Inspection·July 27, 2023

F 0690 R41's Physician order sheet, dated 07/27/2023, documented diagnoses of Neuromuscular dysfunction of bladder, unspecified and Urinary tract infection. Level of Harm - Actual harm Residents Affected - Few R41's Care plan dated, 03/17/2023, documented, Catheter care every shift and (as needed). It continues, Check tubing for kinks each shift. On 07/27/2023 at 10:20 AM, V1 (Administrator) stated she would expect the staff to perform catheter care and incontinent care per the skills check off list. 2. R30's MDS dated [DATE] documents R30 is cognitively intact and requires extensive assistance for toileting needs. R30's Care Plan dated 6/23/2023 documents, (R30) has bladder incontinence (due to) impaired mobility. Interventions include, Check (R30) every 2 hours and as required for incontinence. R30's Care Plan dated 6/23/2022 documents, (R30) has potential for impairment to skin integrity related to urinary incontinence and decreased mobility. It further documents, (R30) is on diuretic (medication that increases urination) therapy. On 7/25/2023 at 9:49 AM, R30 stated, I've sat soiled for 6 hours. I'm what they call a 'heavy wetter'. Staff will come in and say, 'I just changed you'. I don't want to get open areas (pressure ulcers). 3. R17's Face sheet dated 7/26/2023 documents R17 has a personal history of UTIs (Urinary Tract Infections), Vaginitis, Anxiety and Bed Confinement Status. R17's MDS dated [DATE] documents R17 is cognitively intact and requires extensive assistance for toileting needs. R17's Care Plan dated 7/26/2023 documents R17 is incontinent of bowel and bladder. R17's Care Plan dated 7/26/2023 documents R17 has ADL (Activities of Daily Living) Self Care Performance Deficit r/t (related to) current medical condition. It further documents, Toilet Use: (R17) requires assist of 2 staff with toileting. She is inc (incontinent) and checked and changed every 2 hours or more frequently if needed. R17's Care Plan dated 7/26/2023 documents R17 has actual skin issues r/t urine incontinence and has MASD (Moisture Associated Skin Damage) to her buttocks r/t urine incontinence. It further documents R17 has bowel incontinence and interventions include, Provide peri-care after each incontinent episode. R17's Care Plan dated 7/26/2023 documents R17 has a history of renal failure and recurrent abnormal urinalysis with need for monitoring and treatment. On 7/25/2023 at 9:54 AM, R17 stated, They check on my roommate (R30) but then don't check on me. I feel ignored. One time my sheets were brown. I had urinated and had a bowel movement. I get UTI's very easily. I wasn't changed all afternoon that day. It sometimes takes 4-5 hours to get changed. The Facility's Resident Council Minutes dated 6/7/2023 documents cath (catheter) bags not being (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 2 of 8 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 07/27/2023 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 0690 drained. It further documents, Peri (perineal) care not being provided with urine incontinence. Level of Harm - Actual harm Deficiency requires two deficient practice statements. Residents Affected - Few A. Based on interviews and record review the facility failed to timely treat a urinary tract infection (UTI) for 1 of 6 residents (R17) review for urinary incontinent/(UTIs) in the sample of 42. This failure resulted in R17 having symptoms of UTI on 6/2/23, delay of physician notification and treatment, and subsequently being admitted to the critical care unit at the local hospital with diagnosis of UTI with septic shock. Findings include: R17's July 2023 Physician's Order Sheet (POS) documented R17 had diagnoses of long-term use of antibiotics, personal history of urinary tract infections, sepsis, unspecified organism, sever sepsis with septic shock, extended spectrum beta lactamase (ESBL). R17's Minimum Data Set, dated [DATE] documents that R17's Brief Interview of Mental Status score was a 14 which indicates R17 is cognitively intact. MDS documents that R17 is extensive assist of two people for toileting needs and is always incontinent. R17's Care Plan dated 4/26/2017 documents R17 will be free of complications from history of urinary tract infections with interventions of monitor/document/report to MD PRN (as needed) for signs/symptoms of frequency, urgency, malaise foul smelling urine, dysuria, fever, nausea and vomiting flank pain, supra-pubic pain, hematuria, cloudy urine, altered mental status, loss of appetite, behavioral changes. R17's Vital Sign records in the electronic medical record documents on 6/1/2023 at 8:31AM R17 had an elevated temperature of 99.1 degrees (°) Fahrenheit (F). The Vital Sign Records document on 6/2/2023 at 11:56 PM R17 had an elevated temperature of 102.4 ° F. There was nothing in R17's Progress Notes that documented R17's physician was notified of R17 having an elevated temperature. R17's infection screening evaluation assessment dated effective 6/2/2023 documents R17 had a fever of >102° F and had new/marked increase in symptoms of urinary frequency, urinary incontinence, urinary urgency, acute dysuria, and abdominal pain with no notification of physician. R17's clinical record contains fax document to V19 (Physician) dated 6/4/2023 at 5:40 PM documented (R17) has been diaphoretic, clammy, pale, lethargic, has poor appetite on and off all weekend. She seems to be experiencing increased confusion today. She is disorientated and states she does not feel well. Afebrile. States she feels like she has a UTI. Incontinent of urine. States she is having dysuria. R17's Progress Note dated 6/4/2023 at 6:06 PM documents R17 has been diaphoretic, pale, clammy, and lethargic with poor appetite and fluid intake throughout the weekend. Encouraged oral hydration but she has been sleeping a lot. on 6/2/23 at 11:56 pm her temp was 102.4 but was alleviated with acetaminophen. She seems to be experiencing AMS /increased confusion today. She is disoriented and she states she does not feel well. C/o dysuria and vaginal discomfort. She also stated she feels like she has a UTI. Incontinent of urine. Notified (V19's) office. R17's Progress Note dated 6/5/2023 at 3:51 AM documents, Res remains pale, clammy, and diaphoretic. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 3 of 8 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 07/27/2023 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 0690 Level of Harm - Actual harm Residents Affected - Few Res states that something is not right. Res has been very tearful this shift. Afebrile. C/o (complaints of) vaginal discomfort at times with dysuria. (Res) stated that she did not want to go to the hospital, she would wait for response from PCP (primary care physician) r/t (related to) lab orders. R17's Progress Note, dated 6/5/2023 at 10:58 AM documents @ (at) 1000 Call out to V19 (Physician) in regard to resident complaining of not feeling well, resident seems a little confused, complains of dysuria and just not feeling right. New orders received for CBC, CMP and UA with C&S obtained through straight cath. The Progress Note documented @ 10:15am Urine obtained per straight cath and call out to (Local hospital lab) lab, writer spoke with lab and lab is going to come out and draw CBC and CMP and pick up urine while here. R17's Progress Note, dated 6/5/2023 at 7:25 PM documents R17 was experiencing increase pain and Shortness of Breath. The Note documented Writer sent R17 to ER for further evaluation. MD aware. POA called but did not answer phone and unable to leave voicemail. R17 states she will call her husband at the hospital. Writer gave report to ER (Emergency Room) RN (Registered Nurse). R17's Hospital records dated 6/6/2023 documents R17 was admitted to hospital on [DATE] with diagnosis of Septic Shock due to UTI. R17's hospital records document that R17 was in distress from abdominal pain upon presentation at Local Emergency Department and became hypotensive not responding to Intravenous fluids bolus and was started on blood pressure support drug, R17 was admitted to critical care unit. On 07/26/23 at 3:17 PM, V3 (MDS/LPN) states she documented on the infections criteria assessment on 6/4/2023 about R17's temp on 6/2/2023 but did not notify the doctor of the fever or the frequency and urgency at that time. V3 states she does not have any documentation of R17 being monitored from 6/2/2023-6/4/2023 or of the doctor being notified on 6/2/2023 of fever of 102.4 ° F. V3 states V19 was notified on 6/4/2023 of R17's fever and urinary symptoms. On 07/26/23 at 3:26 PM, R17 states that she had a UTI on 6/2/2023 and that staff did not take care of it immediately. R17 states It took a few days for them to treat me and by then I was sick. I went to the hospital and just laid in the bed at the hospital and cried for days. It was very stressful. Facilities policy titled Significant Condition Change of Notification, undated, documents Purpose is to ensure that the resident's family and/or representative and medical practitioner are notified of resident changes such as onset of temperature of 101 degrees or higher with or without symptoms, when any of the situations exists the licensed nurse will contact the resident's representative and their medical practitioner. Prior to calling the medical practitioner the nurses will completer the SBAR assessment, charting will include an assessment of the resident's status as it relates to the change in condition and will be done each shift for 72 hours for residents with change of condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 4 of 8 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 07/27/2023 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide assessment to ensure that pain medications are effective and are controlling pain when needed for 1 of 6 residents (R24) reviewed for pain in the sample of 42. Residents Affected - Few Findings include: R24's Face Sheet, dated 7/19/2023, documents R24 has diagnoses of polyneuropathy, Stage IV pressure ulcers of right and lower back and above right knee amputation. R24's Care Plan, revision date of 5/15/23, documented that R24 has actual impairment to his skin including pressure ulcers/injuries and wounds. The Care Plan Intervention, dated 3/6/23, documented Treat pain as orders prior to treatment/turning etc. to ensure the resident's comfort. R24's Care Plan, dated 3/17/23, documents he is receiving opioid medications for pain. The Care Plan Intervention, dated 3/17/23, documents Administer medications as ordered. R24's Physician order sheet (POS) dated 7 /21/2023 documents Tramadol 50 Milligram (mg), give 1 tablet by mouth three times a day for moderate to severe pain. On 7/25/2023 at 1:37 PM, V20 (Licensed Practical Nurse/LPN) provided dressing changes and treatments to R24 coccyx and lower back. During wound care R24 complained of pain and rated his pain at a 10 (10 being the worse pain). V20 stated would provide pain medication and do dressing to left outer ankle later. On 7/26/2023 at 11:06 AM, R24 stated he always has pain with repositioning and treatments including dressing changes. On 7/26/2023 at11:10 AM, V16 (LPN) entered room and administered Tylenol 325 mg 2 tabs, V16 did not ask R24 to rate his pain level. R24's Progress Note, dated 7/26/2023 at 12:54 PM documents, Nurse Practitioner (NP) at bedside to see resident N.O. (new order) received stop tramadol when Norco (hydrocodone/acetaminophen) arrives. Start Norco 7.5/325 1 tab PO four times a day r/t (related to) pain. NP will follow up in 2 weeks. On 7/27/2023 at 11:03 AM, V3 (Minimum Data Set Coordinator/Care Plan Coordinator) stated that the facility does not have policy on pain. V3 stated that this issue may be covered in the change of condition policy. V3 stated she would expect residents to be assessed for pain and meds administered for pain control. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 5 of 8 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 07/27/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure medications are store at required temperatures and multi-dose medication vials are labeled as to when first accessed/opened for 2 of 4 residents (R217, R218) reviewed for medication storage in the sample of 42. Findings include: On 7/25/2023 at 9:40 AM, the medication storage room was observed with V17 (Licensed Practical Nurse/LPN). At this time, V17 stated it was the responsibility of the night shift nurses to check and document the temperature of the medication storage refrigerator. At this time, there were two medication storage refrigerators. One of the refrigerators contained 3 bags of Intra Venous (IV) medication. This refrigerator did not have a thermometer. There was a box with a vial of Tuberculin (TB) Serum in it. The outside of the box was written opened 6/15/2023 and the manufactory print on the box documented, Discard opened product after 30 days. On 7/25/2023 at 11:05 AM, V2 (Director of Nursing/DON) stated the 3 bags of IV medications (Vancomycin) belonged to R218. V2 stated, Staff are supposed to take temps every night shift. I would prefer temps be taken every shift because these are IV meds. At this time, V2 confirmed there was no thermometer in the refrigerator that R218's IV medications were stored. V2 then removed a vial of TB serum, and the vial was dated 7/20/2023. At this time, V2 stated, There are two different dates. There is no way to know when it was opened. It will have to be wasted. The Facility's Temperature Log for Refrigerator- Fahrenheit Form dated 7/2023 documents, Monitor temperatures closely! 1. Write your initials below in staff initials and note the time in exact time 2. Record temps (temperatures) twice each workday. This form did not document temperature values on 7/3/2023, 7/5/2023, 7/6/2023, 7/10/2023, 7/12/23 ,7/13/2023, 7/17/2023, 7/19/2023, 7/20/2023, and 7/24/2023. The Facility's Immunization Report date range 6/15/2023-7/20/2023 documents R217 received a dose of Tuberculin PPD (purified protein derivative) on 7/19/202. R217's Medication Administration Record (MAR) documents, Tuberculin PPD Solution- inject 0.1 ml (milliliter) intradermally every 365 days. It further documents R217 received it 7/19/2023. The Facility's Storage and Return of Drugs Policy dated 4/2021 documents, Drug supplies for the facility shall be stored under proper conditions, sanitation, temperature, light, refrigeration and moisture. It continues, E. Multi-dose vials and pens shall be stored and dated per manufacturers guidance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 6 of 8 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 07/27/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 3. On 7/24/2023 at 9:25 AM, during incontinent care for R7, V4 (Certified Nursing Aide/CNA) and V5 (Certified Nursing Aide/CNA) donned gloves but did not wash or sanitize hands prior to donning gloves. V5 with right gloved hand cleansed R7's rectal area from front to back with wipes. V5 doffed gloves from left hand then with right-hand donned new gloves. V5 did not sanitize hands prior to donning new gloves. After care, V5 and V4 removed gloves and did not sanitize hands. Residents Affected - Few On 07/27/2023 at 10:20 AM, V1 (Administrator) stated that she would expect the nurse to perform hand hygiene after touching their clothing, hair, or skin prior to giving medication to a resident. She continued to state that she would expect them to perform hand hygiene and change gloves after opening dressing packages and placing them on the residents. On 07/27/2023 at 11:20 AM, V20 (LPN) stated that she did not think the facility had a when to perform hand hygiene or glove changes policy. The facility's policy, Influenza, Prevention and Control of Seasonal., dated, 08/2011, documented, B. Hand hygiene: 1. Staff will perform hand hygiene frequently, including before and after all resident contact, contact with potentially infectious material, and before putting on and upon removal of personal protective equipment, including gloves. It continues, C. Gloves: 1. Gloves will be worn for any contact with potentially infection material. 2. Gloves will be removed after contact, followed by hand hygiene. Based on observation, interview, and record review, the facility failed to perform hand hygiene when performing medications administration, contact with potentially infectious material, and upon contacting residents for 3 of 6 residents (R5, R7, R27) reviewed for infection control in the sample of 42. Findings include: 1. On 07/25/2023 at 7:20 AM, V7 (Licensed Practical Nurse/LPN), was at the medicine cart, she pulled out the medication for R5. V7 then locked the med cart and administered medication to R5 without benefit of hand hygiene. V7 returned to the medication cart, performed hand hygiene with alcohol-based hand rub (ABHR). She then removed stock medication of Vitamin C, Cetirizine HCI, and Stool softener for R27 and placed them in a pill cup. She then pulled on her surgical mask with her right hand and then flipped her hair back out of her face with her left hand. Without doing hand hygiene, took the medication cards out of the medicine cart, placed the individual pills in a medicine cup for R27. V7 then locked the med cart, and without hand hygiene, administered medications to R27. V7 exited R27's room used ABHR, unlocked her medicine cart, and retrieved medication for R7. V7 removed a stock bottle of medication out of the medication cart, and she then rubbed her right ear with her right hand and moved the left side of her hair away from her face with her left hand. She continued, without benefit of hand hygiene, removing medication from the medication packages. V7 poured a cup of water for R7, took her glasses off and put them on the top of her head, locked medication cart, and administered medications to R7 without the benefit of hand hygiene. 2. On 07/26/2023 at 9:45 AM, V3 (LPN) cleansed R5's wound with soap and water, performed hand hygiene and donned gloves. She then opened the abdominal pad package with gloved hands and with the same gloved hands placed abdominal pad on the resident's wound bed. She then opened another abdominal pad package and applied it to the wound bed. She then wrapped it with a gauze dressing, all without the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 7 of 8 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 07/27/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete benefit of hand hygiene or glove changes. V3 then doffed her gloves, performed hand hygiene, donned a clean pair of gloves, opened a betadine sticks package, and painted the left heel. She then opened the border gauze dressing package with the same gloved hands and applied it to the left heel without the benefit of hand hygiene. V3 doffed gloves, performed hand hygiene, got into the treatment cart, and cleaned the bandage scissors with alcohol-based hand rub. She then performed hand hygiene, donned gloves. V3, with the same gloves on, took the scissors, cut the xeroform gauze, placed it in R5's wound bed, then took the same scissors, cut a 2nd piece of xeroform gauze, and placed it in the wound bed, she then, with the same gloved hands, cut a 3rd piece of xeroform gauze and placed it in the wound bed. V3 took a piece of clean gauze and cleaned the blood off of R5's leg. V3 then performed hand hygiene, and donned a new pair of gloves, she then opened a package of abdominal pad and applied it to the wound, with the same gloved hands, opened a 2nd package to the lower part of the left leg wound and then opened a package of gauze wrap and wrapped the area and secured it with tape all without the benefit of hand hygiene or glove changes. Event ID: Facility ID: 145454 If continuation sheet Page 8 of 8