Inspection·July 15, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 7/11/2024 at 10:04 AM, R73's coat pocket was observed with R73 and V4 present. The entire bottom (approximately 3 to 4 inches in length) of one of the pockets on R73's coat was missing. It had a charred (burnt) appearance above the hole. At this time, R73 stated it occurred a couple days ago. V2, Director of Nursing (DON) provided an electronic message dated 4/9/2024 documents, in part, Staff please make sure we are offering or encouraging the residents to put on a smoking vest when they are going outside to smoke to reduce the risk of burning themselves while smoking. a.)2.) R37's Care Plan Activity Report dated 3/24/2023 documents, Cigarette Smoking- I am a smoke[er] and have expressed interest and desire to continue to smoke. I smoked prior to admission. Goals- I will remain safe while under the supervision of staff. Interventions include: Remind me that my staff will be supervising me during smoking and any related behaviors. Also my noncompliance will be monitored and reported to my MD (Medical Doctor) and Family PRN (As needed). Staff will assist me to the smoking area and keep me safe from harm and will apply smoking apron as needed. Provide me a smoking apron to use during my smoking session and that my supplies must be kept at the nurse station to ensure my safety PRN. It also documents on 5/16/2023, I am allowed to go outside to smoke by myself. R37's MDS dated [DATE] documents R37 is moderately cognitively impaired. On 7/8/2024 at 2:21 PM, R37 stated he wears oxygen when he is in his room. R37 then stated, I'm going to smoke now in the [NAME] (covered shelter outside building). R37 stated he does not wear an apron, Because I am not sloppy. a.)3.) R2's Care Plan Activity dated 5/2/2024 documents, Provide me a smoking apron to use during my smoking session and that my supplies must be kept at the nurses' station to ensure my safety PRN. Remind me that my staff will be supervising me during smoking and any related behaviors. Also, my noncompliance will be monitored and reported to my MD and family PRN. R2's MDS dated [DATE] documents R2 is cognitively intact. On 7/9/2024 at 2:30 PM, R2 stated she keeps her lighter in her purse and does not wear a smoking apron. The Facility's Resident Smoking Policy dated October 2023, documents, This Facility has established and maintains safe resident smoking practices. It continues to document, Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) are noted on the care plan and all personnel caring for the resident shall be alerted to these issues. The Facility may impose smoking restrictions on a resident at any time if it determines that the resident cannot smoke safely with the available levels of support and supervision. Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor, or volunteer worker at all times while smoking. Residents who have independent smoking privileges are permitted to keep cigarettes, electronic cigarettes, pipes, tobacco, and other smoking items in their possession. Only disposable safety lighters are permitted. All other forms of lighters, including matches, are prohibited. Residents without independent smoking privileges may not have or keep any smoking items, including cigarettes, tobacco, etc, except under direct supervision. b.) On 7/8/2024 at approximately 10:30 AM, R42 was located at the Nurses' station with a brace on her left foot. R42 was expressing signs of pain and stating, my foot. At this time, V24, Licensed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145729 If continuation sheet Page 2 of 14 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 145729 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlyle Healthcare & Sr Living 501 Clinton Street Carlyle, IL 62231 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 Practical Nurse (LPN) stated R42 has a fractured ankle but V24 was unsure how it occurred. Level of Harm - Minimal harm or potential for actual harm R42's MDS dated [DATE] documents R42 is severely cognitively impaired and requires substantial/maximal assistance with toilet transfers. Residents Affected - Some R42's Care Plan Activity Report dated 5/27/2020 documents R42 has the potential for falls or injury from falls related to medications and history of falls, with a goal of having two or less falls on average per month. It further documents R42 requires one to two assist for transfers, as well as have a sensor pad at all times. R42's Accident/Incident Report dated 6/5/2024 documents R42 experienced a fall with no apparent injury due to not following care plan. It further documents R42's fall was unwitnessed after a Certified Nursing Assistant (CNA) left R42 on the toilet unattended and R42 attempted to stand/ambulate independently. It continues to document R42 has decreased safety awareness due to Dementia. R42's Fall Risk assessment dated [DATE] documents R42 has had 3 or more falls in the past 3 months and is a high fall risk. It further documents R42 was noted sitting on buttocks in front of toilet in her bathroom, after the Certified Nursing Assistant (CNA) assisted R42 to the toilet and left R42 unattended. It further documents R42 attempted to ambulate from the toilet into R42's bedroom independently without success. The CNA was instructed to never leave resident unattended on the toilet when they are a high fall risk and already uses a sensor pad (device to alert staff if a resident is transferring unassisted). R42's Progress Notes dated 6/10/2024 documents R42's doctor was updated regarding left foot swelling/bruising and an x-ray was ordered. R42's Progress Notes dated 6/10/2024 further documents R42 was sent to the local emergency room with a fractured left ankle. On 7/11/2024 at 11:00 AM, V22, Nurse consultant/former Director of Nursing (DON) stated she would expect staff to stay with/supervise a resident while they use the toilet, especially if they are a high fall risk. On 7/15/2024 at 10:15 AM, V15, CNA, stated R42 is a fall risk and V15 would stay in the bathroom with her while R42 is using the toilet. On 7/15/2024 at 10:25 AM, V9, CNA stated she was unsure if R42 is a fall risk, but states they usually are a fall risk if they have a sensor pad and a fall mat on the floor near their bed. The Facility's Strategies for Reducing the Risk of Falls Policy dated March 2018 documents, Elimination-Do not leave the resident unattended in the bathroom until the following have been established: Ability/compliance with call light use. Adequate sitting balance and postural stability. It continues, Staff Communication: Include resident fall risk category during shift report and team conference. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145729 If continuation sheet Page 3 of 14 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 145729 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlyle Healthcare & Sr Living 501 Clinton Street Carlyle, IL 62231 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide complete incontinent care for 4 residents (R3, R17, R38, and R59) of 4 residents reviewed for incontinence in a sample of 46. Findings include: 1. R17's face sheet, print date 7/11/24, documented R17 has diagnoses of Alzheimer's disease, major depressive disorder, hypertension, macular degeneration, anxiety disorder, and osteoporosis. R17's MDS (Minimum Data Set), dated 4/5/24, documented that R17 is severely cognitively impaired, is always incontinent of urine, and is dependent on staff for all ADLS (Activities of Daily Living). On 7/9/24 at 9:20 am V12 CNA (Certified Nurse Assistant) and V16 CNA donned gloves without the benefit of hand hygiene and transferred R17 into bed. V12 and V16 then removed R17's urine-soaked incontinence brief and urine-soaked pants. R17's pants were visibly saturated throughout the buttock and hip regions. V12 then applied perineal cleanser to a disposable cloth and wiped R17's upper pubic region without the benefit of hand hygiene nor changing gloves. V12 then cleansed R17's inner labia with the same disposable cloth as was used to cleanse R17's upper pubic region. V12 did not fold the disposable cloth over nor get a new cloth prior to cleansing R17's inner labia region. V12 did not cleanse R17's outer labia nor inner thighs. V12 and V16 then rolled R17 onto her side and V12 cleansed R17's anal region and then rolled R17 onto her back. V12 did not cleanse R17's buttocks nor hips. V12 then pulled R17's blankets up over her with the same gloves as was used to cleanse R17's genitalia. V12 and V16 then removed their gloves and left R17's room without performing hand hygiene. 2. R3's face sheet, print date 7/11/24, documented R3 has diagnoses of Alzheimer's disease, urge incontinence, orthostatic hypotension, anxiety, and hypertension. R3's MDS, dated [DATE], documented R3 is moderately cognitively impaired and is dependent on staff for toileting hygiene needs and ADLS. On 7/9/24 at 9:55 am V12 CNA pushed R3 in his wheelchair from the dining room to his room. V12 and V16 donned gloves without the benefit of hand hygiene and transferred R3 onto his bedside commode. V12 and V16 then transferred R3 onto his bed and removed his disposable adult incontinence brief and pants. V16 then cleansed the tip of R3's penis with a disposable cloth. V16 did not perform hand hygiene nor change gloves prior to cleansing R3's penis. V16 did not cleanse the entire length of R3's penis, inner thighs, scrotum nor buttock. V16 did not retract R3's uncircumcised penis and cleanse the area. V12 and V16 then covered R3 up and removed their gloves. V12 and V16 did not perform hand hygiene prior to leaving R3's room. 3. R38's face sheet, print date 7/11/24, documented R38 has diagnoses of Alzheimer's disease, hypertension, bipolar disorder, anxiety, and depression. R38's MDS, dated [DATE], documented R38 is severely cognitively impaired and is dependent on staff for all toileting needs and ADLS. On 7/11/24 at 9:20 am V16 CNA pushed R38 in her reclining wheelchair from the dementia unit dining (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145729 If continuation sheet Page 4 of 14 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 145729 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlyle Healthcare & Sr Living 501 Clinton Street Carlyle, IL 62231 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some room into her room. V16 CNA and V21 CNA donned gloves without the benefit of hand hygiene. V16 placed a gait belt around R38's waist. V16 and V21 transferred R38 onto her bed and turned her her left side. V21 wet two washcloths with water and wiped R38's rectum and buttock. V21 did not apply perineal cleanser nor soap to the washcloths. R38 then had an extra-large bowel movement. V16 and V21 cleaned up the bowel movement with disposable cloths. V16 nor V21 cleansed R38's frontal labia region following her bowel movement. V16 then tossed R38's soiled bed pad onto the floor. V21 tossed the soiled washcloths onto the pad that was on the floor. V21 then picked the soiled linens up off the floor, placed them in a bag, and carried them down the hallway with the same gloves on. V16 removed her gloves and pushed R38 back into the dementia unit. V16 did not perform hand hygiene before leaving R38's room nor after leaving R38's room. V16 then proceeded to provide care and transfer other residents in dining room without performing hand hygiene. 4. R59's face sheet, print date 7/11/24, documented R59 has diagnoses of metabolic encephalopathy, dementia, Alzheimer's disease, depression, anxiety, hyperlipidemia, and bipolar disorder. R59's MDS, dated [DATE], documented R59 is severely cognitively impaired and requires substantial maximal assistance with toileting and ADL needs. On 7/11/24 at 9:42 am V21 CNA pushed R59 in her wheelchair from the dementia unit dining room to her bathroom. V21 and V16 donned gloves without the benefit of hand hygiene. V21 and V16 then placed a gait belt around R59's waist and transferred her onto the toilet. V16 stated that R59's adult incontinence brief was a little wet. V16 removed R59's wet brief. V16 and V21 then stood R59 up, V21 wiped R59's rectal and buttock area and then V16 placed a new adult brief on R59. Neither V16 nor V21 cleansed R59's frontal region including inner labia, labia, and inner thighs. V16 and V21 then removed their gloves and assisted R59 back to the dementia dining room. V16 and V21 did not perform hand hygiene before nor after leaving R59's room. On 7/15/24 at 8:47 AM, V1, Administrator and V2 DON stated that they would expect the CNAs to cleanse all resident areas potentially exposed to urine or feces. On 7/15/24 at 10:15 AM, V15, CNA stated that she washes the peri area, groin crease, thigh, private area, back of thighs, buttocks, and lower back of the resident when she provides incontinence care. On 7/15/24 at 10:25 AM, V9, CNA stated that when she provides incontinence care she washes the female resident's middle of the perineal area, the sides, and the buttocks. V9 stated that when she provides incontinence care for male residents she washes the penis, testicles, and buttock. 1.The Facility's Perineal Care Policy, revision date of February 2018, documented it is the purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Preparation 1. Review the resident's care plan to assess for any special needs of the resident. 2. Assemble the equipment and supplies as needed. The following equipment and supplies will be necessary when performing this procedure: 1. Wash basin; 2. Towels; 3. Washcloth; 4. Soap (or other authorized cleansing agent; and 5. Personal protective equipment (e.g., gowns, gloves, mask, etc., as needed). Steps in the procedure: 1. Place the equipment on the bedside stand. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly. 3. Fill the wash basin one-half (1/2) full of warm water. Place the wash basin on the bedside stand within easy reach. 4. Fold the bedspread or blanket toward the foot of the bed. 5. Fold the sheet down to the lower part of the body. Cover the upper torso with a sheet. 6. Raise the gown or lower the pajamas. Avoid unnecessary exposure of the resident's body. 7. Put on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145729 If continuation sheet Page 5 of 14 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 145729 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlyle Healthcare & Sr Living 501 Clinton Street Carlyle, IL 62231 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete gloves. 8. Ask the resident to bend his or her knees and put his or her feet flat on the mattress. Assist as necessary. For a female resident: a. Wet washcloth and apply soap or skin cleansing agent. b. Wash perineal area, wiping from front to back. (1) Separate labia and wash area downward from front to back. (Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area.) (2) Continue to wash the perineum moving from inside outward to the thighs. Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth. (3) If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter. (4) Gently dry perineum. c. Ask the resident to turn on her side with her top leg slightly bent, if able. d. Ask the resident to turn on her side with her top leg slightly bent, if able. e. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. f. Rinse and dry thoroughly. For a male resident. a. Wet washcloth and apply soap or skin cleansing agent. b. Wash perineal area starting with urethra and working outward. C. If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area. d. Retract foreskin of the uncircumcised male. e. Wash and rinse urethral area using a circular motion. f. Continue to wash the perineal area including the penis, scrotum, and inner thighs. g. Thoroughly rinse perineal area in same order, using fresh water and clean washcloth. h. If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter. i. Gently dry perineum following same sequence. j. Reposition foreskin of uncircumcised male. k. Ask the resident to turn on his side with his upper leg slightly bent, if able. l. Rinse washcloth and apply soap or skin cleansing agent. m. Wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks. n. Dry area thoroughly. 9. Discard disposable items into designated containers. 10. Remove gloves and discard into designated container. 11. Wash and dry your hands thoroughly. 12. Reposition the bed covers. Make the resident comfortable. 12. Reposition the bed covers. Make the resident comfortable. 13. Place the call light within easy reach of the resident. 14. Clean wash basin and return to designated storage area. 15. Clean the bedside stand. 16. Wash and dry your hands thoroughly. Event ID: Facility ID: 145729 If continuation sheet Page 6 of 14 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 145729 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlyle Healthcare & Sr Living 501 Clinton Street Carlyle, IL 62231 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 - Some 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 store medications in a sanitary manner and failed to date an open multidose medication vial. This failure has the potential to affect all 21 residents residing in the dementia unit. Findings include: On 7/9/24 at 8:07 am the dementia unit medication storage room was entered with V17 RN (Registered Nurse). A large block of ice buildup was observed in and around the freezer at the top of the small medication refrigerator. The ice buildup was observed dripping onto the bottom of the refrigerator. One box containing a vial of abrysvo 120 mg (milligrams) vaccine for the prevention of respiratory syncytial virus was completely saturated with water. One box containing 3 bisacodyl (stool softner)10 mg suppositories was also completely saturated with water. This medication storage refrigerator also contained one opened multi-dose vial of tuberculin solution. There was no date listed on the vial to indicate when it was opened. On 7/9/24 at 8:15 AM, V17, RN stated that the suppositories, vial of abrysvo, and the tuberculin solution is used as needed for all residents of the unit. V17 stated that the medication refrigerator needs to be defrosted. On 7/15/24 at 8:50 AM, V1, Administrator stated she would expect the medication in the medication room refrigerator to be dated when opened and to be stored in a clean manner. On 7/15/24 at 8:52 AM, V2, DON (Director of Nursing) stated she would expect the medication in the vial to be dated when opened. The facility's Storage of Medications Policy, revision date of November 2020, documented the facility stores all drugs and biologicals in a safe, secure, and orderly manner. 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only person authorized to prepare and administer medications have access to locked medications. 2. Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145729 If continuation sheet Page 7 of 14 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 145729 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlyle Healthcare & Sr Living 501 Clinton Street Carlyle, IL 62231 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 Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served in a manner that prevents foodborne illness. This has the potential to affect all 79 residents living in the Facility. Findings include: On 7/09/24 at 11:35 AM in the large dry storage room, there were two cardboard boxes containing hand sanitizer stored directly next to a bag of sugar and a bag of brown sugar. The top shelf on the large center storage rack had an insect bait trap stored directly next to a box of hot sauce. The second shelf from the top also had an insect bait trap stored next to several jars of poppy seed dressing. The top of the storage rack had scattered mouse droppings. On 7/9/24 at 11:50 AM, there was grease splattered on the backsplash behind the stovetop which was not in use. There was a black, burnt, crusty matter across the stovetop and inside the ovens. On 7/9/24 at 11:52 AM, the walk-in refrigerator held a box of sweet potatoes which were dated 6/19 in black marker. V6, Dietary Manager (DM), stated 6/19 was the delivery date and was unsure how staff would know which date to discard them. There were also eight boxes of cream cheese dated 7/1 in black marker that had been removed from original packaging and did not contain a date of expiration or date to discard them. On 7/9/24 at 11:55 AM, in the walk in freezer, there were two plastic bags containing pie crusts that were not labeled or dated. On 7/9/24 at 11:57 AM, next to the 3 compartment sink there was a rack holding various food service utensils. Above that rack, there was a significant amount of dust on the ceiling vent and food spattered on the wall. There was a meat slicer on the adjacent counter top that was covered in crumbs underneath its plastic cover. On 7/9/24 at 11:50 AM, in the standing refrigerator there were several jars of bouillon that were all dated upon delivery. One jar was opened and half empty and was not dated upon opening. V6, Dietary Manager (DM), stated they should be adding a new date when the product is opened. V23, [NAME] stated the jar should be dated upon opening so staff know when to throw it away. On 7/9/24 at 12:05 PM, in the small dry storage closet, there were large tubs containing oatmeal, sugar, flour and thickener. All were labeled with names, but none were dated. On 7/9/24 at 12:12 PM, the staff and resident refrigerator on the second floor next to dining room had a container of carry out food, a container of an unknown meat, half of a pizza in a cardboard box, cheese covered breadsticks in a cardboard box, pasta salad in a plastic storage container, a plastic container of store bought chef salad, and two submarine sandwiches from a chain restaurant. None of these were labeled with staff or resident names, and none of these were dated. There was a submarine sandwich from a gas station that was covered in mold and dated 12/23/23. There was a package of [NAME] jack cheese with a use by date of 1/28/24. There was a half empty container of broccoli cheddar soup with a use by date of 3/2/24. There was a bag of plums that were not dated, but were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145729 If continuation sheet Page 8 of 14 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 145729 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlyle Healthcare & Sr Living 501 Clinton Street Carlyle, IL 62231 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 Residents Affected - Many covered in mold. There was a bottled coffee beverage dated 2/23/24. The freezer had a previously opened can of soda that was not labeled or dated and was covered with a latex glove. On 7/9/24 at 1:15 PM, food temperatures were obtained from the second floor dining room steam table using a metal calibrated thermometer after the last resident tray was served. The green beans measured 113° Fahrenheit (F) and the two plastic containers of salad measured 69°F and 56°F. On 7/9/24 at 1:17 PM, V6, Dietary Manager (DM), stated, They didn't get it (green bean temperature) up enough when they brought more. She stated she will start working on cleaning up the resident and staff refrigerator right away. On 7/12/24 at 9:20 AM, V1, Administrator stated she expects staff to follow Facility policies. The Facility's Food Preparation and Service Policy revised 11/2022 documents Food and Nutrition Services employees prepare, distribute, and serve food in a manner that complies with safe food handling practices. The Policy documents the danger zone for food temperatures is greater than 41° Fahrenheit (F) and less than 135°F, and all fresh, frozen, or canned vegetables should be cooked to a minimum holding temperature of 135°F. The Facility's Food Receiving and Storage Policy revised 11/2022 documents food shall be received and stored in a manner that complies with safe food handling practices. It documents dry foods stored in bins are removed from their original packaging, and labeled and dated with a use by date. All foods in the refrigerator or freezer are covered, labeled and dated with a use by date. Refrigerated foods are monitored to ensure they are used before their use by date or discarded, including foods that belong to residents. Beverages are dated and discarded within 24 hours. The Policy also documents soaps, detergents, cleaning compounds and other similar substances are stored separately from food storage. The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 7/8/24 documents there are 79 residents living in the Facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145729 If continuation sheet Page 9 of 14 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 145729 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlyle Healthcare & Sr Living 501 Clinton Street Carlyle, IL 62231 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** 5. R42's MDS dated [DATE] documents R42 is frequently incontinent of urine, occasionally incontinent of bowel, and requires substantial/maximal assist from staff for toileting hygiene. Residents Affected - Some R42's Care Plan Activity dated 5/27/2024 documents, Cleanse me after every incontinent episodes of urine or stool and Assist me with changing (briefs)/liners and assisting me with peri-care PRN (as needed). On 7/11/2024 at approximately 9:30 AM, R42 was observed to have been incontinent of bowel and bladder. V9, Certified Nursing Assistant (CNA) began by cleaning R42's buttocks of feces. When R42's buttocks was clean, using the same gloves and without the benefit of hand hygiene, V9 rolled R42, cleansed the frontal peri area, outer and inner labia, applied a clean brief and began changing R42 into clean clothing. V9 performed this whole incontinent care process without the benefit of hand hygiene or changing gloves. On 7/15/2024 at 10:15 AM, V15, CNA, stated she would clean a resident who had an incontinent episode from the front to the back, would use hand hygiene and change gloves in between clean and dirty areas. On 7/15/2024 at 10:25 AM, V9, CNA, stated she would change her gloves if they were dirty or visibly soiled. On 7/15/2024 at 10:35 AM, V1, Administrator stated she would expect staff to change gloves and perform hand hygiene between cleaning feces from a residents' buttocks prior to beginning to clean the area of urinary incontinence. The facility's Handwashing/Hand Hygiene policy, revision date August 2019, documented this facility considers hand hygiene the primary means to prevent the spread of infections. 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 shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. It continues, 9. 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. Based on observation, interview, and record review the facility failed to remove soiled gloves, perform proper hand hygiene, and dispose of soiled linen properly for 5 of 5 residents (R3, R17, R38, R59, R42) reviewed for infection control in a sample of 46. 1. R17's face sheet, print date 7/11/24, documented R17 has diagnoses of Alzheimer's disease, major depressive disorder, hypertension, macular degeneration, anxiety disorder, and osteoporosis. R17's MDS (Minimum Data Set), dated 4/5/24, documented that R17 is severely cognitively impaired, is always incontinent of urine, and is dependent on staff for all ADLS (Activities of Daily Living). On 7/9/24 at 9:20 AM, V16, CNA (Certified Nurse Assistant) pushed R17 in her reclining wheelchair from the dementia unit dining room to her room. V12 CNA and V16 CNA donned gloves without the benefit (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145729 If continuation sheet Page 10 of 14 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 145729 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlyle Healthcare & Sr Living 501 Clinton Street Carlyle, IL 62231 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 of hand hygiene. V12 and V16 then transferred R17 into her bed and then removed R17's urine saturated disposable adult brief and her urine saturated pants. V12 then changed her gloves without performing hand hygiene and performed incontinence care on R17. V16 then removed her gloves and left the room without performing hand hygiene. V16 then returned to R17's room with a cloth pad. V16 donned gloves without performing hand hygiene and placed the cloth pad under R17. V12 then pulled R17's blankets up over her while wearing the same gloves that she had on when she performed incontinence care on R17. V12 and V16 then removed their gloves and left R17's room without performing hand hygiene. 2. R3's face sheet, print date 7/11/24, documented R3 has diagnoses of Alzheimer's disease, urge incontinence, orthostatic hypotension, anxiety, and hypertension. R3's MDS, dated [DATE], documented R3 is moderately cognitively impaired and is dependent on staff for toileting hygiene needs and ADLS. On 7/9/24 at 9:55 AM, V12, CNA and V16, CNA pushed R3 in his wheelchair from the dementia unit dining room into his room. V12 and V16 donned gloves without the benefit of hand hygiene. V12 and V16 transferred R3 onto his bedside commode and then onto his bed. V12 and V16 removed R3's disposable adult brief and pants. V16 performed perineal care on R3 without the benefit of hand hygiene nor did she change gloves. V12 placed soiled linens and R3's dirty clothes into a disposable bag. V12 removed her gloves and left the room with the bag of soiled linens. V12 did not perform hand hygiene before leaving R3's room nor immediately after leaving R3's room. 3. R38's face sheet, print date 7/11/24, documented R38 has diagnoses of Alzheimer's disease, hypertension, bipolar disorder, anxiety, and depression. R38's MDS, dated [DATE], documented R38 is severely cognitively impaired and is dependent on staff for all toileting needs and ADLS. On 7/11/24 at 9:20 AM, V16, CNA pushed R38 in her reclining wheelchair from the dementia unit dining room into her room. V16 CNA and V21 CNA donned gloves without the benefit of hand hygiene. V16 placed and gait belt around R38's waist. V16 and V21 transferred R38 into her bed onto her left side. V21 wet two washcloths with water and wiped R38's rectum and buttock. V21 did not apply perineal cleanser nor soap to the washcloths. R38 then had an extra-large bowel movement. V16 and V21 cleaned up the bowel movement with disposable cloths. V16 nor V21 cleansed R38's frontal labia region following her bowel movement. V16 then tossed R38's soiled bed pad onto the floor. V21 tossed the soiled washcloths onto the pad that was on the floor. V21 then picked the soiled linens up off the floor, placed them in a bag, and carried them down the hallway with the same gloves on. V16 removed her gloves and pushed R38 back into the dementia unit. V16 did not perform hand hygiene before leaving R38's room nor after leaving R38's room. V16 then proceeded to provide care and transfer other residents in dining room without performing hand hygiene. 4. R59's face sheet, print date 7/11/24, documented R59 has diagnoses of metabolic encephalopathy, dementia, Alzheimer's disease, depression, anxiety, hyperlipidemia, and bipolar disorder. R59's MDS, dated [DATE], documented R59 is severely cognitively impaired and requires substantial maximal assistance with toileting and ADL needs. On 7/11/24 at 9:42 AM, V21, CNA pushed R59 in her wheelchair from the dementia unit dining room to her bathroom. V21 and V16 donned gloves without the benefit of hand hygiene. V21 and V16 then placed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145729 If continuation sheet Page 11 of 14 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 145729 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlyle Healthcare & Sr Living 501 Clinton Street Carlyle, IL 62231 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 a gait belt around R59's waist and transferred her onto the toilet. V16 stated that R59's adult incontinence brief was a little wet. V16 removed R59's wet brief. V16 and V21 then stood R59 up, V21 wiped R59's rectal and buttock area and then V16 placed a new adult brief on R59. Neither V16 nor V21 cleansed R59's frontal region including inner labia, labia, and inner thighs. V16 and V21 then removed their gloves and assisted R59 back to the dementia dining room. V16 and V21 did not perform hand hygiene before nor after leaving R59's room. On 7/15/24 at 8:47 AM, V1, Administrator and V2, DON stated that they would expect the CNAs to perform hand hygiene prior to, during, and after providing incontinence care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145729 If continuation sheet Page 12 of 14 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 145729 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlyle Healthcare & Sr Living 501 Clinton Street Carlyle, IL 62231 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the Facility failed to establish an infection prevention and control program that reduces the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use in 4 of 4 residents (R50, R74, R236, R237) reviewed for antibiotic stewardship in the sample of 46. Residents Affected - Many Findings include: 1. The Facility's Infection Control Log for the month of June 2024 does not list a causative pathogen for R50's 6/1/24 urinary tract infection. R50's Urine Culture dated 5/31/24 documents, No Growth and (hand-written) Continue ABT (Antibiotic) r/t (related to) symptoms. R50's Physician Orders document 6/1/24 order for Augmentin ES (Extended Strength) (antibiotic) 600 milligrams (mg) - 42.9mg/5mL (milliliters) - give 5mL twice daily for 10 days starting 6/1/24. R50's Medication Administration Record (MAR) for June 2024 documents R50 received 13 of the 20 ordered doses of Augmentin ES. On 7/11/24 at 9:34 AM, V1, Administrator, stated R50 was sent to the hospital for unusual behavior and combativeness where he was started on an antibiotic. She stated his urine culture showed no microbial growth, but the antibiotic was continued in the Facility due to his symptoms. 2. The Facility's Infection Control Log does not list a causative pathogen for R74's 6/28/24 urinary tract infection. R74's 6/28/24 Physician Order documents 1g (gram) Ertapenem (antibiotic) to be given intravenously daily for 22 days starting 6/28/24. R74's MARs for June and July 2024 document R72 only received 8 of 22 doses of Ertapenem. On 7/11/24 at 8:30 AM, a culture for R74's 6/28/24 urinary tract infection was requested from V1, Administrator. On 7/11/24 at 9:34 AM, V1, Administrator, provided R74's Urine Culture from a previous course of antibiotics which started on 6/22/24. She stated the hospital does not communicate well with facility, and there was a lot of digging to try to find the culture. V1 was unable to provide a culture to justify the use of the antibiotic Ertapenem for R74's 6/28/24 urinary tract infection. 3. The Facility's Infection Control Log does not list a causative pathogen for R236's 5/24/24 urinary tract infection. R236's May 2024 Physician Orders document sulfamethoxazole 800mg - trimethoprim 160mg tablet twice daily by mouth for 7 days was discontinued on 5/31/24. There was no start date listed on the order. R236's MAR for the month of May 2024 documents R236 received all 14 ordered doses of sulfamethoxazole 800mg - trimethoprim (antibiotic) 160mg oral tablets. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145729 If continuation sheet Page 13 of 14 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 145729 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlyle Healthcare & Sr Living 501 Clinton Street Carlyle, IL 62231 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many R236's 5/24/24 Urine Culture documents, Normal Genital Flora and (hand-written) Continue ABT due to symptomatic. On 7/11/24 at 9:34 AM, V1, Administrator, stated R236's antibiotic was also continued due to symptoms. 4-The Facility's Infection Control Log does not list a causative pathogen for R237's 5/8/24 urinary tract infection. R237's May 2024 Physician Orders document 500mg cephalexin (antibiotic) tablet by mouth three times daily for 7 days was discontinued on 5/15/24. There was no start date listed on the order. R237's MAR for the month of May 2024 documents R237 received 11 of the 21 ordered doses of cephalexin. On 7/11/24 at 8:30 AM, R237's Urine Culture from the 5/8/24 urinary tract infection was requested from V1, Administrator. On 7/11/24 at 9:34 AM, V1, Administrator, provided R237's Comprehensive Metabolic Panel (CMP) dated 5/7/24 and stated the antibiotic was continued due to elevated [NAME] Blood Cell (WBC) count. The CMP did not justify the use of the antibiotic cephalexin. On 7/12/24 at 9:20 AM, V1, Administrator, stated she expects staff to follow the Facility's Antibiotic Stewardship Policy and educate new hires on policies and (again) as needed. The Facility's Antibiotic Stewardship Policy revised 12/2016 documents, Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. When a resident is admitted from an emergency department, acute care facility, or other care facility, the admitting nurse will review discharge and transfer paperwork for correct antibiotic/anti-infective orders. When a culture and sensitivity (C&S) is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145729 If continuation sheet Page 14 of 14