Inspection·March 20, 2024

F 0825 Provide or get specialized rehabilitative services as required for a resident. 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 provide rehabilitation services to four (R1, R2, R3, R4) residents out of four residents reviewed for Rehabilitation Services in a sample list of four residents. Residents Affected - Some Findings include: The Facility Daily Census dated 3/20/24 documents 24 residents reside in facility. The Facility Assessment updated 1/9/2024 documents the facility will provide therapy services including Physical Therapy (PT), Speech Therapy (ST) and Occupational Therapy (OT). On 3/20/24 at 3:45 PM V1 (Administrator) stated The previous therapy company gave our facility five days' notice that they were leaving. Their last day was 2/18/24. We (facility) have not had any therapy services since 2/18/24. We (facility) have been working diligently on regaining therapy services from another therapy company. We have not admitted any new residents but those that are involved have not received any therapy. 1.) R1's undated Face Sheet documents R1 admitted to facility on 2/22/2023. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. R1's Physician Order Sheet (POS) dated March 2024 documents physician orders dated 2/8/24 with no discontinuation date for Occupational Therapy (OT) and Physical Therapy (PT) to evaluate and treat as indicated and to start OT upon authorization from insurance carrier. The facility 'Therapy List' updated 2/20/2024 documents R1 was approved for ten therapy visits to be provided three times per week from 2/13/24-3/8/24. On 3/20/24 at 12:48 PM R1 stated I was receiving therapy to strengthen my legs. I only saw them one time before they left. They (therapy) haven't been back since. That was about a month ago. My doctor told me that therapy would be good for me to get stronger. I don't want to lose the strength in my legs. I have a lot of stents around my heart, so I am not supposed to exert myself too much. My doctor told me that strengthening my legs would help my heart not work so hard. I hope my heart doesn't get any worse. I don't know what would happen. 2.) R2's undated Face Sheet documents R2 admitted to facility on 6/3/22. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as cognitively intact. R2's Physician Order Sheet (POS) dated March 2024 documents a physician order starting 2/13/24 for Speech Therapy to Evaluate and Treat as Indicated. Therapy to start upon authorization from insurance carrier. R2's Nurse Progress Note dated 3/6/24 at 10:30 AM documents Care plan meeting held today. Review of cares showed concerns with speech and therapy service needs. Advised that the company is in process of switching over to a new therapy service and unfortunately it is taking longer than projected. Once the new service is up and running, (R2) will be on a list of residents needing therapy services. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145836 If continuation sheet Page 2 of 4 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 03/20/2024 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 0825 Level of Harm - Minimal harm or potential for actual harm The facility 'Therapy List' updated 2/20/2024 documents R2 was approved for ten therapy visits from 2/2/24-3/1/24. On 3/20/24 at 12:45 PM R2 stated R2 was receiving therapy and is not now. R2 stated The therapy company quit so I don't get therapy anymore. Residents Affected - Some 3.) R3's undated Face Sheet documents R3 admitted to facility on 12/28/23. R3's Minimum Data Set (MDS) dated [DATE] documents R3 as cognitively intact. R3's Physician Order Sheet (POS) dated March 2024 documents a physician order starting 2/2/24 with no discontinuation date for Skilled Physical Therapy five times a week for four weeks to include therapeutic exercise, therapeutic activities, neuromuscular reeducation, gait training, electrical stimulation, ultrasound, short-wave diathermy per plan of care End Stage Renal Disease (ESRD). This same POS documents a physician order starting 1/29/24 for Skilled Occupational Therapy three times a week for four weeks to include therapeutic exercise, self-care, neuromuscular reeducation, therapeutic activities, wheelchair management, safety awareness, diathermy/Electric Stimulation (Estim) for diagnosis of ESRD. R3's Nurse Progress Noted dated 2/21/23 at 2:23 PM documents Advised (R3) that due to unforeseen circumstances that our therapy services would be placed on a hold until a new service would be able to start up. The new company is projected to start next week to continue services. (R3) was offered to have an order place to hold therapy order until the new company can start care or have discharge planning started to return home. On 3/20/24 at 3:35 PM R3 stated I came here from the hospital for therapy. They (facility) told me that the therapy department that was here just left one day. (V1) keeps telling me that there is a new therapy company starting but I have not had any therapy in a month. I was on therapy to get my legs stronger so I can go back home. Now, I am just laying here in bed rotting. I want to go home. My legs used to work in the hospital so it wouldn't take much for them to hold me up again. If I don't get therapy soon, I will leave to go somewhere else who has therapy. 4.) R4's undated Face Sheet documents R4 admitted to facility on 2/14/24 and discharge date d of 2/24/24. R4's Minimum Data Set (MDS) dated [DATE] documents R4 as cognitively intact. R4's Physician Order Sheet (POS) dated March 2024 documents a physician order starting 2/15/24 with a discontinuation date of 2/24/24 for Skilled Occupational Therapy five times a week for four weeks to include therapeutic exercise, self-care, neuromuscular reeducation, therapeutic activities, and group therapy. R4's Nurse Progress Note dated 2/21/24 at 11:26 AM documents Advised (R4) that due to unforeseen circumstances that our therapy services would be placed on a hold until a new service would be able to start up. (R4) was offered to have an order place to hold therapy order until the new company can start care or have discharge planning started to return home. On 3/20/24 at 2:30 PM V5 (Licensed Practical Nurse/LPN) stated R4 was utilizing therapy services while at facility. V5 stated R4 went home because R4 could get therapy through home health services since the therapy company quit coming to the facility. On 3/20/24 at 1:30 PM the facility therapy office/gym was locked. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145836 If continuation sheet Page 3 of 4 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 03/20/2024 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 0825 On 3/20/24 from 12:15 PM-4:00 PM No therapy employees were present at facility. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145836 If continuation sheet Page 4 of 4