Inspection·January 6, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 12/31/24 at 12:15 PM, V7, R6's Daughter, stated she is concerned for R6's safety due to R6 not having her call light within reach or her bed and chair alarms on when she comes to visit. V7 stated R6's chair alarm was not on 12/31/2024 when she walked into R6's room. V7 stated she has come to visit R6 multiple times and R6 has not had her chair alarm on and in place. V7 stated she visited R6 on 12/24/2024 and found R6 up in her wheelchair slumped over on her bedside table with her wheelchair not locked, no chair alarm on, and no call light within reach. V7 stated she worries about leaving R6 alone sometimes due to safety issues. V7 stated R6 has had a fall within the last six month due to falling out of the chair because the chair alarm was not on. On 1/2/2025 at 1:36 PM V13, CNA stated if a resident is a fall risk, they will have something posted outside of the room by their name such as a yellow square clock that states high fall risk. V13 stated a resident at risk for falls may have a bed/chair alarm and a floor mat next to bed. V13 stated staff is to make sure resident has shoes or non-grip socks on, call light within reach, and walker/wheelchair close to bed. On 1/2/2025 at 1:40 PM, V16, CNA, stated there should be a yellow star outside of resident's room by their name plate if the resident is a high fall risk. V16 stated staff should make sure the resident's room is free of clutter, the resident has their water, bedside table, and call light within reach, check on the resident frequently, and follow the resident's Care Plan for fall interventions. R6's Health Status Note dated 9/27/2024 at 8:00 PM, documents R6 observed lying on right side near recliner in room. Footrest up on recliner. R6 wearing gripper socks. Checked for injuries. Able to move all extremities without pain or discomfort. Neuro-checks initiated. Chair alarm was sounding. Nurse outside of resident's room. Went in to check resident. Denies having pain. The facility's Call Light Guidance Policy dated 07/01/2023 documents a call light activation device shall be kept within reach while in resident rooms and bathrooms. The facility's Fall Prevention Program/Protocol dated 07/01/2023 documents according to MDS, a fall is defined as: unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (e.g. a resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. The facility's Fall Prevention Program/Protocol revised date 09/06/2023 documents the interdisciplinary will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. A position-change alarm will not be used as the primary or sole intervention to prevent falls, but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145456 If continuation sheet Page 2 of 7 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 01/06/2025 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** Based on interview, observation, and record review, the facility failed to don appropriate Personal Protectant Equipment (PPE) when caring for isolation residents, failed to educate visitors on proper PPE usage during a COVID-19 outbreak, and failed to supply PPE for staff and visitors. This failure has the potential to affect all 57 residents living in the facility. Residents Affected - Many The findings include: V3, Quality Assurance (QA) Nurse, provided a list of those who were COVID positive with 19 residents and 15 staff members listed in the facility. 1. On 12/31/24 at 8:45 AM, R2 was seen lying in bed with V4, Certified Nursing Assistant (CNA), sitting at her bedside with only a N-95 mask on and no further PPE. R2 had an Enhanced Barrier Precaution (EBP) sign posted on entrance to her room with a cart of PPE equipment sitting outside her door. The PPE cart outside R2's door had no gowns in the cart. Per R2's Physician Order, R2 should be on Contact Isolation and not EBP. R2's Physician Order, dated 12/18/24, documents Contact Isolation r/t (related to): MRSE (Methicillin-Resistant Staphylococcus Epidermidis) in wound. 2. On 12/31/24 at 9:45 AM, R3 seen sitting on side of her bed, surgical mask on her forehead. A sign was posted outside her door indicating R3 is on Contact/Droplet Isolation, a PPE cart outside her door was empty. R3's Nursing Note, dated 12/20/24 at 11:26 AM, documents Resident tested positive for COVID. 3. On 12/31/24 at 1:00 PM, R8 was seen lying in her bed. R8 is positive for COVID-19 and is on contact/droplet isolation with a sign at the entrance to her room and a PPE cart outside the door. R9, who is also positive for COVID-19, was seen standing in R8's room talking to her at her bedside with no mask or other PPE on. R9 was then seen walking out of R8's room and into her own room. Staff were seen across the hall with no one saying anything to R9 about wearing a mask or going into other resident rooms. R8's Physician Order, dated 12/27/24, documents Droplet and Contact precautions: Masks (N95), Gloves, Gowns, and Eye Shields. Single Room Isolation (if available), with all services brought to the room, including therapy, meals, and activities. R8's Nursing Note, dated 12/27/24 at 8:17 AM, documents Resident tested positive for COVID. At this time resident c/o (complaint of) being tired and having a runny nose no other s/s (signs/symptoms) present at this time. POA (Power of Attorney) made aware. MD (medical doctor) made aware. R8's Nursing Note, dated 12/31/24 at 3:42 PM, documents Resident continues with covid isolation at this time no signs or symptoms noted, vitals remain stable. R8's Nursing Note, dated 1/1/25 at 10:21 AM, documents Resident continues with covid isolation at this time no signs or symptoms noted, vitals remain stable. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145456 If continuation sheet Page 3 of 7 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 01/06/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many R9's Physician Order, dated 12/27/24, documents Droplet and Contact precautions: Masks (N95), Gloves, Gowns, and Eye Shields. Single Room Isolation (if available), with all services brought to the room, including therapy, meals, and activities. R9's Nursing Note, dated 12/27/24 at 8:12 AM, documents Resident tested positive for COVID. At this time resident c/o being tired, runny nose and a cough. POA is aware and voiced concerns over being here last night with resident. MD made aware. R9's Nursing Note, dated 12/31/24 at 3:43 PM, documents Resident continues with covid isolation at this time no signs or symptoms noted, vitals remain stable. R9's Nursing Note, dated 1/1/25 at 10:17 AM, documents Resident continues with covid isolation at this time no signs or symptoms noted, vitals remain stable. 4. On 12/31/24 at 1:10 PM, V3 (QA Nurse), V9 Minimum Data Set (MDS) Nurse, V5 Licensed Practical Nurse (LPN), and V11 LPN, were all seen standing at the nurse's desk talking with V5 having her N-95 down under her chin. On 12/31/24 at 1:15 PM, V3 stated Yes, I saw that (V5) had her mask under her chin while at the desk. 5. On 1/2/25 at 8:04 AM, V12, LPN, was seen passing morning medications to R13 with a EBP sign posted on the door and a cart of PPE outside the door, V12 stated she was unsure why R13 is on EBP, because she did have COVID, but that should be over now. V12 entered the room with no PPE on, gave R13 her medications, cut up R13's breakfast sitting on her bedside table, then left the room with no hand hygiene seen done before or after medications given or before leaving room. V12 then continued to pass medications to residents on the hall. R13's Physician Order, dated 12/18/24, documents Enhanced Barrier Precautions r/t: Wound. R13's Nursing Note, dated 12/22/24 at 8:52 AM, documents MD notified of residents positive covid test, resident moved rooms to the covid wing and POA (power of attorney) called to update of positive status and current condition. Will mx (monitor) closely, resident is up eating breakfast in room at this time, visual improvement from yesterday. R13's Nursing Note, dated 12/31/24 at 3:40 PM, documents Resident continues with covid isolation at this time no signs or symptoms noted, vitals remain stable. R13's Nursing Note, dated 1/1/25 at 11:15 AM, documents Resident continues with covid isolation at this time no signs or symptoms noted, vitals remain stable. 6. On 1/2/25 at 8:13 AM, V12 was seen passing medications to R14. There was an EBP sign posted outside R14's door. V12 did not don any PPE and walked in the room and gave R14 her medications. V12 did not do hand hygiene before going into R14's room, after giving R14 her medications, and before leaving her room. Per R14's Physician Order, R14 should be on Contact Isolation. V12 continued to pass medications to residents on the hall. R14's Physician Order, dated 12/22/24, documents Contact Isolation r/t (related to): Extended-Spectrum Beta-Lactamases (ESBL) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145456 If continuation sheet Page 4 of 7 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 01/06/2025 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 R14's Physician Order, dated 11/27/24, documents Enhanced Barrier Precautions r/t: urinary catheter. Level of Harm - Minimal harm or potential for actual harm 7. On 1/2/25 at 8:20 AM, V13, CNA, was seen performing incontinence care on R10. There was an EBP sign posted outside her door along with PPE cart. V13 did not change her gloves during resident care. V13 used her soiled gloves to gather trash, cover R10 with a bed sheet, emptied R10's urinary catheter, then doffed her gloves. V13 then went back to R10's bedside and picked up the comforter off the floor and placed it on R10, gave R10 her call light, and adjusted the bed, all with no gloves on. V13 then took R10's breakfast tray out of the room to a cart in the hallway with no further hand hygiene seen done afterwards as she was seen assisting other residents on the hall. Residents Affected - Many R10's Physician Order, dated 12/18/24, documents Enhanced Barrier Precautions r/t: Wound. 8. On 1/2/25 at 9:08 AM, V12, LPN, was seen passing medications to R15 who was on contact/droplet isolation due to positive COVID-19. R15 was sitting in her wheelchair in the hallway with no mask on and no staff directing her to stay in her room. V12 attempted to give R15 her medications while in the hallway and R15 spit them out and the pills fell to the floor. V12 picked up the pills with her bare hands and threw them away. V12 did not wash her hands afterwards and stated she needed to step out for a break and left the floor. R15's Physician Order, dated 12/31/24, documents Droplet and Contact precautions: Masks (N95), Gloves, Gowns, and Eye Shields. Single Room Isolation (if available), with all services brought to the room, including therapy, meals, and activities. R15's Nursing Note, dated 12/31/24 at 2:44 PM, documents Resident tested positive for COVID this AM. POA called and notified of test results. Resident moved to new room for isolation precautions. POA verbalized understanding. R15's Nursing Note, dated 1/1/25 at 10:23 AM, documents Resident continues with covid isolation at this time no signs or symptoms noted, vitals remain stable. 9. On 12/31/24 at 12:52 PM, R7 was seen sitting in her wheelchair in her room. R7 has a contact/droplet isolation sign upon entrance to her room with a PPE cart outside the door. V8, R7's Daughter, was in the room with a surgical mask sitting under her chin and not covering her face, while sitting face-to-face with R7. The resident does not have a mask on, and the visitor had no other PPE on. On 12/31/24 at 12:55 PM, V8, R7's Daughter, stated No one in the facility talked to me about wearing a mask or anything else. I saw the box of masks outside the front door and put one on. When showing her the sign on doorway, V8 stated I didn't know I was supposed to wear any of that. I hope I don't get COVID. R7's Physician Order, dated 5/15/24, documents Contact Precautions due to ESBL urine. R7's Physician Order, dated 11/27/24, documents Enhanced Barrier Precautions r/t: wounds. R7's Nursing Note, dated 12/20/24 at 11:22 AM, documents Resident tested positive for COVID. POA notified and resident moved to private room for isolation precautions. R7's Nursing Note, dated 12/31/24 at 3:40 PM, documents Resident continues with covid isolation at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145456 If continuation sheet Page 5 of 7 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 01/06/2025 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 this time no signs or symptoms noted, vitals remain stable. Level of Harm - Minimal harm or potential for actual harm R7's Nursing Note, dated 1/1/25 at 11:21 AM, documents Resident continues with covid isolation at this time no signs or symptoms noted, vitals remain stable. Residents Affected - Many Tyanna [NAME]: 10. On 12/31/24 at 12:10 PM, a Contact and Droplet Precaution Signage posted outside of R6's door. Sign states for Visitors to please report to nurses' station before entering room. Sign states to perform hand hygiene, gloves and a gown should be worn, N95 mask is required, eye protection of face shield is required, limit transport of resident for essential purposes only, when transporting, resident should wear a mask, limit use of noncritical equipment to a single resident, bag linen to prevent contamination, discard infectious trash to prevent contamination, perform hand hygiene. No PPE isolation cart in front of R6's room. On 12/31/24 at 12:15 PM, V7, R6's POA/daughter, was seen in R6's room without proper PPE on as stated on sign outside of R6's door. V7 wearing just a surgical mask. V7 stated she was notified of R6 testing positive for COVID by the facility. R6's Nursing Note dated 12/20/2024, at 11:32 AM, documents Resident tested positive for COVID. POA called and notified. Resident placed on isolation precautions in current private room. On 1/2/25 at 1:50 PM, V2, Director of Nursing (DON), stated I would expect the staff to perform hand hygiene before, during glove changes, and after resident care. I would expect the staff to change gloves when going from dirty to clean while performing incontinent care. I would expect the staff to wear appropriate PPE for isolation residents and to educate visitors on what PPE to wear for isolation residents. The Facility's Enhanced Barrier Precautions Sign, undated, documents Everyone MUST: Clean their hands, including before entering and when leaving the room. Wear gloves and a gown for the following High-Contact Resident Care Activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound Care: any skin opening requiring a dressing. The Facility's Contact and Droplet Precautions Sign, undated, documents Visitors please report to Nurses station before entering room. Perform hand hygiene. Gloves and gown should be worn. N95 mask is required. Eye protection or face shield is required. Limit transport of resident for essential purposes only. When transporting, resident should wear a mask. Limit use of noncritical care equipment to a single resident. Bag linen to prevent contamination. Discard infectious trash to prevent contamination. Perform hand hygiene. The Facility's Handwashing/Hand Hygiene Policy, undated, documents This facility considers hand hygiene the primary means to prevent the spread of infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 5. Residents, family members and/or visitors will be encouraged to practice hand hygiene through the use of fact sheets, pamphlets, and/or other written materials provided at the time of admission and/or posted throughout the facility. 7. Use an alcohol-based hand rub containing at least 62% alcohol, or alternatively, soap and water for the following situations: b. before and after direct contact with residents; c. before preparing or handling medications; d. before performing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145456 If continuation sheet Page 6 of 7 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 01/06/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many any non-surgical invasive procedures; h. before moving from a contaminated body site to a clean body site during resident care; i. After contact with blood or bodily fluids; k. After contact with objects in the immediate vicinity of the resident; l. After removing gloves; m. Before and after entering isolation precaution settings; o. Before and after assisting a resident with meals. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. The Facility's Transmission Based Precautions Policy, dated 7/1/23, documents Purpose: To provide staff guidelines for transmission-based precautions to protect residents and themselves while providing care. Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. It is the responsibility of all staff and agents of the facility to adhere to the transmission-based precaution guidelines. 5. 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 the type of precaution. a. The signage informs the staff of the type of CDC precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room. Enhanced Barrier Precautions: 1. May be implemented to protect residents 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: a. Indwelling/supra pubic catheters; b. any open skin wounds. 3. Staff and visitors will wear gloves (clean, non-sterile) when entering the room. 4. Staff and visitors will wear a disposable gown when performing high-risk activities with the resident, including but not limited to: b. Toileting/incontinent care; d. Device care of use (central line, indwelling catheter); f. Changing linens; g. Providing hygiene. Contact Precautions: May be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. 4. Staff and visitors will wear gloves (clean, non-sterile) when entering the room. a. While care for a resident, staff will change gloves after having contact with infective material (for example, fecal material); b. Gloves will be removed, and hand hygiene performed before leaving the room. c. Staff will avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves are removed. 5. Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. Droplet Precautions may be implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets (large-particle droplets larger than 5 microns in size, that can be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning). Airborne Precautions are indicated when an individual is infected with a pathogen that is very small (microns or smaller in size) and can be transmitted long distances through the air. 4. Any individuals who enter the room of a resident placed on airborne precautions must wear approved respiratory protection. A resident on airborne precautions will wear a mask when leaving the room or coming into contact with others. The Facility's Centers for Medicare and Medicaid Services Form 671 dated 12/31/2024 documents there are 57 residents residing at the Facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145456 If continuation sheet Page 7 of 7