Inspection·June 6, 2025

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few staff to do restorative care. V1 stated that all certified nurse assistants are responsible for making sure restorative is done. On 06/04/2025 at 10:36 AM, V2 (Director of Nursing/DON) stated that R11 has no contractions or limited range of motion in her lower extremity. V2 stated that R11 just has weakness in her lower extremities. V2 stated that if R11 was to have a decline in range of motion, then she would start either a passive or active range of motion range of motion program. V2 stated that she is not sure why the physical therapy discharge summary stated that R11 had lower extremity range of motion problems. V2 stated that she is not sure why the physical therapist would not recommend a range of motion program for R11 if they observed R11 having range of motion issues. On 06/04/2025 at 11:20 AM, V9 (Certified Occupational Therapy Assistant) stated that R11 has pain in her hips and knees which causes her issues during transfers. V9 stated that R11 doesn't like to do transfers because of the pain. V9 stated R11 can move both her lower extremities but has pain in them. V9 stated that R11 could participate in a range of motion program. V9 stated that the therapy department does not have to recommend a program, that can be done on nursing judgement. V9 stated a range of motion program would help and be beneficial to R11's knees and hips. On 06/05/2025 at 1:00 PM, V2 (DON) stated that the facility does not have a policy for range of motion. V2 stated that if the nurse thinks the resident needs it, they write a program for it. V2 stated that the IDT (interdisciplinary team) will review it and leave it or change it if it needs to be changed. V2 stated she was not aware that R11's MDS and PT (physical therapy) notes documented issues with lower extremity range of motion. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146131 If continuation sheet Page 2 of 9 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 06/06/2025 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement care plan interventions and dietitian recommendations as ordered for 1 (R12) of 1 resident reviewed for nutrition in a sample of 22. This failure resulted in R12 experiencing a 10.26 percent weight loss within three months. Residents Affected - Few Findings include: R12's admission Record documented an admission date of 7/12/2022 and included diagnoses of dementia in other diseases classified elsewhere, chronic diastolic (congestive) heart failure, type 2 diabetes mellitus, major depressive disorder, and end stage renal disease. R12's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 10, indicating R12 had moderate cognitive impairment. Under the section titled Mood, R12 was documented as having little interest or pleasure in doing things and feeling down, depressed or hopeless for several days. Under the section for Functional Abilities and Goals, R12 was assessed as needing setup or cleanup assistance for eating. R12's Dietitian Progress Note dated 5/6/2025 by V13 (Registered Dietitian/RD) documented May wt (weight): 136# w/ (with) a sig wt loss (significant weight loss) noted x (times) 1 mo (month) (5.56%), x 3 mo (12.82%) and x 6 mo (12.26%). BMI (Body Mass Index): 24.9 (WNL) (within normal limits). Diet rx (prescribed): Regular, NAS (No added salt) w/ Thin Liquids, 1500 cc (cubic centimeters) Fluid Restriction, Magic Cup 1x/day and 60 cc 2.0 cal (calorie) Supplement TID (3 times per day). PO (by mouth) intake is reported as varied ~0-100% of meals w/ most meals reported as ~26-50% per the look back report. Meds reviewed- insulin rx in place to support glycemic control; antidepressant rx may alter appetite/wt (weight); diuretic rx may alter fluid balance/wt/electrolytes. Labs dated 4/8/25 reviewed: Cholesterol (H = high), HDL (L = low), LDL (H), Hgb/HCT (hemoglobin/hematocrit) (L), Iron (WNL), TIBC (total iron binding capacity) (L). Iron supplement and atorvastatin rx in place. Practitioner notified of labs. Staff report poor acceptance of the 2.0 cal (calorie) supplement rx to this RD and state that Magic Cup acceptance is hit or miss. At this time will recommend to d/c (discontinue) the 2.0 cal supplement rx, add Mighty Shake BID (twice per day) and recommend MD (medical doctor) to consider an appetite stimulant d/t (due to) generally poor appetite. RD to follow-up PRN (as needed). R12's Care Plan documented a focus area of NUTRITION/HYDRATION: At Risk for Complications with Nutrition and hydration r/t (related to) fluid restriction, diuretic use, impaired cognition, psychotropic med use. Current weight is 154 Height is 62 BMI is 28.2 initiated on 9/18/24 and revised on 12/20/24. The goal listed documents Will have no significant wt changes noted through review date initiated on 12/20/24 with a target date of 8/31/25. The corresponding interventions are documented as follows: Meds /Labs/Treatments as ordered/accepted, initiated 12/20/24; Provide diet as ordered, initiated on 12/20/24; Record weights a minimum of monthly or per MD/RDN, initiated on 9/18/24; Set up meal per resident direction and assist with eating as/if needed and Honor food requests as able, initiated on 12/20/24; and Supplement as ordered, initiated on 9/18/24 and revised on 10/24/24. R12's Weight Log with print date of 6/5/2025 documents R12's weight on 2/27/2025 was 156 lbs (pounds) and her weight on 5/30/2025 was 140 lbs, which equals a significant weight loss of 10.26 percent in three months. On 06/04/25 at 12:50 PM, R12 was sitting at the lunch table with a regular meal of garlic and herb (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146131 If continuation sheet Page 3 of 9 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 06/06/2025 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 0692 Level of Harm - Actual harm pork chop, sweet potatoes, peas, two snickerdoodle cookies and supplement. R12 was observed sleeping at the dining room table with no food touched on her plate while staff were sitting at another table assisting other residents with lunch. No staff were observed encouraging R12 to eat nor offering R12 assistance to feed herself. Residents Affected - Few On 06/04/25 at 1:11 PM, V7 (Certified Nursing Assistant/CNA) and V8 (CNA) both stated, if they have a resident who is not eating or starts to have a decline in feeding themselves, they will encourage resident to eat or attempt to help feed them. V7 and V8 both stated, they would also notify the nurse. On 06/04/25 at 1:13 PM V10 (Licensed Practical Nurse/LPN) stated, she will be notified by the CNA staff if a resident is not eating or declines in feeding self. V10 stated she would notify the provider and Registered Dietitian of resident change/decline. V10 stated R12 has not been wanting to eat and this started around the end of April 2025. V10 feels R12 is a failure to thrive since her husband passed away over a year ago. V10 stated, R12 will go back and forth with her intake of food depending on her mood. V10 stated R12' s Dietary Note by V13 (RD) dated 5/6/2025 is sitting in V11 (Nurse Practitioner/NP's) folder for review. V10 stated, V11 had been in the facility today (6/04/2025) and did not sign V13's recommendations. V10 stated the facility did have a lapse in weekly NP coverage coming into the facility that started around the first of May 2025. V10 stated, she had not worked the week of 5/6/2025, but the nursing staff should have contacted V12 (Medical Provider) or the on-call telehealth service via phone to review V13's progress note and recommendations for R12 prior to today. On 06/04/25 at 1:19 PM, R12 was sitting at the dining room table with a new tray served with garlic and herb pork chop, mash potatoes, peas, snickerdoodle cookie and her magic cup. R12 was again observed sleeping at the dining room table with no food touched on her plate. No staff were observed encouraging R12 to eat nor offering assistance to feed her. On 06/05/2025 at 7:42 AM, R12 was sitting in the dining room with her breakfast in front of her. R12 was not eating and there were staff at another table assisting other residents with breakfast. On 06/05/2025 at 8:12 AM, R12 was observed sitting in the dining room with her breakfast still untouched. R12 had drank her milk and started eating her cereal R12 was observed eating approximately half the bowl of cereal. On 06/05/25 at 9:15 AM, V6 (Dietary Manager) stated R12 had started showing signs of not wanting to eat at meals around the last week of April 2025. V6 stated, R12 started with not wanting to eat some items at meals to then gradually not wanting to eat at any meals over the last 4 weeks. V6 stated R12 does have periods where she will eat and not eat depending on her mood. V6 stated, staff should encourage residents to eat when observed not eating or have a decline in intake. V6 stated, the process for communication with diet changes/recommendations starts with V13 (RD) coming in once a month to review residents. V6 stated that herself, V1 (Administrator) and V2 (Director of Nursing) will receive a copy of V13's progress notes with recommendations. V6 stated, V2 will then take the note with recommendations and put them in the folder for the Nurse Practitioner (NP) to see weekly. V6 stated, once the NP signs the orders, the nursing staff will then make the updates/changes in the resident's electronic health record (EHR). V6 stated, once the changes are made in the resident's EHR, she can update dietary information on her end. V6 stated she did receive V13's progress notes with recommendations on 5/6/2025 via email. V6 stated, to her knowledge V2 did put the progress note in the NP folder to be reviewed. V6 stated the facility did have a lapse in weekly in-person NP coverage at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146131 If continuation sheet Page 4 of 9 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 06/06/2025 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 0692 Level of Harm - Actual harm Residents Affected - Few the facility that started the first week of May 2025. V6 said in her opinion, V12 (Medical Provider) should have been contacted via phone to review V13's progress notes and recommendations by the nursing staff prior to today. V6 stated 4 weeks is too long of a period to wait on reviewing recommendations. On 06/05/25 at 10:23 AM, V11 (Nurse Practitioner/NP) stated, she started weekly in-person visits in the facility on 5/29/2025. V11 stated, the facility did have a lapse of a NP coming into the facility weekly for a few weeks and that did start around the first of May. V11 stated however, the facility did have coverage by an on-call telehealth company or V12 (Medical Provider). V11 stated, in her opinion the facility should have contacted the telehealth service or V12 (Medical Provider) to review V13's progress notes and recommendations for R12 that was dated 5/6/2025, prior to today. V11 stated she did not review R12's recommendations dated 5/6/2025 when she was in the facility on 6/4/2025. On 06/05/25 at 12:19 PM, V2 (Director of Nursing/DON) stated, she does receive V13's monthly notes via email. V1 stated, she did receive R12's progress note with recommendations on 5/6/2025 from V13, however, she was on vacation until 5/12/2025. V2 stated, V6 (Dietary Manager/DM) should have printed out V13's progress note, with her recommendations and given it to the nurse to contact a provider to review. V2 stated V6 noticed the recommendations had not been reviewed and printed them 6/2/2025 for V11 (NP) to review at her weekly visit this week. V2 (DON) stated, if the CNA staff notices a resident who is not eating, they should give them verbal cues, notify V6 (Dietary Manager) and Nurses. V2 stated, the CNA staff should assist to feed the resident as well, if the resident will allow. V2 stated, in her opinion V12 (Medical Provider) should have been notified via phone to review V13's progress note with recommendations in a timely manner. On 06/05/25 at 10:46 AM, V1 (Administrator) stated his expectation would be the nursing staff should have contacted telehealth or V12 (Medical Provider) by phone to review recommendations by V13 for R12. On 06/06/25 at 09:25 AM, V13 (Regional Dietitian) stated the process of communication for her recommendations on residents starts with her emailing them to V1 (Administrator), V2 (DON) and V6 (DM). V13 stated, from there V2 (DON) will print out her progress note with recommendations for a provider to review and sign. V13 stated, then the nursing staff will enter the providers orders into the residents EHR (electronic health record). V13 stated, she did send R12's progress note with her recommendations via email to V1 (Administrator), V2 (DON) and V6 (DM) on 5/6/2025. V13 stated, in her opinion, the facility should have contacted V12 (Medical Provider) to review R12's status and recommendations in a timely manner. R12's Physician Order Summary documented Megestrol Acetate Oral Suspension 200 mg (milligrams) by mouth two times a day for weight loss and liquid supplement two times a day with a start date of 6/5/2025. The facility's Resident Weight Monitoring policy and procedure (revised 3/19) documented under Procedure: 7. If there is an actual significant weight change (i.e. +/-5% x 1 month, +/- 7.5% x3 months, +/10% x 6 months), the resident, POAHC (Power of Attorney for Health Care)/family/guardian, physician, and dietitian are notified. The physician shall be notified using the MD notification of weight change form. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146131 If continuation sheet Page 5 of 9 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 06/06/2025 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 and interview, the facility failed to ensure that dishes were effectively sanitized in the dish machine. This failure has the potential to affect all 17 residents residing in the facility. Residents Affected - Many The Findings Include: On 6/3/25 at 9:45 AM, V3 (Cook) was observed using a quaternary test strip on the chlorine sanitizer. V3 stated at this time that she wasn't sure why the strip wasn't showing any sanitizer in the water. V3 asked V4 (Dietary Aide) about the the testing of the sanitizer level and V4 stated that the bucket needed to be checked first to see if it is empty because they have been having problems getting it delivered. V4 stated that the jug is empty, and they need to go to the store to get bleach to use in the interim until a delivery is made. V4 stated that is what was recommended to use if they ran out. V4 is unsure of which test strip to use because he does not regularly check the sanitizer in the dish machine, he just fills the dish machine when he starts in the morning and gets it ready for use. On 6/3/25 at 10:30 AM, V3 stated that she could check the level of sanitizer in the dish machine because they have bleach now. At this time, V3 used a quaternary strip to check the level of the machine's chlorine sanitizer. The test strip did not change colors. V3 then used the chlorine strip to check the level of sanitizer, but was not sure the level that it needed to be. V3 stated that she thought it needed to be 200 PPM (Parts Per Million). On 6/3/25 at 11:00 AM, V6 (Dietary Manager) stated that she had determined even though the log is filled out for the dish machine sanitizer level, no one is actually checking it, which is why V3 didn't know the correct strip to use or what the recommended PPM level is for chlorine. The facility policy for Ware-washing dish machine with a revision date of 10/09 documented .It is the policy of (name of corporation) that utensils and dishes washed by mechanical dishwasher will be cleaned and sanitized .3. For low temperature dish machines (temperature of water shall not be less than 120 degrees Fahrenheit). Before washing anything use a test strip to check the sanitizer level. A: for chlorine sanitizers, the level should be 50-100 PPM. B: for quaternary sanitizers, the level should be 200 PPM .4. Record either the temperatures or sanitizer level on the Dishmachine Temperature/Sanitizer log 10. Wash dishes according to equipment directions. The Long Term Care Facility Application for Medicare and Medicaid, dated 6/2/25, reports 17 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146131 If continuation sheet Page 6 of 9 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 06/06/2025 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 0851 Level of Harm - Minimal harm or potential for actual harm Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on interview and record review, the facility failed to accurately report Registered Nurse (RN) hours to the payroll-based journal. This has the potential to affect all 17 residents residing in the facility. Residents Affected - Many Findings Include: Review of Staffing Data Submission Payroll Based Journal (PBJ) found at, https://www.cms.gov/medicare/quality/nursing-home-improvement/staffing-data-submission and last modified 9/23/23 stated, .CMS (Centers for Medicare & Medicaid Services) has developed a system for facilities to submit staffing information - Payroll Based Journal (PBJ). This system allows staffing information to be collected on a regular and more frequent basis than previously collected. It is auditable to ensure accuracy. Review of the facility's PBJ report for Fiscal Year Quarter 1 2025 (October 1 - December 31), documented No RN hours on the following dates: 11/17/2024, 11/24/2024, 12/21/2024, 12/22/2024 and 12/29/2024. Nursing schedules reviewed for RN coverage on 11/17/2024, 11/24/2024, 12/21/2024, 12/22/2024 and 12/29/2024 documented coverage was provided by V2 (Director Of Nursing), who was a contracted Registered Nurse at the facility during that time. On 06/05/24 at 10:54 AM, V2 confirmed that she did work the days in question as the Registered Nurse at the facility, although the origination of discrepancy in the PBJ hours reported cannot be determined at this time, other than she doesn't clock in due to being in a salaried position. The Long Term Care Facility application for Medicare and Medicaid dated 6/3/24, documented 17 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146131 If continuation sheet Page 7 of 9 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 06/06/2025 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 06/04/25 10:00 AM, while passing ice to residents, V7 (Certified Nurse Assistant/CNA) was observed bending down to pick up a bag off the hallway floor, then placed the ice scoop in the bag and attached it back to the ice cart. Residents Affected - Many On 06/04/25 10:10 AM, V7 (CNA) stated, she did pick the scoop bag up off the floor because it fell off the ice cart. V7 stated, she did put the ice scoop back in the scoop bag and secured it to the ice cart to be used. V7 stated, she should not have put the scoop bag back in use once it had been on the floor. On 06/04/25 10:36 AM, V2 (Director of Nursing/DON) stated her expectation for staff is to follow standard infection control practices. V2 stated V7 (CNA) should have replaced the ice scoop bag instead of putting it back on the ice cart. On 06/04/25 11:30 AM, V1 (Administrator) stated his expectation is for all staff to follow standard infection control practices. V1 stated, V7 (CNA) should have discarded the ice scoop bag that fell on the floor. The Long Term Care Facility Application for Medicare and Medicaid, dated 6/2/25, reports 17 residents reside in the facility. Based on observation, interview, and record review, the facility failed to follow infection control practices to prevent contamination. This failure has the potential to affect all 17 residents residing in the facility. Findings Include: 1. R16's admission Record documented R16 was admitted to the facility on [DATE] and included diagnoses of Alzheimer's disease, dementia, chronic kidney disease, stage 3, major depressive disorder, anxiety disorder, hyperlipidemia, sleep apnea, history of falling, gastro esophageal reflux disease, vitamin d deficiency, delusional disorder, obstructive sleep apnea, essential primary hypertension, syncope and collapse, and other cervical disc degeneration. R16's Order Summary Report with a print date of 06/05/2025, documented a physician's order to cleanse R (right) lateral ankle with wound cleanser, apply calcium alginate then cover with bordered gauze dressing every day shift and as needed. R16's Care Plan documents a focus area of R16 is at risk for pressure injury and impaired skin integrity related to bowel and bladder incontinence, poor safety awareness. Skin tear to right lateral ankle. Interventions included to assist with turning and repositioning every two hours and as needed, encourage good nutrition and hydration in order to promote healthier skin, keep skin clean and dry, use lotion on dry skin, provide pressure relieving mattress and wheel chair cushion, provide treatments as ordered, skin assessments as per facility policy, and weekly treatment documentation to include measurement of each area of skin breakdowns width, length, and depth, type of tissue and exudate and any other notable changes. R16's Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146131 If continuation sheet Page 8 of 9 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 06/06/2025 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 (BIMS) score of 00, indicating R16 has severe cognitive impairment. Level of Harm - Minimal harm or potential for actual harm On 06/04/2025 at 11:54 AM, V10 (Licensed Practical Nurse/LPN) completed wound care treatment for R16. V10 was observed cleaning R16's ankle and laid R16's leg back on the bed sheet with no barrier. V10 then raised R16's leg again to pat dry the wound to the ankle and laid R16's leg back on the bed sheet with no barrier. V10 again raised R16's leg, applied the calcium alginate and a bordered dressing, then laid R16's leg back on the bed sheet. Residents Affected - Many On 06/04/2025 at 12:13 PM, V10 (LPN) stated I usually place a barrier down, but I must have forgotten. V10 stated she had changed the resident, and her sheets were clean. V10 stated she had the barrier on the bedside table and just forgot to place it down. On 06/04/2025 at 12:16 PM, V2 (Director of Nursing) stated that she would expect staff to have a barrier down under wounds when doing cleaning. V2 stated that you would not clean a wound and lay it on the bed without a barrier. Facility policy titled Aseptic Wound and Skin Treatment Procedure with a date of 01/2018 under purpose documents To prevent contamination of the wound, protect wound from mechanical injury, to stimulate, restore, and promote circulation and healing, prevent further deterioration of skin tissue, prevent necrosis of deeper body structures, and to promote resident comfort. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146131 If continuation sheet Page 9 of 9