Inspection·July 19, 2023

F 0552 Level of Harm - Minimal harm or potential for actual harm 3.) R33's Physician Order Sheet (POS) dated July 2023 documents a physician order for Seroquel 100 milligrams (mg) twice daily for Major Depressive Disorder from 3/1/23-7/6/23/23. This same POS documents a physician order for Seroquel 200 mg twice daily starting 7/7/23 with no end date. This same POS documents a physician order for Seroquel 400 mg every evening at bedtime starting 2/22/23 with no end date. Residents Affected - Few R33's Psychotropic medication consent dated 7/7/23 does not document a Diagnosis for the use of Seroquel. On 7/18/23 at 8:30 AM, V2 (Director of Nurses/DON) stated The admission nurse or the nurse taking the order should get the consent for the Psychotropic medication. The consent should include the diagnosis, reason for taking the medication, the side effects, and benefits. It should also be signed and dated by the resident, resident's representative, and a facility witness. All of these things need to be completed on the consent. We (facility) should also obtain a new consent with each new Psychotropic medication and with any increase in dosage. I will have to do an in-service on this with our nurses. The facility policy titled 'Psychotropic Medication Policy' revised 6/17/22 documents Psychotropic medication shall not be administered without the informed consent of the resident, resident's guardian, or other authorized representative. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145836 If continuation sheet Page 2 of 16 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 145836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shelbyville Healthcare & Senior Living 2116 South 3rd Dacey Drive Shelbyville, IL 62565 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to have comprehensive care plans for four of twelve residents (R5, R8, R15, R19) reviewed for care plans in the sample list of 23. Findings include: 1.) R5's Order Summary dated 7/16/23 documents diagnoses including Metabolic Encephalopathy, Cerebral Infarction, Dementia, Repeated Falls, Muscle Wasting and Atrophy, Muscle Weakness, Need for Assistance with Personal Care, Difficulty in Walking, Unsteadiness on Feet, Cognitive Communication Deficit and Unspecified Dementia with Agitation. This Order Summary documents R5 was admitted on [DATE]. The facility's Fall Analysis Log provided on 7/16/23 documents R5 had a fall on 6/29/23 where R5 slid off the footrest of the recliner and on 7/12/23 where R5 attempted an unsafe transfer. R5's Baseline Care Plan dated 6/5/23 does not document any risk for falling or any interventions to prevent falls. R5's Bed Rail/Transfer Bar Evaluation dated 6/5/23 documents R5 has a history of falls. R5's Care Plan dated 7/12/23 documents R5 had an actual fall with no apparent injury. Interventions listed for this problem are that a motion alarm was applied, determine, and address causative factors of the fall, monitor for pain, bruises, or any changes, check range of motion every shift for 72 hours post fall and vital signs every shift for the first 24 hours. There is no documented fall care plan prior to 7/12/23. On 7/16/23 at 8:31 AM, R5 was in R5's room in the recliner. There was a pressure pad alarm sitting in the wheelchair. There was no motion alarm visible in R5's room. On 7/18/23 at 10:34 AM, V2 stated that R5 had the motion alarm in R5's room yesterday (7/17/23) but it was on the bed. V2 stated it was supposed to be on the floor and R5 was not supposed to have the pressure alarm in place. On 7/19/23 at 12:10 PM, V11 (Care Plan Coordinator/Minimum Data Set Nurse and Infection Preventionist) confirmed that there was not a fall care plan documented prior to the fall on 6/29/23. 2.) R8's Order Summary dated 7/16/23 documents diagnoses including Chronic Obstructive Pulmonary Disease, Diabetes, Cerebral Infarction, Hypertension and Presence of Cardiac Pacemaker. This Order Summary documents an order for oxygen at 2 - 5 liter per minute per nasal cannula continuously every day and night shift with a start date of 2/1/23. R8's Care Plan dated 5/12/22 documents R8 has a potential for alteration in cardiac status with an intervention of oxygen and monitoring per physician's orders. Head of bed up to prevent SOB (shortness of breath), may monitor O2 (oxygen) sats (saturation) as needed. R8's Care Plan does not document that R8 receives oxygen continuously or document any interventions to monitor signs and symptoms of low oxygen or to make sure oxygen nasal cannula is in place. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145836 If continuation sheet Page 3 of 16 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 145836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shelbyville Healthcare & Senior Living 2116 South 3rd Dacey Drive Shelbyville, IL 62565 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 0656 Level of Harm - Minimal harm or potential for actual harm On 7/16/23 at 9:21 AM, R8 is in R8's bed and has oxygen on via a nasal cannula and the oxygen concentrator is on and set at 1.5 liters per minute. On 7/19/23 at 12:10 PM, V11 confirmed that V11 needs to add continuous oxygen to R8's Care Plan and V11 stated V11 will add interventions for the oxygen to R8's Care Plan as well. Residents Affected - Some 3. R15's progress note dated 7/17/2023 at 12:37PM documents Hospice services continues as directed. Resident displays signs /symptoms of pain today. PRN (as needed) pain management as directed with effective results noted. R15's Minimum Data Set (MDS) dated [DATE] documents R15 receives hospice services. On 7/17/23 at 11:30AM, V4 (Licensed Practical Nurse/LPN) stated, R15 is on hospice. R15's Care Plan dated 5/26/23 does not include Hospice services. On 7/19/23 at 11:00AM, V11 (Care Plan Coordinator) stated, I see R15's hospice is not on the care plan. It should have been. I will put it on today. 4. R19's smoking assessment dated [DATE] documents R19 smokes. R19 was observed smoking at designated smoking times/areas daily supervised by staff. R19's Care Plan dated 5/26/23 does not include smoking safety. R19's Minimum Data Set (MDS) dated [DATE] documents R19 smokes. On 7/19/23 at 11:00AM, V11 (Care Plan Coordinator) stated I see R19's smoking is not on the care plan. It should have been. I will put it on today. The facility's policy Comprehensive Care Plan revised 7/20/22 states It is the policy of (the facility) to comprehensively assess and periodically reassess each resident admitted to the facility. This resident assessment shall serve as a basis for determining each resident's strengths, needs, goals, life history, and preferences to develop a person-centered care plan for each resident to describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145836 If continuation sheet Page 4 of 16 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 145836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shelbyville Healthcare & Senior Living 2116 South 3rd Dacey Drive Shelbyville, IL 62565 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 - Minimal harm or potential for actual harm Residents Affected - Few 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 implement resident centered fall interventions and failed to completely investigate falls/determine root cause for one of five residents (R5) reviewed for falls in a sample list of 23. Findings include: 1.) R5's Order Summary dated 7/16/23 documents diagnoses including Metabolic Encephalopathy, Cerebral Infarction, Dementia, Repeated Falls, Muscle Wasting and Atrophy, Muscle Weakness, Need for Assistance with Personal Care, Difficulty in Walking, Unsteadiness on Feet, Cognitive Communication Deficit and Unspecified Dementia with Agitation. This Order Summary documents R8 was admitted on [DATE]. R5's Minimum Data Set (MDS) dated [DATE] documents R5 requires extensive assistance of two staff for transfers and limited assistance of one staff member for ambulating in R5's room. R5's Fall Investigation dated 6/29/23 at 6:00 AM documents, Incident Description: (R5) laying on floor on left side. Lift chair beside (R5) with leg rest up. (R5) states (R5) slid off footrest of the chair onto the floor while trying to get out of chair. (R5) states (R5) slid onto (R5's) buttock but (then) laid down and put hand under (R5's) head to be more comfortable. There was no root cause determined for this fall. On 7/17/23 at 2:13 PM, V2 (Director of Nursing/DON) stated regarding R5's fall on 6/29/23 that R5 is supposed to be a one assist and R5 got up without assistance. V2 stated that V2 does not know why R5 was getting up. V2 stated that R5 is non-compliant. R5's Incident Audit Report dated 7/17/23 for the fall on 7/11/23 documents, Nurse walked in room and observed (R5) sitting on floor about a foot from (R5's) recliner. (R5) had recliner reclined all the way and appears that (R5) slid off the foot of the recliner. (R5) had a pre-existing scab to the left elbow that was bleeding around the scab. No other injuries noted. There was no root cause determined for this fall. This report documents an intervention of a motion alarm. On 7/17/23 at 2:13 PM, V2 stated regarding R5's fall on 7/12/23 that it appeared R5 tried to independently transfer R5's self. V2 stated that R5 is supposed to have a motion alarm in R5's room now because R5 turns off the pressure alarm. On 7/16/23 at 8:31 AM, R5 was in R5's room in the recliner. There was a pressure pad alarm sitting in the wheelchair. There was no motion alarm visible in R5's room. On 7/17/23 at 9:56 AM, V12 (Certified Nursing Assistant/CNA) was in R5's room with another unidentified CNA. V12 stated that R5 walks, and they just help R5. R5 walked out of the bathroom with a gait belt on and a walker in front of R5. V12 and the unidentified CNA were holding onto R5 while walking behind R5 and next to R5. R5 walked to the recliner and sat down on a pressure pad alarm that was sitting in the recliner. V12 lowered the recliner and raised the footrest with the controller. V12 stated that as soon as R5 sits on the pressure alarm it activates. On 7/18/23 at 10:34 AM, V2 stated that R5 had the motion alarm in R5's room yesterday (7/17/23) but it was on the bed. V2 stated it was supposed to be on the floor and R5 was not supposed to have the pressure alarm in place. V2 stated that the motion alarm is on the floor where it is supposed to be now and V2 removed the pressure alarm from R5's room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145836 If continuation sheet Page 5 of 16 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 145836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shelbyville Healthcare & Senior Living 2116 South 3rd Dacey Drive Shelbyville, IL 62565 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 - Minimal harm or potential for actual harm The facility's Fall Prevention policy with a revised date of 11/10/18 documents, Policy: To provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145836 If continuation sheet Page 6 of 16 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 145836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shelbyville Healthcare & Senior Living 2116 South 3rd Dacey Drive Shelbyville, IL 62565 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to administer oxygen at the correct setting for one of two residents (R8) reviewed for oxygen administration in the sample list of 23. Residents Affected - Few Findings include: The facility's Oxygen Therapy policy with a reviewed date of March, 2019 documents, Oxygen (O2) is administered to promote adequate oxygenation and provide relief of symptoms of respiratory distress. Procedure: 1. Verify physician's order. 8. Adjust delivery rate per the physician's order. R8's Order Summary dated 7/16/23 documents diagnoses including Chronic Obstructive Pulmonary Disease, Diabetes, Cerebral Infarction, Hypertension and Presence of Cardiac Pacemaker. This Order Summary documents an order for oxygen at 2 - 5 liter per minute per nasal cannula continuously every day and night shift with a start date of 2/1/23. On 7/16/23 at 9:21 AM, R8 is in R8's bed and has oxygen on via a nasal cannula and the oxygen concentrator is on and set at 1.5 liters per minute. On 7/17/23 at 9:46 AM, R8 is in R8's bed and R8's oxygen concentrator is set at 1.5 liters per minute. On 7/17/23 at 1:38 PM, R8 is in R8's bed in R8's room and R8's oxygen is on via a nasal cannula and the oxygen concentrator is set at 1.5 liters per minute. On 7/17/23 at 2:20 PM, V2 (Director of Nursing/DON)confirmed that the oxygen was set on 1.5 liters and stated that V2 thinks that it is supposed to be set on 2 liters per minute. On 7/17/23 at 3:00 PM, V2 confirmed R8's Physician's Orders document R8's oxygen concentrator is supposed to be set at 2 liters per minute. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145836 If continuation sheet Page 7 of 16 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 145836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shelbyville Healthcare & Senior Living 2116 South 3rd Dacey Drive Shelbyville, IL 62565 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 interview and record review the facility failed to provide the services of a Registered Nurse for eight consecutive hours seven days a week for 11 of 14 days reviewed. This failure has the potential to affect all 34 residents residing in the facility. Findings Include: The facility's Nurse Staffing policy with a review date of 12/7/17 documents, It is the policy of (the facility) to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical, physical, mental, and psychosocial well-being of each resident. Nurse staffing shall be based upon resident evaluation by the Administrator and the Director of Nursing as specified by the Illinois Department of Public Health. On 7/16/23 at 7:55 AM, V4 (Licensed Practical Nurse/LPN) stated that V4 was the only nurse working in the building at that time. The facility's nursing daily working schedules from 7/1/23 through 7/14/23 document the facility did not have the services of a Registered Nurse (RN) for eight consecutive hours on 7/2/23, 7/3/23, 7/4/23, 7/5/23, 7/6/23, 7/7/23, 7/8/23, 7/9/23, 7/12/23, 7/13/23 and 7/14/23. On 7/17/23 at 11:13 AM, V2 (Director of Nursing/DON) confirmed that if there is no RN's (Registered Nurses) documented on the daily staffing sheets there was no RN on duty. If it was a weekend, V2 stated that V2 came in to do the PICC (Peripherally Inserted Central Catheter) line and confirmed if V2 wasn't written on the daily schedule V2 did not work on the floor. The facility's Resident Census and Conditions of Residents report dated 7/16/23 documents 34 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145836 If continuation sheet Page 8 of 16 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 145836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shelbyville Healthcare & Senior Living 2116 South 3rd Dacey Drive Shelbyville, IL 62565 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview, and record review the facility failed to post daily Nurse staffing. This failure has the potential to affect all 34 residents residing in facility. Residents Affected - Many Findings include: The Facility Resident Census and Conditions of Residents report dated 7/16/23 documents 34 residents reside in facility. On 7/16/23, 7/17/23 and 7/18/23 there was no daily nurse staffing information posted in the facility. On 7/17/23 at 12:01 PM, V1 (Administrator) confirmed there is no daily nurse staffing information posted in the facility. V1 stated V1 was not aware that it needed to be posted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145836 If continuation sheet Page 9 of 16 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 145836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shelbyville Healthcare & Senior Living 2116 South 3rd Dacey Drive Shelbyville, IL 62565 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview and record review the facility failed to complete psychotropic medication assessments, implement/evaluate resident centered interventions, and identify and track targeted behaviors for four of six residents (R19, R12, R9 and R18) reviewed for psychotropic medications in a sample list of 23 residents. Findings include: 1. R19's Medication Administration Record (MAR) for July, 1.2023 to July 31,2023 include orders for: 1. CLONAZEPAM (antianxiety) 0.5 Milligram Give 1 tablet orally at bedtime 2. QUETIAPINE (antipsychotic) 25 MG TAB Give 1 tablet orally at bedtime. 3. TRAZODONE (anti-depressant) 150 MG TABLET Give 2 tablet orally at bedtime. 4. VENLAFAXINE ER (antidepressant) 150 MG Capsules Give 1 capsule orally two times a day. R19's Psychotropic Medication Quarterly evaluations are dated 8/26/22, 11/22/22, and 5/25/23. Therefore, they are not done on a quarterly basis. There is no documented psychotropic assessment for R19's Venlafaxine ER. There are no resident specific targeted behaviors being tracked. No nonpharmacological interventions are documented. 2. R12's Medication Administration Record (MAR) for July, 1.2023 to July 31,2023 includes orders for: 1. DULOXETINE HCL DR (antidepressant) 20 MG CAP Give 1 capsule orally one time a day. 2. Buspirone (antianxiety) Tablet 5 MG Give 1 tablet by mouth two times a day. QUETIAPINE (antipsychotic) 25 MG TAB Give 1 tablet orally two times a day. R12's physician's orders for Duloxetine and Quetiapine originated 2/1/23 and R12's order for Buspirone originated 5/4/23. There are no resident specific targeted behaviors being tracked. No nonpharmacological interventions are documented. R12's Psychotropic Medication Quarterly evaluations are dated 6/8/23 and 7/7/23. Therefore, they are not done on a quarterly basis. On 7/19/23 at 11:30AM, V10 (Licensed Practical Nurse/LPN) verified that there are missing psychotropic assessments and nonpharmacological interventions for R19 and R12. V10 stated, I didn't realize the CNAs need to document the interventions they implement when a behavior happens and how the resident responds. 3.) R9's Medical Record documents medical diagnoses of Depression, Anxiety and Bipolar disorder. R9's Physician Order Sheet (POS) dated June 2023 documents a physician order dated 6/27/23 for Trazadone 25 mg every 24 hours as needed. This same POS documents a physician order for Divalproex Sodium Extended Release (ER) 500 mg every bedtime. R9's Medical Record does not include behavior tracking from 2/1/23-7/18/23. R9's Nurse Progress Note dated 6/3/23 at 9:25 AM, documents, (R9) became upset and yelling at staff when staff would not transfer (R9) without walker. When staff attempted to advise why the walker was needed, (R9) began to yell/cuss at staff. (R9) threw his walker at staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145836 If continuation sheet Page 10 of 16 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 145836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shelbyville Healthcare & Senior Living 2116 South 3rd Dacey Drive Shelbyville, IL 62565 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 0758 Level of Harm - Minimal harm or potential for actual harm 4.) R18's undated Face Sheet documents an admission date of 6/15/23 with a medical diagnosis of Depression. R18's Physician Order Sheet (POS) dated July 2023 documents a physician order for Zoloft 25 mg daily for Depression. Residents Affected - Some R18's Nurse Progress Notes do not document any behaviors or signs of depression. R18's Medical Record does not include behavior tracking from 2/1/2023-7/18/23. On 7/18/23 at 9:05 AM, V2 (Director of Nurses/DON) stated behavior tracking was not completed for R9 or R18 since February 2023. V2 stated Our facility started charting electronically on 2/1/23 so apparently those two (R9, R18) got missed when we (facility) inputted all of that information. The facility policy titled 'Psychotropic Medication Policy' revised 6/17/22 documents the behavioral tracking sheet of the facility will be implemented to ensure the behaviors will be monitored. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145836 If continuation sheet Page 11 of 16 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 145836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shelbyville Healthcare & Senior Living 2116 South 3rd Dacey Drive Shelbyville, IL 62565 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to prevent cross contamination during meal service in a sample list of 34 residents. This failure has the potential to affect all 34 residents residing in facility. Findings include: The Daily Census Midnight Report dated 7/16/23 documents 34 residents residing in facility. On 7/16/23 at 12:00 PM, V13 (Head Cook) applied gloves to plate lunch meal. V13 rubbed V13's temple area on face two separate times while wearing serving gloves. V13 then used same contaminated gloves to serve meals. V13 (Head Cook) wore same contaminated gloves to adjust V13's glasses one time, then a separate time, V13 used same contaminated gloves to remove glasses. V13 picked up a meal card from the floor, removed gloves, and used the sink sprayer to rinse the tips of V13's fingers on Left hand for less than two seconds. V13 did not use hand hygiene during meal service after contaminating serving utensils used to plate resident meals. On 7/16/23 at 12:45 PM, V13 (Head Cook) stated, I can't believe I even did that. I know better than to cross contaminate all of the food for the residents. I should have changed my gloves or just not even messed with my face or glasses. I have been doing this long enough to know better. On 7/18/23 at 1:00 PM, V14 (Certified Dietary Manager/CDM) stated, Our (facility) staff has all been trained over and over about cross contamination issues in the kitchen. (V13) Head [NAME] does know better than to wear gloves and touch (V13's) face and glasses. V13 should have removed her gloves, performed hand hygiene, and then went on to finish plating meals. The facility policy titled 'Glove Usage' dated 10/17 documents employees will wash their hands thoroughly before and after wearing or changing gloves. Gloves should be changed after sneezing, coughing, or touching hair and/or face. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145836 If continuation sheet Page 12 of 16 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 145836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shelbyville Healthcare & Senior Living 2116 South 3rd Dacey Drive Shelbyville, IL 62565 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to have the required members attend the Quality Assurance Performance Improvement (QAPI) meetings. This failure has the potential to affect all 34 residents residing in the facility. Residents Affected - Many Findings include: On 7/17/23 at 9:30 AM, the QAPI Quarterly Meeting sign in sheets provided by V1 (Administrator) documents the Quarter 4 of 2022 meeting dated 10/4/22 sign in sheet did not have a Director of Nursing in attendance, the Quarter 1 of 2023 meeting dated 1/3/23 sign in sheet did not have a Director of Nursing in attendance, and the Quarter 2 of 2023 meeting dated 4/4/23 sign in sheet did not have a Director of Nursing in attendance. On 7/17/23 at 9:35 AM, V1 (Administrator) confirmed that they did not have a Director of Nursing (DON) at those meetings. V1 stated that they just hired a DON in May, and they went a long time without one. The facility's Resident Census and Conditions of Residents report dated 7/16/23 documents 34 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145836 If continuation sheet Page 13 of 16 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 145836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shelbyville Healthcare & Senior Living 2116 South 3rd Dacey Drive Shelbyville, IL 62565 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Few Based on observation, interview, and record review, the facility failed to prevent cross contamination during pressure ulcer dressing change for one (R186) resident of two residents reviewed for pressure ulcers. Findings include: R186's Medical Diagnosis list documents a diagnosis of Stage 4 Sacral Pressure Ulcer. R186's Minimum Data Set (MDS) dated [DATE] documents R186 as moderately cognitively impaired. This same MDS documents R186 as requiring extensive assistance of two people for bed mobility, transfers, dressing, toileting, and extensive assistance of one person for personal hygiene. R186's Physician Order Sheet (POS) dated July 2023 documents a physician order for Eravacycline Dihydrochloride Intravenous Solution Reconstituted 50 milligrams (mg) every 12 hours for wound infection. This same POS documents a physician order for Linezolid Oral Tablet 600 MG twice daily for Stage 4 Sacral Pressure Ulcer infection. On 7/17/23 at 2:20 PM, V4 (Licensed Practical Nurse/LPN) completed R186's Stage 4 Sacral Pressure Ulcer dressing change with V9 (Certified Nursing Aide/CNA) assisting. V4 (LPN) removed R186's saturated dressing and placed it on an incontinence pad that was underneath R186. After V4 completed the dressing change, V9 (CNA) removed the incontinence pad saturated with wound drainage and stool. V9 (CNA) handed the soiled, saturated incontinence pad over R186's mid-section to V4. V9 continued to adjust R186's gown, sheets and covers while wearing same contaminated gloves. V4 (LPN) placed the soiled, saturated incontinence pad in a garbage can across the room. V4 then returned to R186 to adjust covers without using hand hygiene. On 7/17/23 at 2:45 PM, V9 (Certified Nurse Aide/CNA) stated, I didn't realize what I was doing but I can see why we (staff) should not do that. It could cause (R186's) wound to get worse. On 7/17/23 at 2:50 PM, V4 (LPN) stated, I thought I did so good right up until the end. R186 has a horrible pressure ulcer that is already infected. I should have been more careful. On 7/18/23 at 8:30 AM, V2 (Director of Nurses/DON) stated, Our (facility) staff should never pass a soiled incontinence brief with infected wound drainage over the top of any resident. R186 already has an infected Stage 4 Pressure Ulcer. We (facility) do not need to make it any worse. I will educate our staff on cross contamination of pressure wounds. The facility policy titled 'Dressing Change' revised 3/16/23 documents staff should remove soiled dressing and place in plastic bag. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145836 If continuation sheet Page 14 of 16 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 145836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shelbyville Healthcare & Senior Living 2116 South 3rd Dacey Drive Shelbyville, IL 62565 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Few Based on interview and record review the facility failed to follow their Antibiotic Stewardship policy for one of two (R19) residents reviewed for Antibiotic Stewardship in a sample list of 23. Findings include: The facility policy titled 'Antibiotic Stewardship Program' reviewed 3/20/23 documents the use of antibiotics in healthcare to protect residents and reduce the threat of antibiotic resistance through a set of commitments and actions designed to optimize the treatment of infections while reducing adverse events associated with antibiotic use. This same policy instructs staff to determine whether the resident's documented signs and symptoms align with the recommended minimum criteria for initiating antibiotics. This same policy instructs staff to determine whether the infection met the criteria for Centers for Disease Control and Prevention (CDC) standard definitions for infection surveillance in long term care. R19's diagnoses list printed 7/19/23 at 9:31AM includes the following diagnoses: Chronic Obstructive Pulmonary Disease and Morbid Obesity. R19's smoking assessment dated [DATE] documents R19 smokes. R19's Medication Administration Record (MAR) dated July 1, 2023, to July 31st, 2023, includes an order for: Levaquin (antibiotic) Oral Tablet 750 MG (Levofloxacin) Give 1 tablet by mouth in the morning related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE. There is no documentation to support an infectious disease process. There are no orders for lab or X-ray to indicate an infectious process. On 7/19/23 at 10:30AM, V11 (Care Plan Coordinator) stated, I saw that there was an order for Levaquin for (R19) and no chest X-ray or lab or any notes to indicate an infection. I wondered about that myself. V11 verbalized the facility does not use a specific criterion for antibiotic necessity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145836 If continuation sheet Page 15 of 16 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 145836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shelbyville Healthcare & Senior Living 2116 South 3rd Dacey Drive Shelbyville, IL 62565 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation, interview and record review, the facility failed to provide bedrooms that measure at least 80 square feet per resident bed. This failure affects 34 out of 34 residents all of whom occupy Medicare or Medicaid certified beds in the facility. Findings include: The facility Daily Midnight Census Report dated 7/16/23 documents 34 residents reside in facility. The undated Centers for Medicare and Medicaid Services Certification and Transmittal, documents 80 of the facility's 80 beds are certified Title 18 (Medicare) and/or Title 19 (Medicaid). Rooms 402-407 are double occupancy and dually certified for Medicare and Medicaid, while rooms 101-112, 201-210, 300-311 and 401 are double occupancy and certified for Medicaid. On 7/17/23 at 1:30 PM, observed V8 (Maintenance Director) measure a resident room. Room measured 72.5 square feet per resident bed in a double occupancy room. Observed R33's room to contain two twin beds, two dressers, one recliner chair, a double-sized closet and privacy curtain to separate beds. On 7/17/23 at 2:00 PM, R33 stated, My room is fine the way it is. I would like a palace, but that ain't gonna happen. It is close but I don't mind. On 7/16/23 at 9:30 AM, V1 (Administrator) stated facility has 80 certified beds all of which do not meet the regulation size of 80 square feet per resident. V1 stated This happens every year. None of our (facility) rooms are regulatory size. They are all too small. We (facility) use some of the rooms for offices but if we had to, we could always turn those back into resident dual occupancy rooms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145836 If continuation sheet Page 16 of 16