Inspection·October 31, 2024

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 10/30/24 at 9:50 AM, V5 (Certified Nursing Assistant/CNA) said residents are scheduled for two showers per week and the CNAs do the best they can at getting them done, but sometimes showers get missed. V5 said showers are to be documented and turned in to the nurse. V5 said if a resident refused the shower then it is supposed to be documented and turned in to the nurse as well. On 10/30/24 at 9:30 AM, V2 (Director of Nursing) said showers are to be given twice per week and shower refusals are to documented. V2 said no further shower documentation was available for R56 or R7. A facility policy titled Bath, Bed/Shower/Tub, with revision date of February 2018, documented the following in part: The purpose of this procedure is to promote cleanliness and provide comfort to the resident, (staff are to document) The date and time the shower/tub bath was performed and if the resident refused the shower, the reason why and the intervention taken. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145323 If continuation sheet Page 2 of 7 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 10/31/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure restorative programs were implemented to prevent a decline in condition for one of one residents (R35) reviewed for position/mobility in the sample of 36. Findings Include: R35's admission Record with a print date of 10/31/24 documents R35 was admitted to the facility on [DATE] with diagnoses that included heart failure, heart disease, insomnia, and obstructive and reflux uropathy. R35's Minimum Data Set (MDS) dated [DATE] documents R35 had a BIMS (Brief Interview for Mental Status) score of 04, which indicates R35 has a severe cognitive deficit. This same MDS does not document any restorative programs or physical therapy. On 10/29/24 at 11:27 AM, V9 (Licensed Practical Nurse/LPN) was observed administering medication to R35. R35 was tearful. V9 questioned R35 why he was tearful and R35 stated that his family wants him to walk but they cannot find a tank (oxygen tank) for him to use. R35 stated he has not walked in he does not know how long and was not sure if he was able. V9 stated she would locate a tank and have someone walk him after lunch. V2 (Director of Nursing/DON) was also present during this interaction and stated she would locate a tank. When V2 returned, she stated she was going to have to have a conversation with (R35) because physical therapy did not have him on their list. On 10/29/24 at 3:20 PM, R35 was sitting in a wheelchair in his room. R35 stated he hadn't walked in a few weeks. R35 stated he did use his walker in his room to ambulate to the bathroom with assist of staff. R35's Order Summary Report dated 10/29/2024 did not document an order for restorative programs. R35's current Care Plan did not document a Focus Area for restorative programs or therapy. On 10/31/24 at 1:00 PM, when asked if she could verify R35 did not have a restorative program on the care plan, V1 (Administrator) stated R35's care plan did document the following interventions under the Covid 19 Focus areas, Encourage doorway exercise activities for modified socialization and Encourage the resident to participate in the facility therapeutic recreation/activity program. R35's PT (Physical Therapy) Discharge summary dated [DATE] documents under Discharge Recommendations and Status, Discharge Recommendations: Shower chair with back, Assistive device for safe functional mobility and Assistance with IADL's (Instrumental Activities of Daily Living). Restorative Programs- Restorative Program Established/Trained=Restorative Ambulation Program. Ambulation Program Established/Trained: Patient is currently able to walk in corridor, walk to dining room, and walk in room, balance is steady, and tier is functional and with Restorative Nursing Program, patient will be able to walk in room with assist of one, and walk in corridor with assist of one, and balance will require the physical support of one, by performing the following Restorative Nursing interventions: allow patient to take his or her time, provide assistance of one and use gait belt. R35's Nursing Restorative Care Program documents R35 has approaches of BUE (bilateral upper (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145323 If continuation sheet Page 3 of 7 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 10/31/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few extremities) with 2 # (pound) fw (free weights) x (times) 25 reps (repetitions) in all available planes and BLE (bilateral lower extremity) exercises with 2 # ankle weights x 25 reps in all available planes. This same Program documents neither approach was signed off as administered prior to 10/22/24. This indicates R35 had restorative program recommendations made during the physical therapy discharge assessment on 9/25/24 and restorative programs were not started until 10/22/24 and the walking program was not included in the restorative programs. On 10/29/24 at 1:55 PM, V8 (Director of Rehabilitation) stated they fill out a care plan form after someone finishes therapy and the care plan form documents what restorative programs a resident should be receiving and then it is given to the Restorative Aid, (V10). On 10/29/24 at 2:04 PM, V10 (Restorative Aid) showed this surveyor the restorative programs for R35 that documents his restorative programs with the date of 10/2024 and documents restorative programs began on 10/22/24. V10 stated to her knowledge there were no restoratives in place prior to 10/22/24 and if there would have been she would have known about them. V10 stated she got the care plan order from therapy and started it the same day on 10/22/24. V10 stated there were no restorative programs in place for R35 prior to 10/22/24. On 10/29/24 at 3:05 PM, V8 (Director of Rehab) stated R35's physical therapy evaluation documents an initial evaluation on 9/21/24, treatment on 9/24/24, and a discharge assessment on 9/25/24. This surveyor reviewed the discharge assessment and asked if the section labeled Discharge Recommendations and Status meant R35 should be walking with his restorative programs, V8 stated, Yes. When asked why the restorative program didn't start until 10/22/24, V8 stated she turned in the initial restorative programs before 10/22/24. When asked why it wasn't started before 10/22/24 she stated she didn't know and would have to check. On 10/30/24 at 2:23 PM, V8 (Director of Rehabilitation) stated she wasn't able to find any programs for R35 prior to 10/22/24 and no information on why there was no walking program. On 10/31/24 at 12:34 PM, when asked if she would expect restorative programs to start once the recommendations were made by physical therapy, V1 (Administrator) stated she would expect it to start as soon as they got everything together for them. This surveyor reviewed with V1, R35's therapy discharge summary was completed 9/25/24 with a recommendation for restorative programs and they were not started until 10/22/24. When asked if that was an acceptable time frame, V1 stated she would give them thirty days to start the restorative programs once the recommendation was made. On 10/31/24 at 2:00 PM, V8 (Director of Rehabilitation) stated someone could theoretically have a decline in their condition and abilities in thirty days. V8 stated they have now started meeting weekly so residents can get started on restoratives as soon as they are finished with therapy. The facility Restorative Nursing Services policy dated 7/2017 documents, Residents will receive restorative nursing care as needed to help promote optimal safety and independence FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145323 If continuation sheet Page 4 of 7 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 10/31/2024 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 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, record review and observation, the facility failed to implement planned fall interventions for 2 (R7 and R52) of 7 residents reviewed for falls in a sample of 36. Findings included: 1. R7's admission Record documented admission to the facility on [DATE] and included diagnoses of muscle weakness, abnormal gait, Parkinson's disease and extra-pyramidal/movement disorder among others. R7's Minimum Data Set (MDS) dated [DATE] documented R7 needs supervision from staff for toileting. This same MDS documented R7's had a Brief Interview for Mental Status (BIMS) score of 14, which indicates R7 was cognitively intact. A nursing note in R7's Electronic Health Record (EHR) dated 9/21/24 at 6:00 AM, documented the following in part: Resident observed lying on floor on back in doorway of room with overturned walker beside him. When asked what happened resident stated that he fell trying to go to bathroom. Resident is alert and verbal per norm. A form titled Illinois Department of Public Health Report with incident date of 9/21/24 at 6:00 AM documented the following in part: IDT (Interdisciplinary Team) reviewed this incident and found on 9/21/24 at 6:00 AM, (R7) got up from his chair in his room un-assisted and attempted to walk to the bathroom and fell . Upon IDT reviewing and investigating this incident, it was determined that (R7) exhibited poor safety awareness .Non-skid strips have been placed in (R7's) room. A bedside commode was placed in (R7's) room near his chair for easier and closer access. Resident's care plan has been updated accordingly. R7's Care Plan documented a focus area of: I am at risk for falls with initiation date of 11/8/2021. This same care plan under the Risk for Falls focus area, listed the following interventions: Bedside commode in resident's room near his recliner for easy access to use the restroom with initiation date of 9/21/2024. On 10/28/2024 at approximately 10:00 AM, R7's room was observed without a bedside commode present. On 10/29/2024 at approximately 10:00 AM and again at 1:45 PM, R7's room was observed without a bedside commode. On 10/30/2024 at 9:15 AM, R7's room was observed without a bedside commode present. On 10/29/2024 at 1:45 PM, R7 said he fell (9/21/24) trying to walk to the bathroom from his recliner. R7 said after his fall, the facility staff did not bring him a bedside commode and never even offered one for his use. R7 denied having any further falls since falling on 9/21/2024. On 10/30/2024 at 9:50 AM, V5 (Certified Nursing Assistant/CNA) stated R7 was not supposed to have a bedside commode as far as she knew. 2. R52's admission Record documented admission to the facility on 1/23/2023 and included diagnoses of dementia, chronic obstructive pulmonary disease and over active bladder. R52's MDS, dated [DATE], documented R52 has a BIMS score of 5, indicating R52 has severe cognitive impairment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145323 If continuation sheet Page 5 of 7 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 10/31/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A facility incident report dated 7/8/2024 documented R52 was observed on the floor next to his bed with his pillow and blanket. Full body assessment done and no injuries. R52 unable to explain if he fell or intended to lie in the floor. R52 unable to explain what happened. IDT reviewed and decided to implement a concave mattress as a safety measure. R52's Care Plan documented the following focus area of At Risk for Falls, initiated 1/23/2023. This same care plan under the Risk for Falls focus area, listed the following interventions: Scoop mattress (concaved mattress) to be applied to R52's bed with initiated date of 7/8/2024. On 10/29/2024 at approximately 10:45 AM, R52's bed was observed with a non-concaved regular mattress on it. On 10/30/2024 at 9:20 AM, R52's bed was observed with the same non-concaved mattress on it. On 10/30/2024 at 9:30 AM, V2 (Director of Nursing) said a scoop mattress (concaved mattress) has higher edges with a lower middle section. V2 said these types of mattresses help prevent a person from rolling out of bed. V2 said she did not know R52 was supposed to have a concaved mattress and she had never applied one to his bed. On 10/30/2024 at 9:50 AM, V5 (Certified Nursing Assistant) said R52 has not had a concaved mattress on his bed that she can remember. A facility policy titled Fall and Fall Risk, Managing, with revision date of March 2018, documented the following in part: When a resident is found on the floor, a fall is considered to have occurred. Staff will identify interventions related to the resident's specific risks to try to prevent the resident from falling and try to minimize complications from falling. Staff will implement a resident centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risk of falling. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145323 If continuation sheet Page 6 of 7 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 10/31/2024 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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to develop and implement a plan of care for a resident with Dementia that included appropriate treatment and services to attain or maintain the highest practicable well being for 1 (R77) of 3 residents reviewed for dementia care in a sample of 36. Residents Affected - Few Findings included: According to his admission Record, R77 was admitted to this facility on 10/10/2024 with diagnoses of dementia, bipolar and anxiety among others. R77's MDS (Minimum Data Set) dated 10/17/2024 documented R77 is never understood, has short and long term memory problems, and due to this R77 could not participate in a BIMS (Brief Interview for Mental Status) assessment. R77's Care Plan, with initiation date of 10/11/2024 included focus areas with interventions for the following problems and risks: urinary tract complications, weakness, self care deficit, risk for falls, risk for pain, risk for skin injury, risk for Covid 19, risk for constipation, black box medication warning and anticoagulant therapy. R77's Care Plan did not include a focus area with planned interventions to address R77's cognitive deficit or dementia. On 10/30/2024 at 9:30 AM, V2 (Director of Nursing) said it was her expectation for dementia care to be included in a resident's care plan if they had a diagnosis of dementia. On 10/30/2024 at 12:55 PM, V7 (Care Plan Coordinator) said R77's Care Plan did not address R77's cognitive deficits or diagnosis of dementia, but should have. V7 said it must have gotten missed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145323 If continuation sheet Page 7 of 7