Health inspection·August 25, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete come in and looked at it. R3 stated he had not reported it to anyone personally and didn't remember who reported it to him.On 8/20/25 at 1:54 PM, R1 stated he was concerned about becoming sick or getting an infection in the open wound of his foot when they discovered the mold like substance in his previous room on the 200 hall. On 8/20/25 at 2:05 PM, V9 (LPN) stated she had seen something that resembled mold in R1s old room. V9 stated she had heard from a night nurse there was also a substance in the closet of R2's room that resembled mold. V9 stated she had reported it to the maintenance man (that is no longer employed at the facility). V9 stated she would not feel comfortable staying in a room that had something that looked like mold in it.On 8/20/25 at 3:50 PM, V1 and V2 visualized the black, green, furry splotches, smears, and spots on the ceilings of the unoccupied room that R1 use to reside in as well as the rooms where R2 and R3 reside. V1 and V2 described the spots as mildew, but stated they are unsure as to what it is for positive. V1 and V2 both denied being aware of these areas of concern prior to this time. The Facility's Environmental/Homelike Environment Policy dated 12/27/23 states, Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Event ID: Facility ID: 146124 If continuation sheet Page 2 of 4 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 08/25/2025 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 0921 Level of Harm - Potential for minimal harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation and interview the facility failed to ensure the air conditioning unit was in working order in the kitchen to provide dietary staff a comfortable working environment. This failure has the potential to affect all 44 residents residing in the facility.Findings include: On 8/20/25 at 10:27 AM, V19 (Dietary Staff) stated the air conditioning unit has been down in the kitchen for approximately the last 3 months. V19 stated the reason for the long wait is the facility was waiting on a quote for new unit. V19 stated it does get hotter than usual in the kitchen with the air conditioning not working causing her to perspire more. On 8/20/25 at 10:32 AM, V15 (Dietary Staff) stated he has worked here one month, and the air conditioning hasn't worked in the kitchen since he's been here. V15 stated it does get hotter than usual in the kitchen with the air conditioner not working causing him to perspire more. On 8/20/25 at 10:35 AM, V16 (Dietary Staff) stated the air conditioning has been broken for a long time in the kitchen. V16 could not remember how long but stated it had been weeks at least. V16 stated it does get hotter than usual in the kitchen with the air conditioner not working causing her to perspire more. On 8/20/25 at 10:43 AM, V17 (Dietary Staff) stated the air conditioning in the kitchen has been broken and not running all summer. V17 stated the facility will have a technician come and work on it, get it fixed and then it's back down again within a few weeks. V17 stated she was told they need a whole new unit. V17 did confirm it gets hot in the kitchen without the air conditioning causing her to perspire more. On 8/20/25 at 10:50 AM, V18 (Dietary Staff) stated the air conditioning unit in the kitchen has been down all summer. V18 stated the kitchen is hotter without the air conditioning running, and it does cause her to perspire more. On 8/20/25 at 10:57 AM, V20 (Dietary Staff) stated the air conditioning in the kitchen has been down all summer. On 8/21/25 11:39 AM, R2 stated he did have some concern about eating food prepared in the kitchen because of the small but increased risk of contamination of food with employees' perspiration. On 8/21/25 at 11:41 AM, R1 stated he did have a small concern about eating food prepared in the kitchen because of the small but increased risk of contamination of food with employees' perspiration. On 8/21/25 at 12:05 PM, V6 (Dietary Manager) stated the air conditioning has been out most of the summer in the kitchen. V6 stated there was possible increased risk for contamination of food with employees' perspiration. V6 said it can become very hot and humid while working in the kitchen. On 8/21/25 at 9:16 AM, V4 (Regional Maintenance Director) stated the air conditioning has been out in the kitchen for approximately two to three weeks this last time. V4 stated the technician has had to come and repair it multiple times in the last few months. V4 stated it has taken so long to get a replacement air conditioning unit is because he is waiting on two more quotes. To replace the whole unit is very expensive and the facility wants to make sure they are not overspending. V4 stated he is reaching out at the end of this week for those last two quotes. V4 stated it also has been very difficult obtain parts for the old unit due to its age. On 8/21/25 at 12:05 PM, V5 (Dietician) stated there is an increased risk of possible contamination of food with dietary staff's perspiration due to the increased temperatures in the kitchen. V5 stated her main concern would be of the dry storage area and temperatures there being over eighty degrees could possibly decrease the freshness of the food stored there.On 8/20/25 at 3:46 PM, the temperature in the kitchen was reading eighty-five degrees Fahrenheit using the surveyor's infrared thermometer. The temperature on the thermostat in the kitchen near the entry of the dry storage area read eighty-seven degrees Fahrenheit. The room felt very warm and humid to this surveyor. On 8/21/25 at 9:03 AM, the temperature in the kitchen using this surveyor's infrared thermometer was ranging from eighty-two to eighty-nine degrees Fahrenheit, and the kitchen's thermostat was registering ninety-three degrees Fahrenheit. To this (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146124 If continuation sheet Page 3 of 4 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 08/25/2025 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 0921 Level of Harm - Potential for minimal harm surveyor, the room felt very warm and humid at this time as well. On 8/21/25 at 10:59 AM, during the kitchen staff prepping for lunch meal, the temperature was eighty-seven degrees Fahrenheit by the thermostat in the kitchen near the dry storage area. This surveyor's infrared thermometer was registering eighty-six to eighty-seven degrees in the kitchen at the same time. The current census of the facility as of 8/20/25 according to the facility's Midnight Census Report documents 44 residents currently in the facility. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146124 If continuation sheet Page 4 of 4