Inspection·June 26, 2025

F 0550 ADL's, and is dependent on staff for mobility. Level of Harm - Minimal harm or potential for actual harm 3. On 6/23/25 at 11:02 AM, R3 stated, At night, I have waited 2 hours for them to answer my call light. R3's admission Record, print date of 6/24/25, documents R3 was admitted on [DATE]. Residents Affected - Some R3's MDS, dated [DATE], documents R3 is cognitively intact and requires assistance from staff for ADL's and mobility. 4. On 6/23/25 at 11:00 AM, R60 stated, It can take over a half an hour for them to come if someone is on break. R60's admission Record, print date of 6/24/25, documents R60 was admitted on [DATE]. R60's MDS, dated [DATE], documents R60 is cognitively intact and requires assistance with ADL's and mobility. 5. On 06/23/25 at 10:55 AM, R174 stated, Sometimes it takes over an hour for someone to come in. This morning I had to walk up to the nurses station to get help. R174's admission Record, print date of 6/24/25, documents R174 was admitted on [DATE]. R174's MDS, dated [DATE], documents R174 is cognitively intact and requires assistance with ADL's and mobility. On 6/25/25 at 11:40 AM, V30, Regional Director of Operations, stated, We do not have a call light policy. I expect the call light to be answered in 5 minutes or less. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 2 of 22 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 06/26/2025 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 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent physical abuse for 1 of 1 resident (R67). This failure affects two residents (R43 and R67) reviewed for abuse in the sample of 43. Findings include: R43's Health Status Note, dated 4/25/2025 at 5:33 PM, documents, Note Text: Resident in dining area got up from sitting went to kitchen window picked up cup of thickened cold liquid. while walking back to her seat she threw out cup of liquids onto another resident (R67). (R67) was tended to and incident was witnessed by 2 kitchen helpers (V4) and (V23). R43 denies doing this upon questioning. (R67) received head to toe assessment without injury. Administrator was informed. R43's Abuse Final Report, dated 5/2/25, documents, On 4/25/25, (R43) was walking to the dish window in the dining room and poured her drink on (R67). Staff intervened and (R43) promptly returned to her seat. It continues, At conclusion of the investigation, based on staff statements, the incident did occur. On 6/25/25 at 9:20 AM, V1, Administrator, stated residents can not throw water on other residents that is abuse. R67's admission Record, print date of 6/24/25, documents R67 was admitted on [DATE]. R67's Minimum Data Set (MDS), dated [DATE] documents R67 is severely cognitively impaired. R43's admission Record, print date of 6/24/25, documents R43 was admitted on [DATE]. R43's MDS, dated [DATE], documents R43 is moderately cognitively impaired. The Abuse, Prevention and Prohibition Policy, dated 3/2025, documents, The facility prohibits mistreatment, neglect, or abuse of residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 3 of 22 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 06/26/2025 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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide the physician with the pharmacy recommendation and to provide limitations or rationale for a physician ordered as needed anti-anxiety medication, for 1 of 3 (R56) residents reviewed for psychotropic medication review, in a sample of 43. Finding includes: R56's Physicians order sheet, dated 6/2025, documented diagnoses of Alzheimer's disease with late onset, Cognitive communication deficit, Neurocognitive disorder with Lewy bodies, Major depressive disorder, Generalized anxiety disorder and panic disorder. R56's Minimum Data Set, dated [DATE], documented that his cognition was severely impaired and that he has had no behaviors exhibited. R56's Care plan, dated 9/10/2024, documented, Monitor/document /report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. R56's Physician's order sheet, documented an order dated 3/1/2025, Lorazepam 0.5 milligrams (mg) take 1 tablet by mouth every 4 hours as needed for anxiety, (shortness of breath), restlessness or agitation. On 06/24/2025 at 4:15PM, V2, Director of Nurses (DON) stated that she was not aware that the Ativan had not been reordered every 14 days. R56's Pharmacy Medication recommendation, dated 12/18/24 and 1/21/25, both documented recommendations for Quetiapine 100mg every morning and 200mg every night to be decreased to Quetiapine 100mg every morning and 150 mg every night. Theses were not sent to R56's Physician. R56's Pharmacy Medication recommendation, dated 3/18/2025, for Quetiapine 100mg every morning and 200 mg every night to be decreased to Quetiapine 100mg every morning and 150 mg every night. This gradual dose reduction was sent to the physician on 3/19/2025 and the medication was reduced. R56's Pharmacy Medication recommendation, dated 2/12/2025, documented Buspirone 30mg twice daily to be decreased to Buspirone 30 mg in the morning and 15 mg at night. This was not sent to his Physician. R56's Physicians order sheet, dated 2/27/2025, documented an order for Buspirone 30 mg every morning and every night. On 06/24/2025 at 01:34 PM, V2, DON, stated that she did not see any notes on when R56's doctor was contacted or what had happened with his Pharmacy Medication Recommendations. On 06/24/2025 at 02:19 PM V2, DON, presented documentation that on 3/19/2024 R56's Nurse Practitioner signed off on the recommendation, but she was unable to find documentation that the Pharmacy recommendations from 12/18/24, 1/21/25 and 2/12/25 were addressed by R56's Physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 4 of 22 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 06/26/2025 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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 06/24/2025 at 4:15PM, V2, DON, stated that she does not have documentation where the doctor was notified about R56's Pharmacy recommendations nor does she have an updated physician's order for R56's Lorazepam. The facility's policy, Psychotropic Medication Use, dated 2/2025, documented, 4. Based on assessing the resident's symptoms and overall situation, the medical practitioner will determine whether to continue, adjust or stop existing psychotropic medication. It continues, 6. The timeframe for PRN (as needed) psychotropic medications, which are not antipsychotic medications, will be limited to 14 days unless a longer timeframe is deemed appropriate by the attending physician or the prescribing practitioner. The timeframe for PRN psychotropic medications which are antipsychotic medications is limited to 14 days without exception, unless the attending provider evaluates the resident and deems it necessary. Event ID: Facility ID: 145454 If continuation sheet Page 5 of 22 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 06/26/2025 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide bathing, personal hygiene and documentation for 5 of 7 (R4, R8, R21, R36 and R224) residents, reviewed for activities of daily living, in a sample of 43. Residents Affected - Some Findings include: 1.On 06/23/2025 at 02:47 PM R8's hair was greasy. On 06/24/2025 at 12:33 PM R8's hair was greasy. R8's Physicians order sheet, dated 6/25/2025, documented diagnoses of Alzheimer's Disease, and Type 2 diabetes mellitus. R8's Minimum data set (MDS) dated [DATE] documented that her cognition was severely impaired and was dependent upon staff for bathing and hygiene. R8's Care Plan dated, 3/11/2025, documented an intervention of BATHING: (R8) requires the assistance from one staff member to assist with bathing. R8's Local hospice documentation, dated for 4/2025 and 5/2025 did not document that received a shower or a bath from 4/7/2025 to 5/12/2025 per hospice documentation. There was no documentation of R8 receiving a shower or bed bath from the staff at the facility. On 06/25/25 at 11:46 AM, No further documentation was presented for R8 showers after several request given to V2, Director of Nurses. The facility's Shower schedule, undated, documented that R8's shower days were Monday and Thursday in the AM On 06/25/2025 at 10:43 AM, V27, Certified Nurse Assistant, (CNA) stated that if hospice does not give a resident a shower that week, then they will give a shower. On 06/25/2025 at 10:44 AM, V26, CNA, stated that if hospice does not give a resident a shower that week, then they will give a shower. On 06/25/2025 at 10:45 AM, V21, Restorative CNA, stated that if hospice does not give a resident a shower that week, then they will give her a shower. 2. On 06/23/2025 at 11:26 AM, R21 was lying in bed asleep. Hair was greasy. On 06/23/2025 at 12:53 PM, R21 was sitting up in her wheelchair at the dining table, hair was greasy and stringy. On 06/24/2025 at 11:46 AM, R21 was sitting up in her wheelchair, at the dining room table, hair remained greasy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 6 of 22 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 06/26/2025 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 0677 Level of Harm - Minimal harm or potential for actual harm Physicians order sheet, dated 6/25/2025, documented diagnoses of Parkinson's Disease without dyskinesia, and need for assistance with personal care. R21's MDS, dated [DATE], documented that her cognition was severely impaired and that she was dependent upon staff for bathing. Residents Affected - Some R21's Care plan, dated 4/28/2024. documented, BATHING: (R21) requires 1 staff participation with bathing. The facility's Shower schedule, undated, documented that R21's shower days were on Monday and Thursday evenings R21's shower documentation, for March 2025, documented that showers were given on 3/17/2025, 3/20/25, and 3/31/25. R21's Shower documentation for April 2025, documented that showers were given on 4/3/25, 4/10/25, 4/14/25, and 4/17/25. R21's shower documentation for May 2025, documented that showers were given on 5/8/25, 5/11/25, and 5/22/25. R21's Shower documentation for June 2025, documented that showers were given on 6/5/25, 6/9/25, 6/16/25, 6/19/25 and 6/23/25. 3. On 06/23/2025 at 830 AM, R224 stated that he hasn't had a shower in 3 weeks. Hair was messy and greasy in appearance. R224's Shower documentation, dated June 2025, documented that no showers have been given. The facility's shower schedule, undated, documented that R224's shower days were Tuesday and Friday Am. R224's Face sheet, dated 6/25/2025, documented an admission date of 6/3/2025 and diagnoses of Cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery and R224's Discharge summary from a regional hospital, dated 5/28/2025 a diagnosis of blindness secondary to CMV retinitis. R224's MDS, dated [DATE], documented that his cognition was moderately impaired and that he required partial to moderate assist with bathing. R224's Care plan, dated 6/4/2025, documented that he required assistance from one staff member for bathing. 4. On 06/24/2025 at 11:07 AM, R36 stated that she writes down the dates of when she gets a shower. R36's piece of paper documented that she received a shower on 5/13/25, 5/27/25, 6/3/25, and 6/10/25. R36 stated that last week they came through and said they were going to give her a bed bath after lunch and then they never came back. R36 was lying in bed, 2nd and 3rd fingers on right hand were dirty and her hair was matted and greasy looking. R36's shower documentation for the month of March 2025, documented that showers were given on 3/18/2025 and 3/30/25. R36's April 2025 shower documentation, documented that a shower was given on 4/8/25. R36's May 2025 shower documentation, documented that showers were given on 5/13/25 and 5/27/25 and her June 2025 shower documentation, documented that showers were given on 6/10/25, 6/13/25, 6/17/25 and 6/22/25. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 7 of 22 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 06/26/2025 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 0677 Level of Harm - Minimal harm or potential for actual harm The facility's Shower Schedule, undated, documented that R36 shower days were Sunday and Thursday evenings. R36's MDS, dated [DATE], documented that her cognition was intact and that she was dependent upon staff for bathing. Residents Affected - Some R36's Care plan, dated 9/4/24, documented, (R36) requires 2 staff participation with bathing. R36's Physicians order sheet, dated 6/25/2025, documented diagnoses of Morbid (severe) obesity due to excess calories, End stage renal disease and need for assistance with personal care. 5. On 06/23/2025 at 09:34 AM R4 was asleep in bed. She had a mustache and a thick amount of hair on her chin. R4's hair was greasy. On 06/23/25 at 10:49 AM, R4 stated that someone named (redacted) shaves her, but she hasn't seen her in 2 days. R4's shower documentation for March 2025, documented that no showers were given in the month of March. R4's April 2025 shower documentation, documented that showers were given on 4/2/25, 4/8/25, and 4/16/25. May 2025 Shower documentation documented that showers were given on 5/2/25 and 5/24/25 and her June 2025 shower sheet documented showers were given on 6/2/25, 6/7/25, 6/10/25, and 6/22/25. The facility's shower schedule, undated, documented that R4's shower days were Monday and Thursday evenings. R4's Physicians order sheet, dated 6/25/2025, documented diagnoses of Chronic obstructive pulmonary disease and Legal blindness. R4's MDS, dated [DATE], documented that her cognition was intact and that she was dependent upon staff for bathing. R4 Care plan, dated 11/13/2024, documented required 1 staff participation with bathing. Her care plan also dated 6/23/2025 documented, I DO NOT LIKE TO BE SHAVED AND WILL REFUSE. On 06/25/2025 at 08:37 AM, V2, Director of Nurses was asked if there was any refusal documentation for bathing for R4, R8, R21, R36, R224 and she was unable to provide information during this investigation. On 06/25/2025 at 10:45 AM, V28, LPN, stated that the CNA's let them know if a resident refuses a shower and that the shower book has the schedule. On 06/25/2025 at 10:50 AM, V27, CNA, stated that the shower schedule is in the book and the chart in (electronic medical record) when the resident refuses. V27 stated that the resident is approached several times if they refuse. On 06/25/2025 at 10:54 AM, V26, CNA, stated that the shower schedule is in the book and the chart in (electronic medical record) when the resident refuses and that the resident is re-approached 3 times about their bath. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 8 of 22 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 06/26/2025 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 06/25/2025 at 10:55 AM, V25, CNA, stated that the shower schedule is in the book and the chart in (electronic medical record) when the resident refuses and that the resident is re-approached 3 times about their bath. On 06/25/2025 at 10:56 AM, V21, Restorative CNA, stated that the shower schedule is in the book and the chart in (electronic medical record) when the resident refuses and that the resident is re-approached 3 times about their bath. The facility's policy, Activities of Daily Living, undated, documented, This facility provides each resident with care, treatment and services according to the resident's individualized care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 9 of 22 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 06/26/2025 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 06/23/2025 at 08:28 AM R225 enteral feeding was not properly labeled and dated. An unknown enteral feeding was infusing at 45ml/hr. R225's Physicians order sheet, dated 6/18/2025, documented, an order for Every shift Nova Source Renal 45ML/Hr. continuous it also documented, NPO diet, NPO texture, NPO consistency R225's Physicians order sheet, dated 06/2025, documented diagnoses of encephalopathy and esophageal varices without bleeding. R225's MDS, dated [DATE], documented that R225 was rarely to never understood and that she required a feeding tube (e.g., nasogastric or abdominal (PEG) for nutrition. R225's Care plan, dated 5/29/2025, documented, My dietary preferences will be honored. Foods I dislike are: NPO. My favorite beverages are: NPO. My favorite foods are: NPO no documentation of tube feeding or flushing. On 06/25/2025 at 11:00 AM, V28, LPN stated that tube feeding orders are found in the physician order sheets and when a new tube feeding is hung, the bag is labeled with date, type of feeding, rate of feeding, residents name and nurses initials. V28 also stated that the new syringe and bottle should also be labeled and dated. On 06/25/2025 at 11:17 AM, V22, RN stated that tube feeding orders are found in the physician order sheets and when a new tube feeding is hung, the bag is labeled with date, type of feeding, rate of feeding, residents name and nurses initials. V28 also stated that the new syringe and bottle should also be labeled and dated. Based on Interview, Observation, and Record Review, the facility failed to follow physician orders and appropriately label resident tube feeding for 2 of 2 residents (R69 and R225), reviewed for tube feeding in the sample of 43. The Findings Include: 1. R69's admission Record, dated 6/24/25, documents R69 was admitted to the facility on [DATE] with diagnosis of Neoplasm of colon, Cerebral Palsy, Dysphagia, Epilepsy, Gastrostomy, and Anemia. R69's Care Plan, dated 5/15/25, documents R69 requires tube feeding for Swallowing problem. Interventions: Check for tube placement and gastric contents/residual volume per facility protocol and record, hold feed if greater than 15 ml (milliliter) aspirate, needs assistance/supervision/cueing with tube feeding and water flushes, needs the HOB (head of bed) elevated 45-degrees during and thirty minutes after tube feed, RD (Registered Dietitian) to evaluate quarterly and PRN (as needed), monitor caloric intake, estimate needs, make recommendations for changes to tube feeding as needed. R69's Minimum Data Set (MDS), dated [DATE], documents R69 has a moderate cognitive impairment and requires substantial/maximal assistance for Activities of Daily Living (ADLs). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 10 of 22 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 06/26/2025 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 0693 Level of Harm - Minimal harm or potential for actual harm R69's Physician Orders (PO), dated 4/21/25, documents Enteral Feed every 4-hours Flush Peg-Tube with 150 ML (milliliter) of water. R69's PO, dated 4/21/25, documents Enteral Feed every shift for G-Tube Isosource 1.5 at 60 ML/hour 23 hours/day. May stop for therapies. Residents Affected - Few R69's PO, dated 4/18/25, documents Flush Peg-Tube with 60 ML of water before & after administration of medication or Bolus, every shift for Peg-Tube management. R69's PO, dated 4/18/25, documents Enteral Feed (see order) diet, NPO (nothing by mouth) texture, NPO consistency, Peg-tube in place. R69's PO, dated 4/18/25, documents Enteral- Change feeding syringe daily, label with name and date, every night shift for G-Tube. R69's Dietary Note, dated 5/26/25 at 10:03 AM, documents RD Tube Feeding Review: HT (height): 67, WT (weight): 5/12 127.6# (pounds), BMI (body mass index): 20.0, resident remains on tube feeding and flush of: Isosource 1.5 @ (at) 60 ML/hour for 23 hours with water flush of 150 ML Q (every) 4 hours. At this time no tolerance concerns reported. Present feeding and flush is providing: 1380 ML total volume formula, 2070 calories, 94 GM (gram) protein, 1949 ML free water. Note free water calculation does not include water flushes with medications. Wts (weights) at this time are showing a loss of 17% in the last month with WT on 4/14 and 4/20 154#. No lab or skin concerns reported at this time. Note present tube feeding and flush is exceeding estimated needs for calories/protein/fluids. At this time no change in tube feeding or flush. Will request to recheck WT and to place on weekly Wts for monitoring. Refer to RD as needed. R69's Electronic Health Record, Vitals/Weights, since admission date, documents R69's Weights: 4/17/25 at 154lbs, 5/12/25 at 127.6lbs, 5/28/25 at 129.2lbs, 6/4/25 at 125.1lbs, 6/11/25 at 131.6lbs, 6/12/25 at 129lbs, and 6/18/25 at 128.7lbs. All weights are not consistent while ranging from 125.1lbs to 154lbs but has had a weight loss compared to admission weight. On 6/23/25 at 9:30 AM, R69's G-Tube syringe is seen on a side table and is undated, a bag with feeding being infused by a pump is unlabeled, and undated, a bag of water hanging and attached to the pump is unlabeled and undated, and a syringe in a plastic container is unlabeled and undated. There are two different cartons of feeding on R69's side table next to her syringe and a gallon of distilled water. There is an 8oz carton of Ensure Original, and an 8oz carton of Jevity 1.5cal. (calories). Unsure of what is infusing into R69 due to it being unlabeled and the cartons of feedings are not what was ordered by the Physician. One carton of Ensure Original 8oz (ounce) (237 ML) = Calories 250, Total Fat 6g (grams), Sodium 210mg (milligram), Carbohydrate 41g, Protein 9g, Fiber 3g, and Sugars 23g. One carton of Jevity 1.5cal 8oz (237ml) = Calories 355, Total Fat 11.8gm Sodium 316mg, Carbohydrate 51.1g, Protein 15.1g, Fiber 5g, and Sugars 3.6g. One carton of Isosource 1.5 cal. 8.45oz (250ml) = Calories 375, Total Fat 14.8g, Sodium 330mg, Carbohydrate 44g, Protein 17g, Fiber 3.8, and Sugars 8g. On 6/24/25 at 12:20 PM, V14, Licensed Practical Nurse (LPN), stated I already checked (R69's) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 11 of 22 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 06/26/2025 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few G-Tube, flushed it, but did not give her any feeding because she still had some in her bag. When asked what feeding R69 was getting, V14 picked up a carton of Jevity 1.5cal off the side table and stated, This is what (R69) is getting for tube feeding. On 6/24/25 at 1:43 PM, V19, Dietitian, stated I was not informed of (R69's) change in product being used. Clinically speaking, Isosource provides 1.5 cal./ml while Ensure Original only provides 1.06 cal/ml. If they are not giving the Isosource as ordered, that may be contributing to (R69's) weight loss. I would expect the facility to contact me of any product changes or if they run out of a product and need something to substitute, I can direct them with the right product. On 6/24/25 at 2:15 PM, V20, Supplies/Medical Records, stated I have plenty of the Isosource, as a matter of fact, I have a lot of cases of it on the shelf right now. On 6/24/25 at 2:32 PM, V19 stated Again, I was not notified of any changes of the Tube Feeding product for (R69). My understanding was that she was getting the Isosource as ordered. If they ran out of the Isosource, the somewhat equal product would be the Jevity 1.5 while waiting for the Isosource to come in. They both have 1.5cal./ml, however the Jevity is less in protein and other things. Any time there is a change in tube feedings, the Physician must be notified to write a substitution order until the supply comes in, because at this point, I do not have ordering privilege at that facility. I am the RD at that facility and come in monthly to review the resident's information and make notes and recommendations. On 6/25/25 at 1:15 PM, V1, Administrator, stated I would expect the nurses to administer tube feedings according to the physician's order, and to label the tube feeding bag with correct information including resident name, product name, date started, and rate of administration. On 6/25/25 at 11:05 AM, V29, LPN, Travel Nurse Manager, stated We don't have a policy on tube feeding. We use the Enteral Tube Feeding Skills Checklist. The Facility's Skills Checklist, undated, documents in part Administer only full-strength feeding tube formulas. Check the Enteral Nutrition Label against the order before administration. Add the following information: Resident name, type of formula, date and time formula was prepared, and rate of administration. Check the order to verify the type, amount, method, and rate of administration. on the formula label document initials, date and time the formula was hung. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 12 of 22 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 06/26/2025 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** 3. On 06/23/2025 at 09:30 AM, R4 was lying in bed, asleep, and her oxygen was on per nasal cannula. R4's oxygen tubing was not dated and there was not humidity bottle. Residents Affected - Some R4's Physicians order sheet, dated 6/25/2025, documented diagnoses of Chronic obstructive pulmonary disease and Legal blindness. It also documented, Oxygen Tubing - Change Weekly every night shift, every Sun for maintenance. Oxygen - clean O2 concentrator filter with water and allow to air dry weekly. Every night shifts every Sun for maintenance. It also documented an order, 2L o2 via Nasal Cannula continuously R4's MDS, dated [DATE], documented that her cognition was intact. R4's Care Plan, undated, documented, (R4) has Oxygen Therapy r/t COPD 4. On 06/23/2025 at 08:36 AM, R22 was asleep in bed, and her oxygen was running, and the tubing was coiled up on the end of her bed, but it was not on her. R22's oxygen tubing was not labeled nor dated. On 06/23/2025 at 11:06 AM, R22 was lying in bed, awake, stated that she does not wear her oxygen all the time and that she gets her nebulizer treatment every 6 hours. R22's nebulizer mask was hanging from the over bed table and the storage bag was sitting on the overbed table. R22's nebulizer tubing was not dated. R22's Physicians order sheet, dated 2/24/25, documented an order for Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083%, 3 ml inhale orally via nebulizer every 6 hours as needed but did not document an order for oxygen. R22's Physicians order sheet, dated 6/2025, documented diagnoses of Chronic obstructive pulmonary disease and influenza due to identified novel influenza A virus with other respiratory manifestations. R22's MDS, dated [DATE], documented that her cognition was intact. R22's care plan did not document interventions for oxygen nor interventions for her nebulizer. On 06/25/2025 at 11:00 AM, V28, LPN, stated that when oxygen and nebulizer tubing is changed weekly, it should be labeled and dated. V28 also stated that the nebulizer mask should be in a bag when not in use. On 06/25/2025 at 11:15 AM, V22, RN, stated that when oxygen and nebulizer tubing is changed weekly, it should be labeled and dated. V28 also stated that the nebulizer mask should be in a bag when not in use. Based on Interview, Observation, and Record Review, the facility failed to label and date Oxygen (O2) and nebulizer tubing, O2 mask, and humidified bottle, failed to provide a humidified water bottle (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 13 of 22 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 06/26/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some for O2 administration, and failed to change the O2 tubing as ordered for 4 of 5 residents (R1, R4, R22, R31) reviewed for O2 therapy in the sample of 43. The Findings Include: 1. R1's admission Record, dated 6/25/25, documents R1 was originally admitted to the facility on [DATE] with diagnosis of Chronic Respiratory Failure with Hypoxia, Chronic Pulmonary Edema, Morbid Obesity, Type 2 Diabetes Mellitus (DM), Major Depressive Disorder, Dysphagia, and Hypertension (HTN). R1's Care Plan, dated 5/8/25, documents R1 has O2 Therapy related to Respiratory illness. Interventions: O2 settings per MD (medical doctor) order, monitor for signs/symptoms (s/sx) of respiratory distress and report to MD PRN (as needed), give medications as ordered by physician, monitor/document side effects and effectiveness. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact and is dependent on staff for all Activities of Daily Living (ADLs). R1's Physician Order (PO), dated 2/26/25, documents Oxygen Tubing - Change Weekly, every night shift every Sun (Sunday). R1's PO, dated 2/26/25, documents Oxygen - clean O2 concentrator filter weekly, every night shift every Sun. R1's PO, dated 2/26/25, documents Oxygen 2L (liters)/min (minute) via nasal cannula (NC), continuously. On 6/23/25 at 10:30 AM, R1 was seen lying in bed on O2 at 3 L/NC via oxygen concentrator with no humidified water bottle attached, and no date on the NC tubing. On 6/24/25 at 8:28 AM, R1 has O2 on 3 L/NC without a water bottle and the NC tubing not dated. On 6/25/25 at 8:40 AM, R1 seen lying in bed with O2 on at 3L/NC via oxygen concentrator with no humidified water bottle attached to concentrator, the NC tubing is not dated. R1 stated she does not remember when her NC was last changed, stated they usually write a date on the tubing, but she does not see a date on this one. 2. R31's admission Record, dated 6/25/25, documents R31 was originally admitted to the facility on [DATE] with diagnosis of Chronic Respiratory Failure with Hypoxia, Morbid Obesity, Aortic Valve Stenosis, Myocardial Infarction, Dysphagia, Spinal Stenosis, Polyneuropathy, Lymphedema, Type 2 DM, Anxiety Disorder, Depression, and Osteoarthritis. R31's Care Plan, dated 4/16/25, documents R31 has O2 Therapy related to respiratory failure. Interventions: O2 settings per MD order, position resident to facilitate ventilation/perfusion matching: Use upright, high Fowler's position whenever possible to allow for optimal diaphragm, monitor for s/sx of respiratory distress and report to MD PRN. R31's MDS, dated [DATE], documents R31 is cognitively intact and is dependent on staff for ADLs. R31's PO, dated 2/27/25, documents O2 at 2L/min via nasal cannula PRN. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 14 of 22 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 06/26/2025 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 Level of Harm - Minimal harm or potential for actual harm R31's PO, dated 2/27/25, documents Oxygen - clean O2 concentrator filter weekly, every night shift every Sun. R31's PO, dated 2/27/25, documents Oxygen - Change nebulizer and nebulizer tubing weekly, every night shift every Sun. Residents Affected - Some R31's PO, dated 7/25/24, documents 2-L per NC cont. every shift. On 6/23/25 at 10:40 AM, R31 was seen lying in bed with O2 on at 2 L/NC via oxygen concentrator with the humidified bottle of water almost completely empty and dated 6/16/25. R31 stated it usually runs dry and she must remind them that she needs a new bottle. R31's NC is dated 6/16/25. On 6/24/25 at 8:30 AM, R31 was seen lying in bed with O2 on at 2 L/NC via oxygen concentrator with the humidified water bottle now empty and both the bottle and NC are still dated 6/16/25. On 6/25/25 at 8:38 AM, R31 was seen lying in bed with O2 on at 2L/NC, via oxygen concentrator with the humidified water bottle still empty and both the water bottle and NC still dated 6/16/25. On 6/25/25 at 1:15 PM, V1, Administrator, stated I would expect the nurses to provide a humidified water bottle for residents on oxygen, label the water bottle and the oxygen tubing when applying a new one, and changing them weekly as ordered. The Facility's Oxygen Administration Policy, dated 3/2025, documents in part General Guidelines: 1. Oxygen therapy is administered by way of an oxygen mask or nasal cannula. Equipment and Supplies: 2. Nasal cannula, nasal catheter, mask (as ordered). 3. Humidifier bottle. 10. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through. 11. Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated. 12. Replenish water in humidifying jar as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 15 of 22 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 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlinville Rehab & Hcc 751 North Oak Street Carlinville, IL 62626 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on Interview, Observation, and Record Review, the facility failed to properly store medications for 1 of 1 resident's (R9) reviewed for safe medication storage in the sample of 43. The Findings Include: On 6/23/25 at 9:55 AM, R9 was seen lying in bed with a cup of medications with 12 pills/capsules in the cup. R9 stated the nurse brings them to her every morning and will leave them with her and she will take them later after she eats her breakfast. On 6/25/25 at 1:15 PM, V1, Administrator, stated I would expect the nurses, while administering medications to residents, to watch the resident take the medications and not to leave them for resident to take on their own. The Facility's Storage and Return of Drugs Policy, dated 4/2021, documents in part B. 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 shall be under the visual control of the responsible nurse at all times when not stored either in a locked room or otherwise made immobile. I. The medication cabinet, medication room, or mobile medication cart shall be the responsibility of the person authorized to handle and administer medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 16 of 22 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 06/26/2025 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a palatable meal to residents at the facility. This failure has the potential to affect all 79 residents residing at the facility. Residents Affected - Many Findings include: 1. During resident council meeting on 6/24/2025 at 10:30 AM R26, R29 and R49 all stated their food is cold when served. R26's Minimum data set (MDS), dated [DATE], documents R26 is cognitively intact. R29's MDS, dated [DATE] documents R29 is cognitively intact. R49's MDS, dated [DATE], documents R49 is cognitively intact. The facility Resident Council Minutes, dated May 8, 2025, documents issues/concerns; food cold. The facility Resident Council Minutes dated June 3, 2025 documents issues/concerns: cold dinner and breakfast. On 6/24/2025 at 11:41 AM food temperatures obtained from steam table prior to first tray; rice 206 degrees, corn 188 degrees, mashed potatoes 152 degrees, gravy 140 degrees, corned beef 162 degrees. On 6/24/2025 12:52 PM during noon meal a test tray was obtained and removed from cart when the last meal tray was served to residents. The test tray consisted of mashed potatoes with gravy, corn, corned beef, and rice. The corned beef was cold, tough and hard to chew, the mashed potatoes with gravy was warm, the rice was cold, gummy and had no taste. The food temperatures obtained per surveyor were corn 140 degrees, mashed potatoes and gravy 131 degrees, rice 119 degrees and corned beef 117.8 degrees. On 6/25/2025 at 12:20 PM V4, Dietary Manager stated she would expect food to be served at the correct temperature and to be palatable. The facility policy general Dining experience, undated, documents residents will have an exceptional dining experience that enhances their quality of life and provides attention to the individual resident's plan of care and dining wishes. The policy documents meal will be nourishing attractive and palatable. The policy documents meals will be served at the appropriate texture and consistency to meet the individuals plan of care, but not limiting the right to make personal choices. The facility policy Monitoring Food Temperature for Meal Service, undated documents food temperatures will be monitored daily to prevent food borne illness and ensure foods are served at palatable temperatures. The policy documents roast pork 145 degrees Fahrenheit (F) for 4 minutes , stuffed foods or casseroles 165 degrees F 15 seconds. 2. On 6/23/25 at 11:02 AM, R3 stated, The food is bad. It is either burnt or just plain bad. The chicken patty is hard as a brick. I order out a lot because of how bad the food is. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 17 of 22 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 06/26/2025 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 0804 R3's admission Record, print date of 6/24/25, documents R3 was admitted on [DATE]. Level of Harm - Minimal harm or potential for actual harm R3's MDS, dated [DATE], documents R3 is cognitively intact. 3. On 06/23/25 at 11:05 AM, R10 stated, The food is awful. It is cold. I always eat in my room. Residents Affected - Many R10's admission Record, print date of 6/25/25, documents R10 was admitted on [DATE]. R10's MDS, dated [DATE], documents R10 is cognitively intact. 4. On 06/23/25 at 11:00 AM, R60 stated, The food portions are small. It isn't hot but lukewarm. R60's admission Record, print date of 6/24/25, documents R60 was admitted on [DATE]. R60's MDS, dated [DATE], documents R60 is cognitively intact. The CMS 671 Long Term Care Facility Application for Medicare and Medicaid dated 6/23/2025 documents a facility census of 79 residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 18 of 22 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 06/26/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, record review and interview the facility failed to store food in a manner to prevent food borne illness. This has the potential to affect all 79 residents at the facility. Residents Affected - Many Findings include: 1. On 6/23/2025 at 8:40 AM there was bowl of ice cream on the floor of walk in freezer. In the dry storage room, 2 boxes of apple juice unopened and 10 large cans of chicken noodle soup in the case were sitting on the floor. The white upright freezer in the dry storage room contained a open, unlabeled, and undated package of 8 turkey patties. A bag of chicken patties in the box that were opened and undated. The 3 compartment refrigerator in kitchen contained 2 single serving bowls of cottage cheese that were uncovered and undated. 3 lettuce salads with cheese covered with clear wrap that were undated. Next to salads on a plastic tray plastic was an individual container of salad dressing and a white condiment container of mayonnaise both were uncovered and not labeled. On 6/25/2025 at 12:20 PM V4, Dietary Manager stated can goods should not be stored on the floor an opened food should be covered, labeled and dated. The facility policy Food Storage (Dry, Refrigerated, and Frozen), undated, documents food shall be stored on shelves in a clean, dry area, free from contaminants. The policy documents leftover contents of cans and prepare food will be stored in covered, labeled and dated containers in refrigerators and/or freezers. The policy documents to store dry food on shelves six inches off the floor to allow for proper sanitation. The CMS 671 Long Term Care Facility Application for Medicare and Medicaid dated 6/23/2025 documents a facility census of 79 residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 19 of 22 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 06/26/2025 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** 3. On 06/23/2025 at 01:17 PM, V8, Activity Director, without benefit of hand hygiene, passed a lunch tray to R226. V8 set up R226's meal tray. She then exited R226's room into the hallway to the meal cart. Residents Affected - Some 4. On 06/23/2025 at 01:19 PM, V8, Activity Director, without benefit of hand hygiene, then retrieved the meal tray for R224 and took it to his room. She set up his tray and explained what was on his tray. On 06/25/2025 at 10:50 AM, V28, LPN, stated that hand sanitizer should be used in between residents when passing meal trays. On 06/25/2025 at 10:52AM, V27, CNA, stated that hand sanitizer should be used in between residents when passing meal trays. On 06/25/2025 at 10:53 AM, V26, CNA, stated that hand sanitizer should be used in between residents when passing meal trays. On 06/25/2025 at 10:55 AM, V25, CNA, stated that hand sanitizer should be used in between residents when passing meal trays. On 06/25/2025 at 10:56 AM, V22, RN, stated that hand sanitizer should be used in between residents when passing meal trays. On 06/25/2025 at 10:58 AM, V12, Restorative CNA, stated that hand sanitizer should be used in between residents when passing meal trays. On 06/25/2025 at 11:05 AM, V8, Activity Director, stated that hand sanitizer should be used in between residents when passing meal trays. On 06/25/2025 at 11:31 AM, V2, Director of Nurses, stated that they have a Skills Checklist for Handwashing but not an actual policy. Based on Interview, Observation, and Record Review, the facility failed to provide proper hand hygiene while assisting residents during meals for 4 of 24 residents (R6, R224, R226, R277) reviewed for hand hygiene in the sample of 43. The Findings Include: R6's admission Record, dated 6/25/25, documents R6 was originally admitted to the facility on [DATE]. R277's admission Record, dated 6/25/25, documents R277 was originally admitted to the facility on [DATE]. On 6/23/25 at 1:00 PM, V7, Certified Nursing Assistant (CNA), was seen sitting in a chair between R6 and R277. V7 was assisting R6 with her food, then would turn and assist R277 with her food. V7 failed to do hand hygiene between residents. V7 was seen grabbing the arms of her chair, grabbing R6's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 20 of 22 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 06/26/2025 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 wheelchair to move her closer to the table, yawning while covering her mouth with her hand, rubbing her face, and then grabbing a dinner roll by her bare hands and asking R277 if she wanted it, all while assisting both residents with their meals and failing to provide any hand hygiene. On 6/25/25 at 1:15 PM, V1, Administrator, stated I would expect the staff to do hand hygiene while assisting residents with feeding in the dining room. On 6/25/25 at 11:10 AM, V2, Director of Nursing (DON) stated We don't have a hand hygiene policy. We only use the Handwashing Skills Checklist. The Facility's Handwashing Skills Checklist, undated, only documents the process of how to wash your hands and does not include when staff should be washing their hands. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 21 of 22 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 06/26/2025 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 offer pneumonia vaccines for 5 of 5 residents (R3, R7, R10, R53, R62) reviewed for vaccines in the sample of 43. Residents Affected - Some Findings include: 1. R53's admission Record, print date of 6/24/25, documents R53 was admitted on [DATE] with diagnoses of Type 2 diabetes and Sleep Apnea. R53's Immunization Record fails to document R53 has had the pneumonia vaccine or declined the vaccine. 2. R10's admission Record, print date of 6/25/25, documents R10 was admitted on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease. R10's Immunization Record fails to document R10 has had the pneumonia vaccine or declined the vaccine. 3. R3's admission Record, print date of 6/24/25, documents R3 was admitted on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease. R3's Immunization Record fails to document R3 has had the pneumonia vaccine or declined the vaccine. 4. R62's admission Record, print date of 6/24/25, documents R62 was admitted on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease. R62's Immunization Record fails to document R62 has had the pneumonia vaccine or declined the vaccine. 5. R7's admission Record, print date of 6/24/25, documents R7 was admitted on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease. R7's Immunization Record fails to document R7 has had the pneumonia vaccine or declined the vaccine. On 6/24/25 at 3:30 PM, V2, Director of Nurses, stated the pneumonia vaccine was not offered this past year. V2 stated she did not know why but they are working on fixing that. The facility has not had an outbreak of pneumonia over the winter or recently. On 06/25/25 at 11:17 AM V29, Travel Nurse Manger, stated We offer the pneumonia vaccination upon admission and yearly. For the policy on who receives the vaccine we follow the CDC (Center for Disease Control) guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145454 If continuation sheet Page 22 of 22