Inspection·May 2, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some lack of materials and funding provided to the facility, or the amount of time he has to make all repairs needed, they just haven't been done yet. V7 acknowledged the present need for repairs and maintenance needing done. On 5/2/24 at 12:00 PM, V2 (Director of Nursing) stated that with the exception of R8, anyone else in the facility could potentially use the communal bathroom located beside room [ROOM NUMBER]. V2 stated R8 does not utilize the shower room as she only receives bed baths. V2 confirmed this includes the use of no rinse hair wash. This means that R1, R2, R3, R5, R6, R7, R9, R10, R11, R12, R13, R14, R15, R17, R18, R121, R122, R123, R171 could all use the communal bathroom in the facility. The undated facility policy titled Physical Plant & Environmental Policy & Guidelines documented, It is of the utmost importance to provide a safe, hospitable, clean and organized facility and grounds to ensure an environment that is conductive to providing the best care, comfort and home-like surroundings for residents. A well maintained building and environment is also important for creating safe work surroundings across all departmental staffing and their ability to effectively, and efficiently provide care and great living environment to all residents and all necessary resources to do so. The building and grounds must be maintained in the best presentable state and must be done so through routine maintenance and upkeep, housekeeping, and ensuring compliance with current federal, state, local and NFPA ( National Fire Protection Association) codes. The Long-Term Care Facility Application for Medicare and Medicaid dated 5/1/24 documented 20 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146131 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 146131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cisne Rehabilitation and Health Care Center 107 North Watkins Street Cisne, IL 62823 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 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure quarterly assessments were completed timely for 6 of 6 (R5, R10, R12, R13, R14, and R15) residents reviewed for quarterly assessments in a sample of 22. Residents Affected - Some The Findings Include: 1. R5's profile face sheet documents an admission date of 4/2/17. R5's quarterly Minimum Data Set (MDS) dated [DATE] Section I documents the following diagnoses: Hypertension, Alzheimer's, and Diabetes. On 5/2/24 at 9:30 AM, V6 (Care Plan Coordinator/MDS) confirmed that R5's quarterly MDS had a target due date of 2/18/24 and was not completed and transmitted until 4/24/24. An MDS validation report provided by V6 on 5/2/24 documents that R5's MDS was transmitted on 4/24/24. 2. R15's profile face sheet documents an admission date of 12/31/22. R15's quarterly MDS dated [DATE] Section I documents the following diagnoses: Hypertension, Renal Insufficiency, Hyperlipidemia, and Non-Alzheimer's Dementia. On 5/2/24 at 9:30 AM, V6 stated that the target due date for R15's quarterly MDS was 3/20/24 and it was not completed/transmitted until 4/28/24. An MDS validation report documents that R15's quarterly MDS was transmitted on 4/28/24. 3. R10's profile face sheet documents an admission date of 12/8/21. R10's most recent quarterly MDS dated [DATE] Section I includes the following diagnoses: Hypertension, Hyperlipidemia, and Alzheimer disease. On 5/2/24 at 9:30 AM, V6 stated that the target due date for R10's quarterly MDS was 3/28/24 and it was not completed/transmitted timely. An MDS validation report documents that R10's quarterly MDS was transmitted on 4/29/24. 4. R12's profile face sheet documents an admission date of 5/20/22. R12's most recent quarterly MDS dated [DATE] Section I documents the following diagnoses: Coronary Artery Disease, Hypertension, Peripheral Vascular Disease, Diabetes Mellitus, and Alzheimer's Disease. On 5/2/24 at 9:30 AM, V6 stated that R12's quarterly MDS had a targeted due date of 4/9/24. An MDS Validation report for R12 documents that the quarterly MDS was transmitted on 4/30/24. 5. R13's profile face sheet documents an admission date of 11/8/22. R13's most recent quarterly MDS dated [DATE] Section I includes the following diagnoses: Osteopathic. On 5/2/24 at 9:30 AM, V6 stated that R13's quarterly MDS had a targeted due date of 2/24/24. An MDS validation report for R13 documents that the quarterly MDS was transmitted on 4/17/24. 6. R14's profile face sheet documents an admission date of 12/1/22. R14's most recent quarterly MDS dated [DATE] Section I documents the following diagnoses: Alcohol Abuse, Seizures, Adjustment Disorder and Mild Cognitive Impairment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146131 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 146131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cisne Rehabilitation and Health Care Center 107 North Watkins Street Cisne, IL 62823 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 0638 On 5/2/24 at 9:30 AM, V6 stated that R14's quarterly MDS had a targeted due date of 3/17/24. An MDS validation report for R14 documents that the quarterly MDS was transmitted on 4/26/24. Level of Harm - Potential for minimal harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146131 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 146131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cisne Rehabilitation and Health Care Center 107 North Watkins Street Cisne, IL 62823 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop person centered comprehensive care plans for 1 (R18) of 12 residents reviewed for care plans in the sample of 22. Findings Include: R18's Profile Face sheet documented R18 as [AGE] years old with an admission date to the facility of 02/20/2024. Diagnoses listed on the Cumulative Diagnosis Log include Odynophagia, Diabetes Mellitus Type II, Chronic Pancreatitis, Superior Mesenteric Artery Syndrome, Distal Esophageal ulceration with possible Barrets, and microcytic anemia. R18's current Physician's Orders documented Tube Feeding Orders Flush Gastrointestinal (G) Tube with 60 ml (milliliters) each side every shift. Also documented is an order for Isosource 1.5 at 25 ml/hour for 240 ml daily if meal intakes are less than 50 percent. R18's Resource: Nutritional Progress Record Form with a date of 04/11/24 titled RD (Registered Dietitian) note documented April weight 123 pounds with a BMI (body mass index) of 16.7 which indicates R18 is underweight. R18's current diet order is pureed, thin liquids, per nursing no longer using enteral feedings. The RD recommended magic cups BID (twice daily) and 60 ml Med Pass TID (three times a day) to provide additional calories / protein to ensure proper nutrient intake and promotion of weight gain. Monitor oral intake and weights. R18's Care Plan documented a Focus Area of The resident has nutritional problem or potential nutritional problem (Specify) r/t (related to) with a date initiated of 2/26/24 and revision on 3/26/24. The Goal documented The resident will comply with recommended diet for weight reduction daily through review date. The Interventions/Tasks listed include: Explain and reinforce to the resident the importance of maintaining the diet ordered. Encourage the resident to comply. Explain consequences of refusal, obesity/malnutrition risk factors. Obtain and monitor lab/diagnostic work as ordered. Report results to MD (Medical Doctor) and follow up as indicated. The care plan does not specify the reason for R18's nutritional problem focus area was due to him being underweight. There is no information included regarding R18 having a G/J tube nor the feedings ordered as needed according to meal intake. The care plan also does not document the most recent information from 4/11/24 that indicates R18 was no longer using enteral feedings. On 05/01/24 at 02:29 PM, V6 (Minimum Data Set [MDS]/Care Plan Nurse) stated the care plans should not have the (Specify) left in the areas. V6 stated that she was rushing trying to complete them and must have forgotten to finish them. V6 stated that R18 should have a care plan regarding gastrointestinal tube, and acknowledged that it had been left out. On 05/02/2024 at 9:24 A.M. V6 stated she had corrected R18's care plan. Review of the care plan now notates specific person centered care. The Comprehensive Care Planning policy with a most recent revision date of 11/1/17 stated, It is the policy of (Corporation Name) to comprehensively assess and periodically reassess each Resident admitted to this facility. The results of this Resident assessment shall serve as the basis for determining each Resident's strengths, needs, goals, life history and preferences to develop a person (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146131 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 146131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cisne Rehabilitation and Health Care Center 107 North Watkins Street Cisne, IL 62823 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 0656 Level of Harm - Minimal harm or potential for actual harm centered comprehensive plan of care for each Resident that will describe the services that are to be furnished to attain or maintaining the Resident's highest practicable physical, mental, and psychosocial well-being. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146131 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 146131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cisne Rehabilitation and Health Care Center 107 North Watkins Street Cisne, IL 62823 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to add identified problem areas and to revise care plans timely for 1 (R12) of 12 residents reviewed for care plan timing and revision in the sample of 22. Findings Include: R12's Profile Face Sheet documents R12 was admitted to the facility on [DATE]. Diagnoses listed on R12's Cumulative Diagnosis Log include Type II Diabetes Mellitus, Gout, Osteoporosis, Squamous Cell Carcinoma, Neuropathy, Peripheral Artery Disease, Coronary Artery Disease, and Dementia. On 5/2/24 at 9:31 AM, R12's wound treatment was observed. R12 was noted to have a betadine treatment applied to the left toes which appeared to be scabbed over. R12 was also observed to have a pressure wound to the left heel. R12's Physician's Orders dated May 2024 documents under Treatment Orders to paint left great toe with iodine daily. Under the same area also documents calcium alginate wet to dry dressing to left heel, cut to fit heel ulcer, moisten calcium alginate with normal saline. Paint margins of heel with betadine and cover with gauze daily. R12's Care Plan lists a Category of Pressure Ulcers and under that category documents Fragile Skin. Prone to bruising and/or Skin Tears. Related diagnosis/condition Dementia. Other Risk Factors Decrease in activities and ADLs (Activities of Daily Living). Resident specific information. All skin tears and/or bruises healed throughout next 90 days. Interventions documented with a start date of 06/02/2022 list the following: Weekly skin checks-document results; Skin checks as needed after injury or combative episodes; Assess new areas for size and injury, report findings to MD (Medical Doctor) and family as indicated; Investigate causes of injury/bruise/skin tear. Consider preceding activity and resident's attention to safety; Treatment as ordered. Cleansing, application of medication, packing an/or dressings change w (with) wound status and progress - See POS (Physician Order Sheet) for current treatments; Monitor site for infection-redness, swelling, drainage, foul smell, decline in function, reduced mobility. Report S & S (signs/symptoms) to MD for follow up orders; Assess for pain and medicate as ordered - See POS for current med, dosage, and schedule. Evaluate effectiveness of pain med, report ineffective pain management to MD for recommendation. R12's care plan shows no updates or revisions added since initiation on 6/02/2022, other than a handwritten note dated 2/17/23 that documents Skin Sleeves to bilateral arms. On in AM (morning) off at hs (night). R12's care plan has no documentation regarding wounds to the left great toe and left heel. There is no documentation noting when R12's wounds were identified, current treatment orders, nor any person centered interventions for pressure ulcer care. On 05/01/24 at 02:29 PM, V6 (Minimum Data Set [MDS]/Care Plan Nurse) stated that she was rushing trying to complete care plans and must have forgotten to finish them. On 05/01/24 at 03:05 PM, V6 stated that the most up to date care plan was in R12's chart. V6 stated if there were any interventions they would be documented on the page under the specific section on the care plan. The Comprehensive Care Planning policy with a most recent revision date of 11/1/17 stated, It is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146131 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 146131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cisne Rehabilitation and Health Care Center 107 North Watkins Street Cisne, IL 62823 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the policy of (Corporation Name) to comprehensively assess and periodically reassess each Resident admitted to this facility. The results of this Resident assessment shall serve as the basis for determining each Resident's strengths, needs, goals, life history and preferences to develop a person centered comprehensive plan of care for each Resident that will describe the services that are to be furnished to attain or maintaining the Resident's highest practicable physical, mental, and psychosocial well-being a. The CCP (Comprehensive Care Plan) shall be reviewed after each Annual, Significant Change and Quarterly MDS (Minimum Data Set) and revised as necessary to reflect the resident's current medical, nursing, and mental and psychosocial needs as identified by the IDT (Interdisciplinary Team) Event ID: Facility ID: 146131 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 146131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cisne Rehabilitation and Health Care Center 107 North Watkins Street Cisne, IL 62823 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure chemical products were stored per current standards of practice and failed to ensure person centered fall interventions were implemented after a fall incident for 2 (R15 and R12) of 2 dementia care residents reviewed for accidents/hazards in the sample of 22. This failure resulted in R15 experiencing nausea and vomiting. Findings Include: 1. R15's Profile Face Sheet documented an Original admit date to the facility as 12/31/22. This form also documented R15 as being a [AGE] year old female. R15's Cumulative Diagnosis Log documented a diagnosis of Early onset Alzheimer's Dementia with Behavioral Disturbance. A Nurses Note dated 1/16/24 at 5 PM documented R15 was observed in her room with a bottle of (Odor Eliminator) in hand and large emesis on the floor. No signs of distress were noted and vital signs are documented as being stable. 30% of the liquid in the bottle is documented as remaining. V5 is documented as being contacted with orders to monitor R15's Vital Signs every 4 hours x 3, push fluids and send to the emergency room if any change in status is noted. On 05/01/24 at 11:40 AM, V2 (Director of Nursing) stated that she was working at the time R15 ingested (Odor Eliminator). V2 stated that R15 couldn't have drank much of the product, because it was a small trial size bottle that had been left in her bedside table, she assumes for staff convenience as R15 had been experiencing loose stools. V2 stated immediately V5 (Medical Director) and the Poison Control Center were contacted. R15 experienced a large emesis following injection of the product with no further concerns noted. V5 had ordered for Vital Signs to be monitored for 3 days and send to the emergency room for evaluation and treatment should R15 experience any change in condition. V2 stated R15 experienced no ongoing ill effects from the consumption of the product and fluids were encouraged to help do a system flush. V2 stated all resident rooms and areas were checked to ensure potentially hazardous liquids were not obtainable by residents. V2 stated the product is no longer used by the facility. V2 confirmed that the product should not have been stored where R15 could obtain and consume it. R15's Minimum Data Set (MDS) with an Assessment Reference Date of 9/6/23 documented in Section C0500 a Brief Interview for Mental Status (BIMS) score of 99 indicating R15 was unable to complete the interview. Section C1000, Cognitive Skills for Daily Decision Making documented a score of 3, indicating Severely Impaired - never/rarely made decisions. R15's Current Plan of Care documented a Problem/Need area with a stated date of 6/6/23 for having Risk factors that require monitoring and intervention to reduce potential for self injury. (Consider medical conditions, sensory alterations, balance, gait, assistive devices, cognition, mood/behavior, safety awareness, compliance, medications, restrictions, restraints) Approach/Interventions listed for this area include, Review quarterly and prn (as needed) Resident's ADL *activities of daily living), mobility, cognitive, behavior and overall medical status. IDT (Interdisciplinary Team) review of changes and needs with resident and/or responsible party (when choose to attend) during care plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146131 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 146131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cisne Rehabilitation and Health Care Center 107 North Watkins Street Cisne, IL 62823 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 Level of Harm - Actual harm Residents Affected - Few A Safety Data Sheet found via https://dermarite.com/wp-content/uploads/2015/05/ByeBye-Odor-Rev-03.pdf with a most recent date prepared of 2/2/23, documented the recommended use for (Odor Eliminator) was to use as an air and fabric freshener. The same safety data sheet listed in Section XI - Toxicology Information: ingestion may cause nausea, vomiting, and diarrhea; you should drink water. Skin; flush skin with water. An undated facility policy titled, Hazardous and Toxic Substances stated, .8. Hazardous and toxic substances shall be stored in locked cabinets or in a similar physically separate placed (sic) and used for no other purpose which is not accessible to residents. 2. R12's Profile Face sheet documented R12 as [AGE] years old with an admission date to the facility of 05/20/2022. Diagnoses listed on Cumulative Diagnosis Log include Type II Diabetes Mellitus, Gout, Osteoporosis, Squamous Cell Carcinoma, Neuropathy, Peripheral Artery Disease, Coronary Artery Disease, and Dementia. R12's Nurse Note dated 03/29/24 with a time of 2:45 PM documented that R12 had a fall in her bathroom. R12 was reminded and encouraged to use call light and wait for assistance before transferring. R12's care plan lists a Category of Falls with a start date of 06/06/2022 and documents R12 has risk factors that require monitoring and intervention to reduce potential for self injury. Risk factors include diagnosis of dementia causing episodes of forgetfulness and unawareness of safety limitations at times. The Goal documents Resident will follow safety suggestions and limitations with supervision and verbal reminders for better control of risk factors thru next 90 days. Interventions listed, all with start dates of 06/06/2022 include: Review quarterly and prn (as needed) Resident's ADL (Activities of Daily Living), mobility, cognitive, behavior and overall medical status. IDT (Interdisciplinary Team) review of changes and needs w/ (with) Resident and/or Responsible Party (when choose to attend) during care plan. Discuss fall related information to review and revise plan as needed. Review quarterly and as needed during daily care and services of Resident's plan for safety, giving verbal cues as needed to gain Resident participation in minimizing risk factors and injury. IDT review of function and referral to PT (Physical Therapy) as needed for change in function, and IDT review of function and referral to OT (Occupational Therapy) as needed for change in function. R12's care plan does not include information regarding the fall that occurred on 3/29/2024, nor were any updated, person centered fall interventions added after the fall incident. On 05/01/24 at 02:29 PM, V6 (Minimum Data Set [MDS]/Care Plan Nurse) stated she was rushing trying to complete the care plans and must have forgotten to finish them. On 05/01/24 at 03:05 PM, V6 stated that the most up to date care plan was in R12's chart. V6 stated if there were interventions they would be documented on the page under the specific section on the care plan. The Comprehensive Care Planning policy with a most recent revision date of 11/1/17 stated, It is the policy of (Corporation Name) to comprehensively assess and periodically reassess each Resident admitted to this facility. The results of this Resident assessment shall serve as the basis for determining each Resident's strengths, needs, goals, life history and preferences to develop a person centered comprehensive plan of care for each Resident that will describe the services that are to be furnished to attain or maintaining the Resident's highest practicable physical, mental, and psychosocial well-being a. The CCP (Comprehensive Care Plan) shall be reviewed after each Annual, Significant Change and Quarterly MDS (Minimum Data Set) and revised as necessary to reflect the resident's current (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146131 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 146131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cisne Rehabilitation and Health Care Center 107 North Watkins Street Cisne, IL 62823 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 medical, nursing, and mental and psychosocial needs as identified by the IDT (Interdisciplinary Team). Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146131 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 146131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cisne Rehabilitation and Health Care Center 107 North Watkins Street Cisne, IL 62823 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to maintain a clean and sanitary ice machine. This failure has the potential to affect all 20 residents residing in the facility. Residents Affected - Many The Findings Include: During initial tour of the kitchen on 4/30/24 at 9:30 AM, the ice machine was found to have a black substance on the inside flap of the ice machine where the ice drops into the bin. Along the hinges of the door and the edges of the lid of the ice machine was a white hard water build up. On 4/30/24 at 9:30AM, V8 (Dietary Manager) stated that the maintenance man cleans the ice machine once a month after hours so the kitchen staff are done with feeding residents. V8 stated that there was not a 2024 monthly cleaning log in the kitchen, so she cannot say for sure when it was last cleaned. On 5/1/24 at 11:30 AM, V7 (Maintenance) stated that he had not yet put a log in the kitchen for the maintenance cleaning of the ice machine but he cleaned it in April. V7 stated that when he cleans it, he tries his best to get it clean and scrub at that black stuff, but it isn't easy to get to that part of the ice machine. V7 stated that he uses a descaler solution to clean the hard water build up and black that grows on the flap. V7 stated that he needs to take it outside and pressure wash it probably to get it cleaned up better. V7 stated that he will put that on his list to get done. The undated Ice Machine Cleaning and Sanitizing Procedures policy documents 19. remove the evaporator cover and spray and wash all interior surfaces of the freezing compartment including the evaporator cover with sanitizer solution. Treated surfaces must remain wet for 60 seconds The Long Term Care Facility Application for Medicare and Medicaid dated 5/1/24, documents that 20 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146131 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 146131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cisne Rehabilitation and Health Care Center 107 North Watkins Street Cisne, IL 62823 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 follow policy and procedure for enhanced barrier precautions for 3 of 12 residents (R2, R12, and R18) reviewed for infection control in the sample of 22. Residents Affected - Few The Findings Include: During initial tour of the facility on 4/30/24 there were no isolation rooms observed in the facility. On 4/30/24 a Resident Matrix was provided with no residents marked for transmission based precautions. 1. R18's Profile Face Sheet documents an admission date of 2/20/24. R18's May 2024 physician orders document a tube feeding order of Isosource 1.5 240mL (milliliters) daily after each meal if meal intake is less than 50% at meals. On 5/2/24 at 10:19AM, V9 (Registered Nurse/Infection Preventionist) stated that R18 has MRSA (Methicillin-resistant Staphylococcus Aureus) in his gastrointestinal tube site so they just keep it covered, but do not do any kind of treatment to the site at this time. On 5/1/24 at 10:00 AM, V3 (Housekeeping) was observed in R18's room folding linens with no Personal Protective Equipment (PPE) on until she put gloves on to empty the trash. At this time, there was an isolation bin located outside of R18's door with PPE in it, and a sign on the door that says stop check with nurses prior to entering. At this time, V3 stated that (R18's) MRSA is worse and he is on isolation. V3 stated that she should have had a gown and gloves on while in his room per policy, and will be sure to do that next time. On 5/1/24 at 11:30 AM, V2 (Director of Nursing/DON) stated that they have placed R18 on isolation due to the culture coming back on his G-tube site. V2 stated that she just learned of this change this morning and that she would expect her staff to follow the policy and procedure on wearing PPE in these rooms. V2 stated at this time they have only talked about enhanced barrier precautions, but have not implemented anything in the facility as of yet, but will start that as soon as a possible. V2 acknowledged that R18 should have been on the precautions prior to the culture resulting in isolation and that all (residents with) wounds and catheters need to be placed on these precautions as well. V2 stated that they have no (residents with) catheters at this time. 2. R2's Profile Face Sheet documents an admission date of 6/6/17. R2's Physician Order Sheet (POS) for May of 2024 includes the following diagnoses: Edema, Hypertension, Diabetes, and Congestive Heart Failure. The POS also includes a treatment order of barrier spray to left and right lower extremities until healed. A 4/26/24 Wound Assessment and Plan in R2's chart documented a venous wound to R2's left lower extremity and included a treatment order to apply a thin layer of zinc barrier cream and loosely wrap with gauze every shift and as needed. R2 was not observed to be on Enhanced Barrier Precautions during the survey on 4/30/24 or 5/1/24. 3. R12's Profile Face Sheet documents an admission date of 5/20/22. A physician order dated 5/1/24 documents R12 has wounds to the left foot and left great toe with a treatment order of calcium (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146131 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 146131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cisne Rehabilitation and Health Care Center 107 North Watkins Street Cisne, IL 62823 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 alginate wet to dry dressing once daily. Level of Harm - Minimal harm or potential for actual harm On 5/1/24 at 11:30 AM, V2 (DON) stated that they do not do the treatments on R12 because her daughter prefers R12 to go to the wound doctor, but sometimes they do an in-between treatment if needed. Residents Affected - Few On 5/1/24 at 9:31AM, V10 (Registered Nurse) verified that R12 receives the treatments by the nurses here in the facility, but she goes out to see her own wound doctor; R12 does not see the one who comes to the facility. On 5/2/24 at 9:31 AM, R12's wound treatment was observed. R12 was noted to have a betadine treatment applied to the left toes which appeared to be scabbed over. R12 was also observed to have a pressure wound to the left heel. R12 was not observed to be on Enhanced Barrier Precautions during the survey on 4/30/24 or 5/1/24. The Enhanced Barrier Precautions policy and procedure dated 7/13/23 documents the purpose is: To reduce transmission of multidrug-resistant organisms (MDRO). The policy states that the enhanced barrier precautions should be used when contact precautions do not apply, for residents with any of the following: open wounds that require a dressing change, indwelling medical devices, and infections or colonized with MDRO .Enhanced Barrier Precautions require use of gown and gloves during high contact resident care activities that provide opportunities for the transfer of MDRO's to staff hands and clothing. Enhance Barrier Precautions is primarily intended to use for care that occurs within a resident's room, when high contact resident care activities are bundled together FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146131 If continuation sheet Page 14 of 14