Inspection·January 17, 2025

F 0641 with appropriate interventions. Level of Harm - Minimal harm or potential for actual harm R63's PASARR Level II, dated 9/9/2024, documented under Level II outcome that Level II approved with no special services. PASRR Level II diagnoses listed for PASRR Level II evaluation included bipolar disorder and unspecified anxiety. Residents Affected - Few On 1/15/2024 at 2:43 PM, V9 (MDS Coordinator) stated, There is a discrepancy with (R63's) admission information that had been entered into the MDS dated [DATE]. V9 stated she should have marked R63 had been considered a Level II by the PASRR documentation, with a diagnosis of having a serious mental illness. 3. R40's admission Record documented an admission date of 11/15/2024, with diagnoses including iron deficiency anemia, dysphasia, unspecified and chronic obstructive pulmonary disease with no diabetic diagnosis documented. R40's MDS documented with an Assessment Reference date of 11/22/2024, documented a Brief Interview for Mental Status Score of 15, indicating cognitively intact. This same MDS under Section N-Medications,

N0350. Insulin documents, A. Insulin Injections-Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days with 1 day entered for the response. R40's Order Summary Report, dated 1/17/2025, with active orders documented no physician order for insulin to be administered. On 1/15/2025 at 9:55 AM, R40 stated she had never been diagnosed with diabetes and had never been given insulin. On 01/15/25 12:53 PM, V9 (MDS Coordinator) stated there is a discrepancy with R40's MDS information that had been entered into the MDS dated [DATE]. V9 stated she should have not marked that R40 had received 1 injection of insulin within the last 7 days. On 1/15/2025 at 1:59 PM, V1 (Administrator) stated she would expect to follow the facility's MDS Completion and Submission Timeframes policy when entering in information. The facility policy titled MDS Completion and Submission Timeframes, (revised July 2017) documents under Policy Interpretation and Implementation, step 1 The Assessment Coordinator or designee is responsible for ensuring that resident assessments are accurate and submitted to CMS' QIES (Centers for Medicare and Medicaid Services' Quality Improvement and Evaluation System). Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145376 If continuation sheet Page 2 of 13 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 01/17/2025 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on interview and record review, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASRR) was completed for a resident with a diagnosed mental disorder for 1 (R23) of 4 residents reviewed for PASRR Screening in the sample of 42. Findings Include: R23's admission Record documented an admission date of 12/30/2022, with diagnoses including unspecified dementia, unspecified severity, with other behavioral disturbance, dysphasia and an additional diagnosis of bipolar disorder added 8/28/24. R23's Annual Minimum Data Set (MDS) documented an assessment date of 11/18/2024. Under section I: Active Diagnosis: I5900 it documents a Psychiatric/Mood Disorder diagnosis of bipolar disorder. On 1/15/2025 at 1:14 PM, V5 (Business Office Manager/BOM) stated R23's electronic health record (EHR) documented a diagnosis of bipolar disorder entered on 8/28/2024. V5 stated she was not employed at the time of this diagnosis, but does verbalize R23 should have been referred for a Level II PASRR. R23's Order Summary, dated 1/17/2025, listed active orders that included Quetiapine Fumarate 50 milligrams. Give 1 tablet daily for bipolar disorder, with a start date of 7/1/2024 documented. The facility was unable to provide any reproducible evidence that the PASRR agency had been contacted to complete a Level II screening, given the mental health diagnoses of bipolar disorder, that are listed on his Order Summary . The facility policy titled Behavioral Assessment, Intervention and Monitoring (revised March 2019) documents under Assessment step 5. New onset or changes in behavior that indicate newly evident or possible serious mental disorder, intellectual disability, or a related disorder will be referred for a PASARR Level II evaluation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145376 If continuation sheet Page 3 of 13 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 01/17/2025 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide activities to residents for 4 of 4 (R31, R43, R52, and R129) residents reviewed for activities in a sample of 42. Residents Affected - Some The Findings Include: R31's admission record documents an admission date of 7/16/24, and includes the following diagnoses: muscular dystrophy, cerebral palsy, and depression. R31's quarterly Minimum Date Set (MDS), dated [DATE], documents in Section C a BIMS (Brief Interview of Mental Status) score of 15, indicating R31 is cognitively intact. On 1/16/25 at 9:30 AM, R31 complained there is not enough to do in the facility, especially on the weekends. R31 stated they sometimes get coloring sheets printed off to color on over the weekend, but not every weekend. During the resident council meeting on 1/15/25 at 10:21AM, R31, R43, R52, and R129, who were all alert to person, place, and time, all stated there is not enough to do on the weekend for activities. Review of resident council minutes for 12 months has no documentation of complaints of lack of activities. On 1/17/24 at 11:30 AM, R52 stated she is the president of the resident council, and they most certainly have complaints every month on the lack of activities that occur, especially on the weekend. On 01/16/25 at 12:05 PM, V24 (Certified Nurse Assistant/CNA) stated she works day shift every other weekend. This past weekend, on 1/11/25 and 1/12/25, V24 said she worked both Saturday and Sunday. V24 stated sometimes there are activity staff there on the weekend, but she has never been asked to do activities on the weekend, nor would she have time to do them, not even to start a movie. V24 went on to state this past weekend, there were no activity staff present that she saw, and most residents usually sit in front of the TV on the weekend. Review of the January 2025 activities calendar shows there are activities planned on the weekend. On 12/11/25 they were supposed to have 1. what are we thankful for? 2. Sip and Sit 3. Thank You goodies for staff 4. Would you rather? On 12/12/24 activities listed as planned: 1. Back in the day. 2. Back porch chatter 3. Memory Lane Social Hour 4. Noodle ball. On 1/17/24 at 11:00 AM, V19 (Social Services) stated she is the interim Activities Director until they can find someone to hire for the position. V19 stated the CNA's are supposed to ensure activities are offered over the weekends. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145376 If continuation sheet Page 4 of 13 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 01/17/2025 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 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 maintain range of motion for 1 of 1 (R52) residents reviewed for range of motion in a sample of 42. The Findings Include: R52's admission Record documents an admission date of 9/12/23. This same document includes the following diagnoses: major depressive disorder, anxiety disorder, other specified joint disorders, morbid obesity, and other intervertebral disc displacement, lumbar region. R52's quarterley MDS (Minimum Data Set), dated 2/23/24, documents in Section GG that her functional limitation in range of motion that she has an impairment on one side of lower extermity. R52's most recent quarterly MDS, dated [DATE], documents in Section C that R52 has a BIMS (Brief Interview of Mental Status) of 15, indicating R52 is cognitively intact. Section GG documents for functional limitation in range of motion that R52 has an impairment on both sides for lower extremities. Section GG also documents for self care that R52 is dependent on toileting and putting on/taking off footwear, substantial/maximal assistance for personal hygiene and lower body dressing and shower/bathe self, and partial/moderate assistance of upper body dressing and oral hygiene. The same section for mobility documents: resident is dependent for tub/shower transfer, toilet transfer, chair/bed transfer and substantial/maximal assistance for rolling to left/right and sitting to lying. Section O of this same MDS documents R52 received 7 days of passive range of motion (with a look back period of 7 days). On 1/16/25 at 2:20 PM, R52 stated Occupational Therapy works with her on using a sliding board and hand strengthening for her carpal tunnel, but no one does anything with her lower extremities, and she figures it is because she doesn't have a hip joint and won't ever walk again. R52 stated she has not had any type of lower body exercises, and she prefers to stay in her hospital gown until she gets up for the day. R52 stated she tries to sit up for 2-3 hours in a chair, but due to her healed pressure sore on her bottom, she is careful about putting too much pressure on it. R52 stated she requires the help of staff to get dressed, but even when they dress her, they do not do any type of passive range of motion. On 01/16/25 at 02:21 PM, V10 (Certified Nurse Assistant/CNA), V17(CNA), and V18 (CNA) state they do not have anywhere to chart if they do range of motion. V10, V17, and V18 stated they think restorative nursing does the range of motion, however, she does not see all the residents. V10, V17, and V18 all stated they do not give the residents passive range of motion, unless dressing them counts. Review of current R52's Care Plan does not have a focus area in regards to limited range of motion, receiving therapy, or exercises to prevent a decline. Review of R52's current Order Summary Report does not have an order for R52 to receive restorative nursing, and this was confirmed by V23 (Rehabilitation Director) on 1/17/24 at 3:00 PM. V23 also confirmed at this time, ]R52 only receives therapy on her upper extremities due to carpal tunnel and is not seen by restorative aide for exercises. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145376 If continuation sheet Page 5 of 13 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 01/17/2025 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The facility policy titled Resident Mobility and Range of Motion Policy, with a revision date of 7/15/24, documents: 1. Residents will not experience an avoidable reduction in range of motion (ROM). 2. Residents with limited range of motion will receive treatment and services to increase and/or prevent further decrease in ROM. Therapy services will assess per physician order and develop ROM plan as needed. 3. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. Residents may receive directed services with therapy which include ROM prior to resident being placed on restorative services 6. The care plan will be developed by the interdisciplinary team based on the comprehensive assessment, and will be revised as needed. 7. The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in , and/or improve mobility and range of motion Event ID: Facility ID: 145376 If continuation sheet Page 6 of 13 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 01/17/2025 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide an environment free of accident hazards for 1 (R16) of 4 residents reviewed for accidents in the sample of 42. This failure resulted in R16 acquiring a laceration to her left lower leg resulting in 12 sutures being placed. This past noncompliance occurred between 11/27/24 and 11/28/24. The findings include: R16's admission Record documented an admission date of 7/15/2024, and diagnoses including neurocognitive disorder with lewy bodies, weakness, and unspecified diastolic (congestive) heart failure. R16's Minimum Data Set (MDS), dated [DATE], documented under section GG- Mobility that R16 is dependent, which means helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort for a chair/bed-to chair transfer. R16's Care Plan documents focus areas of potential impairment to skin integrity, with an initiation date of 7/18/24, and Potential for falls/injury r/t (related to) dx (diagnoses) of pain, weakness, visual loss, hx (history) of falls, incontinence, unsteady on feet, need for assistance with personal care, tremors, Parkinson's, abnormalities with gait and mobility, with an initiation date if 7/16/24. Documented interventions for these focus areas include: padded bed rails, avoid mechanical trauma, and enablers padded to reduce risk of injury. R16's Progress Note, dated 11/27/2025 at 3:00 PM authored by V16 (RN), documented, during a transfer of (R16) by (V16) and (V15) bumped her left lower leg on a sharp edge of grab bar causing two lacerations. Physician notified and (R16) sent to local emergency via ambulance. R16's Progress Note, dated 11/27/2024 at 5:44 PM, authored by V16 (RN) documented R16 returned to the facility with both lacerations to left lower leg sutured at local hospital. The facility's Initial Incident Report, dated 11/27/2024 with the final investigation, documents R16's bed rail had been noted to be missing a black safety cap at the end of the bed rail leaving a sharp area open. The bed rail had immediately replaced, and staff provided an in-service on safety measures when transferring dated 11/28/2024. The facility's Investigation Report, dated 11/27/2024, for R16's injury documented a predisposing environmental factor marked that furniture needs repair. R16's after visit summary from the local hospital, dated 11/27/2024, documented under procedure and tests performed during visit had laceration repair. On this same document under Instructions documented follow up for wound re-check, for suture removal. On 1/16/2025 at 12:23 PM, V7 (Special Care Manager) stated R16 had a laceration to her left lower leg a few months ago. V7 stated she had not been present during the incident, but her understanding had been the laceration occurred when R16 had been sitting up to the side of the bed and then transferred to her wheelchair by V14 (Certified Nurse Assistant/CNA) and V15 (CNA), when her left lower leg had gotten caught on the lower metal piece of the grab bar that had a black safety cap cover (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145376 If continuation sheet Page 7 of 13 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 01/17/2025 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 0689 missing. V7 stated the facility replaced the black safety cap, covered the ending with a pool noodle, and wrapped it with coban for padding. Level of Harm - Actual harm Residents Affected - Few On 1/16/2025 at 2:22 PM, V8 (Infection Preventionist/IP Nurse) stated R16 did have an incident on 11/27/2024. V8 stated V16 (Registered Nurse/RN) requested for her to come evaluate R16's laceration. V8 stated when she arrived to R16's room, V15 had been applying pressure to R16's left lower leg. V8 stated she had assessed the laceration, and requested for R16 to be sent to the local emergency room for further evaluation. V8 stated her understanding of the incident had been the lacerations occurred while V14 and V15 were transferring R16 to her wheelchair from her bed. V8 stated her understanding is R16 bumped her lower left leg on the edge of her grab bar. On 1/17/2025 at 9:24 AM, V14 (Certified Nurse Assistant/CNA) stated he had been present during R16's laceration to her left lower leg back in November 2024. V14 stated he and V15 (CNA) had dressed R16 then transferred her to her wheelchair from her bed while using a gait belt. V14 stated after R16 had been transferred, V15 noticed blood on the floor. V14 stated V15 applied pressure to R16's left lower leg, and he had gone to get the nurse to evaluate R16. V14 stated after evaluation by V16 (Registered Nurse/RN) and V8 (IP Nurse), R16 went to the local hospital for evaluation via ambulance. V14 stated R16 returned from the local hospital with sutures to her left lower leg. V14 stated after the investigation, it appeared that R16 had bumped her left lower leg on the edge of her grab bar that was missing a black safety cover. V14 stated the facility immediately fixed the grab bar with replacing the black safety cover, placed a pool noodle, and covered it with coban wrap. On 1/17/25 at 9:30 AM, V15 (CNA) stated R16 had been transferred from her bed to wheelchair while using a gait belt. V15 stated she noticed blood on the floor and turned to R16 and lifted her pant legs where she noticed a laceration to R16's left lower leg (calf area). V15 stated she immediately grabbed a clean pillowcase to apply pressure to and elevated her left leg. V15 stated she requested V14 (CNA) to notify the nurse to come to the room. V15 stated V16 (RN) came to the room and evaluated R16. V15 stated R16 had been sent to the local emergency room for further evaluation. V15 stated R16 returned to the facility with sutures to her left lower leg. V15 stated after the investigation, it appeared that R16 had bumped her left lower leg on the edge of her grab bar that was missing a black safety cover. V15 stated the facility immediately fixed the grab bar with replacing the black safety cover, placed a pool noodle, and covered it with coban wrap for padding. V15 verbalized confirmation of her undated investigation statement. On 1/17/2025 at 9:37 AM, V16 (Registered Nurse/RN) stated she had been called to R16's room to evaluate her. V16 stated when she arrived at the room, V15 (CNA) had been applying pressure to R16's lower leg while she had it elevated. V16 stated she had R16 transferred via ambulance to the local hospital for further evaluation of her left lower leg. V16 stated R16 did return to the facility with sutures to the lacerations of her left lower leg. V16 stated upon her assessment, her understanding of the incident had been during R16's transfer by V14 and V15, R16 had bumped her left lower leg on the bottom edge of her grab bar that was missing a black safety cover. V16 stated the facility immediately fixed the grab bar with replacing the black safety cover, placed a pool noodle over it, and covered it with coban wrap for padding. On 1/16/2025 at 12:25 PM, R16's right lower grab bar was observed to have a pool noodle placed over the black safety cap and coban wrapped around it for padding. Prior to the survey date, the facility took the following actions to correct the non-compliance: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145376 If continuation sheet Page 8 of 13 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 01/17/2025 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 0689 1. R16's bed rails have been assessed and padded by V1 (Administrator), V3 (Director of Nursing), V25 (Regional Coordinator) on 11/27/2024. Level of Harm - Actual harm Residents Affected - Few 2. All residents with side rails/enablers have been identified on 11/27/2024 by V1 (Administrator), V3 (Director of Nursing), V25 (Regional Coordinator) on 11/277/2024. 3. All side rails/enablers have been assessed and padded, if necessary, by V1 (Administrator), V3 (Director of Nursing), V25 (Regional Coordinator) on 11/27/2024. 4. The Maintenance Director (V26)/Administrator (V1) and or designee will audit to ensure the safety. Any issues identified will be immediately corrected and reviewed during the next regular scheduled QAPI (Quality Assurance and Performance Improvement) meeting with a completion date of 11/28/2024. 5. Reviewed Facility Inservice Sign in Sheet, dated 11/27/2024, with education on transfers with limb placement, enabled-bed rails, and resident room floors, re-educated on reporting defects to the maintenance department, transfers, and safe working order. In-service completed by V25 and V26. Staff signatures noted. 6. Reviewed the Facility QAPI (Quality Assessment and Performance Improvement) Meeting, dated 11/28/2024, that documented plan of correction including adaptive equipment inspections, side rail/enabler padded, with goals of all enablers will be in safe working order and side rails/enablers will be placed on weekly preventative maintenance schedule with any issues identified will be immediately corrected. Re-education given to all facility personnel on reporting any defects/potential defects to the maintenance department. All plan of correction actions were documented on 11/28/2024 as completed. QAPI form with staff signatures, action plan with goals and target dates completed by 11/28/2024 verified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145376 If continuation sheet Page 9 of 13 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 01/17/2025 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic medications for 1 of 1 (R52) residents reviewed for unnecessary medications in a sample of 42. The Findings Include: R52's admission record documents an admission date of 9/12/23. This same document includes the following diagnoses: major depressive disorder and anxiety disorder. R52's Minimum Data Set (MDS), dated [DATE], documents in section C, Cognitive Patterns, that R52 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R52 is cognitively intact. R52's January 2025 Order Summary Report includes the following medication orders: Ativan 1 milligram tablet by mouth every 6 hours as needed related to anxiety disorder. Ativan has a start date of 1/7/25 and an end date of 1/21/25. Buspirone 10 milligrams tablet by mouth two times a day related to anxiety disorder. This had an original start date of 9/12/23. Escitalopram 20 milligrams tablet one time a day related to major depressive disorder with original start date of 9/12/23. R52's Care Plan has a focus areas of: The resident has depression related her advanced kidney disease and resident has anxiety related to advanced kidney disease. and Potential for adverse reaction related to antidepressant medication use with an initiation date of 7/23/24. Documented interventions include: administer medications as ordered and monitor/document for side effects and effectiveness, assist the resident in developing a program of activities that is meaningful and of interest, musical bingo, resident council, the resident needs adequate rest periods, the resident prefers to rest after meals, and the resident needs time to talk daily, 1:1 visits to allow resident to express feelings. R52's Behavior Monitoring and Interventions Report from 9/1/24-current shows two days of recorded behaviors. On 12/28/24, R52's behavior tracking documents she had one instance of being anxious and sad/tearful, with an intervention of redirect and documented improvement. R52's behavior tracking also documents on 10/6/24 she had one instance of being sad/tearful with interventions of reapproach, 1:1, offer food/drink, and provide comfort and the behaviors improved. A Consultant Pharmacist Medication Regimen Review Communication, dated 6/26/24, documents a recommendation to: Please assess risk versus benefit and if your patient would benefit from a dose reduction of Buspirone 10 milligrams, Escitalopram 20 milligrams, and Lorazepman 1 milligram every 6 hours. The Physician's response, dated 7/16/24, documents the checked box of I disagree and documented patient is stable for now. On 01/16/25 at 12:43 PM, R52 stated she is not sure why she is on Buspar, as she never had been prior to coming here. R52 went on to state no one has ever spoken to her in regards to trying to reduce her Buspar or Escitalopram. R52 stated she has always been on an anti-depressant even prior to admitting to the facility, but never the anti-anxiety. On 1/16/24 at 2:00 PM, V17 (Certified Nurse Assistant/CNA) stated R52 does not regularly have any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145376 If continuation sheet Page 10 of 13 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 01/17/2025 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 0758 type of behaviors that she is aware of. Level of Harm - Minimal harm or potential for actual harm On 1/17/24 at 1:30 PM, V22 (CNA) stated he is not aware of R52 having any type of behaviors. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The facility policy titled Psychotropic Medication Use and Reduction documents 1. Residents will only receive psychotropic medication when necessary to treat specific conditions for which they are indicated and effective. 2. The attending Physician and other staff along with input from the resident, will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and other. 3. The attending Physician will identify, evaluate and document, with input from other disciplines, resident and consultants as needed, symptoms that may warrant the use of psychotropic medications. Event ID: Facility ID: 145376 If continuation sheet Page 11 of 13 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 01/17/2025 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide meals at a palatable temperature when delivering hall trays for 3 of 3 (R59, R69, and R74) residents reviewed for food palatability in a sample of 42. Residents Affected - Few The The findings Include: 1. R59's admission record documents an admission date of 6/19/24, and includes the following diagnoses: Diabetes Mellitus Type 2, anxiety disorder, pressure ulcer of left heel, muscle weakness, and unspecified open wound to foot. R59's quarterly Minimum Data Set (MDS), dated [DATE] Section C, documents a BIMS (Brief Interview of Mental Status) score of 15, indicating he is cognitively intact. On 1/15/25 at 12:06PM, R59 stated he chooses to eat in his room for all meals. R59 stated most of the time, all of his food is cold when it is delivered to him. R59 went on to state he sees the tray get delivered to the hallway, but there are times it takes over 20 minutes for the nursing staff to then get the trays passed out. 2. R69's admission record documents an admisison date of 10/14/24, and includes the following diagnoses: hisotry of falling, unsteadiness on feet, and neuropathy. On 1/15/25 at 1:00 PM, R69 stated she eats in her room for all meals due to it being her preference. R69 stated when her tray is delivered to her, the majority of the time her food is cold. R69 stated she has not asked the staff to heat it up because she knows they are busy and does not want to bother them. 3. R74's quarterly MDS, dated [DATE] Section C, documents a BIMS of 15, indicating she is cognitively intact. On 1/15/24 at 2:00 PM, R74, who was alert to person, place, and time, stated she eats her meals in her room and the food is cold when it finally reaches her. Review of Resident Council meeting minutes from July 3, 2024, had a problem brought up that the meals are not warm when served on the hall. The resolution to this concern was V20 (Dietary Manager) explained that covers were being ordered to help solve the issue with the food. Resident Council meeting minutes from January 7, 2025 had a problem brought up that there was cold food being delivered on the hallways and the resolution was to ask the food delivery person to use the microwave to heat it up. On 1/16/24 at 10:09 AM, V19 (Social Services) stated she currently does the resident council meetings because they are looking to hire a new Activities Director. V19 stated during the January meeting, the residents decided on the resolution of asking the staff to reheat the plates if the food is too cold, because they cannot seem to get the food delivered hot enough after complaining. On 1/17/24 at 11:30 AM, V20 (Dietary Manager) stated she was unaware that the problem was brought up in January regarding cold food, and back in July she had told the resident council she would look (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145376 If continuation sheet Page 12 of 13 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 01/17/2025 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete into pricing covers for the plates for hall tray deliveries. V20 stated an in service was completed and she thought the temperatures had improved, so the covers were never actually ordered. V20 stated the hall trays have the plate covered with foil to keep the food warm, and the carts they use are open to air and not insulated. The facility policy titled In Room Dining documented a Guideline: Although we encourage long term residents to eat in the dining rooms to encourage socialization and monitoring, in room dining is offered to the resident that may refer to stay in their room or who might be so critically ill or physically unable to go to the dining room. Procedure: .3. meals served in rooms may be periodically checked at the point of service for palatable food temperatures. Food temperatures of hot foods on room trays at the point of service are preferred to be at 120 degrees Fahrenheit or greater to promote palatability for the resident. If there is a concern about the temperature or palatability of the meal, a new meal should be ordered from dining services Event ID: Facility ID: 145376 If continuation sheet Page 13 of 13