Health inspection·February 18, 2022

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R24 was unable to answer due to severe limitations in cognition due to dementia. V1 could not produce written evidence of the interviews. V1 stated she also questioned R43 as a part of the investigation but forgot to write it down. V1 stated after these interviews, she determined no further action was needed as R3 was not previously known to display sexual acting out behavior, and R3 stated he was patting down a prisoner, which was consistent with his previous employment duties. V1 stated that staff pretty much constantly supervise R3, and she is not concerned about the possibility of R3 acting out sexually with other residents. V1 did state that immediately after the incident, staff had discussed transferring R3 to a dementia care unit due to the incident, and as additionally he has become more resistant to care and verbally aggressing toward staff. V1 stated R3 was having issues with R3's blood sugar at that time and was not able to be transferred, and there was no further discussion of transfer even after R3 stabilized physically. V1 stated she did not notify local law enforcement of the incident because she had determined that R3 had no sexual intent when touching R24's breasts and was acting out due to R3's dementia. On 2/17/21 at 10:36am, R43 was alert and oriented to person place time and purpose. R43 stated R43 has never been interviewed by V1 and stated she has had no interactions with V1 other than saying Hi in passing. R43 stated R3 self-propels in and out of resident rooms on a regular basis, including R43's room. R43 stated when this occurs, R43 tells R3 to leave, and R3 does. R43 stated R3 is not constantly supervised by staff and has plenty of opportunity to come in contact with other residents in an unsupervised setting. On 2/18/22 at 9:25am, V12 corroborated V11's account of the incident. V12 stated she had never witnessed R3 act out sexually prior to this incident. V12 stated R3 self-propels freely around on the first-floor unit and has been known to go into other residents rooms without permission. R3's Face Sheet lists diagnoses including unspecified Dementia and unspecified Hallucinations. R3's 1/19/22 Minimum Data Set (MDS) BIMS documented a score of five, indicating R3's has severe cognitive deficits. R24's Face Sheet listed diagnoses including unspecified Dementia. R24's 12/17/21 MDS BIMS documented a score of 99, indicating R24's confusion is so severe that R24 was unable to complete the interview. The facility's Abuse Policy dated 4/22/19 documented, It is the policy of (the facility) to immediately report and complete an investigation in the event of (an) allegation (of) known or suspected sexual abuse. The facility will immediately report allegations of this nature to the law enforcement .(and)follow directions given by law enforcement .(The) Report will be made to the city police.(phone number and address listed). Protection: Promptly protect the residents who are the alleged victims .Protect other residents who might be at risk . Ensure that no retribution occurs to the complainant .Analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences .Identify events occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation. In response to allegations of abuse the facility will have evidence that all alleged violations are thoroughly investigated.(and) prevent further potential abuse while the investigation is in progress. The facility Administrator will be responsible for maintaining the documents related to all reports of suspected crime. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145406 If continuation sheet Page 2 of 17 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 145406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Randolph County Care Center 312 West Belmont Sparta, IL 62286 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 0608 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. Based on record review and interview, the facility failed to report an incident of resident-to-resident sexual abuse to local law enforcement for 2 of 2 residents (R3, R24) reviewed for abuse in the sample of 25. Findings include: A correspondence titled, Report to IDPH (the Illinois Department of Public Health) authored by V1 (Administrator) dated 12/31/21 stated, On 12/30/21 at approximately 13:16(1:16pm), (V12 Housekeeping Supervisor) witnessed and reported (R3) rubbing (R24) breast. The residents were separated with R3 being redirected. No injury (to R24) was noted. (Both resident's) [NAME] of Attorney and Medical Doctors were notified. (When interviewed about the incident), (R3) stated he was patting him down. No further incidents were noted. (V12) was interviewed and she stated (R3 and R24) were in the hall and (R3 ) was patting (R24 ) breasts with both hands. (R24) clothing was in place. (R3) was (previously) an employee at (a mental health facility) for many years, (and)has a diagnosis of dementia, with a BIMS (Brief Interview for Mental Status Score) of 5 (indicating severe cognitive deficits.) A correspondence to IDPH authored by V1 dated 1/10/22 documented, This is a revised report related to an incident that took place on 12/30/21 (regarding R3 and R24). Upon interview (R24) had clear speech (but) was unable to say what happened. (R24) has a BIMS score of 99 (Indicating R24s cognition is so impaired the test was unable to be administered.) No injuries were reported. (R3 and R24) were separated with no further incidents noted. There was no documentation presented to indicate that the facility had notified local law enforcement authorities about the incident. On 2/17/22 at 9:45am, V 1 stated she is the staff member responsible for investigating abuse allegations and reporting them to law enforcement. V1 stated the above referenced letters represented the entirety of the documentation of the sexual abuse investigation from the incident which occurred between R3 and R24 on 12/30/21. V1 stated she did not notify local law enforcement of the incident because she had determined that R3 had no sexual intent when touching R24's breasts and was acting out due to his dementia. The facility's Abuse Policy dated 4/22/19 documented, It is the policy of (the facility) to immediately report and complete an investigation in the event of (an) allegation (of) known or suspected sexual abuse. The facility will immediately report allegations of this nature to the law enforcement .(and)follow directions given by law enforcement .(The) Report will be made to the city police.(phone number and address listed). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145406 If continuation sheet Page 3 of 17 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 145406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Randolph County Care Center 312 West Belmont Sparta, IL 62286 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to thoroughly investigate an incident of resident-to-resident sexual abuse for 2 of 2 residents (R3, R24) reviewed for abuse in the sample of 25. Residents Affected - Few Findings include: A correspondence titled, Report to IDPH (the Illinois Department of Public Health) authored by V1, Administrator, dated 12/31/21 stated, On 12/30/21 at approximately 13:16(1:16pm), (V12, Housekeeping Supervisor) witnessed and reported (R3) rubbing (R24) breast. The residents were separated with R3 being redirected. No injury (to R24) was noted. (Both residents) [NAME] of Attorney and Medical Doctors were notified. (When interviewed about the incident), (R3) stated he was patting him down. No further incidents were noted. (V12) was interviewed and she stated (R3 and R24) were in the hall and (R3 ) was patting (R24 ) breasts with both hands. (R24) clothing was in place. (R3) was (previously) an employee at (a mental health facility) for many years, (and)has a diagnosis of dementia, with a BIMS (Brief Interview for Mental Status Score) of 5 (indicating severe cognitive deficits.) A correspondence to IDPH authored by V1 dated 1/10/22 documented, This is a revised report related to an incident that took place on 12/30/21 (regarding R3 and R24). Upon interview (R24) had clear speech (but) was unable to say what happened. (R24) has a BIMS score of 99.(Indicating R24s cognition is so impaired the test was unable to be administered.)No injuries were reported. (R3 and R24) were separated with no further incidents noted. On 2/17/22 at 9:18am, V11 (Licensed Practical Nurse), stated that on 12/20/21 at around 1:15pm, she was in the nurses' station when she heard V12 yell for her. When V11 ran out of the nurses' station, she observed R3 and R24 were sitting in their wheelchairs in the hallway, and V12 stated R3 had had his hands on R24's breasts. V11 stated she separated the residents and immediately reported the incident to V1. V11 stated it is V1's responsibility to investigate all reports of abuse. V11 stated she performed an immediate physical exam of R24. V11 stated both residents were placed on every 15-minute checks for three days. V11 stated R3 had never previously displayed sexual acting out behavior. On 2/17/22 at 9:45am, V1 stated she is the staff member responsible for investigating allegations of abuse. V1 stated these two letters represented the entirety of the documentation of the sexual abuse investigation from the incident which occurred between R3 and R24 on 12/30/21. V1 stated she was informed of the incident immediately after it happened by V11 who was second on the scene after V12. V1 stated she interviewed V11 and V12, but no other employees. V1 stated she interviewed R3 and R24, with R3 stating He was patting a prisoner down, and R24 was unable to answer due to severe limitations in cognition due to dementia. V1 could not produce written evidence of the interviews. V1 stated she also questioned R43 as a part of the investigation but forgot to write it down. V1 stated after these interviews, she determined no further action was needed as R3 was not previously known to display sexual acting out behavior, and R3 stated he was patting down a prisoner, which was consistent with his previous employment duties. V1 stated that staff pretty much constantly supervise R3, and she is not concerned about the possibility of R3 acting out sexually with other residents. V1 did state that immediately after the incident, staff had discussed transferring R3 to a dementia care unit due to the incident, and as additionally he has become more resistant to care and verbally aggressing toward staff. V1 stated R3 was having issues with his blood sugar and was not able to be transferred at that time, and there was no further discussion of transfer even after he stabilized physically. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145406 If continuation sheet Page 4 of 17 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 145406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Randolph County Care Center 312 West Belmont Sparta, IL 62286 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 2/17/21 at 10:36am, R43 was alert and oriented to person place time and purpose. R43 stated R43 has never been interviewed by V1 and stated R43 has had no interactions with V1 other than saying Hi in passing. R43 stated R3 self-propels in and out of resident rooms on a regular basis, including R43's room. R43 stated when this occurs, R43 tells R3 to leave, and he does. R43 stated R3 is not constantly supervised by staff and has plenty of opportunity to come in contact with other residents in an unsupervised setting. On 2/18/22 at 9:25am, V12 corroborated V11's account of the incident. V12 stated she had never witnessed R3 act out sexually prior to this incident. V12 stated R3 self-propels freely around on the first-floor unit and has been known to go into other residents rooms without permission. R3's Face Sheet lists diagnoses including Unspecified Dementia and Unspecified Hallucinations. R3's 1/19/22 Minimum Data Set (MDS)BIMS documented a score of five, indicating R3's has severe cognitive deficits. R24's Face Sheet listed diagnoses including Unspecified Dementia. R24's 12/17/21 MDS BIMS documented a score of 99, indicating R24's confusion is so severe that R24 was unable to complete the interview. The facility's Abuse Policy dated 4/22/19 documented, It is the policy of (the facility) to immediately report and complete an investigation in the event of (an) allegation (of) known or suspected sexual abuse . In response to allegations of abuse the facility will have evidence that all alleged violations are thoroughly investigated.(and) prevent further potential abuse while the investigation is in progress. The facility Administrator will be responsible for maintaining the documents related to all reports of suspected crime. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145406 If continuation sheet Page 5 of 17 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 145406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Randolph County Care Center 312 West Belmont Sparta, IL 62286 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 2/15/22 at 10:26 am, R3 was observed in R3's room, sitting in a wheelchair. R3 was alert but oriented only to self, at times giving nonsensical responses to the surveyor's questions. R3's Face Sheet documented an admission date of 7/15/20. This document listed V19 as R3's Power of Attorney. A Nursing Progress Note dated 2/5/22 documented, New order received to send (R3) to the emergency room for evaluation and treatment of hyperglycemia. (R3) left the facility at (9:12 pm) via (local ambulance service). There was no documentation found in R3's Clinical Records to indicate V19 was given written notice of R3's transfer to the hospital on 2/5/22. On 2/16/22 at 11:00 am, V1 (Administrator) stated that no paperwork is sent with a cognitive resident or to the emergency contact in writing when transferred to the hospital. V1 went on to state that residents are sent out to the emergency room they send an admission profile and current orders for the accepting hospital. The family is called and notified, but nothing is sent in writing about notice of transfer. A document provided by V2 (Director of Nursing) on 2/18/22 at 10:00 am has a subject line of: Notice Requirements before Transfer/Discharge with a dated 1/7/19. This further document the intent as: It is the policy of (Name of Facility) to notify the resident and their legal guardian of the before transfer and/or discharge according to state and federal guidelines. The procedure states: 1. Before the facility transfers or discharges a resident, the facility will: B) notify the resident and, if known, a family member or the resident's representative of the transfer or discharge and the reason for the move in writing and in a language and manner they understand. 2. R1's admission record documents that V16 (Emergency Contact) is the power of attorney for care. R1's Minimum Data Set (MDS) dated [DATE] Section G documents that R1 has a Brief Interview for Mental Status of 15, indicating that R1 has no cognitive impairment. R1's nursing progress notes document that on 2/5/22 at 10:45 am, that V17 (Surgeon) sent orders to have R1 admitted to hospital for infection in R1's knee. There was no documentation found in R1's Clinical Records to indicate R1 or V16 were given written notice of R1's transfer to the hospital on 2/5/22. Based on interview and record review, the facility failed to notify a resident and/or resident's representatives in writing of hospital transfers for 3 of 3 residents (R1, R3, R33) reviewed for hospitalizations in a sample of 25. Findings Include: 1. Review of R33's admission Record documents R33's original admission date to the facility as 1/3/22. This same document lists V10 (Resident Representative) as R33's responsible party. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145406 If continuation sheet Page 6 of 17 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 145406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Randolph County Care Center 312 West Belmont Sparta, IL 62286 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 0623 On 2/15/22 at 10:36 pm, R33 was alert to person only. Level of Harm - Minimal harm or potential for actual harm Review of R33's Clinical Record documents an entry on 1/17/22 at 5:45 pm which states R33 was found lying on the floor on R33's back. R33 knows R33's name but unable to explain how R33 got on the floor. Neurological flow sheet started due to 3.0 cc (cubic centimeter) hematoma on left, upper, back of head. Blood pressure and pulse elevated. Order received to send to local hospital for evaluation and treatment. Residents Affected - Few Review of R33's Clinical Record documents after being evaluated at the local hospital, R33 was transferred to an out-of-town hospital for evaluation and treatment where R33 was admitted from 1/17/22 - 1/25/22 with a primary diagnosis of subdural hematoma. There was no documentation found in R33's Clinical Records to indicate V10 was given written a notice of R33's transfer to the hospital on 1/17/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145406 If continuation sheet Page 7 of 17 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 145406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Randolph County Care Center 312 West Belmont Sparta, IL 62286 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 0625 Level of Harm - Minimal harm or potential for actual harm Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R3's Face Sheet documented an admission date of 7/15/20. This document listed V19 as R3's Power of Attorney. Residents Affected - Few A Nursing Progress Note dated 2/5/22 documented, New order received to send (R3) to the emergency room for evaluation and treatment of hyperglycemia. (R3) left the facility at (9:12 pm) via (local ambulance service). No documentation could be found in R3's Clinical record to incident V19 was given written information regarding the facility's bed hold policy when R3 was sent out to the hospital on 2/5/22. On 2/16/22 at 11:00 am, V1 (Administrator) stated when a resident is transferred from the facility nothing is sent the resident or family regarding the bed hold policy because it is in the admission packet. Review of the undated facility policy titled Bed Reserve Policy Notification documents, This Bed Reserve Policy will be given to you at the time of admission and a copy will be given to you each time you are transferred from the facility. 2. R1's admission record documents that V16 (Emergency Contact) is the power of attorney for care. R1's Minimum Data Set (MDS) dated [DATE] Section G documents that R1 has a Brief Interview for Mental Status of 15, indicating that R1 has no cognitive impairment. R1's nursing progress notes document that on 2/5/22 at 10:45 am, that V17 (Surgeon) sent orders to have R1 admitted to hospital for infection in R1's knee. No documentation could be found in R1's Clinical record to indicate V16 or R1 was given written information regarding the facility's bed hold policy when R1 was sent out to the hospital on 2/5/22. Based on interview and record review, the facility failed to provide written notice of the facility's Bed Hold policy to a resident and/or resident's representative at the time of a resident transfer to the hospital for 3 of 3 (R1, R3, R33) residents reviewed for hospitalization in the sample of 25. Findings Include: 1. Review of R33's admission Record documents her original admission date to the facility as 1/3/22. This same document lists V10 (Resident Representative) as R33's responsible party. On 2/15/22 at 10:36 am, R33 is alert to person only. Review of R33's Clinical Record documents an entry on 1/17/22 at 5:45 pm which states R33 was found lying on the floor on R33's back. R33 knows R33's name but unable to explain how R33 got on the floor. Neurological flow sheet started due to 3.0 cc (cubic centimeter) hematoma on left, upper, back of head. Blood pressure and pulse elevated. Order received to send to local hospital for evaluation and treatment. Review of R33's Clinical Record documents after being evaluated at the local hospital, R33 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145406 If continuation sheet Page 8 of 17 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 145406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Randolph County Care Center 312 West Belmont Sparta, IL 62286 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 0625 Level of Harm - Minimal harm or potential for actual harm transferred to an out-of-town hospital for evaluation and treatment where R33 was admitted from 1/17/22 1/25/22 with a primary diagnosis of subdural hematoma. No documentation could be found in R33's Clinical record to incident V10 was given written information regarding the facility's bed hold policy when R33 was sent out to the hospital on 1/17/22. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145406 If continuation sheet Page 9 of 17 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 145406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Randolph County Care Center 312 West Belmont Sparta, IL 62286 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Few Based on observation, interview, and record review the facility failed to implement fall interventions for 1 of 4 residents (R33) reviewed for accidents in the sample of 25. This failure resulted in R33 suffering a fall resulting in a subdural hematoma requiring hospitalization for monitoring and treatment. Findings Include: R33's admission Record documents R33's original admission date to facility as 1/3/22. R33's Minimum Data Set (MDS) dated [DATE] documents a BIMS score of 09, indicating cognitive impairment. This same MDS documents in Section G0110 that R33 requires limited assistance from 1-person physical assist for transfers, walking in room, and walking in corridor. R33's Morse Fall Scale dated 1/3/22 documents a score of 75, indicating R33 is at high risk for falls. R33's Plan of Care documents a focus area that states, The resident is high risk for falls r/t (related to) Confusion, Gait/balance problems, unaware of safety needs. An intervention listed for this focus area documents a date initiated as 1/10/22 which states, The resident uses chair/bed electronic alarm. Ensure the device is in place as needed. Facility Final Report incident dated 1/24/22 documents a fall with major injury for R33. The report states, Upon further investigation of fall from 1/17/22, per nurse's notes and staff interviews, resident had been sitting at the table outside of the nurse's station where (R33) ate (R33's) evening meal. The nurse was with R33 and had left the area to take medications to another resident. Nurse states she was gone for no longer than 5 minutes. Upon her return, nurse found Resident laying on R33's back on the opposite side of the table. Resident had (R33's) walker with (R33), no objects noted on the floor which is carpeted. Resident was admitted [DATE]. Diagnosis of dementia with a BIMS (Brief Interview for Mental Status) score of 9. Requires SBA (stand by assistance) - A (assist)x1 for locomotion. Resident is forgetful and attempts to ambulate without assistance. admitted for rehab after frequently falling at home, last fall resulting in left femoral neck fracture requiring a pinning and acute subdural hematoma according to CT (computed tomography) scans from 12/28/21. CT scans from 1/17/22 show acute on subacute subdural hematoma. Resident continues to be admitted to (Name) out of town hospital at this time with an expected return to our facility tomorrow 1/25/22. On 2/17/22 at 9:59 am, V2 (Director of Nursing) states that she completed the fall investigation for R33 regarding the 1/17/22 fall. V2 states it was determined R33's chair alarm had been left on a chair in R33's room, while R33 fell from a chair located in the lounge area outside of the nurses' station. V2 states R33 had a history of falls and staff were educated on ensuring R33's chair alarm was moved to whatever chair R33 was utilizing. V2 confirms R33's Plan of Care indicated R33 was to have a chair alarm in place. V2 states R33 received hospital evaluation and treatment for a subdural hematoma as a result of the fall. V2 states that R33 had a smaller subdural hematoma from a fall prior to R33's admission to the facility, but after the fall on 1/17/22, reports show it had now grown in size. On 2/17/22 at 10:25 am, V4 (Certified Nurse Assistant) states that she was working with R33 on 1/17/22 when she fell. V4 states that she did not witness R33's fall but arrived later after the fall (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145406 If continuation sheet Page 10 of 17 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 145406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Randolph County Care Center 312 West Belmont Sparta, IL 62286 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 had occurred and V5 (Licensed Practical Nurse) was tending to R33. V4 states that R33 utilized a bed and chair alarm. V4 states that R33 did not have R33's chair alarm in place at the time R33 fell. V4 states that R33 had been with visitors who had brought R33 to the lounge area at the end of the visit. V4 states the chair alarm was not put back in place after the visitors left. V4 confirms education was provided on ensuring R33's alarm is present and working wherever R33 is sitting. On 2/17/22 at 1:58 am, V5 (Licensed Practical Nurse) states that she was working the night R33 fell. V5 states that R33's baseline status is confused. V5 states that R33 utilizes a chair alarm and confirms it was not in place at the time of the fall. V5 states that R33 was sent to the local emergency room for evaluation and treatment. R33's Clinical Record documents a nursing note made on 1/17/22 with an effective time of 5:45 pm which documents R33's blood pressure and pulse were elevated post fall. The same note documents a 3.0 cc hematoma was present to the back, upper, left portion of R33's head. R33's pupils were differing in size, with the right measuring 4 mm (millimeter) and left measuring 2 mm. V18 (physician) was contacted with orders to send R33 to the local hospital for evaluation a treatment. R33's local hospital Emergency Department Clinical Report documents R33 arrived by ambulance and was seen on 1/17/22 at 7:08 pm. Review of the Radiology Report located in this same document dated 1/17/22 documents a CT Scan of the Brain was complete without contract. The Impression listed on this report documents, 1. Acute on subacute subdural hematoma in the left cerebral fossa measuring up to 17 mm with associated mass effect on the left hemisphere and approximately 6 mm of left-to-right midline shift. 2. There appears to be a small volume of left subarachnoid hemorrhage This report documents under Progress and Procedures that the case has been discussed with trauma service and R33 will be transferred to an out-of-town hospital for a Medium sized, chronic, traumatic left subdural hematoma. R33's Neurosurgery Consult Note from the out-of-town hospital dated 1/17/22 made by V6 (Physician) documents an Assessment stating, [AGE] year old female with prior fall and small SDH (subdural hematoma) presents s/p (status post) fall tonight with increasing size to SDH to 17 mm with 5 mm midline shift. Neurologically intact but confused. Concern for acute deterioration, so recommend ICU (Intensive Care Unit) care. Will discuss possible surgical intervention with patient and family. R33's out of town hospital Summary of Care documents R33 was admitted to the hospital from [DATE] 1/25/22 with a primary diagnosis of Subdural hematoma. This report documents repeated CT scans of the Brain were complete along with neurological referral and treatment of the subdural bleed. Imaging Results for a CT of head without contract complete on 1/20/22 documents in Findings that R33 Is now status post left frontal approach subdural drain placement. There is a mild interval decrease in the size of the left cerebral convexity subdural collection. The maximum depth of this residual collection is approximately 0.8 cm (previously 1.2 cm). The collection is predominately hypodense with minimal hyperdense blood products. The mass effect on the left cerebral hemisphere and ventricles is significantly decreased. There is residual bowing of the septum pellucidum with near complete resolution of the midline shift. R33 was discharge back to the facility on 1/25/22 with orders to follow up with R33's Primary Care Provider in two weeks. R33's Subdural Drain Procedure Note documents on 1/18/22, R33 had a subdural drain placed. The note documents a 2 (centimeter) incision was made. Subcutaneous tissue and the [NAME] were dissected until the skull was identified. A handheld twist drill was used to create a [NAME] hole. The [NAME] hole was undermined with a straight bone [NAME]. The dura was incised in a cruciate fashion with a #11 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145406 If continuation sheet Page 11 of 17 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 145406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Randolph County Care Center 312 West Belmont Sparta, IL 62286 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 scalpel blade. A trauma catheter was inserted and directed frontally and tunneled away from the incision site. Dark brown crank case fluid consisted with a chronic subdural hematoma was visualized upon [NAME] incision and within the collection system. The drain was secured to the skin with nylon suture. The catheter was serilly connected to the distal collection system with confirmation of spontaneous flow of fluid through to the collection system. After appropriate hemostasis was obtained, the wound was closed with running nylon suture. On 2/15/22 at 10:36 AM, R33 was observed residing in the facility, sitting in R33's wheelchair, with a functioning chair alarm in place. R33 was alert to person only. The facility's undated policy titled, Fall Policy states the mission statement is, to identify residents at risk for falls and provide guidelines for prevention and treatment post fall. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145406 If continuation sheet Page 12 of 17 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 145406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Randolph County Care Center 312 West Belmont Sparta, IL 62286 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview, and record review the facility failed to provide 8 hours of daily Registered Nurse coverage. This failure has the potential to affect all 43 residents residing in the facility. Residents Affected - Many Findings Include: On 2/17/22 at 10:20 am, V2 (Director of Nursing) acknowledges there are days that the facility does not have Registered Nurse (RN) coverage. V2 states that the facility has two Registered Nurses employed at the facility, V13 and V14 (Registered Nurse), but since the beginning of the year they have worked on the same weekend, which then leaves the opposite weekend with no RN coverage. V2 verifies the accuracy of nursing schedules provided and states the facility does not have any nursing waivers. Review of the Nursing Schedules from 2/1/22- 3/28/21 documents no RN coverage was provided at the facility on 2/1/22, 2/5/22, 2/6/22, and 2/15/22. The Resident Census and Conditions of Residents Form (CMS-672) dated 2/15/22 there are 43 residents living in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145406 If continuation sheet Page 13 of 17 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 145406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Randolph County Care Center 312 West Belmont Sparta, IL 62286 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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm Based on interview, observation, and record review, the facility failed to develop and implement a Plan of Care encompassing Dementia Care Services for 2 of 12 residents (R3, R33) reviewed for Care Planning in the sample of 25. Residents Affected - Few Findings include: On 2/15/22 at 10:26 am, R3 was observed in R3's room, sitting in the wheelchair. R3 was alert but oriented only to self, at times giving nonsensical responses to the surveyor's questions. A correspondence titled, Report to IDPH (the Illinois Department of Public Health) authored by V1 (Administrator) dated 12/31/21 stated, On 12/30/21 at approximately 13:16(1:16 pm), (V12 Housekeeping Supervisor) witnessed and reported (R3) rubbing (R24) breast. The residents were separated with R3 being redirected. No injury (to R24) was noted. [NAME] of Attorney and Medical Doctors were notified. (R3) stated he was patting him down. No further incidents were noted. (V12) was interviewed and she stated (R3 and R24) were in the hall and (R3) was patting (R24) breasts with both hands. (R24) clothing was in place. (R3) was (previously) an employee at (a mental health facility) for many years, (and)has a diagnosis of dementia, with a BIMS (Brief Interview for Mental Status Score) of 5 (indicating severe cognitive deficits.) A correspondence to IDPH authored by V1 dated 1/10/22 documented, This is a revised report related to an incident that took place on 12/30/21 (regarding R3 and R24). Upon interview (R24) had clear speech (but) was unable to say what happened. (R24) has a BIMS score of 99. (Indicating R24's cognition is so impaired the test was unable to be administered.) No injuries were reported. (R3 and R24) were separated with no further incidents noted. On 2/17/22 at 9:18 am, V11 (Licensed Practical Nurse) stated that on 12/30/21 at around 1:15pm, she was in the nurses' station when she heard V12 yell for her. R3 and R24 were sitting in their wheelchairs, and V12 stated R3 had had R3's hands on R24's breasts. V11 stated she separated the residents and immediately reported the incident to V1. V11 stated R3 had never previously displayed sexual acting out behavior. On 2/17/22 at 9:45 am, V1 stated the above referenced letters represented the entirety of the sexual abuse investigation from the incident which occurred between R3 and R24 on 12/30/21. V1 stated she interviewed R3 who stated, He was patting a prisoner down. V1 stated that staff pretty much constantly supervise R3 and she is not concerned about the possibility of R3 acting out sexually with other residents. V1 did state that immediately after the incident, staff had discussed transferring R3 to a dementia care unit due to the incident, and as additionally he has become more resistant to care and verbally aggressing toward staff. V1 stated R3 was having issues with his blood sugar and was not able to be transferred at that time, so there was no further discussion of transfer even after R3 stabilized physically. On 2/17/21 at 10:36 am, R43 was alert and oriented to person place time and purpose. R43 stated R3 self-propels in and out of resident rooms on a regular basis, including R43's room. R43 stated R3 is not constantly supervised by staff and has plenty of opportunity to come in contact with other residents in an unsupervised setting. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145406 If continuation sheet Page 14 of 17 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 145406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Randolph County Care Center 312 West Belmont Sparta, IL 62286 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 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 2/18/22 at 9:25 am, V12 stated she witnessed R3 place R3's hands on R24's breasts. V12 stated R3 self-propels freely around on the first-floor unit and has been known to go into other resident's rooms without permission. R3's admission Face Sheet dated 7/15/20 lists diagnoses including Unspecified Dementia and unspecified Hallucinations. R3's 1/19/22 BIMS documented a score of five, indicating R3's has severe cognitive deficits. R3's Care Plan with a review date of 2/15/22 did not list a problem area nor associated interventions addressing R3's dementia related roaming and sexual acting out behavior. On 02/17/22 at 2:44pm, V3, Care Plan Coordinator, confirmed the care plan had not been updated to include dementia related roaming and sexual acting out behaviors. 2. R33's admission Record documents an original admission date to the facility as 1/3/22. This same document lists R33 has a diagnosis of Unspecified Dementia without behavioral disturbance. R33's Current Plan of Care documents no care plan in place for activities. On 2/15/22 at 10:36 am, R33 was observed sitting in R33's wheelchair at a table in the lounge area on the 2nd floor. No activities were observed being offered or taking place with R33. R33 is alert to person only. R33 states I guess I just sit here; I don't know. On 2/17/22 at 11:31 am, V7 (Activities) states that R33 will participate in activities at times. V7 states that R33 mainly has 1:1 activities completed or if residents are having snacks, R33 will participate in those. V7 states that R33 can be difficult to keep entertained in a group setting. On 2/17/22 at 12:20 pm, V3 (Assistant Director of Nursing) states that V7 inadvertently missed developing in writing a plan of care for R33's activity needs. V3 states that V7 is getting the correction made and plan developed now. A facility policy titled Comprehensive Resident Centered Care Plan dated 1/21/19 documents, A comprehensive care plan will be: a. Developed within 7 days after completion of the comprehensive assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145406 If continuation sheet Page 15 of 17 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 145406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Randolph County Care Center 312 West Belmont Sparta, IL 62286 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. 2. On 2/15/22 at 9:56 am, R24 was in the first-floor common area sitting in a wheelchair. R24 was alert but did not respond to the surveyor. V11 (Licensed Practical Nurse/LPN), who was standing nearby, stated R24 is very confused and often does not respond verbally. On 2/15/22 at 12:10 pm, R24 was observed to be asleep at the table during lunch service in the dining room. R24 was served a lunch of chicken, potatoes, and broccoli at 12:22 pm. R24 continued to sleep until 12:41pm with no intervention from staff. R24 then awoke and consumed 100 percent of R24's tea and water but did not eat at all. At 1:10 pm, R24 self-propelled out of the dining room, having consumed only fluid and had not been offered an alternative meal by staff. On 2/16/22 at 12:28 pm, V9 (LPN) sat R24's tray of lasagna, salad, and dessert in front of R24, and R24 stated R24 didn't want it. V9 told R24 she needed to try to eat something and left without offering R24 a substitute meal. R24 drank 100% of the tea and water but consumed no food. At 12:50 pm, R24 self-propelled out of the dining room after having had no intervention by staff. R24's Care Plan with a review date of 1/13/22 documented a problem area, Potential nutritional problem due to dementia, with a corresponding goal, (R24) will maintain adequate nutritional status, and a corresponding intervention Monitor, document, report refusing to eat. 3. On 2/15/22 at 10:09 am, R25 was interviewed in R25's room. R25 was alert and oriented only to self. On 2/16/22 at 12:10 pm, R25 was observed during lunch service in the dining room. At 12:13 pm, V9 placed R25's lunch of lasagna, green beans, and dessert in front of R25, and R25 stated, I don't want it, take it away. V9 told R25, You need to try to eat it, but did not offer a substitute meal. At 12:48 pm, V8 (Dietary Aid) asked R25 if R25 was ready to have R25's tray cleared from the table. V8 noted R25's untouched food and stated, Aren't you going to eat any of that?, to which R25 stated, No, I didn't order it, and I don't like it. V8 stated, Well, we give you what's on the menu, and cleared away the tray without offering R25 an alternate meal. R25's Care Plan with a revision date of 1/6/22 documented a problem area, Potential nutritional problem related to dementia, with a corresponding goal, (R25) will consume at least 75 percent of food and fluids at each meal, and a corresponding intervention, Monitor intake and record at each meal. On 10/17/22 at 2:55pm, V2, Director of Nurses, confirmed that staff should have offered R24 and R25 alternate foods with equal nutritive value. Based on observation, interview, and record review failed to accommodate residents' food preferences for 8 of 12 residents (R14, R22, R23, R24, R25, R27, R28, and R43) reviewed for preferences in a sample of 25. The Findings Include: 1. On 2/17/22 at 1:10 pm, R25 and R28 were seated in the dining room with their lunch plate still on the table. Both resides were alert to person, place and time R28 stated that R28 asked for sliced onion for R28's ham today and V8 (Dietary Aide) told him They were fresh out. R28 went on to state (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145406 If continuation sheet Page 16 of 17 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 145406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Randolph County Care Center 312 West Belmont Sparta, IL 62286 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some that R28 never gets what R28 asks for during the meals. R28 stated that today at lunch R28 also asked for some juice for the ham and the black-eyed peas but no one would give R28 any. R25 and R28 further stated that they do not know what they have to offer other than what is served. If the staff remember to write the menu on the board, they cannot see the board that far away and no one tells them what the substitute is. R25 and R28 went on to state that the staff do not listen to them when they ask for food items on the menu, so they do not bother to ask for substitutes. R28 had only eaten the ham on R28's lunch plate and R25 had only eaten the dessert. On 2/17/22 at 1:25 pm, V15 (Dietary Supervisor) stated that they had onions and V8 knows that they do and could be given at request. During resident council on 2/16/21 at 10:00 am, R22, R23, R27, R28, and R43, stated that the dietary staff and staff working in the dining room during lunch do not listen to what the residents like and serve foods that go to waste. The chicken is too tough and dry with no gravy on top, and the substitute is never listed as an option or communicated them and is typically a leftover of something from the previous meals. All residents present during the meeting were alert to person, place, and time. Review of the patient complaint report dated 9/3/21 resulting from a resident council document that the residents stated during the meeting that dietary aids ignore them when they ask for something and the menu is not always written on the board upstairs. 4. On 02/16/22 at 12:27 PM, R14's lunch meal tray was delivered to her containing lasagna, green beans, lettuce salad with ranch dressing, cheesecake slice, and a roll. On 2/16/22 at 12:38 pm, R14 was observed as eating green beans, a couple bites of salad, 3/4 of cheesecake piece, and a roll. Through continuous observation, R14 was observed not even attempting to eat the lasagna. R14 is alert to person only. On 2/16/22 at 12:46 pm, V9 (Licensed Practical Nurse) approached and asked R14 if R14 was going to eat the lasagna in which R14 stated no, I don't like that. V9 was observed taking R14's meal tray with no alternative food substitute offered. Review of R14's Plan of Care Plan documents a Focus area of The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) Dementia, Impaired balance, argumentative and resistive to care at times. Interventions listed for this Focus area includes, EATING: The resident is able to feed self after staff sets up her meals. Staff supervises to make sure she eats and doesn't lose track of what she is to do. Review of the not dated policy provided by the facility titled, Mealtime Observation for Food Acceptance & Food Replacement states, Residents will be observed during mealtimes to monitor acceptance and intake of food and beverage items and offered food replacement of similar nutritive value or other food selections the resident might enjoy. Additionally, the same document states, Staff members observing meals in the dining room will offer appropriate meal and beverage substitutions for a noted poor intake of a food item or an expressed concern about taste, temperature, or quality of the meal served. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145406 If continuation sheet Page 17 of 17