Inspection·September 25, 2025

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to be worn when entering a room where a resident has tested positive for Covid. When asked if V16 should have worn eye protection, a gown, and an N95 when she entered R34 and R57's room, V15 stated she would have to check on that. 3. R44's admission Record with a print date of 09/25/2025 documents R44 was admitted to the facility on [DATE] with diagnoses that include atrial fibrillation, heart failure, chronic kidney disease, and vascular dementia. R44's MDS dated [DATE] documents R44 has a BIMS score of 05, indicating a severe cognitive deficit. R44's Order Summary Report dated 9/25/25 documents a physician order of, Contact Isolation Per Facility Protocol Related To (+) for Covid. R44's current Care Plan does not document a Focus area related to Covid and/or Transmission Based Precautions. On 09/22/2025 at 12:58 PM, V17 (Environmental Services) entered R44's room after donning a gown, gloves, and an N95. V17 did not don eye protection prior to entering R44's room. When asked why she didn't don eye protection prior to entering the room, V17 stated they didn't have any available on the unit for her to don so she didn't put eye protection on. This surveyor observed face shields (eye protection) in bins/door storage on the same unit throughout this same time frame. On 9/25/25 at 9:00 AM, V1 (Administrator) stated staff should wear full PPE, including gown, gloves, eye protection, and N95 when entering a room where a resident has tested positive for Covid and is on droplet precautions. The facility Isolation Policy-Categories of Transmission-Based Precautions dated January 2023 documents, Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Droplet Precautions: 1. Droplet Precautions may be implemented for an individual documented or suspected to be infected with microorganism transmitted by droplets (large-particle droplets).that can be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning). 2. Residents on droplet precautions will be placed in a private room if possible. a. When a private room is not available, residents may share a room with a resident infected with the same microorganism or with limited risk factors.3. Masks will be worn when entering the room. 4. Gloves, gown, and goggles should be worn if there is a risk of spraying respiratory secretions. Airborne Precautions: 1. Airborne precautions are indicated when an individual is infected with a pathogen that is very small.and can be transmitted long distances through the air. 2. Preventing the spread of airborne pathogens requires a room with special air handling and ventilation called an airborne infection isolation room (AIIR). 3. If an AIIR is not available, a resident suspected of having an airborne infectious disease shall be masked and transported to a facility with an AIIR. The facility Coronavirus Prevention and Control policy dated 7/9/2022 documents, . Residents with Confirmed Covid-19.Staff wear full PPE (N95, respirator, gown, gloves, eye protection. 4. R76's admission Record documents an admission date of 3/21/25 with diagnoses including but are not limited to type II diabetes mellitus with diabetic neuropathy, peripheral vascular disease, peripheral vascular angioplasty, and long term use of anticoagulants. (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 09/25/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R76's most recent care plan documents R76 has a focus area dated 4/1/25 of being at risk for impaired skin integrity. Interventions for this focus area include but aren't limited to float heels while in bed dated 4/1/25, observe for signs and symptoms of breakdown/infection dated 4/1/25, and skin assessment on admission and weekly dated 4/1/25. Another focus area dated 6/13/25 documents R76 has an actual alteration in skin integrity. Interventions for this focus area include but are not limited to pressure relief surface to bed dated 9/23/25 and to see treatment orders on physician's order sheet and skin and wound tabs. R76's Physician's Order Summary Report includes but are not limited to Enhanced Barrier Precautions due to organism in urine dated 7/28/25, cleanse bilateral lower extremity wounds with wound cleanser, pat dry and apply mupirocin 2% ointment to wound of left proximal leg, then cover with gauze and wrap lower left extremity from toes to knee daily to prevent picking /scratching dated 9/23/25, and to clean right mid leg wound with wound cleanser pat dry and apply mupirocin 2% ointment and cover with gauze daily dated 9/23/25. R76's MDS dated [DATE] in section I documents a diagnosis of peripheral vascular disease and diabetes mellitus. R76's Skin and Wound Evaluation's dated 9/24/25 document a venous stasis ulcer to right dorsum of 3rd toe that was present on admission that measured 0.2 centimeters (cm) by 0.5cm by 0.6cm with granulation tissue, a venous ulcer to right medial malleolus that measures 1.1cm by 1.7cm by 0.9cm covered with 10% of epithelial tissue and 90% granulation tissue, a wound labeled as other that are caused from R76 scratching at her skin located on the right shin, and a wound of left lateral lower leg caused from scratching self. On 9/24/25 at 3:52 PM, R76's dressing changes and treatments to multiple wounds of bilateral lower extremities performed by V4 (Registered Nurse/RN) and V3 (Assistant Director of Nurses) was observed. Upon entering the room there was EBP signage observed on R76's door and supplies located outside of the room including disposable gloves and disposable gowns. V4 donned and doffed gloves and performed hand hygiene between dressings and from cleaning to applying the dressing of each wound. V4 was not observed wearing a disposable gown while providing care and treatment of R76's wounds. On 9/25/25 at 7:57 AM, V4 stated EBP is followed for when providing high contact care like dressing and treatment of wounds, if the resident is infected with a multidrug resistant organism or has any implanted medical devices such as a urinary catheter or intravenous catheter. V4 stated before providing wound care on 9/24/25 to R76 she should have donned a disposable gown. V4 agreed EBP was not fully followed since she did not don a disposable gown before providing care to R76's wounds. 5. R5's admission Record documents an admission date of 6/10/22 and diagnoses including but are not limited to type II diabetes mellitus with diabetic neuropathy, repeated falls, and unspecified dementia. R5's most recent Care Plan documents a focus area of R5 is at risk for actual alteration in skin integrity dated 9/21/25. Interventions related to this focus area include but are not limited to float heels while in bed dated 10/16/24, incontinence care and apply barrier cream dated 10/16/24, pressure relieving mattress dated 10/16/24, and treatments as ordered dated 10/16/24. R5's Physician's Order Summary Report documents the following orders including Enhanced Barrier Precautions due to wound dated 9/25/25, apply equal parts of nystatin cream and zinc to surrounding (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 09/25/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some area and apply a small dressing to coccyx laceration and scratches on buttocks every shift, and to apply zinc oxide ointment 10% apply to coccyx buttocks dated 9/12/25. R5's MDS dated [DATE] documents in section I diagnoses of multi drug resistant organism pneumonia and diabetes mellitus. Section M of same MDS documents R5 has a pressure ulcer injury/a scar over a bony prominence, or a non-removable dressing/device. R5's Skin/Wound Evaluation dated 9/18/25 documents R5 has a pressure wound, stage 2 located on medial coccyx. Wound measurements on that date were 0.4 centimeters (cm) by 1.5cm by 0.3cm. Same skin evaluation documents 100% of wound bed was granulation tissue. Same skin evaluation documents scratch marks as well to buttocks. Progress for wound was documented as improving. On 9/24/25 at 3:44 PM, dressing change on R5's coccyx and buttocks performed by V4 and assisted by V14 (Certified Nurse's Aide /CNA) was observed. V4 donned gloves and performed the dressing changes to R5's coccyx and buttocks according to physician's orders. V4 donned and doffed gloves and performed hand hygiene between wounds and between cleansing and applying new dressings according to current standards of practice. V4 and V14 were not observed wearing disposable gowns while providing wound care. There was no EBP signage on R5's door or any EBP or PPE supplies on or near the entryway to R5's room. On 9/25/2025 at 7:57 AM, V4 stated EBP is used when treating wounds, a resident has an infection caused by a multidrug resistant organism or had implanted medical devices. V4 stated she as well as V14 should have donned a disposable gown along with disposable gloves before providing wound care to R5. V4 agreed EBP was not completely followed while providing wound care because gowns were not donned for the dressing changes. V4 also agreed there was no signage on the door of R5's room or any EBP supplies located at or near the door of R5's room. On 9/25/25 at 12:44 PM V2 (Director of Nurses/DON) stated EBP should be employed when providing wound care, if a resident is infected with a multidrug resistant organism, or if a resident has some sort of implanted medical device that extends from the body. V2 stated EBP includes but isn't limited to the wearing of disposable gowns, gloves and sometimes face shields depending upon the care being provided. V2 stated she would expect EBP precautions to be followed and personal protective equipment be worn including disposable gowns and gloves for providing wound care to residents. V2 agreed V4 and V14 should have donned disposable gowns along with their disposable gloves before providing wound care to R5 and R76. The facility's Enhanced Barrier Precaution (EBP) policy dated 3/28/24 documents that EBP expands the use of personal protective equipment and refer to an infection control intervention designed to reduce transmission of multidrug resistant organisms that employs targeted gown and glove use during high contact resident care activities. Facility's EBP policy also states EBP will be instituted for those residents deemed to be at high risk for multi drug resistant organisms with any of the following: wounds and or indwelling medical devices even if the resident is not known to be infected or colonized with a multidrug resistant organism. Examples of high contact resident care activities requiring gown and glove use for EBP include wound care meaning any skin opening requiring a dressing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145323 If continuation sheet Page 4 of 4