Inspection·April 30, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 4/25/2025 at 5:33 PM, V6 (Family of R149) stated, My dad was deaf, and we were using a white board to communicate. When my dad was at the nursing home, he was completely helpless and at the mercy of the facility. When I went to visit him, I saw this message written on the white board and took a picture of it because it said to 'stop abusing the call light, this is your last warning. It gave me goosebumps because it was not right. We met with the administrator, and I showed her the photo and she said she would address it. My dad passed away a few weeks later. When I was picking up his stuff, I asked whatever happened with the message left on the whiteboard and staff said they had done an investigation. When I asked more questions, nobody could tell me anything. Nobody knew who wrote the message they said they did not know. I asked if they still worked there, and nobody knew anything, and it did not set right with me. I just hope they really investigated this and found out who would write such a message and hope he or she does not still work in the nursing home. To me it was unsettling that anyone would threaten my poor helpless dad. No final report or investigation was provided by the facility for this allegation of abuse for R149 on 9/18/2023. 2.) R9's Face Sheet undated documents, pertinent medical diagnosis as Unspecified Diastolic (Congestive) Heart Failure, Major Depressive Disorder, Suicidal Ideation, Cervical Disc Disorder with Myelopathy, High Cervical Region, Fusion of Spine, Cervical Region, Spinal Stenosis, Cervical Region, Unsteadiness on Feet and Weakness. The Facility Reported Incident (FRI) dated 3/27/24 documents a staff member reported that another staff member raised her voice and used a curse word, while in R9's room providing care. Alleged staff member has not been on duty since allegation was made. Administrator, MD and POA were notified of the allegation, V31 (police officer) was also notified. Upon resident interview he stated that the staff member did raise her voice at him but would not quote anything that was said. Interview with reporting staff member who was in the room alleged that co-worker raised her voice and used a curse word in the presence of the resident. Alleged staff member denies that she used a curse word but did state she was tired and may have sounded rude. She also stated she did not intend to cause the resident any distress. Multiple other residents were interviewed and denied any issues with staff yelling and all stated, they felt safe at the facility. (R9) states that he feels safe and has no adverse effects from interaction with this staff member. No other staff members report negative interactions with the alleged staff member. Due to the employee's interaction with the resident facility administration terminated employee. On 4/26/24 at 10:22 AM R9 stated, all I said to the Certified Nursing Assistant/CNA was that I did not want to be left on the bed pan for 35-45 minutes. Since it was the changing of shift, I asked her to pass it on to the next shift. That's when she (V24) began yelling at me. I yelled back at her because I don't have to take it from anybody. On 4/26/24 at 10:26 AM V10 (R9's spouse) stated, she can verify R9's statement because sometimes when she come in to visit her husband is not in the room. He is in the bathroom and that he has been in the bathroom over 35-minutes. When she questioned the staff, they dismiss her stating he has not been in the bathroom that long. On 4/30/24 at 9:38 AM V26 (CNA) stated she reported the incident to the Administrator the next morning after the incident because V24 (CNA) was telling the other staff that the resident (R9) had cursed at her. V26 stated she witnessed V24 yelling and cursing at (R9). V24 did not initially hear what R9 said, but when R9 repeated that he just wanted V24 to alert the on-coming shift that he (R9) was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145406 If continuation sheet Page 2 of 8 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 04/30/2024 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on the bedpan, V24 became upset and started yelling and screaming at V9 calling him (R9) a f*****g drunk. (R9) did stand up for himself and kept repeating that he was not accusing her (V24) of anything. He (R9) was really quiet afterwards and offered to apologize to V24 if he offended her. V24 was suspended and did not return to the facility afterwards. On 4/30/24 at 10:30 AM, V25 (Registered Nurse/RN) stated she did not witness the incident between V24 (CNA) and R9. The CNA (V26) reported to her that V24 was being rude and abrasive with resident (R9). V25 stated she did not interview either V24 or R9. V24 was suspended and did not return to the facility. R9 did not exhibit any changes in behaviors. Police report dated 3/29/24 at 7:12PM, documents, that V1 (Administrator) contacted the area Police Department to report a verbal confrontation that took place between V24 and R9. V1 reported that V24 the staff member later identified as V24 yelled and used foul language towards (R9). V1 reported that nothing physical took place during the incident. Also, that action taken against the staff member was that she was suspended from work. (State Agency for Aging) was being contacted due to a prior report of an incident with staff. On 4/30/24 at 10:42 AM V1 (Administrator) stated the report was referring to the prior incident with another resident (R6). No one from (State Agency for Aging) had been out to investigate. On 4/02/24 a typed statement of the interview with V24 (CNA) documents V24 admits she might have gotten a little loud with the resident, but it was getting to be at the end of her shift, and she might have been tired. She did not recall cussing or pointing in residents' face. The interview was witnessed by the V3 (Assistant Director of Nursing). V24's termination letter dated 4/01/24 documents, V24's employment was being terminated at the facility, due to the following violation of the Care Centers' work rules: Speaking loudly at and cursing at the resident. V24's (CNA) timecard dated 3/26/24- 4/08/24, do not document, any days worked after 3/27/24 at 10:01 PM. The facility's Policy Subject: Abuse Neglect Exploitation ADN Misappropriation of Property Prevention. dated 4/22/19 documents, Verbal/Written Abuse- is defined as the use of oral/written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include but are not limited to: threats of harm; saying things to frighten a resident, such as telling a resident that he/she will never be able to see his /her family again. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145406 If continuation sheet Page 3 of 8 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 04/30/2024 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 interview and record review the Facility failed to ensure all abuse allegations were investigated thoroughly and completed for 1 of 4 residents (R149) reviewed for abuse in the sample of 31. Residents Affected - Few Findings include: R149's Initial Investigation Report sent 9/18/2023 at 10:59 AM, documents, To whom it may concern: Resident's family member brought to my attention this morning a picture from 9/16/2023 of his white board with a handwritten message stating to Stop abusing the call light, last warning. MD (Medical Doctor) notified. DON (Director of Nursing) interviewed resident. He has no recollection of seeing the message. Investigation to continue. (Author V1- Administrator). On 4/25/2024 at 4:14 PM, V1 (Administrator) stated, I cannot find the final report for this investigation. I am not sure who the staff member was and/or what the outcome was regarding this allegation. (R149) is no longer in the facility. I have no interviews from other residents and or staff regarding this allegation. On 4/25/2024 at 4:22 PM, V2 (Director of Nursing) stated, I was not working here, that was a different DON. I am not familiar with anything regarding (R149). On 4/25/2024 at 4:32 PM, V3 (Assistant Director of Nursing) stated, I was here at the time, but I cannot tell you anything. I do not know anything about the investigation and/or staff member related to (R149). On 4/25/2025 at 5:33 PM, V6 (family of R149) stated, My dad was deaf, and we were using a white board to communicate. When my dad was at the nursing home, he was completely helpless and at the mercy of the facility. When I went to visit him, I saw this message written on the white board and took a picture of it because it said to 'stop abusing the call light, this is your last warning.' It gave me goosebumps because, it was not right. We met with the Administrator, and I showed her the photo and she said, she would address it. My dad passed away a few weeks later. When I was picking up his stuff, I asked whatever happened with the message left on the whiteboard and staff said they had done an investigation and when I asked more questions, nobody could tell me anything. I asked who wrote the message. They said they did not know. I asked if they still worked there, and nobody knew anything, and it did not set right with me. I just hope they really investigated this and found out who would write such a message and hope he or she does not still work in the Nursing Home. To me it was unsettling that anyone would threaten my poor helpless dad. On 4/30/2024 at 1:02 PM, no abuse investigation was provided by the facility, documenting any observations, interactions, interviews, witnesses, or record review regarding this allegation. The Abuse Policy dated 4/22/2019 documents, (Facility) will develop and operationalize policies and procedures for screening training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property; to include the use of physical and or chemical restraints. The purpose is to assure that the facility is doing all that is within control to prevent occurrences. Investigation: Investigate different types of incidents and identify the staff member responsible for the initial reporting, investigation of alleged violations and reporting of results to the proper authorities. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145406 If continuation sheet Page 4 of 8 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 04/30/2024 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 - Immediate jeopardy to resident health or safety Residents Affected - Many Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident's coffee was served at safe temperatures to prevent burns/injury. This failure resulted in an Immediate Jeopardy when R21 sustained a second degree burn from spilling hot coffee on himself on 2/8/2024 and the facility continued to provide all residents' coffee at unsafe temperatures. Findings include: The Immediate Jeopardy began on 2/8/2024 when R21 sustained a second degree burn from spilling hot coffee on himself. On 4/26/2024 at 1:50 PM, V1 (Administrator), V2 (Director of Nursing/DON) and V3 (Assistant Director of Nursing/ADON) were notified of the Immediate Jeopardy. The surveyor confirmed by observations, record review and interview, that the Immediate Jeopardy was removed on 4/30/2024 but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of in-service training. 1. R21's Physicians Order Sheet (POS) dated April 2024, documented a diagnoses of multiple sclerosis (MS), pneumonia, unspecified organism, bacteremia, urinary tract infection, sepsis, unspecified organism, colostomy status, presence of urogenital implant, stiffness of right knee, not elsewhere classified, stiffness of left knee, not elsewhere, weakness, other reduced mobility, problem related to care providers dependency, unspecified, Proteus (mirabilis) (morganii) as the cause of diseases classified elsewhere an a pressure ulcer of sacral region. R21's Minimum Data Set (MDS) dated [DATE] documented that R21 was cognitively intact for decision making. R21's Care Plan 4/13/2024 documented, The resident has limited physical mobility related to Multiple sclerosis (MS) dated initiated 4/13/2022. It continues, Resident uses an electric wheelchair, resident is on a regular diet, resident has multiple sclerosis. The resident has limited physical mobility related to MS. 2/8/2024 spilled coffee on thigh, blister healed 2/12/2024. R21's Progress Note, dated 2/8/2024 at 1:01 PM, documented, Note Text: MD (Medical Doctor) notification received regarding treatment to open area to right thigh r/t (related to) popped blister from resident's spilled coffee. (V4) APRN (Advanced Practice Registered Nurse) agree with treatment to cleanse right thigh with NS (Normal Saline). Applied xeroform, cover with DD (dried dressing) and secure with tape. Change daily and prn (As needed). POA and resident aware of new order. R21's Skin Assessment, dated 2/13/2024 at 12: 50 PM, Right front thigh scabbed, 1 length x 0.4 width; front thigh scabbed length 0.5 x width 0.3. Referral to (Wound Company) x 2 scabs right front thigh. No new skin issues. On 4/25/2024 at 12:02 PM, R21 stated, I was going to get a cup of coffee off of the table, there are cups and everything available and I was helping myself to a cup of coffee and my nerves got the best of me and I accidentally dumped the coffee on my lap. I got blisters on my thigh, but I am okay now. On 4/30/2024 at 10:32 PM, V25 (Certified Nursing Assistant/CNA) stated, When I was assisting (R21) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145406 If continuation sheet Page 5 of 8 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 04/30/2024 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 - Immediate jeopardy to resident health or safety to bed I noticed he had a quarter size burn on his top thigh. When I asked him what happened he stated he got burned with the coffee. Normally, we have the coffee available in the dining room with cups available to residents to have coffee. 2. On 4/25/2024 at 11:11 AM, V19 (Dietary Manager) stated I have received complaint about the coffee being hot, but I am not aware of any resident being injured from the hot liquid. Residents Affected - Many On 4/25/2024 at 12:06 PM in the main dining room the lunch service was taking place and there are thermal cups available for use and a machine with coffee in it on a table. The plastic thermal cups do not have lids. The coffee machine has a lever that you pull down and fill the coffee cup with. A cup of coffee water temperature was taken with a calibrated metal thermometer and documents a temperature of 160.5 degrees Fahrenheit (F). On 4/25/2024 at 12:07 PM, V5 (CNA), stated, We have coffee available for our residents all day. Anytime they want a drink they can go to the window and ask, and we always have coffee available. On 4/25/2024 at 12:11 PM during lunch coffee was available to all residents and R150 and were observed getting up and getting her own cup of coffee. The coffee was steaming from the cup. On 4/25/2024 at 12:14 PM, R150 stated, Yes, the coffee is really hot, look at that steam. 04/25/2024 2:06 PM R42 went into the dining room and got herself a cup of coffee. On 4/25/2024 at 2:06 PM, in the main dining room there is a group activity going on and there are thermal cups available to use. A cup of coffee temperature was taken with a calibrated metal digital thermometer and documents a temperature of 160.5 degrees F. On 4/25/2024 at 2:08 PM, R42 stated that she always gets her own coffee here and there is always coffee sitting there on the table with cups. She continued to state, The coffee is really hot you can see the steam coming out of it. I usually put my silverware in my coffee to cool it off. I love coffee. On 4/25/2024 at 2:59 PM, in the main dining room there are residents inside watching a movie on the projector screen. The coffee is still available and coffee temperatures were taken with a calibrated metal digital thermometer and documents a temperature of 159.5 degrees F. On 4/25/2024 at 3:13 PM, V7 (Dietary Cook) stated, We always try and have hot coffee always available for residents. On 4/25/2024 at 4:10 PM, the coffee temperature was taken with a metal, digital thermometer and documents a temperature of 158.5 degrees F. On 4/26/2024 at 12:47 PM, V19 (Dietary Manager) stated I just took the temperatures on the coffee, and they were 180 degrees Fahrenheit, and the holding temperature was 165 degrees. I talked with Folgers manufacture, and they recommended the temperature to be 195 degrees to 205 degrees Fahrenheit. On 4/25/2024 at 2:26 PM, V21 (Nurse Practitioner) stated, If a resident had a burn and there was a blister, I would expect it was a second- or third-degree burn. If the coffee or hot liquid was extremely hot it could easily cause a second- or third-degree burn. (R21) was treated for a blister/burn. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145406 If continuation sheet Page 6 of 8 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 04/30/2024 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 - Immediate jeopardy to resident health or safety Residents Affected - Many On 4/25/2024 at 2:29 PM, V22 (Medical Director) stated, If a resident gets a blister from a burn, I would consider it to be a second degree burn. Ideally, we would not want the liquid to be that hot so if a resident did spill the drink, and with this population they are some high-risk groups, there would not be any injury from spilling the beverage. The Precautions for Hot Beverages Policy, dated 2022, documented, The temperature for brewing and serving hot beverages will be based on the manufacture recommendations for the beverage equipment utilized in each community. Although, the recommended setting for proper brewing will vary based on community equipment, it is recommended that the temperature of the equipment be set at the lowest possible temperature for adequate brewing, anticipated to be in the range of 160 F to 170 degrees F. The serving temperature should be approximately 10 to 15 degrees less that the brewing temperature. Additional precautions may be implemented based on the needs of each resident and may include Assessing and identifying those individuals served who are at high risk for burning themselves with hot beverages. Ensure staff monitors the identified high-risk residents during mealtimes, and/or when hot beverages are served. Utilizing spill proof lids and cups for those individuals identified as high risk for spillage and potential for burning. Assessing those individuals who request beverages served hotter than the guidelines outline above for the ability to consume hot beverages independently and safely. The Long -Term Care Facility Application for Medicare and Medicaid form dated 4/23/2024 documented the facility had a census of 51 residents. The Immediate Jeopardy that began on 2/8/24 was removed on 4/30/24 when the facility took the following actions to remove the immediacy: 1. On 4/26/2024 at 4:00 PM, the coffee maker machine in the dining room was removed by V19 (Dietary Manager) and is no longer in use for meals or activities. 2. Safe hot liquid temperature range identified by Manufacturer recommendations for the beverage equipment utilized. A. It is recommended that the temperature of the equipment be set at the lowest possible temperature brewing anticipated to be in the range of 160 degrees to 170 degrees Fahrenheit. 3.On 4/30/2024 at 8:00 AM, V19 (Dietary Manger) will ensure coffee temperatures are brewed at recommended levels and temperatures will be monitored until the coffee reaches a safe temperature (between 135 to 145 degrees) and the temperature is documented on temperature logbook by dietary cooks and overseen by the dietary manager. A-Once the coffee is at an acceptable safe temperature range documented on the logbook the coffee will be available for resident consummation. B-All coffee will be handed out of the kitchen by dietary staff and no longer be available to self- serve. No coffee will be available for use unless it has reached the safe temperature level recorded by staff. 4. On 4/30/2024 Kitchen staff will be in serviced by V19 (Dietary Manager) on coffee temperatures logging coffee temperatures and ensuring coffee has been cooled to the safe temperature before residents are served any coffee. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145406 If continuation sheet Page 7 of 8 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 04/30/2024 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 - Immediate jeopardy to resident health or safety Residents Affected - Many 5. On 4/30/2024 Certified Nursing Assistants and nursing staff will be in-serviced by V2 (Director of Nursing) and V3 (Assistant Director of Nursing) regarding getting coffee from the kitchen and not serving coffee that has not been cooled, residents' capabilities of handling hot coffee/hot beverages, and watching for steam and potential for burns. No staff (kitchen, CNAs, nursing) will begin shift prior to getting this Inservice. This is to ensure that anyone who is taking time off will be in-serviced prior to starting their shift. 6. Hot Liquid beverage policy was reviewed/revised by V1(Administrator) on 4/30/24. A.V19 (Dietary Manager) in-service all kitchen personal on Hot Liquid policy on 04/30/24. B.V2 and V3 in-serviced Nursing and CNAs on the new policy for Hot Beverages on 4/30/24. 7. QAPI Plan: A. On 4/30/2024 at 8:00 AM, V19 (Dietary Manger) will ensure coffee temperatures are brewed at recommended levels and temperatures will be monitored until the coffee reaches a safe temperature (between 135 to 145 degrees) and the temperature is documented on temperature logbook by dietary cooks and overseen by the dietary manager and all kitchen staff are aware and taking temperatures and documenting temperatures in the log. Staff will be in serviced on watching for steam and taking temperatures before serving residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145406 If continuation sheet Page 8 of 8