Health inspection·July 13, 2023

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide residents privacy during transferring and wound care for 2 of 4 residents (R27 and R42) reviewed for privacy in a sample of 40. Residents Affected - Few Findings include: 1. On 07/11/2023 at 1:25 PM, V16, Physical Therapy Assistant, brought R27 back into her room, asked R27 if she wanted to lay down. R27 stated Yes. R27's roommate, R159 was in the room at the time. V16 did not close the curtain between R27 and R159 nor did she close the blind to the window to provide privacy during transferring R27 to the bed or during repositioning. 2. On 07/12/2023 at 9:45 AM, V15, Registered Nurse (RN) entered R42's room to perform wound care. V7, Licensed Practical Nurse (LPN) also entered R42's room and shut R42's door to the hallway but no one closed the blinds to the window facing the patio where residents, staff and visitors were. V15 performed a dressing change to R42 left buttock with his buttock facing the open window to the patio. R52 and V19, R52's husband, were outside of R42's window while the dressing change was being performed. Also walking past R42's window was V20, Activities Director, and R21. V20 was pushing R21 in a wheelchair while the window blinds were opened. On 07/12/2023 at 3:55 PM, during an interview with V1, Administrator, and V2, Director of Nurses, both stated that they would expect the staff to provide privacy by pulling the door shut, pulling the privacy curtain, and shutting the window blinds when providing care to residents. The facility's policy, Resident Rights, dated October 2017, documented, Privacy and Confidentiality. The resident has a right to person privacy and confidentiality of his or her personal and medical records. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meeting of family and resident groups but this does not require the facility to provide a private room for each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145502 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 145502 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Taylorville Care Center 600 South Houston Taylorville, IL 62568 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 follow physician's orders for the treatment of pressure ulcers for 1 of 3 residents (R36) reviewed for pressure ulcers in the sample of 40. Residents Affected - Few Findings include: The Facility's Wound Summary Report dated 6/1/2023-6/30/2023 documents R36 has an open area to her left hip which was identified on 4/20/2023 and was not present upon admission. It continues to document the pressure ulcer has been open 72 days. It further documents the initial size was 0.4 cm (centimeters) x 0.4 cm. The Facility's Wound Log documents R36's pressure ulcer is declining and as of 6/29/2023, the pressure ulcer measures 1.5 cm x 1 cm. R36's Minimum Data Set, MDS, dated [DATE] documents R36 is cognitively impaired, frequently incontinent of bowel/bladder and requires extensive assistance for turning and repositioning. R36's Care Plan dated 6/5/2023 documents, Problem: I am at risk for skin breakdown r/t (related to) incontinence, decreased mobility secondary to dx of dermatitis, PVD (peripheral vascular disease), hx (history) of diabetes, pain, decreased nutritional intake. Reoccurring left hip ulcer. Approach: Apply all treatments as per MD order. Approach: Left hip- provide treatment as ordered. Monitor for s/s (signs and symptoms) of infection. Notify MD, hospice and POA (Power of Attorney) of any change in condition. R36's Physician's Orders dated 6/29/2023 documents, Cleanse open area to left hip with wound cleanser. Pat dry. Apply collagen with silver sheet to wound bed and cover with border gauze every day and PRN for soiling and dislodging. On 7/11/2023 at 11:14 AM, R36's left hip had a bandage dated 7/9/2023. On 7/12/23 at 9:14 AM, V3, Assistant Director of Nursing (ADON) stated that the floor nurses are responsible for doing the pressure ulcer treatments. On 7/13/2023 at 11:47 AM, V1, Administrator, stated she would expect treatment orders to be followed and carried out as the physician prescribed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145502 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 145502 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Taylorville Care Center 600 South Houston Taylorville, IL 62568 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - 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 ensure residents have water available for hydration purposes for 2 of 3 residents (R25, R33) reviewed for hydration in the sample of 40. Residents Affected - Few Findings include: 1. R25's Minimum Data Set, MDS, dated [DATE], documents R25 is severely impaired cognitively. It further documents R25 eats and drinks independently but requires set up. R25's Care Plan dated 5/22/2023 documents R25 has limited physical ability, a history of Urinary Tract Infections (UTI) and is at risk for impaired nutrition and hydration related to cognitive loss. R25's Care Plan includes approaches to encourage adequate fluid intake. On 7/10/2023 at 9:20 AM, R25 was in her room, with her bedside table nearby. There was no available water/fluids or water pitcher in R25's room. At this time, V5, Certified Nursing Assistant (CNA) stated there is not enough water pitchers for every resident and that she brought the issue to (V21's, Medical Records) attention because she does the ordering. On 7/10/2023 at 2:25 PM, R25 was in her room, with no water pitcher or fluids available. On 7/11/2023 at 8:21 AM, R25 was in her room, without water or any form of hydration accessible. On 7/11/2023 at 3:00 PM, R25 was in her room, without water or any form of hydration accessible. On 7/12/2023 at 9:20 AM, R25 was in her room, without water or any form of hydration accessible. 2. R33's MDS dated [DATE] documents R33 is independent with eating and drinking. R33's Care Plan reviewed 6/19/2023 documents, Category: Dehydration/Fluid maintenance. Problem-R33 is at risk for alteration in fluid volume related to use of diuretic medication. Approach Encourage fluids with meals and in between as tolerated. It further documents R33 has limited physical mobility. On 7/10/2023 at 9:45 AM, R33 was in her room with no water pitcher/fluids available. On 7/10/2033 at 2:26 PM, R33 was in her room, with no water pitcher/fluids available. On 7/11/2023 at 8:21 AM, R33 was in her room, without water or any form of hydration accessible. On 7/11/2023 at 3:00 PM, R33 was in her room, without water or any form of hydration accessible. On 7/12/2023 at 9:20 AM, R33 was in her room, without water or any form of hydration accessible. On 7/11/2023 at 2:04 PM, V9, Certified Nursing Assistant (CNA) stated the staff pass ice water once a shift, but R25 and R33 don't have a water pitcher because they will sling it in the hall if it is in front of them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145502 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 145502 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Taylorville Care Center 600 South Houston Taylorville, IL 62568 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 7/12/2023 at 3:28 PM, V1, Administrator stated she would expect residents to have fluids readily available, unless they were NPO (Nothing by Mouth). The Facility's Policy dated December 2016 documents, Hydration: Policy It is the policy of (Facility) to provide residents with adequate fluids, including water and other liquids that are consistent with resident needs and preferences and sufficient to maintain resident hydration. Procedure 1. Fluids and snacks will be offered to each resident in accordance with the Dietary Snack times or based on individual needs or preferences. 2. Staff will offer fluids on a routine basis. This will be in addition to the fluids offered on the meal tray. 3. All residents will be encouraged to drink the fluids offered. 4. Snacks will be offered at HS (bedtime) to all residents. Event ID: Facility ID: 145502 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 145502 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Taylorville Care Center 600 South Houston Taylorville, IL 62568 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 Residents Affected - Many 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 record review and interview, the facility failed to provide a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week on the dates. This has the potential to affect all the 60 residents living in the facility. Findings include: On 07/12/23 at 10:16 AM staffing schedules documented no RN for 8 consecutive hours on the dates of 6/10/2023, 6/25/2023, 7/8/2023 and 7/9/2023. On 07/12/23 at 10:18 AM, V2 (Director of Nursing) stated she did not have RN coverage for the dates of 6/10/2023, 6/25/2023, 7/8/2023 and 7/9/2023. On 07/12/23 at 11:45 AM V1, Administrator, stated she is aware that there are a few days that there was not an RN on staff. The Facility's Resident Census and Conditions of Residents form, CMS 672, dated 7/10/2023 documents that the facility has 60 residents living in the facility. The CMS 672 documented that the facility has 3 residents with pressure ulcers, 10 residents who are bedfast all or most of time, 6 residents with indwelling catheters, 4 residents on Hospice, 12 residents with injections, one resident with an ostomy, one resident on dialysis, 3 residents on antibiotics, 34 residents receiving psychoactive medications and 30 residents on pain management program. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145502 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 145502 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Taylorville Care Center 600 South Houston Taylorville, IL 62568 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review, the Facility failed to ensure mediations that require refrigeration were monitored for the correct/current temperature for storage as well as ensure medications were stored in properly labeled packaging. This Failure has the potential to affect all 60 residents residing in the Facility. Findings include: 1. On 7/10/2023 at 2:11 PM, the medication storage room was observed with V8, Registered Nurse. There was a Refrigerator Temperature Log labeled Med (Medication) Room-Month-May with one Entry, 36 on the 25th. V8 stated, Oh that's not good. Oh great, that's from May. when questioned about the Temperature Log. At this time, the temperature was checked, was 35 degrees (Fahrenheit) and this observation was verified by V8. The Refrigerator Temperature Log further documents, 11-7 Shift is to do nightly checks on the refrigerator temperatures and the temps are to be maintained between 36-40. On 7/11/2023 at 1:58 PM, V2, Director of Nursing stated that the medication fridge houses insulin, suppositories, and their emergency stock Lorazepam. 2. On 7/10/2023 at 2:30 PM, the A-Hall and C-Hall medication cart was inspected with V15, RN. At this time, there were multiple assorted pills scattered in the bottom of the drawer and not contained in a labeled container. V15 stated, I'd say there are least twenty pills down there. The Facility's Storage of Medications Policy dated April 2007 documents, The Facility shall store all drugs and biologicals in a safe, secure and orderly manner. 1. Drugs and biologicals shall be stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. It continues to document, Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. The Facility's Resident Census and Conditions of Residents Form dated 7/10/2023 documents there are 60 residents residing at the Facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145502 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 145502 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Taylorville Care Center 600 South Houston Taylorville, IL 62568 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to perform appropriate hand hygiene while passing out and setting up meal trays for residents and providing care to prevent the spread of infection for 3 of 8 residents (R7, R23 and R27) reviewed for infection control, in a sample of 40. Residents Affected - Few Findings include: 1. 07/10/23 12:15 PM, V12, Certified Nurse Assistant (CNA), without benefit of hand hygiene, rubbed her face, then took a lunch tray to R7 and buttered his roll. She then returned the tray to the window. She did not perform hand hygiene. V12 then touched her shirt and then took R23's lunch tray to her, buttered the roll for her, returned the tray to the kitchen window. 2. On 07/11/2023 at 1:25 PM, V16, Physical Therapy Assistant, brought R27 back into her room, asked R27 if she wanted to lay down. R27 stated yes. Without benefit of hand hygiene or donning gloves, V16 took off her gait belt and placed it on R27, and assisted her into bed, and positioned her by lifting R27's bilateral legs onto the bed and by taking a bed pad and pulling her up in bed. On 07/12/2023 at 3:50 PM, V1, Administrator, and V2, Director of Nurses, both stated that they would expect the staff to perform hand hygiene before and after serving a meal tray and if the touch their face, hair, or clothing and before and after resident care. The facility's policy, Hand Hygiene, undated, documented, Indications for Hand Hygiene: 1. Before having direct contact with residents. 2. Before having contact with residents' food. It continues, Wear gloves when contact with blood or other potentially infection materials (other body fluids, secretions and excretions,) mucous membranes, non-intact skin and contaminated items will or could occur. It continues, Wear gloves if touching a residents' food (e.g., buttering bread.) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145502 If continuation sheet Page 8 of 8