Inspection·May 15, 2023

F 0690 Level of Harm - Actual harm Residents Affected - Few R1's Minimum Data Set (MDS) dated [DATE] documents she is alert and oriented and is dependent on staff for bed mobility. The MDS documents R1 requires extensive assist with transfers, dressing, and toileting. It documents she is always incontinent of bowel and bladder. R1's Care Plan, undated, documents Care Plan Problem as Self-Care Deficit as Evidenced by: Needs assistance with ADLs (Activities of Daily Living) related to pain, weakness, DM (Diabetes Mellitus), HTN (hypertension), ASHD (atherosclerotic heart disease), osteoarthritis, macular degeneration, and obstructive uropathy. R1's Care Pan interventions document Toilet Use - One-person physical assist required. Personal Hygiene - One-person physical assist required. Bed Mobility - One-person physical assist required. Another of R1's Care Plans, undated, documents (R1) is incontinent of Bowel / Bladder related to stress, urge, mixed, Diabetes, history of frequent UTI with history of ESBL (Extended spectrum beta-lactamase infection), diuretics, and anti-depressant. Interventions for this care plan include Clean peri-area with each incontinence episode. R1's Hospital Records were reviewed and document R1 was hospitalized with the diagnosis of Urinary Tract Infections on the following dates: 9/8/22-9/15/22: Diagnosis: Sepsis and ESBL UTI 10/17/22-10/25/22: Diagnosis: Acute Cystitis and Acute Lower UTI, which was treated with antibiotics for 7 days while in hospital. Urine culture was positive for Klebsiella pneumoniae and E-coli. 11/11/22-11/17/22: Diagnosis: Sepsis/UTI caused by Klebsiella pneumoniae and Providencia stuartii. R1 was treated with intravenous antibiotics to treat the UTI while in hospital. 12/30/22-1/11/23: Diagnosis: Acute complicated UTI/acute cystitis with hematuria due to ESBL. R1 received 10 days of intravenous antibiotics to treat UTI during this hospitalization. 3/6/23-3/11/23: Diagnosis: Sepsis/UTI caused by Klebsiella Pneumonaie. R1's Progress Notes dated 2/8/23 at 8:57 AM documents, Resident complaining of burning sensation when urinating. Notified MD (medical doctor). Orders to do a UA (Urinalysis) on resident. Resident approves. Review of progress notes do not document any attempts to obtain UA on 2/8/23. R1's Progress Note dated 2/9/23 at 3:16 PM documents, UA to be done for lab pick up one time only for 1 day. Attempted to collect UA today but urine was contaminated with resident's feces. Endorsed to next shift. There was no documentation of R1's urine being obtained until her Progress Note dated 2/17/23 at 1:45 PM which documented, Resident's urine collected today via straight cath (catheter) to check for UTI, sample sent to the lab. R1's Progress Note dated 2/21/23 at 3:38 PM documents, Received call from (staff) at (MD) office regarding the resident's complaint of burning while urinating and is requesting a urinalysis. This nurse informed caller that her urine has been collected today and has been sent to the lab. The MD office requested for a copy once result is available. (MD) office Fax # ***-***-****. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145571 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 145571 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Ridge Health & Rehab Ctr One Perryman Street Lebanon, IL 62254 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 R1's Progress Note dated 2/21/23 at 5:43 PM documents, Bactrim DS Oral Tablet 800-160 mg Give 1 tablet by mouth two times a day for UTI for 10 days. Not available. Level of Harm - Actual harm Residents Affected - Few R1's Medication Administration Record (MAR) documents R1 received her first dose of Bactrim DS for her UTI on 2/21/23, 14 days after she first complained of signs and symptoms of a UTI. On 5/12/23 at 2:35 PM R1 stated she had a urinary tract infection in February. She stated she had pain and burning when she urinated and told the nurse about it, and they said they were going to check her urine to see if she had an infection. R1 stated the only way they can get her urine sample is by straight cathing her. R1 stated she did not know why they didn't get her sample right away, but she continued to have the pain and burning until they finally got her some medicine for it. R1 stated she does not want to get the facility in trouble, but they need to shape up. On 5/12/23 at 9:00 AM V1 (Administrator) presented a statement for V17 (R1's Nephrologist) that V1 stated showed R1's UTIs are unavoidable. The statement documented, This is a patient with a history of frequent urinary tract infections as a result of a long-term history of diabetes and incomplete bladder emptying. She has had multiple infections and unfortunately has developed more resistant bacterial infections given the frequent need for antibiotic exposure including ESBL strains which is an unavoidable potential outcome in this setting. On 5/12/23 at 8:52 AM V17 (Nephrologist) stated R1's medical conditions do increase her risk of UTIs, but not receiving timely and thorough incontinent care is going to increase the risk of her having more frequent UTIs. He stated R1 is at risk for UTIs no matter what, but he would expect her to have thorough incontinent care whenever she is incontinent to decrease the frequency of infections. He stated not getting appropriate care definitely would contribute to her UTIs. 2. On 5/12/2023 at 9:51 AM R3 turned her call light on. R3 stated she was needing changed as she was wet and had a bowel movement in her diaper. On 5/12/2023 at 9:52 AM V18 (CNA) stated she did not change R3 yet since she's been here. V18 stated the midnight shift probably changed her before they left. On 5/12/2023 at 9:56 AM V20 (Licensed Practical Nurse/LPN) answered R3's call light. R3 told her she needed changed she had peed three or four times in her diaper and had a bowel movement. V20 told R3 she would let her CNA know. R3 kept saying to V20 (LPN), I know it's not 11:00 to get changed yet but I need changed. V20 stated again, I'll let the CNA know you need changed. On 5/12/2023 at 10:10 AM, V9 (CNA) unfastened tape on R3's adult incontinent brief and opened it. R3's diaper was saturated with strong smelling urine and there was a large amount of bowel movement in adult incontinent brief. R3 stated she wants washed good and wants her petroleum jelly to put on her bottom, legs, and above her waist because she's been sitting in urine all morning. V9 used the no rinse perineal cleanser. R3 stated Nobody has ever used that stuff before. V18 (CNA) sprayed perineal cleanser from the bottle to R3's right side and left side of her groin, and middle of groin area. R3 yelled Don't spray that stuff like that, it's cold! V18 swiped in a front to back motion with one swipe to right, left, and middle groin area with a dry washcloth. V18 never used a wet washcloth to the left, right, or middle of the groin area. V18 did not separate R3's labia to cleanse the urine and feces from R3's inner folds, and stool was observed to the middle part of R3's groin area after cleansing was completed. V18 did not cleanse R3's left or right inner thighs. V18 and V9 rolled R3 over to her right side and there was a large amount of bowel movement/stool on R3's buttocks and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145571 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 145571 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Ridge Health & Rehab Ctr One Perryman Street Lebanon, IL 62254 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Actual harm Residents Affected - Few inner thighs. V9 sprayed cleanser on a wet washcloth and swiped front to back over R3's buttock area, then V9 swiped nine times cleansing the stool from R3's anal area. [NAME] stool was noted on R3's soaker pad underneath the diaper. V9 did not cleanse R3's left side of buttocks or hip area. V9 then put petroleum jelly on R3's left hip and buttocks area without cleansing those areas. V9 did not cleanse R3's left or right backside of the inner thighs. V9 placed the clean incontinent brief and clean soaker pad underneath R3, then V9 and V18 rolled R3 over on her left side. [NAME] stool was still noted on R3's left upper inner thigh with Vaseline spread over the stool. R3's right hip area noted to be red, with no open areas. V9 did not cleanse R3's right buttocks or hip area when she had rolled her over to her left side. No petroleum jelly was applied to right buttocks area. R3's MDS dated [DATE] documents R3 is alert and oriented. It further documents R3 is dependent on staff for bed mobility, transfers, and toileting, and she is occasionally incontinent of bladder and always incontinent of bowel. R3's Care Plan, undated, documents Self-Care Deficit as Evidenced by: Needs assistance with ADLs Related to generalized weakness, difficulty walking, DM, COPD (Chronic Obstructive Pulmonary Disease), CHF (Congestive Heart Failure), Osteoarthritis, hypothyroidism, HTN, HLD (Hyperlipidemia), ASHD. Interventions for this care plan document Bed Mobility - One-person physical assist required, Transfer: One-person physical assistance required, Personal Hygiene - One-person physical assist required, and Toilet Use - One-person physical assist required. 3. On 5/10/23 at 9:55 AM R4 was sitting up in her wheelchair in her room. R4 said she could not hear good, so surveyor communicated with paper and pen. Surveyor questioned R4 on paper if she was getting changed/incontinent care timely. R4 stated, No. They change me when they put me to bed at night and then don't change me again until I get up in the morning. They get me up at 4:15 AM and I am always soaked, and my bed is wet, but I have to lay there until they are ready to get me up. They never change me through the night. I'm wet right now but I won't get changed until 1:00 PM, right after lunch. They are busy during breakfast and then they have stuff to do. It doesn't matter if I put on my call light, that's when I get changed. At 10:00 AM R4 put her call light on to let staff know she is wet. R4 stated, It doesn't matter. They won't come. I'll get changed after lunch like I always do. R4 did go ahead and put on call light, and it was promptly answered by V9 (CNA). R4 stated, I need my diaper changed. V9 stated, Ok, I'll be right back. Within a few minutes V9 returned with another CNA (V8) who stated she is R4's CNA. V8 used a bath towel and wet it in R4's sink. V8 stated the facility is short on washcloths. R4 stood up from R4's wheelchair and V8 removed R4's wet incontinent brief. V8 then used the wet towel to wipe in a back-and-forth motion, never switching to a clean part of the towel, to clean R4's buttocks and rectum, then put a new incontinent brief on her and assisted R4 to sit back down in her wheelchair. V8 did not attempt to cleanse R4's vagina or lower abdomen or groin. V8 stated this is the only way R4 will let us do care, with her standing. V8 stated R4 doesn't want to lay down. Another CNA walked into R4's room and R4 started getting agitated, stating, How many people want to see my a**? The CNA remained in the room as V8 was just putting R4's incontinent brief back on. V8 stated the last time R4 had been checked and changed was probably around 6:30 AM because she (V8) arrived to work at 6:40 AM and R4 was already up and dressed in her chair and her bed was made. V8 stated this was normally the time they changed R4, before lunch. After V8 and other CNA left the room, R4 asked what had been said because she was unable to hear. Informed her V8 said this was normally the time they changed R4, before lunch, and R4 stated, No this is not. It's always around 1:00 PM. During her care, R4 apologized to V8, stating, I know this is not my time to get changed. While care observed R4's buttocks noted to be red. V8 stated, Her skin is just red, but she doesn't have any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145571 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 145571 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Ridge Health & Rehab Ctr One Perryman Street Lebanon, IL 62254 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 open areas. Level of Harm - Actual harm R4's Electronic Medical Record (EMR) documents R4 was hospitalized from [DATE] to 2/13/23 with diagnosis of UTI. Urine culture done on 2/12/23 documented the causative bacteria for UTI was Raouitella planticola >100,000 and Proteus Mirabillus >10,000-49,000. Residents Affected - Few R4's Physician Order dated 2/24/23 documents: Bactrim DS 800/160 mg Q12H (every 12 hours) x7 days to treat her UTI. R4's Physician Order dated 2/13/23 documents: Cephalexin 250 mg Q12H for UTI for 5 administrations. On 5/12/23 at 11:45 AM V2 (Director of Nursing/DON), stated she is not sure what happened with R1's urinalysis not being done in a timely manner. She stated sometimes R1 can be a little difficult with care. V2 stated she would expect any residents who are incontinent to be toileted before and after meals and at a minimum at least every two hours. V2 stated when incontinent care is performed, she expects staff to thoroughly cleanse any areas on the resident that is soiled with urine or feces. She stated on female residents she would expect staff to spread the labia and thoroughly cleanse the vaginal folds and urethra. V2 stated she would expect staff to change gloves and perform hand hygiene any time they are soiled, when going from clean to dirty area and when coming into and leaving a resident's room. The facility's ADL Support Policy, revised 5/2/23, documents, Purpose: to provide staff with guidance on providing support with ADLs to residents. Policy: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The facility's Incontinence Care Policy revised 5/16/22 documents, Purpose: To provide guidelines to all nursing staff for providing proper incontinence care in order to clean skin clean, dry, free of irritation and odor. Policy: All incontinent residents will receive incontinence care in order to keep skin clean, dry, and free of irritation and/or odor. Incontinence care will be provided as required It is the responsibility of the CNA to provide incontinence care. It is the responsibility of the charge nurse to ensure that all incontinent residents receive appropriate incontinence care. It is the responsibility of the Director of Nursing that all nursing staff have received adequate training on the provision of proper incontinent care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145571 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 145571 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Ridge Health & Rehab Ctr One Perryman Street Lebanon, IL 62254 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 Based on observation, interview, and record review the facility failed to complete hand hygiene, glove changes and handle linens in a manner which prevents the spread of infection for 1 of 3 residents (R1) reviewed for infection control in the sample of 10. Residents Affected - Few Findings include: 1. On 5/5/23 at 9:40 AM V4 (Certified Nursing Assistant/CNA) removed R1's adult incontinent brief and it was saturated with brown colored urine. R1 had also had a bowel movement. R1 stated, It itches down there. My gown is wet because the diaper was too wet, and it leaked through. V4 put a bath towel under the faucet in R1's sink to wet it and put a small amount of soap on the towel. V4 assisted R1 to turn onto her left side and cleansed the fecal material from her buttocks and rectum, using a back and forth wiping motion, not turning to clean areas on the towel when she moved to different areas. V4 threw that towel directly onto the floor. V4 then rolled R1 onto her back and used one wet wash cloth to wipe her lower abdomen, right and left groin, and over her pubic region, but did not spread R1's labia to cleanse her inner folds. V4 then threw the washcloth on the floor. V4, wearing the same soiled gloves, applied barrier cream to R1's groin and inner thighs, and turned her to her side and applied barrier cream to her buttocks. V4 then removed her gloves for the first time since starting incontinent care and donned new gloves without performing hand hygiene. V4 then put a new incontinent brief on R1, put her socks and pants on, then removed her wet gown, and left the room, still wearing her gloves, to get another towel. V4 came back into room and wet that towel in the sink but did not use it. V4 removed R1's wet gown and put an undershirt and sweatshirt on R1 without cleansing her abdomen or lower back that was wet with urine. V4 lowered R1's bed, removed a pillow from R1's wheelchair, and removed her gloves and left the room without performing hand hygiene, to get someone to come and help her transfer R1 from the bed into her chair. R1 stated, I get bladder infections all the time. I was just in the hospital with one not too long ago. On 5/12/23 at 11:45 AM V2 (Director of Nursing), stated she would expect any residents who are incontinent to be toileted before and after meals and at a minimum at least every two hours. V2 stated when incontinent care is performed, she expects staff to thoroughly cleanse any areas on the resident that is soiled with urine or feces. She stated on female residents she would expect staff to spread the labia and thoroughly cleanse the vaginal folds and urethra. V2 stated she would expect staff to change gloves and perform hand hygiene any time they are soiled, when going from clean to dirty area and when coming into and leaving a resident's room. V2 stated staff should put dirty linens in a plastic bag until they can take it to the soiled utility room or put it in the hampers. On 5/12/23 at 2:35 PM R1 stated one of the staff came and asked her about the clothes on the floor when writer was observing her care, and she asked what that was about. Surveyor explained to her that while her incontinent care was observed, the CNA threw the dirty towels on the floor instead of putting them in a plastic bag. R1 stated that's the way they always do it; they throw them on the floor. R1 stated she never sees them use a plastic bag. The facility's undated policy, Handwashing/Hand Hygiene, documents, Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: 1. All personnel shall be trained and regularly in serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel will follow the handwashing/hand hygiene procedure to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use alcohol-based hand rub containing at least 62% alcohol; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145571 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 145571 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Ridge Health & Rehab Ctr One Perryman Street Lebanon, IL 62254 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; h. before moving from a contaminated body site to a clean body site during resident care; and i. after contact with blood or bodily fluids; 1. After removing gloves; 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. Event ID: Facility ID: 145571 If continuation sheet Page 7 of 7