Inspection·July 1, 2024

F 0550 on staff for toileting, bed mobility, transfers, and is frequently incontinent of bowel and bladder. Level of Harm - Minimal harm or potential for actual harm 4. On 06/25/24 at 10:00 AM, R5 stated, They don't have enough staff on night shift last night. I sat on the bedside commode for an hour and 15 minutes last night. R5 was questioned if the aides told him why it took so long, R5 stated, There was 2 CNA's for A and B hall. The one aide was working on both halls because the other aide was agency and she said, I am pregnant, and I am not doing a thing. R5 was questioned how waiting this long made him feel, R5 stated, It is what it is. Residents Affected - Some R5's admission Record, print date of June 25,24, documents that R5 was admitted on [DATE] with diagnoses of morbid obesity and Panniculitis. R5's Minimum Data Set, dated [DATE], documents that R5 is cognitively intact, uses a wheelchair, requires touch / supervision assist for toileting, hygiene, bed mobility, partial / moderate assistance for transfers. occasionally incontinent of urine, and frequently incontinent of bowel. On 6/26/24 at 4:05 PM, V18 MDS / Care Plan Licensed Practical Nurse, stated, The facility does not have a policy on call light answer times. V18 stated the expectation is that the light is answered in 3 to 5 minutes. The Resident Council meeting Minutes, dated 6/5/24, documents Call lights not being answered for 30 -45 minutes. The Illinois Long Term Care Ombudsman, dated 10/17, documents, The program strives to protect and promote the rights and quality of life for those who reside in long-term care facilities. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 2 of 32 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 07/01/2024 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 0600 Level of Harm - Minimal harm or potential for actual harm Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on interview and record, the facility failed to prevent employee to resident verbal abuse for one of six residents (R41) reviewed for abuse in the sample of 44. Residents Affected - Few Findings include: 1. R41's Face Sheet date 6/11/24 documents R41 has diagnoses of mental disorder and altered mental status. R41's Alleged Verbal Abuse Incident Report dated 6/4/2024 documents R62's predisposing physiological factors are behaviors, confusion, and impaired memory. The Facility's Report of Alleged Resident Abuse dated 6/4/24 at 6:15 AM documents there was an allegation of verbal mistreatment and abuse and two employees, V13, Licensed Practical Nurse, LPN and V14, LPN who were suspended. The Facility's Final Investigation dated 6/11/2024 documents, In the morning of June 24th, staff members at (Facility) reported to the Administrator (ADM) that two nurses had an inappropriate verbal interaction with a resident (R41). An investigation was initiated, and staff members were suspended. It continues to document, Three staff members report that (R41) was at the nurses' desk where nurses were completing shift change. (R41) persistently told the staff she did not want to live at the facility and wanted to go to (another local town) to see her son. Circumstances beyond her control prevent her son from visiting the Facility but (R41) is not able to understand this. (R41) has diagnoses of altered mental status, symptoms including cognitive function and awareness and mental disorder not classified. It further documents, (V15, Medical Records) reports observing and hearing both (V13, LPN (Licensed Practical Nurse) and V14, LPN) telling (R41) to 'shut up'. These observations are corroborated from two other staff members. R41's Care Plan dated 6/4/2024 documents R41 has a potential psychosocial well-being problem related to possible abuse. On 6/24/24 at 9:30 AM, V1, Administrator, stated, I was notified that (V14 Licensed Practical Nurse, LPN) and (V13, LPN) had told (R41) to shut up during shift change. (R41) is confused and can be very repetitive. The staff did not notify me directly they had told (V21, Business Office Manager), and (V21) called me. There was a bit of a delay. The incident happened around 6:15 AM and I was notified at 7:30 AM. By this time (V13) had already gone home because it was the end of shift. (V14) was pulled off of the floor and statements were taken. (V14) was told to go home. Both (V13 and V14) were both suspended at that time. After the investigation the abuse was substantiated, and both were terminated. On 6/25/2024, at 3:04 PM, V9 Registered Nurse (RN), stated, I was at the nurses' station doing shift change in the morning. (R41) was saying over and over again that she wanted to go home. (V13) asked (R41) to be quiet several times so they could get report and count. (V13 and V14) told her (R41) to shut up. I heard it all. I didn't do anything with it, and I should have. V9's, Registered Nurse (RN)'s statement undated, documents, Resident was at nurses station yelling, saying, she doesn't live here. Nurse was giving report and doing narc (narcotics) count. (V13) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 3 of 32 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 07/01/2024 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few yelled at resident, told her to shut up. Resident still continued to yell. (V14) then told her to shut up and wheeled resident to the dining room. V15's statement dated 6/4/2024 documents, Around the time of 6:15-6:30 am while nurses and CNAs were giving report at the nurses station. (R41) repeatedly kept saying, 'I don't live here'. It continues, That is when (V14) yelled to (R41),' Shut up all ready. Go somewhere else. We don't need you to live here'. (V13) was at the nurses' station stated/almost yelling, We get it you don't think you live here. (V13) then pushed (R41) into the dining room in front of the DON (Director of Nursing) office door and said, We need you to shut up. We are trying to give our morning reports and get our jobs done. We can't do that if you keep yelling you don't live here. I stated to the nurses at the nursing station that this is not ok. I walked in the dining room and told (V40, CNA) and said this was not ok when we seen (V13) together in the dining room. On 6/26/2024 at 12:25 V15, stated, I came in early that day (6/4/2024). I was by the nurse's station. (V13 and V14) were yelling and cussing at (R41). They said, 'We don't care where you live. She doesn't realize. She's confused. They also said, 'We can't do our f**king job'. At that point, I said, 'this is not ok'. I walked into the dining room and (V40) was in there and agreed. I witnessed (V13) wheel (R41) into the dining room by the DON's office. She got right up in her face and was intimidating her, saying, 'Shut the f**k up'. I did not report it in a timely manner. I didn't have my cell phone and I had to go on a transport. I know you are supposed to immediately report it. (V1) wasn't here but (V21) notified her. (V14) stayed on the floor (providing patient care) even though they were made aware. They made her stay until the DON came in. I know I am a mandated reporter. I felt it was wrong. I know the policy. Corporate told me anyone in the building could walk anyone out, even if they are nurses. On 6/27/2024 at 10:38 AM V40, Certified Nursing Assistant (CNA) stated, I was in the dining room early in the morning. I heard a nurse scream at her to shut up. It was (V14, LPN). I heard (V13, LPN) saying stuff can't remember what exactly. It was not appropriate, and it was her tone. (V15, Medical Records) and I looked at each other, like Is it abusive/reportable? did we just hear what we think we just heard? I told (V21, Business Office Manager) what I heard. (V21) said it needed to be reported and called (V1, Administrator). V40's statement dated 6/4/2024, documents, At around 6:15 AM I was sitting in the dining room sorting (meal) tickets when I heard (R41) at the nurses' desk asking for her clothes. She said, 'Where are my clothes. I don't live here'. (V13) replies, very loudly, 'I don't care if you live here or not, go away'. (R41) repeated herself again and the nurse (V14) screamed at her, 'shut up'. (V15) stopped next to me and just looked stunned. I asked (V15). 'Since when is it ok to talk to a resident like that or tell a resident to shut up?' I reported to (V21) as soon as she got here. On 6/27/24 at 10:45 AM, V21 stated, I called (V1). (V40) reported it to me. I text (V1), and she was on her way. I didn't see or hear anything, but I felt it was my responsibility to report. I am not sure what time (V14) left but I know it wasn't right away, even after (V1) got here. V14's Timecard dated 6/4/2024 documents V14 clocked in at 5:51 AM and clocked out at 8:35 AM. The Facility's Abuse, Prevention, and Prohibition Policy dated 1/2024 documents, Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Resident must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family member or legal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 4 of 32 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 07/01/2024 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 0600 guardians, friends, or other individuals' misappropriation of resident property. The residents must not be subjected to abuse by anyone. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 5 of 32 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 07/01/2024 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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 operationalize their abuse policies and procedures for conducting thorough investigation of allegations of abuse, protect residents during abuse nvestigations, and report allegations of abuse to the administrator immediately for two of 6 residents (R5, R41) reviewed for abuse policy and procedures in the sample of 44. Residents Affected - Few Findings include: 1. On 06/25/24 at 10:00 AM, R5 stated, A few weeks ago we were sitting in the dining room, there is a resident (R41) that repeats she wants to go home. (V11, Certified Nurse Aide, CNA) got right in her face and told her, You are never going to go home again to see your son because he is in prison. R5 was questioned if he told anyone of this, R5 stated, I told (V10, Social Service Director, (SSD) and (V1, Administrator). They came back and told me that (V11) needed to be retrained. I think that it was mental abuse. On 6/25/24 at 2:30 PM, V11, CNA, stated that he has never been involved in an allegation of abuse for R41. V11 stated that R41 is hard of hearing, and she always says that she wants to go home over and ever. On 6/25/24 at 3:03 PM, V9, Registered Nurse, (RN), stated, I was at the nurses station doing shift change in the morning. V14 LPN (Licensed Practical Nurse) was up there too. (V13) was giving report to her nurse. (R41) was saying over and over again that she wanted to go home. (V13) and (V14) both told her to shut up. I did not notify (V1) of it, but I know someone did. At this time, (V11) was not present. I do know that when he came in for his shift, he was not allowed to work the hall. I don't know why though. On 6/26/24 at 7:15 AM, V20, CNA, stated, I was told by (V11) when I came in that when he (V11) came to work he was not allowed to go onto the hall because 2 residents had complained about him. He was told that (R5 and R43) had made complaints about the way he treated (R41). He told me that he was told to stay off of their halls when he was able to work on the floor later in the day. He was never suspended while they did the investigation. V20 was questioned if the allegation of abuse had to do with the allegation of (R41) being told to shut up, V20 stated, No it was another allegation that they (R5 and R43) had made about the way V11 treated R41. On 6/26/24 at 12:09 PM, V10, stated, I had interviewed (R5) while I was interviewing residents regarding the incident involving 2 nurses (V13 and V14) and R41. R5 told me that he thought (V11) was rough and loud in his voice while working with her. He said that he had yelled at her. I wrote the statement and gave it to V1, Administrator. I wrote word for word of what he said, read it back to him and then gave it straight to the Administrator. V1 said that she would take care of it. V1 did the follow up with R5. V2, Director of Nurses, was also involved in it too. On 6/26/24 at 3:17 PM, V1, stated that interviews were being taken from residents related to (V13 and V14) telling R41 to shut up. V1 stated I had collected all interviews and put them into a pile. I did not review them because I was still gathering information. I sent all the information to (V43, Regional Nurse Consultant), to let her review. I had a meeting that day from 4:00 PM to about 5:40 PM. Later that evening or the next day, I can't remember which, she (V43) called me and asked me if I had seen (R5's) statement. I told her no. (V2, Director of Nursing), came to me on 6/4/24 after my (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 6 of 32 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 07/01/2024 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few meeting and told me that we have an issue regarding V11. V11 was already working on the floor. He starts at 2:00 PM. He was pulled from the floor. I am not sure of what time it was. We both went down and talked to (R5). At that time, he said that she felt that (V11) was making fun of (R41). At no time, did he say that (V11) got in her face and yelled at her like his statement says. I then interviewed (V11). He said that he did not make fun of her. He said that he was trying to reorient her to reality. I and (V2) felt that it was a misunderstanding and we retrained him on effective communication, and he went back to work. I did not get any other interviews from other residents or staff about (V11). R5's admission Record, print date of June 25,24, documents that R5 was admitted on [DATE] with diagnoses of morbid obesity and Panniculitis. R5's Minimum Data Set, dated [DATE], documents that R5 is cognitively intact. R5's Abuse Investigation Investigative Questionnaire, dated 6/4/24, untimed, documents, (V11) kept teasing resident (R41) who wanted to go to [NAME] to her son, (V11) yelled in residents' face shut up, ain't no one in [NAME] want you. 2. The Facility's Final Investigation dated 6/11/2024 documents, In the morning of June 24th, staff members at (Facility) reported to the Administrator (ADM) that two nurses had an inappropriate verbal interaction with a resident (R41). An investigation was initiated, and staff members were suspended. It continues to document, Three staff members report that (R41) was at the nurses' desk where nurses were completing shift change. (R41) persistently told the staff she did not want to live at the facility and wanted to go to (another local town) to see her son. Circumstances beyond her control prevent her son from visiting the Facility but (R41) is not able to understand this. (R41) has diagnoses of altered mental status, symptoms including cognitive function and awareness and mental disorder not classified. It further documents, (V15, Medical Records) reports observing and hearing both (V13, Licensed Practical Nurse, LPN) and (V14, LPN) telling (R41) to 'shut up'. These observations are corroborated from two other staff members. On 6/24/24 at 9:30 AM, V1 Administrator, stated, I was notified that (V14 Licensed Practical Nurse, LPN) and (V13 LPN) had told (R41) to shut up during shift change. (R41) is confused and can be very repetitive. The staff did not notify me directly they had told (V21, Business Office Manager), and (V21) called me. There was a bit of a delay. The incident happened around 6:15 AM and I was notified at 7:30 AM. By this time (V13) had already gone home because it was the end of shift. (V14) was pulled off of the floor and statements were taken. (V14) was told to go home. Both (V13 and V14) were both suspended at that time. After the investigation the abuse was substantiated, and both were terminated. On 6/25/2024, at 3:04 PM, V9, Registered Nurse (RN), stated, I was at the nurses' station doing shift change in the morning. R41 was saying over and over again that she wanted to go home. (V13) asked (R41) to be quiet several times so they could get report and count. (V13 and V14) told her (R41) to shut up. I heard it all. I didn't do anything with it, and I should have. On 6/26/2024 at 12:25 V15, stated, I came in early that day (6/4/2024). I was by the nurse's station. (V13 and V14) were yelling and cussing at (R41). They said, 'We don't care where you live. She doesn't realize. She's confused. They also said, 'We can't do our fucking job'. At that point, I said, 'this is not ok'. I walked into the dining room and (V40, CNA) was in there and agreed. I witnessed (V13) wheel (R41) into the dining room by the DON's office. She got right up in her face and was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 7 of 32 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 07/01/2024 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 0607 Level of Harm - Minimal harm or potential for actual harm intimidating her, saying, 'Shut the fuck up'. I did not report it in a timely manner. I didn't have my cell phone and I had to go on a transport. I know you are supposed to immediately report it. (V1) wasn't here but (V21) notified her. (V14) stayed on the floor (providing patient care) even though they were made aware. They made her stay until the DON came in. I know I am a mandated reporter. I felt it was wrong. I know the policy. Corporate told me anyone in the building could walk anyone out, even if they are nurses. Residents Affected - Few On 6/27/2024 at 10:38 AM V40, Certified Nursing Assistant (CNA) stated, I was in the dining room early in the morning. I heard a nurse scream at her to shut up. It was (V14, LPN). I heard (V13, LPN) saying stuff can't remember what exactly. It was not appropriate, and it was her tone. (V15, Medical Records) and I looked at each other, like Is it abusive/reportable? did we just hear what we think we just heard? I told (V21, Business Office Manager) what I heard. (V21) said it needed to be reported and called (V1, Administrator). On 6/27/24 at 10:45 AM, V21 stated, I called (V1). (V40) reported it to me. I text (V1), and she was on her way. I didn't see or hear anything, but I felt it was my responsibility to report. I am not sure what time (V14) left but I know it wasn't right away, even after (V1) got here. V14's Timecard dated 6/4/2024 documents V14 clocked in at 5:51 AM and clocked out at 8:35 AM. The Facility's Abuse, Prevention, and Prohibition Policy dated 1/2024 documents, Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Resident must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family member or legal guardians, friends, or other individuals. Policy- This facility prohibits mistreatment, neglect, or abuse of residents. It continues, The facility administrator will be designated as the facility Abuse Coordinator and will be responsible for overseeing the Abuse Prevention and Prohibition Program and directing any abuse investigation. If the administrator is not available to address this role, the administrator will designate a person in charge in their absence to fulfill the role. This person would normally be the Director of Nursing. It further documents, Prevention- The resident has the right to be free from verbal, mental, sexual, exploitation or physical abuse; corporal punishment and involuntary seclusion. It continues, Investigation- Resident abuse must be reported immediately to the administrator. The Facility administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. While a facility investigation is under way, steps will be taken to prevent further abuse. If a person is identified in in the allegation of abuse, that person will not be allowed access to the facility while the investigation is in progress, except to meet with the administrator as part of the investigation. The person identified in the allegation of abuse will have no contact with residents or other employees during the investigation process. Implement steps to prevent further potential abuse. Initiate investigation including reporting to all required agencies. Complete a thorough investigation. Two management level staff will conduct interviews with witnesses or other staff, residents, or visitors, who could have knowledge of the allegation. Witnesses will be asked to assist with completing statements if indicated. Every employee will be interviewed who was working on the specific hall/wing that the affected resident resides on. If the allegation occurred on a specific shift, all staff for the identified shift only will give a statement if indicated. Interview the resident if they are cognitively able to answer questions in a private setting free from any intimidating factors. Request that a staff member who has a special rapport participate if possible. If the resident is not interviewable, question the roommate an any family or friends who visit frequently with completion of a questionnaire. Complete and summarize the investigation within 5 business days. Review outcome of investigation report with the Regional Nurse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 8 of 32 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 07/01/2024 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Notify the employee in question of their reinstatement or termination. The policy continues, Protection: The facility will immediately remove any alleged perpetrator from any further contact with any resident. Employee Allegations: when an employee is the alleged perpetrator of abuse or neglect, that employee shall immediately be barred from any further contact with residents through suspension, pending the outcome of the facility investigation, prosecution, or disciplinary action against the employee. Employee Allegations: When an employee is the alleged perpetrator of abuse or neglect, that employee shall immediately be barred from any further contact with resident through suspension, pending the outcome of the facility investigation, prosecution, or disciplinary action against the employee. The administration and or the Director of Nursing will replay this suspension. At that time, the alleged staff member will be advice of the allegation and encouraged to assist in completing a statement relevant to the facts. Reporting/Response: The Facility employee or agent, who becomes aware of abuse or neglect, shall immediately report the matter to the facility Administrator or his/her designated representative in the administrator's absence. The Facility administrator, employee or agent who is made aware of any allegation of abuse or neglect shall report or cause a report to be made to the mandated state agency per reporting criteria. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property will be reported immediately to the administrator. The person made aware of allegation of abuse or neglect, or the administrator will report the allegations of abuse and neglect to the mandated state agency and law enforcement. The allegation will be reported no later than 2 hours, or per state regulations, after the allegation is made. Event ID: Facility ID: 145454 If continuation sheet Page 9 of 32 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 07/01/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately report an allegation of abuse to administrator and the State Survey Agency for 2 of 24 residents (R5, R41) reviewed for reporting of abuse in the sample of 44. Findings include: 1. On 06/25/24 at 10:00 AM, R5 stated, A few weeks ago we were sitting in the dining room, there is a resident (R41) that repeats she wants to go home. (V11, Certified Nurse Aide, CNA)) got right in her face and told her, 'You are never going to go home again to see your son because he is in prison.' R5 was questioned if he told anyone of this, R5 stated, I told (V10, Social Service Director, SSD) and (V1, Administrator). They came back and told me that (V11) needed to be retrained. I think that it was mental abuse. On 6/26/24 at 12:09 PM, V10, stated, I had interviewed (R5) while I was interviewing residents regarding the incident involving 2 nurses (V13, CNA and V14, CNA) and (R41). R5 told me that he thought (V11) was rough and loud in his voice while working with her. He said that he had yelled at her. I wrote the statement and gave it to (V1). I wrote word for word of what he said, read it back to him and then gave it straight to the Administrator. V1 said that she would take care of it. (V1) did the follow up with (R5). (V2, Director of Nurses), was also involved in it too. On 6/26/24 at 3:17 PM, V1, stated that interviews were being taken from residents related to (V13 and V14) telling R41 to shut up. V1 stated I had collected all interviews and put them into a pile. I did not review them because I was still gathering information. I sent all the information to (V43, Regional Nurse Consultant), to let her review. I had a meeting that day from 4:00 PM to about 5:40 PM. Later that evening or the next day, I can't remember which she called me and asked me if I had seen (R5's) statement. I told her no. (V2) came to me on 6/4/24 after my meeting and told me that we have an issue regarding (V11). (V11) was already working on the floor. He starts at 2:00 PM. He was pulled from the floor. I am not sure of what time it was. We both went down and talked to (R5). At that time, he said that he felt that (V11) was making fun of (R41). At no time, did he say that (V11) got in her face and yelled at her like his statement says. I then interviewed (V11), he said that he did not make fun of her. He said that he was trying to reorient her to reality. I and (V2) felt that it was a misunderstanding and we retrained him on effective communication, and he went back to work. There was no documentation that this allegation of abuse was reported to Illinois Department of Public Health (IDPH). R5's Abuse Investigation Investigative Questionnaire, dated 6/4/24, untimed, documents, (V11) kept teasing resident (R41) who wanted to go to [NAME] to her son, (V11) yelled in residents' face shut up, ain't no one in [NAME] want you. 2. The Facility's Report of Alleged Resident Abuse dated 6/4/24 at 6:15 AM documents there was an allegation of verbal mistreatment and abuse and two employees, V13 and V14 were suspended. The Facility's Final Investigation dated 6/11/2024 documents, In the morning of June 24th, staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 10 of 32 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 07/01/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few members at (Facility) reported to the Administrator (ADM) that two nurses had an inappropriate verbal interaction with a resident (R41). An investigation was initiated, and staff members were suspended. On 6/24/24 at 9:30 AM, V1 Administrator, stated, I was notified that (V14 Licensed Practical Nurse, LPN) and (V13 LPN) had told (R41) to shut up during shift change. (R41) is confused and can be very repetitive. The staff did not notify me directly they had told (V21, Business Office Manager), and (V21) called me. There was a bit of a delay. The incident happened around 6:15 AM and I was notified at 7:30 AM. On 6/25/2024, at 3:04 PM, V9 Registered Nurse (RN), stated, I was at the nurses' station doing shift change in the morning. R41 was saying over and over again that she wanted to go home. (V13) asked (R41) to be quiet several times so they could get report and count. (V13 and V14) told her (R41) to shut up. I heard it all. I didn't do anything with it, and I should have. On 6/26/2024 at 12:25 V15, stated, I came in early that day (6/4/2024). I was by the nurse's station. (V13 and V14) were yelling and cussing at (R41). They said, 'We don't care where you live. She doesn't realize. She's confused. They also said, 'We can't do our fucking job'. At that point, I said, 'this is not ok'. I walked into the dining room and (V40) was in there and agreed. I witnessed (V13) wheel (R41) into the dining room by the DON's office. She got right up in her face and was intimidating her, saying, 'Shut the fuck up'. I did not report it in a timely manner. I didn't have my cell phone and I had to go on a transport. I know you are supposed to immediately report it. (V1) wasn't here but (V21) notified her. (V14) stayed on the floor (providing patient care) even though they were made aware. They made her stay until the DON came in. I know I am a mandated reporter. I felt it was wrong. I know the policy. Corporate told me anyone in the building could walk anyone out, even if they are nurses. On 6/27/2024 at 10:38 AM V40, Certified Nursing Assistant (CNA) stated, I was in the dining room early in the morning. I heard a nurse scream at her to shut up. It was (V14, LPN). I heard (V13, LPN) saying stuff can't remember what exactly. It was not appropriate, and it was her tone. (V15, Medical Records) and I looked at each other, like Is it abusive/reportable? did we just hear what we think we just heard? I told (V21, Business Office Manager) what I heard. (V21) said it needed to be reported and called (V1, Administrator). On 6/27/24 at 10:45 AM, V21 stated, I called (V1). (V40) reported it to me. I text (V1), and she was on her way. I didn't see or hear anything, but I felt it was my responsibility to report. I am not sure what time (V14) left but I know it wasn't right away, even after (V1) got here. V14's Timecard dated 6/4/2024 documents V14 clocked in at 5:51 AM and clocked out at 8:35 AM. The Facility's Abuse, Prevention, and Prohibition Policy dated 1/2024 documents, The facility administrator will be designated as the facility Abuse Coordinator and will be responsible for overseeing the Abuse Prevention and Prohibition Program and directing any abuse investigation. If the administrator is not available to address this role, the administrator will designate a person in charge in their absence to fulfill the role. This person would normally be the Director of Nursing. Reporting/Response: The Facility employee or agent, who becomes aware of abuse or neglect, shall immediately report the matter to the facility Administrator or his/her designated representative in the administrator's absence. The Facility administrator, employee or agent who is made aware (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 11 of 32 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 07/01/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete of any allegation of abuse or neglect shall report or cause a report to be made to the mandated state agency per reporting criteria. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property will be reported immediately to the administrator. The person made aware of allegation of abuse or neglect, or the administrator will report the allegations of abuse and neglect to the mandated state agency and law enforcement. The allegation will be reported no later than 2 hours, or per state regulations, after the allegation is made. Event ID: Facility ID: 145454 If continuation sheet Page 12 of 32 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 07/01/2024 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 0610 Respond appropriately to all alleged violations. 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 protect residents and prevent further potential abuse during abuse investigations and conduct thorough abuse investigations for 2 of 6 residents (R5, R41), reviewed for investigation/prevention/corrections of alleged violation of abuse in the sample of 44. Residents Affected - Few Findings include: 1. On 06/25/24 at 10:00 AM, R5 stated, A few weeks ago we were sitting in the dining room, there is a resident (R41) that repeats she wants to go home. (V11, Certified Nurse Aide, CNA) got right in her face and told her, You are never going to go home again to see your son because he is in prison. R5 was questioned if he told anyone of this, R5 stated, I told (V10, Social Service Director, (SSD) and (V1, Administrator). They came back and told me that (V11) needed to be retrained. I think that it was mental abuse. On 6/25/24 at 2:30 PM, V11, CNA, stated that he has never been involved in an allegation of abuse for R41. V11 stated that R41 is hard of hearing, and she always says that she wants to go home over and ever. On 6/25/24 at 3:03 PM, V9, Registered Nurse, (RN), stated, I was at the nurses station doing shift change in the morning. V14 LPN was up there too. V13 was giving report to her nurse. R41 was saying over and over again that she wanted to go home. V13 and V14 both told her to shut up. I did not notify V1 of it, but I know someone did. At this time, V11, CNA was not present. I do know that when he came in for his shift, he was not allowed to work the hall. I don't know why though. On 6/26/24 at 7:15 AM, V20, CNA, stated, I was told by (V11) when I came in that when he came to work, he was not allowed to go onto the hall because 2 residents had complained about him. He was told that (R5 and R43) had made complaints about the way he treated (R41). He told me that he was told to stay off of their halls when he was able to work on the floor later in the day. He was never suspended while they did the investigation. V20 was questioned if the allegation of abuse had to do with the allegation of (R41) being told to shut up, V20 stated, No it was another allegation that they (R5 and R43) had made about the way (V11) treated (R41). On 6/26/24 at 12:09 PM, V10, stated, I had interviewed (R5) while I was interviewing residents regarding the incident involving 2 nurses (V13 and V14) and R41. R5 told me that he thought (V11) was rough and loud in his voice while working with her. He said that he had yelled at her. I wrote the statement and gave it to V1, Administrator. I wrote word for word of what he said, read it back to him and then gave it straight to the Administrator. V1 said that she would take care of it. V1 did the follow up with R5. V2, Director of Nurses, was also involved in it too. On 6/26/24 at 3:17 PM, V1, stated that interviews were being taken from residents related to (V13 and V14) telling R41 to shut up. V1 stated I had collected all interviews and put them into a pile. I did not review them because I was still gathering information. I sent all the information to (V43, Regional Nurse Consultant), to let her review. I had a meeting that day from 4:00 PM to about 5:40 PM. Later that evening or the next day, I can't remember which she called me and asked me if I had seen (R5's) statement. I told her no. (V2, Director of Nursing) came to me on 6/4/24 after my meeting and told me that we have an issue regarding (V11). (V11) was already working on the floor. He starts at 2:00 PM. He was pulled from the floor. I am not sure of what time it was. We both went down and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 13 of 32 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 07/01/2024 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 0610 Level of Harm - Minimal harm or potential for actual harm talked to (R5). At that time, he said that he felt that (V11) was making fun of (R41). At no time, did he say that (V11) got in her face and yelled at her like his statement says. I then interviewed (V11), he said that he did not make fun of her. He said that he was trying to reorient her to reality. I and (V2) felt that it was a misunderstanding and we retrained him on effective communication, and he went back to work. I did not get any other interviews from other residents or staff about (V11). Residents Affected - Few R5's Abuse Investigation Investigative Questionnaire, dated 6/4/24, untimed, documents, (V11) kept teasing resident (R41) who wanted to go to [NAME] to her son, (V11) yelled in residents' face shut up, ain't no one in [NAME] want you. 2. The Facility's Final Investigation dated 6/11/2024 documents, In the morning of June 24th, staff members at (Facility) reported to the Administrator (ADM) that two nurses had an inappropriate verbal interaction with a resident (R41). An investigation was initiated, and staff members were suspended. On 6/24/24 at 9:30 AM, V1 Administrator, stated, I was notified that (V14 Licensed Practical Nurse, LPN) and (V13 LPN) had told (R41) to shut up during shift change. (R41) is confused and can be very repetitive. The staff did not notify me directly they had told V21, Business Office Manager, and V21 called me. There was a bit of a delay. The incident happened around 6:15 AM and I was notified at 7:30 AM. By this time V13 had already gone home because it was the end of shift. V14 was pulled off of the floor and statements were taken. V14 was told to go home. Both V13 and V14 were both suspended at that time. After the investigation the abuse was substantiated, and both were terminated. On 6/26/2024 at 12:25 V15, CNA, stated, I came in early that day (6/4/2024). I was by the nurse's station. (V13 and V14) were yelling and cussing at (R41). They said, 'We don't care where you live. She doesn't realize. She's confused. They also said, 'We can't do our fucking job'. At that point, I said, 'this is not ok'. I walked into the dining room and (V40) was in there and agreed. I witnessed (V13) wheel (R41) into the dining room by the DON's office. She got right up in her face and was intimidating her, saying, 'Shut the fuck up'. I did not report it in a timely manner. I didn't have my cell phone and I had to go on a transport. I know you are supposed to immediately report it. (V1) wasn't here but (V21) notified her. (V14) stayed on the floor (providing patient care) even though they were made aware. They made her stay until the DON came in. I know I am a mandated reporter. I felt it was wrong. I know the policy. Corporate told me anyone in the building could walk anyone out, even if they are nurses. On 6/27/24 at 10:45 AM, V21 stated, I called (V1). V40) reported it to me. I text (V1), and she was on her way. I didn't see or hear anything, but I felt it was my responsibility to report. I am not sure what time (V14) left but I know it wasn't right away, even after (V1) got here. V14's Timecard dated 6/4/2024 documents V14 clocked in at 5:51 AM and clocked out at 8:35 AM. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 14 of 32 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 07/01/2024 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide notice of bed hold policy to the resident and/or resident representative upon transfer to hospital for 1 of 1 resident (R7) reviewed for notice of bed-hold in a sample of 44. Findings include: R7's Face Sheet, dated 5/1/24 documented R7 was readmitted from the hospital on 5/1/24 and documents diagnoses of COPD (chronic obstructive pulmonary disease) and pneumonia. R7's Minimum Data Set (MDS) dated [DATE] documents cognitive impairment with a BIMS (Brief Interview Mental Status) of 3. R7's Progress Notes dated 4/26/2024 documents R7 was admitted to (local hospital). Review of R7 record review fails to document any bed-hold notification was provided to R37 and/or V36, Power of Attorney (POA). On 6/25/204 at 2:05 PM, V16 Licensed Practical Nurse (LPN) stated that a face sheet, medication list, order summary, code status is sent with the resident when they go to the hospital. On 6/25/2024 at 2:15 PM, V10 Social Worker, stated, The ombudsman (resident advocate) is sent a batch email at the end of the month. V10 stated a bed-hold sheet and transfer/discharge paperwork should be sent with the resident. V18 stated they are sent with a SBAR, face sheet, advanced directive, bed hold policy and transfer policy. She states that the nurses document this in the progress notes. On 6/25/2024 at 2:20 PM, V18, Licensed Practical Nurse, LPN, stated that the nurses should document the bed-hold policy in the progress notes. On 6/26/2024 at 12:00 PM, V1, Administrator, states that her expectation is that staff should follow the policy on what papers should be sent and be retrained if they don't know what this policy is. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 15 of 32 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 07/01/2024 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 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the Physician prescribed skin/wound treatments for 1 of 6 residents (R5) reviewed for wounds and quality of care in the sample of 44. Residents Affected - Few Findings include: 1. On 06/25/24 at 10:00 AM, R5 stated that he does get cellulitis in his abdomen often. R5 was questioned if he gets a treatment to his abdominal folds. R5 stated that he gets nystatin powder to his folds and to his groin. R5 was questioned if he gets any type of barrier disposable cloth placed in his abdomen to collect the moisture, he stated that he does not. On 6/25/24 at 3:00 PM, V3, Assistant Director of Nurses, (ADON), entered R5's room to look at his abdomen. R5 was questioned if he gets a disposable cloth to absorb the moisture between his folds, R5 stated, You mean InterDry? I used to, but I don't anymore. It's been a while since I had one. R5 was questioned if he knew why. R5 stated, It is kind of hard to get it in the fold because the fold is so large and heavy. R5 stated that his abdominal fold does get moisture trapped in between the fold. On 6/25/24 at 3:03 PM, R5 stood up and exposed his abdominal folds. No InterDry moisture wicking sheet was observed. R5's abdominal fold was red and irritated. On 6/25/24 at 3:10 PM, V3, stated that since the Physician ordered InterDry for his abdomen the nurses should be doing it and not falsifying documentation that they are doing it when they are not. R5's admission Record, print date of June 25, 2024, documents that R5 was admitted on [DATE] with diagnoses of morbid obesity and Panniculitis. R5's Physician Orders, dated 5/21/2024, documents, Cleanse posterior scrotum, inverted penis BID with mild soap and water, pat dry and apply barrier ointment. Apply InterDry moisture wicking sheets to abdominal fold and bilateral groin leaving wick at each end for moisture evaporation. Apply nystatin cream to bilateral groin rash. R5's Minimum Data Set, dated [DATE], documents that R5 is cognitively intact. R5's Treatment Administration Record, dated July 2024, documents, that R5's abdominal fold received treatment including InterDry on 6/23/24 day and night shift 6/24/24 day shift. On 7/1/24 at 11:40 AM, V18, Minimum Data Set / Licensed Practical Nurse, stated that the staff are expected to follow all Physician orders. The policy Wound Assessment, dated 3/21, fails to document to follow Physician Orders for treatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 16 of 32 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 07/01/2024 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 Based on observation, record review and interview the facility failed to identify, assess, and treat pressure ulcers for 2 of 7 residents (R38 and R125) reviewed for pressure ulcers in the sample of 44. Residents Affected - Few Findings include: 1. On 06/24/24 at 9:30AM, R125 was sitting in wheelchair in his room. R125 was observed with both bare feet on the floor and pressure sores to bilateral heels without any type of dressing on them. R125 stated They are leaving them open to air. On 6/27/2024 10:29 AM V8, Wound Nurse, and V42, Licensed Practical Nurse, LPN, provided treatment to R125's pressure ulcers. There were dressing in place to bilateral heels prior to treatment. V8 removed dressings cleansed wounds and applied debridement ointment, calcium alginate and foam border dressing. R125's right heel unstageable per V8. V8 stated R125 was to have treatments done as ordered and heels are not to be left open to air. R125's Physician Orders (PO) dated 6/14/2024 documents Cleanse wound to left heel, apply Santyl, calcium alginate and cover with dry dressing every night shift for vascular wounds AND as needed for soiling or unscheduled removal. R125's PO dated 6/14/2024 documents Cleanse wound to right heel, apply Santyl and cover with dry dressing every night shift for vascular wounds AND as needed for soiling or unscheduled removal. R125's Care Plan, dated 6/19/2024 documents R125 has potential/actual impairment to skin integrity related to pressure (right hip) Venous R (right) anterior knee, R lateral knee, left heel, right heel, left shin. The facility policy Pressure Ulcer/Pressure injury prevention, revised 3/2022, documents if pressure ulcer /pressure injury is present, provide treatment to heal it and prevent the development of additional pressure ulcers/pressure injuries. 2. On 6/24/24 at 12:15 PM, R38 was lying in her bed. R38 was lying onto her left side. R38 had a large abdomen that lays onto the mattress. R38 stated that she only lays this way. R38 stated that she has been dealing with the pressure ulcer on the abdomen for a long time. She stated that it will heal and then it will open back up. R38 stated that she does have an area on the back of her leg near her bottom. On 6/25/24 at 2:45 PM, V3, Assistant Director of Nurse, (ADON) and V39, Certified Nurse's Aide (CNA) entered R38's room to look at pressure ulcer dressings. R38's left gluteal fold has cream and a small open area which is difficult to see related to R38's position. On 6/25/24 at 2:45 PM, R38 and V39 both stated that the left gluteal fold has a pressure ulcer. On 6/27/24 at 9:33 AM, V8, Wound Nurse / Licensed Practical Nurse, (LPN) entered R38's room to change R38's pressure ulcer dressing and wound dressings. The left gluteal fold pressure ulcer is approximately 0.5-centimeter (cm) x 0.5 cm. The wound bed is red. V8 cleansed with normal saline, applied calcium alginate, and applied a foam dressing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 17 of 32 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 07/01/2024 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 On 6/26/24 at 3:15 PM, V3 was questioned why there was no documentation of the left gluteal fold pressure ulcer in R38's medical record. V3 stated that she did not know, and she would review the record. On 6/27/24 at 9:30 AM, V8 stated that she looked at R38's gluteal fold pressure ulcer the evening before (6/26/24). V8 stated she was unaware of the pressure ulcer or how long it has been there. Residents Affected - Few R38's Pressure Ulcer Weekly Wound Evaluation, dated 6/26/24, documents that R38 has a new stage 2 pressure ulcer to the left gluteal fold measuring 1 cm x 0.5 cm x 0.1 cm which first presented on 6/26/24. The policy Pressure Ulcer / Pressure Injury Prevention, dated 3/22, documents that all residents should have a daily skin observation of the skin during care given by the CNAs. This policy fails to document assessment, measurement, and documentation of the pressure ulcer, notification of the doctor, and obtaining orders for the pressure ulcer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 18 of 32 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 07/01/2024 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 - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 06/24/24 at 11:54 AM V7, CNA, and V3, Assistant Director of Nursing (ADON) provided R59 incontinence care. V7 removed R59's pants and undid R59's adult diaper. V7 stated R59 has pooped and was incontinent of urine. V7 rolled the adult diaper under R59. V7 turned R59 to left side. V7 used disposable wipes and cleansed rectal area from front to back. V7 did not cleanse buttocks. V7 then placed R59 on back. V7 cleansed left groin, then right groin. V7 separated labia and made one swipe with disposable wipe from front to back. V7 did not cleanse inner thighs prior to drying R59. R59's Care Plan dated 2/21/2024 documents that R59 has bladder incontinence. R59's care plan documents wash, rinse, and dry perineum. 4. On 06/26/24 at 08:46 AM V22 CNA and V23, Certified Occupational Therapist Aide, COTA, went into R128's room transferred R128 from sit to stand to the toilet. V22 removed R128's adult diaper. R128's adult diaper was full of liquid stool. R128 stated he still needed to go to the bathroom. At 9:11 AM, V24 CNA and V22 with sit to stand lift lifted R128 to standing position. V24, with disposable wipes reached in from behind R59 and swiped from front to back using numerous wipes until no visual stool. At no time did V22 or V24 cleanse R128's scrotum or peri area during incontinent care. R128's Care Plan, dated 6/14/2024 documents R128 has bladder incontinence, and impaired m mobility. R128's Care Plan documents wash, rinse and dry perineum after incontinent episodes. On 7/1/2024 at 10:25AM V25, CNA, stated that when providing incontinent care on a male resident the scrotum is to be cleansed, the penis and the foreskin is to be pulled back and cleansed. 3 Based on interview, observation, and record review, the facility failed to provide complete incontinent care for 4 of 5 residents (R57, R59, R62, R128) reviewed for incontinence care in the sample of 44. Findings include: 1. On 06/26/24 at 2:35 PM, V38, Certified Nurse Aide, (CNA) and V39 CNA entered R57's room to provide incontinent care. R57's incontinent brief was moderately saturated with urine. V38 with disposable peri-wash cloths wiped the right groin, then left groin, and gently wiped over the labia twice. R57 was rolled over onto her right side and the rectal area and both buttocks were cleansed. V38 placed a new incontinent brief on R57. V38 failed to spread and cleanse the labia and cleanse the inner thighs. R57's admission Record, print date of 6/26/2024, documents that R57 was admitted on [DATE] with diagnoses of Functional Urinary Incontinence, Paranoid Schizophrenia, and need for assistance with personal care. R57's Minimum Data Set (MDS), dated [DATE], documents that R57 is severely cognitively impaired, requires substantial / maximal assistance from staff for toileting, personal hygiene, Partial / (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 19 of 32 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 07/01/2024 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 moderate assistance with mobility, and is frequently incontinent of bowel and bladder. Level of Harm - Minimal harm or potential for actual harm On 6/26/24 at 2:55 PM, V18, MDS / Care Plan Licensed Practical Nurse (LPN), stated, The facility does not have an incontinent care policy. We expect the nursing staff to follow standards of practice. Residents Affected - Some On 6/27/24 at 11:20 AM, V41, Regional Directors of Operations, stated that the expectations of staff are that complete incontinent care will be provided. 2. R62's MDS dated [DATE] documents R62 is cognitively intact. R62's Care Plan dated 6/27/2024, documents R62 has a catheter and a wound to the back of her right thigh. On 6/24/2024 at 10:30 AM, R62 stated she has open wounds and a urinary catheter. R62 stated she needs cleaned up (provided incontinent care). On 6/25/2024 at 10:40 AM, V29, CNA entered R62's room and R62 informed V29 that R62 needed incontinent care. R62 had a small soft bowel movement (BM). There was also BM on R62's catheter tubing. V29 began to provide incontinent care to R62 without donning a gown. V29 cleansed the area of R62's buttocks. R62's dressing to R62's open wound to R62's buttocks was soiled with BM. V29 removed R62's dressing with the same gloves used to cleanse the feces off R62's buttocks. V29 then cleansed R62's catheter tubing, without the benefit to hand hygiene or changing gloves. V29 then rolled R62 over and cleansed R62's groin area. At this time, R62 thanked V29 and stated, Usually they just clean my backside and not the front (peri/groin area) and I don't want any more infections. On 6/25/2024 at 10:55 AM, V8, Wound Nurse, entered R62's room to replace R62's dressing to her buttocks. V8 stated R62 also had an open wound to R62's right gluteal fold. When V8 lifted R62's right buttock cheek, there was still feces remaining in the crevice. V8 cleansed the remaining feces. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 20 of 32 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 07/01/2024 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. 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 maintain an occlusive dressing for a Peripherally Inserted Central Catheter (PICC) for 2 of 2 residents (R33, R175) reviewed for Intravenous Therapy in the sample of 44. Residents Affected - Few Findings include: 1. On 6/24/24 at 1:25 PM, V6, Registered Nurse, (RN) entered R175's room to hang an Intravenous (IV) medication through a PICC (Peripherally Inserted Central Catheter) line. V6 told R175 that she was going to hang her IV (Intravenous) antibiotic. R175 extended her right arm showing a double lumen PICC line in the right upper arm. The dressing was not adhered to the skin at the bottom and the right side of the dressing. The dressing was dated 6/19/24. R175 stated, Do you see my dressing? V6 stated, Yes, I have got to get you an IV pole. V6 returned with an IV pole and hung the IV medication without changing the dressing. On 6/26/24 at 8:58 AM, V6, was questioned why she did not change R175's PICC line dressing was not changed when she noticed it was not occlusive anymore, V6 stated, I am not sure. I did go back and change it when the IV was finished. V6 stated that the PICC line dressing should be changed once a week. On 6/26/24 at 9:02 AM, V3, Assistant Director of Nurses (ADON), stated that the PICC line dressing should be changed every week or when it becomes loosened. R175's admission Record, print date of 6/26/24, documents that R175 was admitted on [DATE] with a diagnosis of abscess of the salivary gland. R175's June 2024 Medication Administration Record or Treatment Administration Record fails to document a PICC line dressing change every week or as needed. 2. On 06/24/24 at 03:04 PM, R33 was sitting in dining room with a dual lumen PICC line the dressing is dated 6/11/24 the bottom or the right side of the occlusive dressing is not attached. R33 stated that she gets an IV every day and it is hung in the morning. R33's admission Record, print date of 6/26/24, documents that R38 was admitted on [DATE] with diagnoses of Renal and Perinephric Abscess and Urogenital Implant. R33's Medication Administration Record, dated June 2024, documents that R33's Ertapenem Sodium Injection Solution Reconstituted 1 GM (gram) was hung on the day shift (6:00 AM - 6:00 PM) R33's June 2024 Treatment Administration Record documents that R38's PICC line dressing was not change on the day shift. R33's Health Status Note, dated at 6/24/2024 at 6:45 PM, documents, Resident has had no reaction noted to ABT (antibiotic) r/t (related to abscess). Changed dressing to PICC, area looks good, intact, PICC in place, no s/s (sign and symptom) of infection noted. Resident pleasant, makes needs known. The Organizational Aspects of IV Therapy, dated 7/2016, documents, 5. Caring for and maintaining (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 21 of 32 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 07/01/2024 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 0694 infusion equipment and catheters 9peripheral and central venous access catheters). This includes flushing, dressing changes, site assessment, site rotation, changing IV tubing and needleless connection devices. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 22 of 32 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 07/01/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 change nebulizer therapy tubing on a weekly basis for 1 of 8 residents (R65) reviewed for respiratory therapy in the sample of 44. Residents Affected - Few Findings include: 1. On 06/26/24 at 03:00 PM R65's nebulizer machine and tubing were on nightstand beside the bed. R65's tubing dated 6/2/2024. R65 stated oxygen tubing and nebulizer tubing used to be changed on a weekly basis. R65's Minimum Set (MDS) dated [DATE] documents R65 is cognitively intact with a Brief Interview of Mental Status (BIMS) of 15. R65's Face Sheet dated 6/27/2024, documents a diagnosis in part of Chronic Obstructive Pulmonary Disease (COPD) and sleep apnea. R65's Physician Order (PO) dated 3/11/2024 documents Ipratropium-Albuterol Solution 0.5-2.5 (3) Milligram (MG) /3 Milliliter (ML) inhale orally every 6 hours as needed for Shortness of Breath (SOB). R65's PO, dated 2/19/24, documents oxygen tubing-change weekly every night shift, every Sunday. On 7/1/2024 at 7:55AM, V18, MDS coordinator stated the facility does not have a specific policy for nebulization tubing, but the tubing is to be changed weekly same as the oxygen tubing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 23 of 32 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 07/01/2024 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 - Actual harm Based on observation, interview, and record review the facility failed to identify, assess, and implement interventions for pain for 1 of 6 residents (R129) reviewed for pain in the sample of 44. This failure resulted in R129 moaning in pain due to not being assessed and treated with pain medication for 44 minutes. Residents Affected - Few Findings include: 1. On 6/24/2024 at 11:50AM R129 stated to V3 Assistant Director of Nursing (ADON) that her stomach was hurting. R129 was lying in bed groaning with facial grimacing. V3 told R129 that she would let her nurse know and left R129's room. On 6/24/24 at 12:10 PM R129 continued to groan while belching and stating, Oh God, I want to die. On 6/24/24 at 12:15 PM V7, Certified Nursing Assistant (CNA) entered R129's room to turn her on her left side. R129 stated, I'm hurting like I have to poop, please hurry for the nurse. V7, CNA stated she would notify R129's nurse now. V7 exited R129's room. V7 CNA was observed speaking with V6, Registered Nurse (RN) at the end of hall passing medications. V6 continued to do medication pass after being told R129 was in pain. On 6/24/24 at 12:25 PM, R129 stated her pain is a level is 10 on a scale of 1-10 with 10 being highest pain. R129 stated that her nurse has not been in to check on her yet. On 6/24/24 at 12:27 PM V37, CNA entered R129's room and took R129's vital signs which had not been taken. R129's blood pressure was 154/70, heart rate 68. V37 stated R129's temp was 98.4 and oxygen saturation 98%. V37 exited R129's room and reported readings to V6 RN who is still passing medications at the end of the hall. On 6/24/24 at 12:30 PM V6 entered R129's room and listened her lungs and stomach while asking Does it hurt when I press on your stomach anywhere? R129 stated she had pain when V6 pressed on her left lower abdominal quadrant. V6 stated R129 had active bowel sounds and did not feel any hard areas on her stomach. V6 stated, I can't remember when I was told she had pain, I've been busy it could have been 5 minutes ago. V6 stated she had not contacted the doctor about this. V6 left room without asking R129 to rate her pain. on 6/26/24 at 1:03 PM, R129 stated nobody likes to wait, I know they are busy and I'm not the only one, I'm just one of the people, regarding waiting for almost an hour on 6/24/24 after reporting she was in pain. R129's Care Plan, dated 6/192024 documents R129 is at risk for pain related to depression. R129's care plan documents to monitor, record/report to nurse resident complaints of pain or requests for pain medication. R129's care plan documents evaluate the effectiveness of pain interventions. Review alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and cognition. R129's Physician's Orders, PO, dated 6/12/24 documented Pain Scale: Record q shift: 0-1 No Pain; 2-3 Mild Pain; 4-5 Moderate Pain; 6-7 Severe Pain; 8-9 Very Severe Pain; 10 Worst Possible Pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 24 of 32 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 07/01/2024 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 Level of Harm - Actual harm R129's Medication Administration Record (MAR) dated June 2024 documents Acetaminophen tablet 325mg (milligrams) give 2 tablets by mouth every 4 hours as needed for mild pain (1-4 on pain scale). R129's MAR documents that R129 was administered 2 Tylenol 325 mg at 12:44PM. R129's MAR does not document orders for any type of pain medication for any pain other than mild pain. Residents Affected - Few On 7/1/2024 V18, MDS coordinator stated the facility does not have a pain policy. V18 stated it is expected that staff assess residents for pain and administer pain medication according to physician's order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 25 of 32 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 07/01/2024 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide enough staff to care for residents in a timely manner for (R38, R22, R50, R5) reviewed for sufficient nursing staff in the sample of 44. Findings include: 1. On 06/24/24 at 12:30 PM, R38 was questioned if call light response is timely, R38 stated, Sometimes it takes hours for them to come.R38 was asked if she knew why it takes so long, R38 stated, They just say we are really backed up. R38's Minimum Data Set (MDS), dated [DATE], documents that R38 is cognitively intact, dependent on staff for toileting, bed mobility, and uses a wheelchair. 2. On 6/24/24 at 11:26 AM, R22 was questioned if her call light is answered timely, R22 stated, At night it can take over an hour. R22's MDS, dated [DATE], documents that R22 is cognitively intact, uses a wheelchair, is dependent on staff for toileting, requires partial / moderate assistance for hygiene, substantial / maximal assistance for bed mobility, and dependent on staff for bed to chair transfer. 3. On 6/24/24 at 12:35 PM, R50 was questioned about how timely the staff answer the call light, R50 stated, On the weekends, the staff can take hours for them to come in and answer the light because there is not enough staff. R50's MDS, dated [DATE], documents that R50 is cognitively intact, uses a wheelchair, is dependent on staff for toileting, bed mobility, transfers, and is frequently incontinent of bowel and bladder. 4. On 06/25/24 at 10:00 AM, R5 stated, They don't have enough staff on night shift last night. I sat on the bedside commode for an hour and 15 minutes last night. R5 was questioned if the aides told him why it took so long, R5 stated, There was 2 CNAs for A and B hall. The one aide was working on both halls because the other aide was agency and she said, I am pregnant, and I am not doing a thing. R5's MDS, dated [DATE], documents that R5 is cognitively intact, uses a wheelchair, requires touch / supervision assist for toileting, hygiene, bed mobility, partial / moderate assistance for transfers. occasionally incontinent of urine, and frequently incontinent of bowel. On 7/1/24 at 8:23 AM, V44, CNA scheduler stated, The CNAs work on 8-hour shifts; 6 AM to 2 PM, 2 PM 10 PM, 10 PM - 6 AM. Most CNA's work 8-hour shifts but I do have a few that work 12-hour shifts. Depending on the census, on day shift the highest is 9 which is 80 or above and the lowest 70 or less is 6. The evening shift, the highest is 8 and lowest is 5. The night shift highest is 5 and lowest is 3. 3 CNAs on night shift is not enough. The fall pod requires 1 CNA just for those 4 residents, then we need at least 3 other CNAs for the other residents. Before the fall pod R57 really needed one to one supervision because she was a fall risk. It is ridiculous for it to take the CNAs over an hour to answer the call lights. I come in and work that shift if we are shorthanded and there is no reason for that. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 26 of 32 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 07/01/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to ensure physician ordered medication was readily available for administration for 1 of 5 residents (R62) reviewed for pharmacy services and procedures in the sample of 44. Findings include: On 6/24/2024 at 10:30 AM, R62 stated she has been out of her Effexor, which she takes for depression. R62 continued to state, They let me run out of my Effexor. It is an anti-depressant and I have to have it. I take it twice a day and I didn't have it last night or this morning. It's completely out of my system. I have withdrawals and it makes me sick. Please check on it. I can already feel it in my body that I missed doses. It's ridiculous. R62's Minimum Data Set (MDS) dated [DATE] documents R62 is cognitively intact. R62's Care Plan dated 6/27/2024, documents R62 has a mood problem related to her diagnosis of Depression and R62 receives an antidepressant. It further documents, Administer medications as ordered. R62's Physician's Orders dated 6/27/2024 documents, Venafaxine (Effexor) HCL Oral Tablet 100 mg-Give one tablet by mouth every morning and at bedtime for antidepressant. R62's Medication Administration Record dated June 2024, documents 6 for one dose on 6/23/24 and two doses on June 24, 2024. It further documents that 6 indicates See Progress Note. On 6/26/24 at 10:24 AM, V3, Assistant Director of Nursing (ADON) stated she was aware R62 had ran out of her depression medication and did not receive doses as prescribed. V3 further stated, If it gets down to the last one the card there is a re-order button on the MAR. It should be re-ordered when it turns blue on the card about 7 days prior. She (R62) told me Monday (6/24/2024) she was out of her Effexor (depression medication). I called pharmacy and had it e-ran (emergency delivery from pharmacy). It came in a little after lunch (Monday 6/24/24). On 7/1/2024 at 9:20 AM, V3 stated there was not an entry made in R62's Progress Notes on 6/23/2024 for the missing medications dose. On 7/1/2024 at 9:33 AM, V3 provided two Progress Notes from 6/24/2024, on at 9:10 AM and one at 8:14 PM, that documented N/A, which V3 verified indicated that the medication was not available. The Facility provided an Hours of Operation & Cutoff Times document that states, The facility staff should specifically request any items that cannot wait until the next regularly scheduled pharmacy delivery. The after-hours representative will arrange for a local pharmacy to fill a 3-day supply of the requested items and coordinate a delivery with a driver to take it directly to the home. The Facility's General Pharmacy Information dated 4/2021 documents, Refills after above time will be sent with the next day's delivery unless the nurse indicates that it is needed that day. Refills are to be communicated either electronically through the interface or by faxing the refill re-order form that contains the prescription barcode. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 27 of 32 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 07/01/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm The Medication Fact Sheet dated January 2016 from the website American Association of Psychiatric Pharmacists (aapp.org) documents, Missing doses of venlafaxine may increase your risk for relapse in your symptoms. Stopping venlafaxine abruptly may result in one or more of the following withdrawal symptoms: irritability, nausea, feeling dizzy, vomiting, nightmares, headache, and/or paresthesis (prickling, tingling sensation on the skin). Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 28 of 32 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 07/01/2024 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. 3. On 06/24/24 at 11:11 AM during medication pass, R1's fluticasone Propionate suspension nasal spray in box in medication cart without a pharmacy label. V35, Licensed Practical Nurse, LPN stated the medications should be labeled. R1's Medication Administration Record (MAR)dated June 2024 documents Fluticasone Propionate suspension 2 sprays in each nostril one time a day as needed for congestion. 4. On 6/27/2024 at10:29 AM during wound treatments V8, Wound Nurse, removed tube of wound debridement ointment from treatment cart for R125. R125's medication did not have a pharmacy label. R125's name was handwritten on the tube of medication. V8stated she does not know what happened to box with label. V8 stated the medication should have a pharmacy label. R125's physician order (PO) dated 6/14/2024 documents Santyl External Ointment 250 UNIT/GM (Collagenase) Apply to AFFECTED AREA topically everyday shift for WOUND CARE. Based on observation, interview, and record review, the facility failed to remove outdated medication from the medication refrigerator, date an insulin pen after opening, and ensure medications are labeled for 3 of 18 residents (R1, R68, R125) reviewed for labeling and storage of medication in the sample of 44. Findings include: 1. On 06/25/24 at 09:15 AM, the medication storage room was inspected and contained R1's Cephalexin 250 milligrams (mg) oral suspension. Open date of 06/08/24 and the directions read to discard after 14 days. On 06/25/24 09:20 AM, V3, Assistant Director of Nursing (ADON) confirmed that the Cephalexin should have been discarded after 14 days. 2. 06/25/24 at 09:33 AM, the medication cart on the A hallway was inspected and contained2. R68's Humalog Kwik Pen was opened but did not have an open dated on the pen. V16, Licensed Practical Nurse (LPN) stated the pens are good for 30 days after opening. She said R68 uses a pen in less than 30 days so she knows it is probably still good, but she will dispose of the pen and get her a new one since there is no open date on it. On 06/27/24 at 10:50 AM, V3 stated she would expect for the nursing staff to always date any medication after opening it and to check the medication before using. The facility's policy for Delivery, Storage, and Return of Drugs or Supplies, with a revision date of 12/21, documents F. Residents' medications shall be properly labeled and stored at or near the nurse's station in a locked cabinet, a locked medication room, or in one or more locked mobile medication carts of satisfactory design for such storage. All mobile medication carts, when not stored either in a locked room or otherwise made immobile, shall be under the visual control of the responsible nurse at all times. G. The medications of each resident shall be kept and stored in their originally received containers. Medications shall not be transferred between containers. It further documents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 29 of 32 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 07/01/2024 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 I. Multi-dose vials and pens shall be stored and dated per the manufacturer's guidance. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 30 of 32 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 07/01/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 6/24/2024, at 11:54 AM V7 provided incontinent care on R59. R59 was incontinent of urine and bowel movement. V7 donned gloves. V7 did not sanitize hands prior to donning gloves. V7 then began going through wardrobe and drawers looking for pants for R59. V7 removed R59's pants and incontinent brief and did not sanitize hands prior to donning gloves after rolling a soiled adult incontinent brief under R59. Residents Affected - Some R59's Care Plan dated 2/21/2024 documents that R59 has bladder incontinence. 2. On 6/24/24 at 1:25 PM, V6, Registered Nurse, (RN) entered R175's room to hang an Intravenous (IV) Medications through a PICC (Peripherally inserted central catheter) line. R175's room door had enhanced barrier precaution sign on the door. V6 entered room without donning a gown or performing hand hygiene. Once in the room. donned gloves with no hand hygiene, hung, cleansed the lumen, changed gloves without hand hygiene and administered the IV medication. V6 removed her gloves, donned another pair of gloves, then cleansed the red lumen with 10 milliliters (mls) of Normal Saline followed by 5 ml of Heparin. On 6/26/24 at 10:45 AM, V6 was questioned as to why she did not follow the enhanced barrier precautions by wearing a gown and perform hand hygiene with donning and doffing gloves, V6 stated, I just forgot. 3. On 6/25/24 at 8:45 AM, V16, Licensed Practical Nurse (LPN), was observed administering medications to R20. V16 donned without hand hygiene at th3e beginning of the medication preparation. The policy Infection Prevention and control Manual - Enhanced Barrier precautions, undated, documents, Enhanced barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) acquisition (such as residents that have wounds or indwelling medical devices). High contact resident care activities where a gown and gloves should be used include: Transferring residents from one position to another (for example, from bed to wheelchair). Changing briefs or assisting with toileting. Caring for or using an indwelling medical device. Performing wound care. The Infection Prevention and Control Manual, dated 2019, documents, Wear gloves when it can reasonably anticipated that contact with blood or other body potentially infectious materials, mucous membranes, non-intact skin, or potentially contaminated intact skin. Based on observation, interview and record review, the Facility failed to perform hand hygiene, and utilize appropriate Personal Protective Equipment (PPE) to prevent the spread of infection for 4 of 24 residents (R62, R20, R59, R175) reviewed for infection control in the sample of 44. Findings include: 1. R62's Minimum Data Set (MDS) dated [DATE] documents R62 is cognitively intact. R62's Care Plan dated 6/27/2024, documents R62 has a catheter, impairment to skin integrity to her sacrum and right posterior (backside) of her thigh, as well as requires Contact isolation. On 6/24/2024 at 10:30 AM, R62 stated she has open wounds and a urinary catheter. There was no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 31 of 32 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 07/01/2024 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 - Some signage for any kind of isolation precautions on R62's door nor any Personal Protective Equipment (PPE). R62 stated she needs cleaned up (provided incontinent care) On 6/25/2024 at 10:40 AM, V29, Certified Nursing Assistant (CNA) entered R62's room and R62 informed V29 R62 needed incontinent care. R62 had a small soft bowel movement (BM). There was also BM on R62's catheter tubing. V29 began to provide incontinent care to R62 without donning a gown. V29 cleansed the area of R62's buttocks. R62's dressing to R62's open wound to R62's buttocks was soiled with BM. V29 removed R62's dressing with the same gloves used to cleanse the feces off R62's buttocks. V29 then cleansed R62's catheter tubing, without the benefit to hand hygiene or changing gloves. V29 then rolled R62 over and cleansed R62's groin area. At this time, R62 thanked V29 and stated, Usually they just clean my backside and not the front (peri/groin area) and I don't want any more infections. V29 then applied opened the bedside drawer and applied a clean adult brief with the same gloves used to cleanse areas of fecal contamination. On 6/25/2024 at 10:55 AM, V8, Wound Nurse, entered R62's room to replace R62's dressing to her buttocks. V8 set R62's dressing supplies on R62's bed, without a barrier. V8 then moved the supplies to a bedside table. V8 began cleansing the open area with a wound cleanser. V8 did not apply a gown prior to providing care to R62's open wound. V8 removed and disposed of the gloves but did not perform hand hygiene prior to applying new gloves and proceeded to complete the dressing change to R62's buttocks. V8 stated R62 also had an open wound to R62's right gluteal fold. When V8 lifted R62's right buttock cheek, there was still feces remaining in the crevice. V8 cleansed the remaining feces and again, changed gloves, but did not perform hand hygiene. On 6/27/2024 at 1:00 PM, V3, Assistant Director of Nursing (ADON) stated she would expect hand hygiene in between glove changes and when providing care between dirty areas and clean areas. V3 also stated, Anyone with a wound, (catheter), or anything that would make them more susceptible to infections should be on enhanced barrier precautions. Sometimes the sign (announcing precautions) falls off the door. V3 stated she was not aware R62's door did not have an enhanced barrier precaution sign or Personal Protective Equipment (PPE) readily available. On 7/1/2024 at 9:20 AM, V3 stated R62 is enhanced barrier precautions and staff should be wearing a gown when providing wound or catheter care. At this time, V18, Licensed Practical Nurse/MDS coordinator added R62 is on enhanced barrier precautions due to her wounds and catheter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 32 of 32