bacteremia .patient recently admitted to (outside hospital) on 12/22/23 and found to have E. coli UTI (Urinary Tract Infection) and Streptococcus bacteremia. Patient had sacral wound culture on 12/22 which grew Proteus. Patient underwent debridement of the sacral ulcer on 12/28 and bone culture grew Enterococcus, Enterobacter, E. Coli. Tissue grew Enterococcus and Pseudomonas. Patient started on wound vac .Recommendations: Unfortunately there was not much benefit of long-term treatment of sacral osteomyelitis in bed-bound patient as soon as we stop antibiotics the infection will come back and progress. To assure success in treatment, patient has to be motivated, repositioned frequently with hospital bed, evaluated for nutritional status, and potential diverting colostomy .continue empiric antibiotics but I would recommend 14 days of treatment for soft skin tissue infection rather than full 6 weeks of treatment of osteomyelitis . The facility's revised April 2018 Pressure Ulcers/ Skin Breakdown - Clinical Protocol documented in part . the nurse shall describe and document/ report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue .The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents .During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or poorly-healing wounds .The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions . The facility's revised April 2019 Administering Medications policy documented in part .4. Medications are administered in accordance with prescriber orders, including any required time frame .22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. The date and time the medication was administered; b. The dosage; c. The route of administration; .g. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145323 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145323 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The signature and title of the person administering the drug. 24. Topical medications used in treatments are reordered on the resident's treatment record (TAR) . The facility's revised May 2017 Change in a Resident's Condition or Status policy documented in part .Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status .The nurse will notify the resident's Attending Physician or physician on call when there has been a (an): d. significant change in the resident's physical/ emotional/ mental condition; e. need to alter the resident's medical treatment significantly; .A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff .c. Requires interdisciplinary review and/ or revision to the care plan .Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/ mental condition or status .The nurse will record in the resident's medical record information related to changes in the resident's medical/mental condition or status . Event ID: Facility ID: 145323 If continuation sheet Page 5 of 5