Inspection·January 26, 2024

F 0656 needs should have been incorporated and stated she just missed it. Level of Harm - Minimal harm or potential for actual harm The Therapeutic Diets policy, with a revision date of October 2017, documented, Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. Residents Affected - Few The Care Planning - Interdisciplinary Team policy, with a revision date of September 2013, documented, Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident 1. A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145376 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 145376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakview Nursing & Rehab 1320 West 9th Street Mount Carmel, IL 62863 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 - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide therapeutic diets for two residents on dialysis (R11, R27) of four residents reviewed for therapeutic diets in the sample of 37. Residents Affected - Few Findings include: 1. R11's Face Sheet documented an admission date of 9/20/23, and listed diagnoses including Acute Kidney Failure and Diabetes Type 2. R11's Physicians Order Sheet documented an order for hemodialysis Monday, Wednesdays, and Fridays at a local dialysis provider, and a diet order for a renal diet, low in fiber, with thin liquids and and a 1000 ml (milliliter) total per day fluid restriction. On 1/23/24 at 12:09 pm, R11, who was alert and oriented, stated she is on dialysis and is to receive a renal diet and fluid restriction. R11 stated she is often served foods she knows she is not supposed to eat, such as bananas and potatoes. R11 stated when this occurs, she does not say anything to staff, but she does not eat the food item. R11 was observed eating her lunch, which consisted of a sloppy joe on bun, french fries, baked beans, and a snickerdoodle cookie. The diet card was not with the plate. When the Surveyor asked R11 if these foods were allowed on her diet, R11 stated, Probably not, but they all taste good, so I am eating them. On 1/24/24 at 12:03 pm, R11 was again observed eating lunch in her room. The meal consisted of a bowl of chicken chunks in thickened broth, peas, a breadstick, and a brownie. The diet card was not with the plate. R11 stated she was not sure if any of the foods were not on her diet, but everything tasted good, so she decided she was going to eat it all. On 1/24/24 at 2:24 pm, V3, Dietary Manager, stated R11 should have been served a low fiber renal diet, which on 1/23/24 was to have been low sodium hamburger on bun, low sodium corn, and low sodium green beans, and a snickerdoodle cookie. V3 stated on 1/24/23, R11 should have been served baked chicken breast with pasta, low sodium peas, bread with margarine, and a brownie. V3 stated she was not sure why R11 did not receive the correct diet, but it may have been due to the diet cards being printed out without the correct diet on them. 2. R27's Face Sheet documented an admission date to the facility as 8/3/23. R27's Minimum Data Set (MDS), with an Assessment Reference Date of 11/3/23, documented in Section I, Active Diagnoses including Renal Insufficiency, Renal Failure, or End-Stage Renal Disease. R27's Physician Orders for January 2024 document her diet order as being, Liberal Renal CCHO (consistent controlled carbohydrate diet), Mechanical Soft Diet with thin liquids. 1500 cc (cubic centimeter) fluid restriction. On 01/24/24 at 12:06 PM, V5 (Certified Nurse Assistant) was observed delivering R27's meal tray to her room. R27 was observed lying in bed, drowsy. V5 reported R27 had dialysis this morning, which wears her out and requested her meal be saved for later. The food served was observed as being mechanical soft consistency chicken & dumplings, peas, a breadstick, and brownie. The meal tray contents observed reflected the foods printed on diet ticket, as well as the contents being confirmed by V5. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145376 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 145376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakview Nursing & Rehab 1320 West 9th Street Mount Carmel, IL 62863 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 01/24/24 at 2:03 PM, V3 (Dietary Manager) stated R27 should have received the renal diet as listed on the diet spreadsheet. Review of the diet spreadsheet documented the renal lunch menu that should have been served on 1/24/24 was to be, LS (low sodium) baked chicken breast with pasta, LS peas, bread/margarine, and brownie. On 01/24/24 at 2:21 PM, V3 confirmed there were a glitch in their computer system and R27 was not provided her renal diet as prescribed for lunch on 1/24/24. The Therapeutic Diets policy, with a revision date of October 2017, documented, Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145376 If continuation sheet Page 4 of 4