Health inspection·April 3, 2025

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few require assistance. V7 states activities take care of nail cleaning and trimming but if dirty nails are observed they should be cleaned during showering. On 04/02/25 at 12:50 PM, V8 (Activities Aide) stated they do nails on Wednesdays and Fridays of every week. They remove polish and polish nail. V8 stated they clean nails once or twice a month by soaking them. On 04/02/25 at 12:50 PM, V2 (Director of Nursing) stated they do not have a specific day or time they clean nails or a set schedule. V2 stated they try to do it on days they are well staffed. V2 stated she will tell staff at the beginning of the day to do nail care on residents during that day. V2 stated nails should also be checked during showering. V2 stated if a family member tells a staff member that a residents fingernails need to be cleaned then that staff member should either clean the nails or ask someone else to do it. On 04/02/25 at 12:23 PM, V1 (Administrator) stated residents get showers twice a week. R81's Shower sheets documents R81 received showers on 03/17/2025, 03/20/2025, 03/21/2025, and 03/28/2025. These sheets did contain any information related to R81's fingernails. A policy titled Fingernails/Toenails, Care of dated February 2018 documents The purposes of this procedure are to clean the nail bed, to keep nails trimmer and to prevent infections. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident . General Guidelines: 1. Nail care includes regular cleaning and regular trimming . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146134 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 146134 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Saline Care Nursing & Rehab 120 South Land Street Harrisburg, IL 62946 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to identify, assess, and treat wounds for 1 of 5 (R92) residents reviewed for wounds in the sample of 41. Residents Affected - Few Findings Include: R92's admission Record with a print date of 4/3/25 documents R92 was admitted to the facility on [DATE] with diagnoses that include cellulitis, sepsis, hypertension, hypotension, chronic obstructive pulmonary disease, cirrhosis of liver, and urinary retention. R92's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score of 15, indicating R92 is cognitively intact. This same MDS documents R92 requires substantial/maximal assistance of staff for bed mobility and has pressure ulcers, deep tissue injuries, and skin tears. R92's current Care Plan documents a Focus area of At risk for alteration in skin integrity. Date Initiated: 10/25/24. This same Focus area documents the following interventions all initiated on 10/24/24, Educate resident and family on skin conditions and prevention of skin breakdown .Float heels while in bed Incontinence care. Apply barrier cream Monitor labs that can affect skin .Notify dietary as needed Observe for signs and symptoms of skin breakdown/infection Pressure reducing cushion to wheelchair Pressure relieving mattress .Provide supplements as ordered Skin assessment on admission and weekly .Treatment orders: see POS (physician order sheet) and skin and wound tab . On 4/3/25 at 11:06 AM, V11 (Registered Nurse/RN) was observed administering treatments with V16 (Regional Nurse), V18 (Certified Nursing Assistant/CNA), and V17 (Wound Specialist). R92 had multiple open areas on the sacrum that were identified as pressure ulcers with previous treatment orders in place. The areas were cleaned and treated as ordered by the physician using current standards of practice. After R92's sacrum was assessed and treated this surveyor asked V11 (RN) and V18 (CNA) if that was the only open areas/wounds R92 had and they responded, Yes. As they were repositioning R92, this surveyor noted active bleeding in R92's groin and asked V11 and V18 about it. V17 (Wound Specialist) identified the area as a skin tear and gave orders for treatment of the area. V11 (RN) administered the treatment as ordered per current standards of practice. During treatment of the skin tear, this surveyor noted a separate area just below R92's buttock that was open. This surveyor brought this area to the attention of V11 (RN) who got V17 (Wound Specialist) who had left the room after giving orders for the skin tear. V17 (Wound Specialist) assessed the area below R92's buttocks and gave orders for a treatment. V11 (RN) treated the area per current standards of practice. After the area was treated this surveyor asked to see R92's feet and heels. V18 (CNA) removed R92's socks and this surveyor noted an open area that was covered with eschar and the surrounding tissue was red on the outer aspect of R92's right ankle. There was a dressing covering the inner aspect of R92's right ankle. Again, V11 (RN) got V18 (Wound Specialist) who had left R92's room. V17 (Wound Specialist) removed the dressing to the inner aspect of R92's ankle, assessed both areas, gave orders for the areas and again left the room. V11 (RN) hand sanitized, donned gloves, cleaned the area on the inner aspect of R92's ankle, without changing gloves or hand sanitizing, V11 then cleaned the wound on the outer aspect of R92's ankle. V11 doffed his gloves and hand sanitized and treated the inner aspect and outer aspect, again without changing his gloves or hand sanitizing between the two areas. This surveyor then asked to do a skin check on R92's upper body. After removing R92's shirt a skin tear was noted to R92's right elbow. There was no treatment in place on this area. Again V11 (RN) got V17 (Wound Specialist) who had left the room, V17 assessed the area on R92's right elbow and gave treatment orders. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146134 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 146134 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Saline Care Nursing & Rehab 120 South Land Street Harrisburg, IL 62946 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R92's Skin and Wound Evaluation dated 3/26/25 documents a deep tissue injury on R92's sacrum acquired in house. This same assessment does not document any of the other areas noted during the observation. R92's Wound Specialist Note dated 3/27/25 documents R92 had an unstageable deep tissue injury to his sacrum and a skin tear to his left hand. The other areas noted during the observation were not documented on this assessment. R92's Order Summary Report dated 4/3/25 documents a physician order to clean left inner ankle with wound cleaner, pat dry, and apply hydrocolloid every three days and as needed with a start date of 4/3/25 and an order to clean wound on the sacrum, pat dry, apply hydrocolloid dressing every three days and as needed. There are no orders documented on the Order Summary Report for the other wounds noted during the observation. R92's Progress Notes document on 4/2/25, New order obtained-left inner ankle- cleanse with wound cleaner. Pat dry. Apply hydrocolloid. Change every 3 days and PRN (as needed) . There is no assessment and/or measurement of this area documented in R92's medical record. R92's Skin Observations: Comprehensive CNA Shower Review dated 4/2/25 documents one open area on R92's left foot and documents under Charge Nurse Assessment: MD (Physician) aware-see wound Dr (doctor) tomorrow- tx (treatment) in place. R92's Physician Telephone Orders dated 4/2/25 documents an order to see wound dr (doctor) for left foot wounds duoderm every three days. R92's report titled Other dated 4/2/25 documents under Nursing Description, Resident has a new open area to right inner ankle. Area assessed and noted granulation tissue with no drainage or odor noted. Notified (name of primary physician) and he gave new orders to cleanse with wound cleaner. Pat dry-Apply Hydrocolloid. Change every 3 days and PRN (as needed) and wound doctor to see and fully assess in the morning on 4/3/25. R92's Wound Specialist Progress note dated 4/3/25 documents the following wounds, 1. Stage 2 pressure wound to sacrum that measures 6.5 x 8.9 x 0.2 cm (centimeter), 2. skin tear left dorsal hand that measures 0.5 x 0.9 x 0.2 cm, 3. skin tear of right groin that measures 3.5 x 2.4 x 0.2 cm, 4. unstageable deep tissue injury right lateral ankle that measure 1.1 x 0.9 x not measureable cm greater than one day in duration, 5. non pressure wound of right upper medial foot that measures 1.5 x 2.1 x 0.2 cm greater than one day in duration, and 6. skin tear wound of right forearm that measures 2.0 x 2.0 x 0.2 cm greater than one day in duration. On 04/03/25 at 2:24 PM, V2 (Director of Nurses) stated she would expect newly identified wounds to be measured, assessed, and an incident report to be filed out. V2 stated she would expect nursing staff to change their gloves and hand sanitize after cleaning and/or treating a wound and before cleaning/treating another wound. The wound policy provided to this surveyor titled, Prevention of Pressure Ulcers/Injuries dated July 2017 documents, .Any areas identified while performing or assisting with personal care or ADL's (Activities of Daily Living) charge nurse will be notified f. Nursing will do a complete review of the area and notify the physician for further orders/treatments/assessments. g. Assessments of new wounds will be completed within 24 hours and/or according to physician orders FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146134 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 146134 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Saline Care Nursing & Rehab 120 South Land Street Harrisburg, IL 62946 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 0912 Level of Harm - Potential for minimal harm Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation, interview, and record review the facility failed to provide at least 80 square feet of living space for 4 of 4 residents (R1, R13, R56, and R97) reviewed for room size in a sample of 41. Residents Affected - Some Findings include: On 4/1/25 at 10:30 AM, V1 (Administrator) stated that Side 2 of the facility has a room size waiver assessment. V1 stated these rooms are Medicare/Medicaid certified for two residents. V1 stated rooms 203-206, 208-209, 211-212, 215-220, 222-227, 229-231, 234-235, 238-239, 241-242, 244-248 are all waivered rooms and don't meet the proper room size. On 4/3/25 at 1:56 PM, V13 (Maintenance Director) stated R13 and R56's room was less than 80 square feet per resident, which is less than the requirement. V13 used the measuring tape to measure the length and width of R13 and R56's room and stated, 12.5 by 12 feet, indicating that the rooms were 150 square (sq.) feet (ft.), or 75 sq. ft. per bed. The measurements did not include the closet and bathroom. A that time R13 and R56 were both in their room. The smaller sized room contained two beds and two nightstands. On 4/3/25 at 1:56 PM, R13 and R56 who were both alert to person, place and time stated they are ok with their room size and do not have problems with it. On 4/3/25 at 2:04 PM, V13 stated R97 and R1's room was less than 80 square feet per resident, which is less than the requirement. V13 used the measuring tape to measure the length and width of R97 and R1's room and stated, 12.5 by 12 feet, indicating that the rooms were 150 square (sq.) feet (ft.), or 75 sq. ft. per bed. The measurements did not include the closet and bathroom. R97 and R1 were both in their room. The smaller sized room contained two beds and two nightstands. On 04/03/25 at 2:04 PM, R97 and R1 who were both alert to person, place and time stated they are fine with their room. An undated facility room roster provided by V1 on 03/31/25, documents R13, R56, R97, and R1 reside in the rooms observed and measured by V13. Review of 6 months of Resident Council meeting minutes indicated no concerns related to the size of the rooms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146134 If continuation sheet Page 5 of 5