Inspection·April 18, 2024

F 0656 On 04/18/24 at 10:19 AM, R19 said no one has come in and put the strips down or put up any signs yet. Level of Harm - Minimal harm or potential for actual harm On 04/18/24 at 10:25 AM, V1, Administrator stated she would expect for all the interventions to be in the new room when a resident is moved. Residents Affected - Few The facility's policy Care Plan Policy, dated 07/01/23, documents Purpose: To provide guidance to the facility in developing, implementing and communication the individualized plan of care of residents. Policy: Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145456 If continuation sheet Page 2 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145456 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeside Health & Rehab Center 1200 University Avenue 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure fall interventions were in place to prevent further falls for 1 of 3 residents (R19) who were reviewed for falls/accidents in a sample of 30. Findings include: On 04/17/24 at 10:20 AM, Upon entering R19's room she was observed to be sitting in her room in her wheelchair. There were no non-skid strips on either side of her bed, there was no sign located in her room that stated Call Don't fall, and no sign posted in her room to remind her not to bend over and pick up objects. On 04/18/2024 at 10:19 AM, This surveyor went in to speak with R19 again. There were no non-skid strips observed beside the bed and there was still no signage posted reminding her to call for help or to not bend over and pick up objects. R19's Face Sheet, print date of 04/18/24, documents R19 has the following diagnoses but not limited to unspecified sequelae of cerebral infarction, Parkinson's disease without dyskinesia, and dementia. R19's Minimum Data Set (MDS), dated [DATE], documents R19 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15 and requires partial/moderate assistance with toileting assistance, part of dressing, personal hygiene, and transfer. R19's Care Plan, with admission date of 02/04/2021, documents: I am at risk for falls. I admitted to facility with diagnoses of cerebral infarction, high blood pressure, diabetes, depression, neuropathy, CHF, obesity, Parkinson's Disease. Interventions include but are not limited to Call Don't Fall sign posted in view in room, Non-skid tape on the floor right side of bed, and sign placed in R19's room to remind her to not bend over and pick up objects. R19's Fall Investigation, dated 03/06/24, was reviewed and documents R19 was heard yelling out for help and when staff went in to check on R19 she was observed on the floor near her bed. R19 told staff she had went to the bathroom and when she went to lie back down in bed she slipped onto the floor. It also documents R19 sustained a skin tear to her left thigh. It documents the root cause of the fall is R19 was self-transferring to bed and slipped off side of the bed. The new intervention was to place non-skid strips on the floor next to right side of the bed. R19's Fall Risk Assessment, dated 03/07/24, documents R19 has a fall risk score of 16 (high) and she has had one to two falls in the last 3 months. On 04/17/24 at 10:20 AM, R19 stated she remembers fall a little while back, but she was on another hall when that fall happened. She said after that fall they put the non-skid strips down on the floor. R19 stated those strips on the floor helped her a lot and helped her from slipping and sliding because she was able to put her feet right on them. She also said in her other room she had signs on the wall. One was reminding her not to bend over to pick up things and the other was to remind her to use her call light, but she doesn't have any of that since moving her to this room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145456 If continuation sheet Page 3 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145456 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeside Health & Rehab Center 1200 University Avenue 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 0689 On 04/18/24 at 10:19 AM, R19 said no one has come in and put the strips down or put up any signs yet. Level of Harm - Minimal harm or potential for actual harm On 04/18/24 at 10:25 AM, V1, Administrator stated she would expect for all the interventions to be in the new room when a resident is moved. Residents Affected - Few The facility's policy Accidents & Incidents, dated 07/01/23, documents Purpose: To provide staff with guidelines for investigating, reporting Accidents and Incidents. Policy: All accidents/incidents involving a resident will be documented in Risk Management. The nursing team will complete an investigation with the root cause and new interventions. It further documents 4. Investigate and follow up Action: A. The Charge Nurse must conduct an immediate investigation of the accident/incident and implement immediate appropriate interventions to affected parties. It also documents E. The D.O.N (director of nursing), IDT, and/or Designee will conduct an investigation of the accident/incident as well. Findings will be indicated in the appropriate area. The IDT will review within 24 hours or next business day and discuss and attempt to prevent further falls. F. The Care Plan Coordinator will be notified of the accident/incident so that appropriate changes may be made to the care plan as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145456 If continuation sheet Page 4 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145456 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeside Health & Rehab Center 1200 University Avenue 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview, observation and record review the Facility failed to provide a RN (Registered Nurse) 8 hours a day 7 days a week. This has the potential to affect all 51 residents of the facility. Residents Affected - Many Findings include: The Facility's Nursing Schedule, dated 3/10/24, documented there was no RN on duty 3/10/24. The Facility's Nursing Schedule, dated 3/17/24, documented there was no RN on duty 3/23/24. The Facility's Nursing Schedule, dated 3/24/24, documented there was no RN on duty 3/24/24 nor on 3/30/24. The Facility's Nursing Schedule, dated 3/31/24, documented there was no RN on duty 3/31/24 nor on 4/6/24. The Facility's Nursing Schedule, dated 4/7/24, documented there was no RN on duty on 4/7/24 nor on 4/13/24. The Facility's Nursing Schedule, dated 4/14/24, documented there was no RN on duty on 4/14/24. On 4/15/24 at 10:13 AM V2 DON (Director of Nursing) stated the facility does not have a RN on duty everyday and that her full time RN recently went from full time to PRN (as needed). V2 stated she generally works Monday through Friday from 8:00 AM to 4:30 PM. On 4/17/24 at 2:45 PM V2 DON stated the facility does not have a staffing policy. On 4/18/24 at 9:30 AM V1 Administrator stated the facility does not have a staffing policy and the facility staffs according to census needs. The Facility's Resident Census Report and the CMS 671 form, dated 4/15/24, documented that there were 51 residents in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145456 If continuation sheet Page 5 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145456 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeside Health & Rehab Center 1200 University Avenue 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 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to post nurse staffing information. This has the potential to affect all 51 residents of the facility. Residents Affected - Many Findings include: On 4/15/24 at 10:20 AM, the daily nurse staffing was not posted. On 4/15/24 at 10:25 AM V6, Medical Records/CNA (Certified Nurse Assistant), stated we normally post it up by the front door, but I don't see it anywhere today. On 4/15/24 at 10:30 AM V1, Administrator, stated she is new and does not know who is responsible for posting the daily staffing. On 4/15/24 at 10:34 AM V2 DON (Director of Nursing) stated she just started working at the Facility in January and she does not know who is responsible for posting the daily nurse staffing. On 4/17/24 at 1:15 PM the daily nurse staffing information was observed on a bulletin board on the hallway behind the nurse's station. The daily nurse staffing information was not posted in a prominent place and was not readily accessible to residents and visitors. The Facility's Posting Daily Staffing Policy, dated 7/1/23, documented the Facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. 1. Within two hours of the beginning of each shift, the number of Licensed Nurses (RNs, LPNs, and LVNs) (Registered Nurses, Licensed Practical Nurses, and Licensed Vocational Nurses) and the number of unlicensed nursing personnel (CNAs) (Certified Nurse Assistants) directly responsible for resident care will be posted in a prominent location (accessible to resident and visitors) and in a clear and readable format. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145456 If continuation sheet Page 6 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145456 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeside Health & Rehab Center 1200 University Avenue 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. 0n 4/17/24 at 1:52 PM, V2 DON stated R28 has not had a medication reduction in the past year. V2 stated R28 has not had a psychiatric evaluation. R28's pharmacy recommendation dated 2/28/2024 to attending physician documents R28 is receiving Buspar 15 mg (milligram) every am and 30mg every PM for generalized anxiety, since 7/27/2023 and lorazepam 0.5mg twice a day (BID) for generalized anxiety disorder since 11/25/2020 and also continues on Seroquel 25mg bid and Zoloft 50 mg at bedtime (hs). The following statement was marked on the sheet: residents target symptoms returned or worsened after the most recent GDR attempt within the facility. A dose reduction at this time would likely impair resident's function or cause psychiatric instability by exacerbating medical or psychiatric disorder as supported by the following clinical rationale and evidence of the following symptoms anxiety. R28's Care Plan documents that R28 has a behavior problem of displaying threatening behavior (raising arms/hands back as if to strike out) related to Alzheimer's or related dementia, poor safety awareness related to cognitive impairment, and a behavior problem of yelling out related to anxiety when agitated. R28's Care plan does not document psychotropic medication with any type of medication reduction plan in place. The Facility's Policy, Psychotropic Medications Policy/ Chemical Restraints documents, Date Initiated: 07/01/23. Purpose: to provide guidelines to ensure that residents who receive antipsychotic/psychoactive medications are maintained at the safest and lowest dosage necessary to control the resident's condition. Policy: In accordance with federal and state regulations, it is this facility's policy that residents will not be given unnecessary medications. Residents shall only be given antipsychotic drugs when clinically indicted according to appropriate diagnosis and physician's order. Residents who receive antipsychotic/psychoactive medications shall have gradual dose reductions attempted in accordance with state and federal regulation and behavior interventions reviewed, unless clinically contraindicated. Procedure: When an antipsychotic/psychoactive medication is selected for use, the specific clinical diagnosis for which the drug is being given must be in the resident record. The care plan will include objectives for gradual dose reduction as well as alternative interventions to assist in gradual dose reduction in accordance with state and federal guidelines. Based on interview and record review, the Facility failed to justify why a Gradual Dose Reduction (GDR) was not attempted per a pharmacy recommendation; and, failed to ensure the resident had the proper diagnosis for the psychotropic medications for 2 of 6 residents, (R4, R28) reviewed for unnecessary medications in the sample of 30. Findings include: 1. R4's Face sheet dated 4/17/2024 does not include a diagnosis of depression or anxiety. R4's Order Summary Sheet dated 4/17/2024 documents, does not include depression or anxiety under the Diagnoses portion. R4's Order Summary Report dated 4/17/2024 documents R4 takes Sertraline 100 mg (Milligrams) once a day for depression. Monitor for anxiety, agitation, restlessness, nausea and vomiting, tachycardia (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145456 If continuation sheet Page 7 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145456 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeside Health & Rehab Center 1200 University Avenue 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 0758 (rapid heartbeat), confusion, tremors and muscle rigidity. Level of Harm - Minimal harm or potential for actual harm R4's Order Summary Report dated 4/17/2024 documents Trazodone 50 mg at bedtime for Depression. Monitor for anxiety, agitation, restlessness, nausea and vomiting, tachycardia (rapid heartbeat), confusion, tremors and muscle rigidity. Residents Affected - Few R4's Order Summary Report dated 4/17/2024 documents, Psychotropic Medication Side effect monitoring every shift. R4's Careplan and Face Sheet that were provided on 4/17/2024, fails to include the use of the psychotropic medication or plans for a decrease in dosage/s. R4's Note to Attending Physician/Prescriber dated 2/19/2024 documents, Resident takes more than one antidepressant Trazodone 50 MG (milligrams), Sertraline 100 MG Q (Every) AM (Morning). The use of two or more antidepressants simultaneously may increase the risk of side effects and require additional documentation concerning the rationale under CMS (Central Management Services) F757. It continues to document, Please address the following: (Please check the appropriate response). [] Duplicate agents are being used due to differing mechanisms of action that results in augmentation in managing symptoms of depression. Usage is based on clinical experience or medical literature and the risk vs (versus) benefit has been considered. [] Duplicate agents with similar mechanisms are being used in an attempt to use lower dosages of each individual agent. Usage is based on clinical experience or medical literature and the risk vs the benefit has been considered. [] Duplicate agents are being used for different indications (please specify below). [] Other rationale (Please describe below). There was nothing marked to indicate a rationale. It continues to document the prescriber (V10, Medical Director, MD) disagreed with the Pharmacist's recommendation, but did not list the rationale. On 4/17/2024 at 10:00 AM, V2 Director of Nursing (DON) stated R4 was admitted to the facility on [DATE]. V2 stated the Physician (V10) should have put an explanation to why he declined the Gradual Dose Reduction (GDR). On 4/17/2024 at 10:23 AM, V2 stated a GDR should be attempted within 30 days of admission and quarterly. On 4/17/2024 at 10:15 AM, R4 was observed in bed sleeping. R4 woke up briefly during the interview, stated she was very sleepy and fell back asleep during the brief interview. On 4/17/2024 at 10:20 AM, V2, Director of Nursing (DON) asked R4 if she was sleepy today to which R4 responded, Yes. On 4/17/2024 at 1:15 PM, R4 was observed still sleeping in bed. On 4/17/2024 at 2:55 PM, R4 stated she was incontinent of urine because she just got out of bed. R4 stated, I've been asleep all day. On 4/17/2024 at 11:36 AM, V3, Licensed Practical Nurse (LPN) verified, Sure she doesn't when V3 was asked if R4's Facesheet included the diagnosis of Depression/Anxiety. At this time, V3 also verified R4's Care Plan did not address the goal of reducing R4's psychotropic medications. On 4/17/2024 at 11:41 AM, V12, Regional Nurse Consultant stated, It's (Depression diagnosis) not on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145456 If continuation sheet Page 8 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145456 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeside Health & Rehab Center 1200 University Avenue 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 0758 the diagnosis list, but we need to add it on there. 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: 145456 If continuation sheet Page 9 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145456 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeside Health & Rehab Center 1200 University Avenue Carlinville, IL 62626 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review, the Facility failed to ensure medications were stored safely until administration and not left at bedside for 1 of 16 residents (R4) reviewed for medication storage in the sample of 30. Findings include: On 4/17/2024 at 10:00 AM, V2 Director of Nursing (DON) was asked to identify a pill that was laying on R4's bed sheet. V2 stated she was unsure but would find out what the pill was. At this time, R4 stated, I just forgot about taking it (the pill). On 4/17/2024 V2 stated the pill was identified as R4's Torsemide (medication taken for edema/swelling). R4's Order Summary Report dated 4/17/2024 documents, Torsemide 20 mg (Milligrams): give 1 tablet by mouth one time a day related to edema. On 4/18/2024 at 10:25 AM, V2 stated, (R4) dropped her pill. We notified the doctor. I would want them to ensure the pills are swallowed. The Facility's Policy, Medication Administration Policy/Procedure dated 7/1/2023 documents, Purpose: To ensure proper administration of oral medications. It continues to document it is the responsibility of all licensure nursing staff to safely administer medications to residents. It further documents, Ensure medication has been swallowed before leaving. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145456 If continuation sheet Page 10 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145456 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeside Health & Rehab Center 1200 University Avenue 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to obtain stool for occult for 1 of 6 residents (R47) reviewed for labs in the sample of 30. Residents Affected - Few Findings include: 1. R47's health status note dated 4/11/2024 at 7:21 documents received call from physician office new order occult stool x3. R47's health status note dated 4/17/2024 at 13:54 documents (R47) was taken to the bathroom and denied the urge to have a bowel movement. Once Certified Nursing Assistant (CNA) assisted (R47) up from his toilet seat. CNA noticed that (R47) did have a small bowel movement into the toilet. Unable to collect sample at this time. On 04/18/24 at 10:45 AM V2 Director of Nursing (DON) stated she had reviewed R47's toileting sheets and R47 had 3 stools in the time frame the stool for occult blood was ordered. V2 stated R47 also had a stool on 4/17/2024 at 13:54 and stool for occult was not collected because staff removed specimen collection container from the toilet prior to R47 using the toilet. V2 stated there had been miscommunication in regard to stool for occult on R47. V2 stated the facility had missed 4 opportunities to obtain stool for occult for R47. The facility policy Physician Orders dated 4/21/2022 documents the facility will obtain process and implement physician orders given by a licensed physician and received by a licensed nurse. The policy documents it is the responsibility of the Director of Nursing (DON)ON/designee to ensure that all licensed healthcare workers within the facility know the physician order process. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145456 If continuation sheet Page 11 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145456 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeside Health & Rehab Center 1200 University Avenue 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** 2. On 04/16/24 at 10:33 AM, during pressure sore treatment R15 was in bed on her left side facing the window. V9, Certified Nursing Assistant (CNA) in R15's room with gown and gloves on. Sign outside R15's room documents enhanced barrier precautions, clean hands, including before entering and when leaving the room. V6 (Medical records/CNA) stated she is going to be in room. V6 did not sanitize hands prior to donning gloves. V6 donned gloves and gown and entered R15's room. V8, Licensed Practical Nurse (LPN) dons gloves. V8, LPN did not sanitize hands prior to donning gloves. V8 then removes gloves and stated does not have stuff ready aa she cannot enter the room with the cart. V8, LPN then gatherers all supplies for dressing change and hands to V6, CNA who is already in room with Personal Protective Equipment (PPE). V8 then puts on gown does not sanitize hands, dons gloves and enters R15's room. V8, LPN removed dressing from R15's right and left thigh and inner buttocks. R15's dressings all dated 4/15/2024. V8, LPN cleansed all wounds, and packed wounds to inner buttocks, V8, LPN doffed gloves and donned another set of gloves. V8 did not sanitize hands between glove changes. V8, then doffed gloves stated, I cannot do this anymore and exited R15's room. V8 did not sanitize hands prior to leaving R15's room. Residents Affected - Few On 4/18/2024 at 10:25 AM, V2 stated, it is the expectation of staff to use hand hygiene between gloves changes, before and after resident contact. The Facility's Transmission Based Precautions Policy dated 7/1/2023 documents, It is the Responsibility of all staff and agents of the facility to adhere to the transmission-based precaution guidelines. It continues to document, When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door so that personnel and visitors are aware of the need for, and they type of precaution. It continues to document, Enhanced Barrier Precautions may be implemented to protect resident who are not known or suspected to be infectious but are at high risk for becoming infected due to compromised medical conditions. These conditions include but are not limited to: indwelling catheters/suprapubic catheters, any open skin wounds, indwelling medical devices, colonized MDROS (organisms). It continues, staff and visitors will wear gloves (clean none-sterile) when entering the room. The Facility's Hand Washing Policy dated 7/1/2023 documents, Purpose: To provide guidelines for adequate hand washing in order to reduce the transmission of organisms from resident to resident, staff to resident, and from resident to nursing staff. Policy: This facility considers hand hygiene the primary means to prevent the spread of infections. All staff will properly wash hands after direct contact with any contaminated substance, after direct resident care, and as instructed. It further documents, 5. Employees must wash their hands for 15 to 20 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: A. Before and after direct contact with residents. B. when hands are visibly dirty or soiled with blood or body fluids. C. After contact with blood, body fluids, secretions, mucous membranes or non-intact skin. D. After removing gloves. E. After handling items potentially contaminated with blood, bodily fluids or secretions. The facility Enhanced Barrier Precaution sheet undated documents everyone must clean their hands, including before entering and when leaving the room. Based on observation, interview and record review, the Facility failed to use hand hygiene between glove changes prior to entering an Enhanced Barrier Precaution room; and, failed to utilize gloves while in the Enhanced Barrier Precaution room and while touching surfaces with potential bodily fluid (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145456 If continuation sheet Page 12 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145456 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeside Health & Rehab Center 1200 University Avenue 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 contamination for 2 of 24 residents (R4 and R15) reviewed for infection control in the sample of 30. Level of Harm - Minimal harm or potential for actual harm Findings include: Residents Affected - Few 1. R4's Minimum Data Set (MDS) dated [DATE] documents R4 is occasionally incontinent of bladder and frequently incontinent of bowel. On 4/17/2024 at 10:00 AM, V2 Director of Nursing (DON) was asked to identify a pill that was laying on R4's bed sheet. R4's white fitted bed sheet had a yellow discoloration in the form of circular ring, underneath R4's mid-section. The pill was laying on this area with an over-turned medication cup. At this time V2 felt the bed sheet, ungloved, and stated it was dry, but she was unsure what the discoloration was. R4 then placed the pill back in the medication cup. V2 then left R4's room with the pill and medicine cup, without the benefit of hand hygiene. V2 then walked to the nurse's station and logged into the computer system. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145456 If continuation sheet Page 13 of 13