Inspection·April 18, 2023

F 0684 Level of Harm - Minimal harm or potential for actual harm R1's Physician Order, dated 3/28/23, documents Apply skin sleeves daily. every night shift for skin care related to other Non-thrombocytopenic Purpura. R1's April 2023 Treatment Administration Record (TAR), has no documentation R1 had skin sleeves applied every night on 4/5 and 4/11/23. Residents Affected - Few R1's March 2023 TAR, has no documentation R1's geri sleeves were applied on 3/24/23. R1's April 2023 TAR has no documentation R1's skin protective sleeves were applied on 4/12 and 4/13/23. R1's Physician Order, with start date of 3/7/23 and discontinued date of 4/2/23, documents Clean skin tear to left elbow daily with normal saline. Apply TAO (triple antibiotic ointment) to wound and cover with dry dressing until healed. R1's March 2023 TAR has no documentation R1 received treatment to her left elbow skin tear on 3/7, 3/9, 3/14 and 3/15/23. R1's Physician's Order, with start date of 2/23/2023 and discontinued date of documents Cleanse abrasion to left shin & left lateral calf with wound cleanser, apply xeroform to wound bed, cover with ABD (abdominal pad-highly absorbent pad), wrap with gauze bandage roll, secure with tape every night shift. R1's March 2023 TAR documents R1 did not receive the treatment to left shin and left lateral calf on 3/6 and 3/7/23, 3/9, 3/13, 3/14 and 3/15/23. R1's April 2023 TAR documents R1 did not receive the treatment to left shin and left lateral calf on 4/5 and 4/11/23. On 4/17/23, at 2:00 PM, R1 was wearing no (trade name) skin protective sleeves. There were no skin protective sleeves located in her room. On 4/17/23 at 2:40 PM, V10 (Certified Nursing Assistant/CNA) stated, We haven't seen R1's skin-sleeves in a long time. If I know R1, she probably took them off and they disappeared. I don't remember even seeing R1 with them on. R1's April 2023, dated 4/17/23, documented R1 was wearing skin protective sleeves although they were unavailable. 2. R2's admission Record, dated 4/13/23, documents that R2 was admitted to the facility on [DATE] and was discharged on 4/5/23 with diagnoses of Atherosclerosis of native arteries of bilateral lower extremities, Traumatic brain injury, Pressure ulcer Sacrum Stage 3, Falls, UTI's (Urinary Tract Infections), Neuromuscular dysfunction of bladder, TIA (Trans ischemic Attack), Left upper arm amputation. R2's Care Plan, dated 3/2/23, documents R2 has actual impairment to skin integrity r/t (related to) fragile skin, History of pressure wounds to left lateral shin, right medial shin, right posterior heel, left lateral heel, left lateral ankle, left great toe, left foot 1st digit, left foot 2nd digit, left medial heel, pressure to sacrum. Interventions: Apply offloading boots as resident will allow, Avoid mechanical trauma: Constrictive shoes, cutting and trimming corns and calluses, adhesive tapes, Improper shaving, vigorous massage, avoid shearing while repositioning when in bed, carefully dry between toes, needs pressure redistributing cushion to protect the skin while up in chair, needs pressure relieving boots to bilateral feet at all times, needs turned and repositioned every two (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 2 of 9 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 145454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlinville Rehab & Hcc 751 North Oak Street Carlinville, IL 62626 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hours and more frequently if needed, encourage good nutrition and hydration in order to promote healthier skin, float heels while in bed as tolerated, low air loss mattress to bed, monitor/document/report to MD PRN for s/sx of infection: [NAME] drainage, foul odor, redness and swelling, red lines coming from the wound, excessive pain, fever, observe extremities for s/sx or poor tissue perfusion: Poor cap refill, poor pulses, cyanosis, clubbing, lack of sensation, cold to touch. Document changes from baseline. Report significant findings to MD. R2's MDS, dated [DATE], documents that R2 was cognitively intact and is totally dependent of one to two staff members for most of his ADLs. R2's MDS documents R2 had suprapubic catheter in and was always incontinent of bowel. R2's MDS documents R2 is at risk for pressure ulcers and requires a pressure reducing device for chair and bed, is on the turning & repositioning program, and requires the application of dressings. R2's PO, start date of 1/25/23, documents Apply skin prep to left foot 2nd digit daily every night shift for healing. R2's TAR, dated March 2023, documents no skin prep was done to R2's left foot/second digit and great toe (every day) on 3/6/23, 3/7/23, 3/9/23, 3/14/23, and 3/23/23. R2's PO, start dated of 1/25/23, documented Apply skin prep to left medial heel daily every night shift for healing. R2's March 2023 TAR, documents no skin prep was done to this left media heel on 3/6, 3/7/3/9, 3/14 and 3/23/23. R2's PO, start date of 3/23/23, documents Cleanse left lateral shin with wound cleaner, apply Calcium alginate AG to wound bed, cover with ABD pad, wrap with gauze bandage roll, secure with tape and apply (brand) elastic supportive bandage, over bandage daily and PRN till healed every night shift for healing. R2's March 2023 TAR had no document a treatment was completed on the R2's left lateral shin on 3/6, 3/7, 3/9, 31/4 and 3/23/23. R2's Health Status Note, dated 4/6/23 at 8:04 AM, documents Wound Nurse had spoken with V6 (Wound Doctor) to clarify his assessment, it stated (R2) had a stage 4 pressure area to left ankle lateral aspect, the wound bed assessment is arterial, clarified that his areas are arterial due to non-compressible veins. On 4/13/23 at 10:30 AM, V3 (Minimum Data Set Coordinator), stated, R2 had uncompressible veins and had constant wounds on his legs. All of his wounds were arterial. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 3 of 9 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 145454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlinville Rehab & Hcc 751 North Oak Street Carlinville, IL 62626 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 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide timely turning and repositioning, pressure relief, and pressure ulcer treatments per physician's orders for 4 of 4 residents (R1, R2, R3, R4), reviewed for pressure ulcers in the sample of 4. Residents Affected - Some Findings include: 1. On 4/13/23 at 1:15 PM, R3 was lying in bed with an arterial ultrasound being done on her left lower extremity. R3 has a right below-the-knee amputation. R3 had a left ankle dressing which was dry/intact and dated 4/13/23. A soft boot seen sitting on the floor by the wall at foot of her bed. R3 was lying on her back. On 4/13/23 at 1:18 PM, R3 stated R3 stated, The staff never puts the soft boot on my left foot or lifts my foot off the bed. I didn't have the boot on last night (4/12/23) or all day today while I was in bed. I somewhat turn myself in bed because the staff never come and turn me. They do come in and change my dressing just about every day, but there have been days when no one changed it at all. On 4/13/23 at 3:50 PM, R3 remained in her bed, on her back with her head of the bed elevated, soft boot remains on the floor. On 4/13/23 at 3:52 PM, R3 stated My boot is still on the floor, they still have not put it on me today. On 4/17/23 at 9:33 AM, R3 stated, They changed my dressing yesterday (Sunday 4/16/23) but no one changed it on Saturday (4/15/23). R3's admission Record, dated 4/13/23, documents that R3's had diagnoses of Sepsis, Lymphedema, Anemia, Type 2 DM (Diabetes Mellitus), Pressure Ulcer left ankle Stage 3, Cognitive communication deficit, HTN (Hypertension), Acute Ischemic Heart disease, Venous Insufficiency, CKD (Chronic Kidney Disease). R3's Care Plan, dated 3/27/23, documents R3 has actual impairment to skin integrity r/t pressure left ankle. Interventions: Administer treatments as ordered and monitor for effectiveness. Avoid shearing while repositioning when in bed, needs to turn/reposition at least every 2 hours, more often as needed or requested, needs pressure redistributing cushion to protect the skin while up in chair, encourage good nutrition and hydration in order to promote healthier skin. Evaluate wound for: Size, Depth, Margins: peri-wound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify physician as indicated, float heels while in bed as tolerated, Inform the resident/family/caregivers of any new area of skin breakdown, Pressure redistributing mattress on bed. It continues R3 has bladder incontinence Impaired Mobility. Interventions: Brief Use: R3 uses disposable briefs. Change PRN, Incontinent: Check R3 every two hours and as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. R3's Minimum Data Set (MDS), dated [DATE], documents that R3 is cognitively intact with a BIMS (Basic Interview for Mental Status) of 13. R3 requires extensive assistance from one to two staff members for all her Activities of Daily Living. R3's MDS documents R3 is at risk for pressure ulcers and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 4 of 9 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 145454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlinville Rehab & Hcc 751 North Oak Street Carlinville, IL 62626 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 - Some has a stage 4 pressure ulcer over bony prominence. R3 MDS documents R3 requires a pressure reducing device for his chair and bed, is on the Turning & Repositioning program, Nutrition, or hydration interventions to manage skin problems, pressure ulcer care, application of ointments/medications and dressings. The Facility's Electronic Wound/Pressure Ulcer Log dated 1/14/23 through 4/13/23, documents R3 has a Stage IV pressure ulcers to her left heel. On 4/17/23 at 11:25 AM, V3 (MDS Nurse) stated, I was told that R3's dressing was not done on Saturday, and I will be talking to that nurse. Just like they tell us in Nursing School, if it is not documented, it was not done. R3's Braden Scale Assessment, dated 3/23/23, documents that R3 is at risk for pressure sores with a score of 15. A Braden Score of 15-18 = at risk, 13-14 = moderate risk, 10-12 = high risk, 9 or below = very high risk. R3's Braden Scale Assessment, dated 12/9/22, documents that R3 is at risk for pressure sores with a score of 15. A Braden Score of 15-18 = at risk, 13-14 = moderate risk, 10-12 = high risk, 9 or below = very high risk. R3's Physician Order, dated 3/28/23, documents Gentamicin Sulfate External Cream 0.1 % (Gentamicin Sulfate (Topical). Apply to left lateral malleolus topically every shift for wound healing related to pressure ulcer of left ankle, stage 3, cleanse area with generic wound cleanser. then apply Gent ointment, cover with Calcium Alginate and secure with silicone foam. R3's Physician Order, dated 4/10/23, documents LLE (left lower extremity) arterial doppler and ABI (ankle-brachial index) BLE (bilateral lower extremities) for wound to left ankle exposed to muscle layer. dx (diagnosis): venous insufficiency, weak pedal pulse, swelling LLE, Breakdown of wound to muscle. R3's Skin and Wound Evaluation, dated 4/11/23, documents that R3 has a pressure ulcer Stage 4 to left lateral malleolus, in-house acquired, size 3.9 CM (centimeters) X 3.6 CM X 2.0 CM. No evidence of infection, moderate serous drainage. Progress: Improving - area smaller in size per (V6, Wound Physician) evaluation, treatment as ordered. R3's TAR, dated March 2023, documents no pressure ulcer treatments were done to R3's left ankle on 3/3/23, 3/5/23, 3/24/23, and 3/29/23. No heel protector was applied to R3's left foot (every shift) on 3/2/23, 3/3/23, 3/5/23, 3/7/23, 3/8/23, 3/9/23, 3/16/23, 3/22/23, 3/24/23, 3/26/23, and 3/29/23. R3's TAR, dated April 2023, documents no pressure ulcer treatments were done to R3's left ankle (every shift) on 4/3/23, and 4/11/23 X 2. No heel protector was applied to R3's left foot (every shift) on 4/11/23 X 2, and 4/15/23. 2. R4's admission Record, dated 4/13/23, documents that R4 was admitted to the facility on [DATE] and has diagnoses of Respiratory failure, CHF (congested heart failure), Hemiplegia/Hemiparesis, Flaccid-Hemiplegia, Dysphagia, COVID-19, MRSA (Methicillin-Resistant Staphylococcus Aureus), Ventricular premature depolarization, GERD (Gastroesophageal reflux disease), ESRD (end stage renal disease), UTI, Anxiety disorder, Major depressive disorder, Cerebral infarction, Type 2 DM, Hypothyroidism, HTN, Atrial Fibrillation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 5 of 9 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 145454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlinville Rehab & Hcc 751 North Oak Street Carlinville, IL 62626 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 - Some R4's Care Plan, dated 3/3/23, documents (R4) has an actual impairment to skin integrity r/t fragile skin. Stage 3 PI (pressure injury) to left buttock. Interventions: Avoid shearing while repositioning when in bed, encourage good nutrition and hydration in order to promote healthier skin. Evaluate wound for: Size, Depth, Margins: peri-wound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify physician as indicated, float heels while in bed as tolerated, needs pressure redistributing cushion to protect the skin while up in chair, is to have cushion in chair at dialysis, needs assistance with turning and repositioning every two hours and more frequently if needed, monitor dressing when providing care to ensure it is intact and adhering. Report lose dressing to nurse, monitor skin rashes for increased spread or signs of infection, pressure redistributing mattress on bed, provide protein for healing per RD recommendation. R4's MDS, dated [DATE], documents that R4 is cognitively intact with BIMS 15. R4 requires total dependence on two staff members for transfers, toilet use, and bathing. R4's MDS documents R4 requires extensive assistance from one or two staff members for all other ADLs. R4's MDS documents R4 is always incontinent of both bowel and bladder, at risk for pressure ulcers, and has a Moisture Associated Skin Damage (MASD). The MDs documents R4 requires pressure reducing device for chair and bed, is on the Turning & Repositioning program, and requires the application of ointments/medications and dressings. R4's Braden Scale Assessment, dated 3/23/23, documents that R4 is at risk for pressure sores with a score of 15. R4's Braden Scale Assessment, dated 10/27/22, documents that R4 is at moderate risk for pressure sores with a score of 14. On 4/13/23 at 2:30 PM, R4 stated, I can turn myself to my left side, but I have to ask the staff to turn me to my right side due to paralysis. The staff do not routinely come in and turn or reposition me, and that is why I have to ask. The nurses will change my dressing most of the time, but there have been times when no one came in to do it. On 4/17/23 at 2:25 PM, R4 was back from Dialysis, lying in bed on her back. R4 had a pillow under her right leg/foot elevated off bed. R4 stated, My foot is getting mushy, and it hurts when it is sitting on the bed. They did change my dressing on my butt today. R4's Physician Order, dated 3/8/23, documents Cleanse left buttock wound with wound cleanser. Pat dry. Apply collagen powder and calcium alginate nightly and PRN. R4's TAR, dated March 2023, documents no wound care and/or treatments were done to R4's buttocks on 3/7/23, 3/9/23, 3/14/23, and 3/23/23. No Calazime ointment applied to R4's buttocks on 3/1/23, and 3/7/23. R4's TAR, dated April 2023, documents no pressure ulcer treatments were done to R4's buttock on 4/5/23, 4/10/23, and 4/11/23. 3. On 4/13/23 at 1:25 PM, R1 was lying on her left side with bilateral soft boots on. R1 was on a soft canoe mattress, and a cushion was seen on her wheelchair. R1's Face Sheet, dated 4/13/23, documents that R1 has diagnoses of dementia, lumbar compression (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 6 of 9 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 145454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlinville Rehab & Hcc 751 North Oak Street Carlinville, IL 62626 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 fracture, contracture of left knee, left hip replacement, falls. Level of Harm - Minimal harm or potential for actual harm The Facility's Wound/Pressure Ulcer Log dated 1/14/23 through 4/13/23, documented R1 had a Stage IV Pressure Ulcer to her left lateral malleolus. Residents Affected - Some R1's Care Plan, dated 3/3/23, documents R1 has actual impairment to skin integrity related to urinary incontinence and decreased mobility, chronic discoloration to bilateral lower extremities, scarring to left scapula, sacrum and right hip, abrasions to left shin and left lateral calf. Pressure area to left lateral malleolus. Interventions: Administer treatments as ordered and monitor for effectiveness, Avoid shearing while repositioning when in bed, Encourage good nutrition and hydration in order to promote healthier skin, Ensure appropriate protective devices geri-sleeves are applied to bilateral lower extremities and bilateral upper extremities, Float heels while in bed as tolerated, Heel Protectors on when in bed, needs pressure redistributing cushion to protect the skin while up in chair, needs turned and repositioned every 2 hours and more frequently if needed, Monitor dressing when providing care to ensure it is intact and adhering. Report loose dressing to charge nurse, Monitor pressure areas for changes in color, sensation, temperature and report any change to nurse, Monitor/document/report to MD (medical doctor) PRN (as needed) for s/sx (signs/symptoms) of infection: [NAME] drainage, Foul odor, Redness and swelling, Red lines coming from the wound, Excessive pain, Fever, Observe extremities for s/sx or poor tissue perfusion: Poor cap refill, Poor pulses, Cyanosis, Clubbing, Lack of sensation, cold to touch. Document changes from baseline. Report significant findings to MD, Pressure redistributing mattress on bed. R1's MDS, dated [DATE], documents R1 has severe cognitive impairment and is totally dependent on one to two staff members for all Activities of Daily Living (ADLs). R1's MDS documents R1 is always incontinent of both bowel and bladder. R1's MDS documents R1 is at risk of pressure ulcers and has a stage 4 pressure ulcer over bony prominence. R1's MDS documents R1 requires pressure reducing device for chair and bed, is on a turning and repositioning program, nutrition, and hydration interventions to manage skin problems, pressure ulcer care, and the application of ointments/medications and dressings. R1's Braden Scale Assessment, dated 3/13/23, documents that R1 is a High Risk for pressure sores with a score of 12. A Braden Score of 15-18 = at risk, 13-14 = moderate risk, 10-12 = high risk, 9 or below = very high risk. R1's Physician's Order (PO), with start dated of 3/15/23, documents Cleanse area to left ankle with wound cleanser, pat dry. Apply xeroform to wound bed. Cover with dry dressing every dayshift for wound healing. R1's March 2023 TAR has no documentation R1 received treatment to her left ankle on 3/15 and 2/24/23. R1's PO, with start date of 3/26/23, documents that R1 should have calazime cream to coccyx every shift for shearing. R1's March 2023 TAR has no documentation R1 received the calazime treatment on 3/29/23. R1's PO, with start dated of 9/25/22, documents that R1 should have skin prep to boney prominence to bilateral feet every shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 7 of 9 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 145454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlinville Rehab & Hcc 751 North Oak Street Carlinville, IL 62626 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 R1's March 2023 TAR has no documentation R1 received treatment to boney prominence to bilateral feet on evening shift on 3/7 and night shift on 3/6 and 3/7/23. R1's PO, dated 4/3/23, documents, Cleanse shearing to sacrum with wound cleanser, apply calcium alginate and cover with dry dressing. Every night shift for Shearing. Residents Affected - Some R1's April 2023 TAR has no documentation R1 received the treatment to her sacrum on 4/5 and 4/11/23. R1's Physician Order, dated 4/9/23, documents, Cleanse area to left ankle with wound cleanser. Pat dry. Apply xeroform to wound bed. Cover with dry dressing daily and PRN. Every night shift for wound healing. R1's April 2023 TAR, has no documentation R1 received the above treatment to her left ankle on 4/11/23. 4. R2's admission Record, dated 4/13/23, documents that R2 was admitted to the facility on [DATE] and was discharged on 4/5/23 with diagnoses of Atherosclerosis of native arteries of bilateral lower extremities, Traumatic brain injury, and Pressure ulcer Sacrum Stage 3. R2's Care Plan, dated 3/2/23, documents R2 has actual impairment to skin integrity r/t (related to) fragile skin, history of pressure wounds to left lateral shin, right medial shin, right posterior heel, left lateral heel, left lateral ankle, left great toe, left foot 1st digit, left foot 2nd digit, left medial heel, pressure to sacrum. Interventions: Apply offloading boots as resident will allow, Avoid mechanical trauma: Constrictive shoes, cutting and trimming corns and calluses, adhesive tapes, Improper shaving, vigorous massage, avoid shearing while repositioning when in bed, carefully dry between toes, needs pressure redistributing cushion to protect the skin while up in chair, needs pressure relieving boots to bilateral feet at all times, needs turned and repositioned every two hours and more frequently if needed, encourage good nutrition and hydration in order to promote healthier skin, float heels while in bed as tolerated, low air loss mattress to bed, monitor/document/report to MD PRN for s/sx of infection: [NAME] drainage, foul odor, redness and swelling, red lines coming from the wound, excessive pain, fever, observe extremities for s/sx or poor tissue perfusion: Poor cap refill, poor pulses, cyanosis, clubbing, lack of sensation, cold to touch. Document changes from baseline. Report significant findings to MD. R2's MDS, dated [DATE], documents that R2 is cognitively intact and is totally dependent of one to two staff members for most of his ADLs. R2's MDS documents R2 had suprapubic catheter in and was always incontinent of bowel. R2's MDS documents R2 is at risk for pressure ulcers and requires a pressure reducing device for chair and bed, is on the turning & repositioning program, and requires the application of dressings. R2's Braden Scale Assessment, dated 3/23/23, documents that R2 is a high risk for pressure sores with a score of 11. R2's PO, dated 1/25/23, documented Apply foam dressing to sacrum daily. Every night shift for preventative. R2's March 2023 TAR has no documentation that the foam dressing was applied on 3/6 and 3/7/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 8 of 9 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 145454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlinville Rehab & Hcc 751 North Oak Street Carlinville, IL 62626 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 R2's PO, dated 3/7/23, documents Apply sure prep to boney prominence of feet/digits nights every night shift for wound healing/preventative. R2's March 2023 TAR has no documentation the sure prep was applied to boney prominence of feet /digits on 3/7, 3/14/ and 3/23/23. Residents Affected - Some R2's PO, dated 8/19/22, documented Offload heels with heel protectors every shift for wound healing. R2's March 2023 TAR has no documentation R2's heels were offloaded on 3/1 during the day and evening shift, 3/6 during the night shift, 3/7 and 3/9 during the evening and night shift, 3/14 during the night shift, 3/22 during the evening shift, 3/22 during the evening shift, 3/23 during the evening and night shift and on 3/29/23 during the evening shift. R2's April 2023 has no documentation R2's heels were offloaded on 34/3 during the evening shift. R2's Health Status Note, dated 3/25/23 at 11:02 PM, documents Area to sacrum has gotten larger and now requires a tx (treatment) of Calcium Alginate and cover with dry dressing. PCP (Primary Care Physician) aware. On 4/13/23 at 3:00 PM, V4 (Wound Care Nurse) stated, I do the facility's wound report/log, the residents monthly skin checks, the once-a-week wound measurements, and I round with V6 (Wound Physician) once a week. I also do rounds on the floors, usually once in the morning and again in the afternoon, to make sure the residents are getting turned and repositioned, heels are floated, etc. The floor nurses are the ones who actually change the dressings daily. On 4/18/23 at 9:50 AM, V1 (Administrator) stated, I would expect the staff to turn and reposition a resident, float heels, and apply skin-sleeves as indicated in their respective Care Plan. I would expect the Nurses to change the residents' dressings as ordered by the Physician. The Facility's Pressure Ulcer / Pressure Injury Prevention Policy, dated 3/2022, documents A pressure ulcer / injury (PU/PI) can occur wherever pressure has impaired circulation to the tissue. A facility must: Identify whether the resident is at risk for developing or has a PU/PI upon admission and thereafter; Evaluate resident specific risk factors and changes in the resident's condition that may impact the development and/or healing of a PU/PI; Implement, monitor and modify interventions to attempt to stabilize, reduce or remove underlying risk factors; and If a PU/PI is present, provide treatment to heal it and prevent the development of additional PU/PI's. 1. Assessment: A standardized pressure ulcer / pressure injury risk assessment (Braden Scale) will be used to identify residents who are at risk for the development of pressure ulcer / pressure injury. This assessment will be completed upon admission, weekly X 4 weeks, quarterly and when a significant change in the resident's condition is noted. 2. Planning: An individual Plan of Preventions will be developed to meet the needs of the resident. It will include the consideration of mechanical support surfaces, nutrition, hydration, positioning, continence, skin condition and overall clinical condition of the resident as well as the risk factors as they apply to each individual. 3. Implementation: Interventions for the prevention of pressure ulcer / pressure injury will be individualized to meet the specific needs of the resident. Interventions will consider the assessment of risk and skin condition of the resident. Minimize Pressure: Turning and Repositioning - every two to three hours when in bed, or more frequent depending on the need of the resident. Every hour as tolerated when in a chair. Relieve pressure to heels by using pillows or other devices. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 9 of 9