Health inspection·December 6, 2024

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many could not smell the solution. V3 was asked to explain and V3 stated, when I had the mask on, I could not smell the solution. V3 was asked if she could smell the solution when she did not have the mask on and V3 replied yes, the best I can remember. V3 was asked how she protects herself and other residents when she cares for a COVID positive residents and V3 stated I use a regular (pointing at her surgical mask) and then I change into a new one when I leave the room. V3 was asked if when she was getting fitted for the N95 if different sizes of masks were offered and V3 stated yes there were 2 different sizes. V3 was asked what other PPE was required in a Droplet Isolation room and V3 stated a gown and gloves. On 11/26/2024 at 11:13 AM, V4 (CNA) was noted down the hall. V4 was asked if she wears an N95 mask when caring for COVID positive residents. V4 stated no I do not because I have never been fit tested. V4 was asked when she started working at the facility and V4 stated I have worked here for 2 years. V4 was asked what PPE she wears when caring for a COVID positive resident and V4 stated I wear my surgical mask and I change it when I leave. V4 was asked what other PPE she wears, and she stated gloves. V4 was asked if she wears eye protection and V4 stated No because I don't know where they are and have never seen them in the bins. V4 was asked if she has received education on COVID precautions, or Infection Control and proper prevention, V4 stated I have, but it has been a while. V4 was asked if she used a PAPR (Power Air Purifying Respirator) and V4 stated No, I don't wear those. 2. R2's admission Record documents an admission date of 1/22/2021 and included diagnoses of Huntington's Disease, Neuromuscular Dysfunction, Muscle Wasting, and Anxiety. R2's MDS dated [DATE] documented a BIMS score of 15, indicating R2 is cognitively intact. A facility document titled Covid Test documented R2 was positive for Covid on 11/24/2024. On 11/26/2024 at 10:32AM, R2's room was noted to have isolation bins outside the door with N95 masks, gowns, and gloves in them. There was no eye protection noted in the bin. R2's door was halfway open, and R2 was resting in bed at this time. R2 was the only resident occupying this room. No Isolation signage was noted on R2's door. On 11/26/2024 at 10:33AM, V5 (CNA) was observed entering R2's room wearing only a surgical mask. V5 did not wear an N95 mask and did not don a gown, gloves, or eye protection prior to entering R2's room to provide care. On 11/26/2024 at 11:17AM, V5 (CNA) was standing at the nurse's station wearing a surgical mask. V5 was asked what type of mask she wears when caring for a COVID positive resident. V5 stated she wears a surgical mask because she has never been fit tested. V5 stated she started to put on an N95 to go into a COVID positive room and another CNA told her she was not allowed to wear that if she had not been fit tested. V5 stated she has worked at the facility about 2 months. On 11/26/2024 at 12:30PM, R2 was noted to be alert and oriented, and stated she was just tired and wanted to sleep. R2 did not want to be interviewed, stating I am just too tired. 3. R3's admission Record documents admission date of 11/7/2023. R3's MDS dated [DATE] documented a BIMS score of 10, indicating moderate cognitive impairment. A facility document titled COVID Test documented R3 was tested on [DATE] and results were positive. On 11/26/2024 at 10:15AM, R3's room had a bin outside the door with PPE observed to include N95 masks, gowns, and gloves. The door of R3's room had signage noting Respiratory/Droplet Isolation and listed the PPE required to enter the room. The signage documented N95 respirators, gloves, gowns, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146124 If continuation sheet Page 2 of 5 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 146124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE White County Rehab and Nursing 615 West Webb Street Carmi, IL 62821 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 eye protection was required. Level of Harm - Minimal harm or potential for actual harm On 11/26/2024 at 10:30AM, R3 was noted to be non-interviewable. Residents Affected - Many 4. R4's admission Information documents an admission date of 12/8/2023 and included diagnoses of Muscle Atrophy and Wasting, Chronic Obstructive Pulmonary Disease, Anxiety, and Dyspnea. R4's MDS dated [DATE] documented a BIMS score of 15, indicating R4 is cognitively intact. A facility document titled COVID Test documented R4 tested positive for COVID on 11/25/2024. A Progress Note dated 11/26/2024 at 9:33AM documented R4 was sent to the emergency room per family request, for evaluation. On 11/26/2024 at 2:38 PM, V14 (Transportation Aide) was observed unloading R4 from the facility van. V14 stated she was returning from the Emergency Room. At this time, V14 was observed wearing only a surgical mask. R4 was not wearing a mask. V14 was asked if she was aware R4 tested positive for COVID and V14 replied Yes. R4 was confused and not interviewable at this time. R4 was transported through the facility via wheelchair with no mask on. 5. A facility document titled Covid Test documented R5 tested positive for COVID on 11/19/24. R5 had Droplet Isolation signage on the door listing the required PPE needed to enter including N95 respirators gloves, gowns, and eye protection. On 11/26/2024 at 2:30PM, V9 (Housekeeper) was walking around in R5's room and then exited the room. V9 was only wearing a surgical mask while in R5's room. V9 did not have an N95 mask on, nor a gown, gloves, or eye protection. V9 had the housekeeping cart outside the room but did not have any supplies in the room. V9 stated he had not been fit tested yet and he wears a surgical mask. 6. On 11/26/2024 at 2:20PM, R6 was noted sitting in the hallway without a mask on. R6 stated she has not had Covid, and she doesn't want it. R6 stated she doesn't like wearing a mask. R6 stated she does not have a roommate. 7. On 11/26/2024 at 2:24PM, R7 was sitting in the hallway with a mask pulled down on her chin. R7 stated I have a roommate and neither one of us has had COVID. 8. On 11/26/2024 at 2:26PM, R8 was sitting in the hallway without a mask. R8 stated her roommate tested positive so R8 was moved out immediately. R8 stated I am now in a room by myself, and I just hope I do not get COVID. R8 stated she was heading outside to smoke, and she doesn't wear a mask when going out to smoke. R8 stated so far, she is feeling good. At no time during the above observations on 11/26/24 between 2:20PM and 2:30PM while R6, R7 and R8 in the hallway, were the residents encouraged by staff to wear a mask. On 11/26/2024 at 12:10PM, V2 (Director of Nursing/DON) was asked what type of PPE is required/expected to be worn in a COVID positive resident's room, and V2 stated N95, gown, eye protection, and gloves. V2 was asked what staff wear if they have not been fitted for the N95's and V2 stated we have 2 PAPR's (Powered Air Purifying Respirators) in the facility. V2 was asked if those were enough for the staff to be able to care for all 12 of the COVID positive residents. V2 stated not really. V2 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146124 If continuation sheet Page 3 of 5 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 146124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE White County Rehab and Nursing 615 West Webb Street Carmi, IL 62821 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 asked if she was aware that the CNA staff currently working today say they have not been fit tested for N95 masks or that they failed the fit test. V2 stated I have a couple CNA's that passed the fit testing, but they are neither one working today. V2 stated she would reach out to corporate and see if they could get more PAPRs to have more available to use. V2 was asked if she does the N95 fit testing and V2 stated yes, fit testing is done annually and upon hire. V2 stated they had several (staff) fail the testing. V2 said I have had several to fail the test because they could not smell the solution before the mask was applied. V2 stated she has her Certification for Infection Preventionist. V2 stated she has provided the staff with education on COVID and Infection Control, but it has been a little while. On 11/26/2024 at 1:26PM, V6 (Regional Clinical Director & Registered Nurse/RN) stated she was aware that most of the staff were unable to pass the Respirator Fit Test. V6 stated the problem is that most of the staff had COVID in the past and lost their sense of taste and smell and so they cannot efficiently pass a Respiratory Fit Test. V6 stated the staff have to fill out a medical questionnaire prior to fit testing and if for any reason they don't pass the evaluation or can't take the test properly because of loss of taste or smell then it would be a liability on the company if we allowed them to wear the N95. V6 was asked if any of the staff at this facility had a medical condition that prohibited that staff member from wearing an N95, V6 stated not that she is aware of. V6 stated she was not aware of any staff being allowed to work if they were COVID positive. V6 was asked what the staff are to do when they must care for COVID positive residents and they cannot or are not allowed to wear a N95, V6 stated they are supposed to wear a PAPR. V6 asked if two PAPRs in this facility were enough for the staff to efficiently take care of the now 14 positive residents (at the time of this interview), and V6 stated no and I was not aware of the facility only having two. V6 stated she would get more PAPR machines in the facility today. V6 was asked what PPE was expected/required for the staff to wear when caring for a COVID positive resident, and V6 stated N95 or a PAPR, eye protection, gown, and gloves. V6 was asked how often Respiratory Fit testing was done in the facility, V6 stated annually and upon hire. V6 stated she was not aware of any new hires not having Respiratory Fit testing completed. V6 stated she would make sure those get done as soon as possible. On 11/26/2024 at 1:55PM V7 (MDS Coordinator - Registered Nurse/RN) stated she wears an N95 when caring for COVID positive residents. V7 stated she was fit tested at her other place of employment, but she failed the fit testing at this facility. V7 stated she does have her sense of taste and smell and doesn't understand why she didn't taste or smell the solution that was used during her fit testing here. V7 stated she will not enter a room of a COVID positive resident without an N95. V7 stated I am unsure if they have new solution or testing supplies here, but I have not had a repeat fit test so far. On 11/26/2024 at 2:34PM V10 (Registered Nurse/RN) was noted sitting at the nurse's station with a surgical mask in place. V10 stated she wears an N95 into the COIVD positive rooms when providing care. V10 stated she was fit tested at another place of employment but has not been fit tested at this facility, but she will not provide care to a COVID positive resident without an N95 to wear. V10 stated she was unaware of other staff entering COVID positive rooms without an N95 or PAPR on. V10 stated she has worked at this facility for a couple of months. The facility's Resident Listing Report dated 11/26/24 documented 54 residents residing in the facilty. The facility's Isolation Precautions Policy and Procedure dated October 28th, 2024 documents purpose: To establish transmission-based precautions for resident who are suspected or confirmed to have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146124 If continuation sheet Page 4 of 5 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 146124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE White County Rehab and Nursing 615 West Webb Street Carmi, IL 62821 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 communicable diseases/infections that can be transmitted to others. Under Droplet Precautions the document stated 1. Implement droplet precautions for resident suspected confirmed to be infected with a communicable disease/infection transmitted via droplets generated by sneezing, talking, or during procedures such as suctioning. 2. Residents shall be placed in a private room when available. If a private room is not available, residents may be cohorted with roommate with the same illness. 3. Prior to entering the isolation room, the following steps are required: a. Perform hand-hygiene and apply gloves and mask prior to entering room; b. While providing direct resident care, remove gloves and perform hand hygiene after coming in contact with infectious material, c. Remove gloves and perform hand-hygiene before leaving room (do not use alcohol-based hand gels for isolation due to suspected or confirmed Clostridum difficile); 4. Adequately clean/disinfect item with an approved solution prior to removing the item from the room and before use on another resident. The Facility Assessment COVID-19 dated 9/12/2024, documents Health Care Personnel (HCP) and Essential Caregivers who enter the room of a patient with known or suspected COVID-19 should adhere to Standard Precautions and use a respirator (or facemask if a respirator is not available or did not pass a fit test), gown, gloves, an eye protection. When available respirators (instead of facemasks) are preferred: they should be prioritized for situations where respiratory protection is most important and the care of patients with pathogens requiring Airborne Precautions. Document lists other PPE (Personal Protective Equipment) include eye protection, gloves, and gowns. According to https://www.cdc.gov/covid/hcp/infection-control/index.html, Infection Control Guidance: SARS-CoV-2 documents the following CDC recommendations for Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic (Updated 3/18/24): 2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection: Personal Protective Equipment HCP (Health Care Personnel) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Respirators should be used in the context of a comprehensive respiratory protection program, which includes medical evaluations, fit testing and training in accordance with the Occupational Safety and Health Administration's (OSHA) Respiratory Protection standard (29 CFR 1910.134) Additional information about using PPE is available in Protecting Healthcare Personnel FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146124 If continuation sheet Page 5 of 5