Inspection·August 9, 2024

F 0578 not indicate R179's code status. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145836 If continuation sheet Page 2 of 12 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 08/09/2024 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to promote resident's right to a safe, comfortable homelike environment. This failure affects one of two residents (R14) reviewed for the environment on the sample of 28. Findings include: R14's Minimum Data Set, dated [DATE] documents the following: R14's Brief Interview of Mental Status score as 14 out of a possible 15, which indicates no cognitive impairment. On 08/06/24 at 10:05 am, R14 was lying in bed. Between the head of R14's bed and R14's bedside dresser there was an unpainted, 10-inch hole. The hole had loose, crumbling white plaster-like substance. R14 stated I have gotten use to looking at that. It is not pretty. The hole in the wall has been there since I came to the facility, two years ago. It could use some attention. On 8/7/24 at 11:15 am, during a resident group meeting, R14 stated I told you yesterday about the hole in my wall. You saw it. It is terrible. I set on the side of my bed and eat. I can't help but see it. You should have looked at the ceiling. Rain came in and dripped down, leaving my ceiling is disrepair. The maintenance man (V9 Maintenance Director) said there was a plastic (private grocery company) bag in the gutter. He (V9) removed it and I have not had any leaks since. The ceiling still looks terrible. I have had leaks before, and the old owner never fixed the roof leaks. I would really like my whole room remodeled but that is an unreasonable request. The ceiling and hole in the wall should be repaired though. On 8/7/24 at 1:35 pm V9 (Maintenance Director) and surveyor entered R14's room. There was a three foot long by eight-inch-wide area of the ceiling that had dark brown stains that appeared to be from water seepage. There were also chunks of plaster, stained with water marks bulging at the wall and ceiling junction. The wall below the junction had a two-foot wide by one-foot-high section, above the top window frame with plaster chipped plaster and water like marks. V9 then confirmed the hole on the wall between resident bed and dresser was crumbling plaster. V9 stated The roof was repaired approximately three years ago. The damage to (R14's) ceiling, and wall above the window was a troubled area then and continues to be a troubled area. There was a plastic bag in the gutter and a ton of rain backed up to that troubled area of (R14's) window and ceiling. That was a few months ago. Corporate is very aware of these issues in (R14's) room. They have to release the funds in order for these areas to be fixed. They have not released the funds. The undated facility policy Physical Plant & Environmental Policy & Guidelines documents the following: Policy Statement: It is of the utmost importance to provide a safe, hospitable, clean and organized facility and grounds to ensure an environment that is conducive to providing the best care, comfort and home-like surroundings for residents. A well-maintained building and environment is also important for creating safe work surroundings across all departmental staffing and their ability to effectively, and efficiently provide care and great living environment to all residents and all necessary resources to do so. The building and grounds must be maintained in the best presentable state and must be done so through routine maintenance and upkeep, housekeeping, and ensuring compliance with current federal, state, local and NFPA codes. This includes making certain a safe and hospitable environment as possible is maintained in the event of an emergency for sheltering 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 12 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 08/09/2024 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 0584 Level of Harm - Minimal harm or potential for actual harm Policy Implementation: The facility Administrator must ensure that the overall scope and effective procedures are followed by each departments supervisors and staff or request of approved contractors for creating and maintaining a safe and comfortable environment for the residents, visitors and staff. Ensure maintenance work orders are completed in a timely manner and ensure items necessary for repairs are ordered to complete repairs. Maintenance/Approved Contractors Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145836 If continuation sheet Page 4 of 12 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 08/09/2024 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 R14's Bilevel positive airway pressure (Bi-PAP) mask was replaced in a timely manner which resulted in facial skin breakdown. This failure affected one of one resident (R14) reviewed for the respiratory medical equipment on the sample list of 28. Residents Affected - Few Findings include: R14's Current Physician Order Summary Sheet documents the following: BiPAP wear nightly. Observe resident every four hours while in use. Cleanse mask as needed after each use every shift related to Chronic Obstructive Pulmonary Disease (COPD) Unspecified. R14's Minimum Data Set, dated [DATE] documents the following: R14's Brief Interview of Mental Status score as 14 out of a possible 15, which indicates R14 has no cognitive impairment. R14's Care Plan dated 8/04/24 documents the following: Resident has a potential impairment related to fragile skin. The resident will maintain or develop clean and intact skin by the review date. Educate resident/family/caregivers of causative factors and measures to prevent skin injury. R14's same Care Plan documents the following: The resident has oxygen therapy related to COPD. The resident will have no signs or symptoms of poor oxygen absorption through the review date. BiPAP when sleeping. Setting: expiratory pressure: 5: inspiratory pressure: 15. On 08/06/24 at 9:57 am R14 was lying in bed with an undated Bi-level Positive Airway Pressure (BPAP) facemask on R14's full face secured with straps. On 8/7/24 during resident group interview at approximately 11:15 am, R14 had raw, red bumpy, irritated skin around R14's mouth. The irritated skin above R14's upper lip extended up both sides of R14's nose. The irritated skin on both sides of R14's mouth extended under R14's bottom lip. R14 stated There are liners that go inside my CPAP (Bi-Pap on Physician Order) mask that prevent chapping and irritating my chin and around my mouth. I have been telling the nurses and they passed it on the (V1) Administrator and the DON (V2 Director of Nursing). She (V2) orders all the medical stuff and I have waited well over a week. On 8/8/24 at 8:40 am V2 (DON) acknowledged R14's raw, red, bumpy irritated skin and stated she followed up with medical supply distributor yesterday regarding R14's BiPAP mask order. V2 stated The medical supply company said the facility already received the mask. V2 stated she searched throughout the facility and cannot find the mask was ever received. V2 stated she re-ordered and is having the BiPAP mask shipped overnight. V2 also stated It (new mask) should be here today. (R14's) face is visibly red and irritated. We should have followed up on the original order sooner. The facility provided Resident Rights for People In Long-Term Care Facilities pamphlet dated revised November 2018 documents the following: You should receive the services and/or items included in the plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145836 If continuation sheet Page 5 of 12 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 08/09/2024 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 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 a resident's departure alert system safety bracelet intervention, for twelve days after a resident's elopement. This failure affects one of four residents (R129) reviewed for incident /accidents on the sample list of 28. Findings include: R129's admission Diagnoses Sheet dated 7/24/24 documents the following: Altered Mental Status, Unspecified, Other Abnormalities of Gait and Mobility, Unspecified Lack of Coordination. Unsteady On Feet, and Other Malaise. R129's Admission, Elopement Risk Assessments dated 7/24/24 documents R129 is at high risk of elopement, has a history of elopement from home, is ambulatory, cannot communicate and wanders into other resident rooms. R129's Minimum Data Set (MDS) dated [DATE] documents R129 has a Brief Interview of Mental Status Score of 00 out of a possible 15, which indicates severe cognitive impairment. The same MDS documents R129 has had wandering behaviors 1-3 days during the seven day look back period. R129's Behavior Note signed by V11 (Social Service Director) dated 07/26/2024 at 11:06 am documents the following: Note Text: Res (resident R129) has been wandering the halls and exit seeking. She is easy to redirect and wants staff to go outside with her. She would benefit from having a (departure alert system bracelet) for safety. Orders have been put in for new (departure alert system bracelets) as there are no extras in the building. Please monitor carefully. R129's Health Status Note dated 7/26/24 signed by V14 (Licensed Practical Nurse/LPN) dated 07/26/2024 at 11:59 documents the following: Note Text: Res exited facility x1 (one time). Staff responded to door alarm sounding. Res redirected back inside facility without difficulty. R129's Health Status Note dated 7/30/2024 at 05:40 am documents the following: Note Text: Res (R129) up and wandering since (11:00 pm), (over the time period of six hours and forty minutes per this note note). Res attempted to exit out of back door this morning. Easily redirected. On 8/6/24 at 9:25 am V5 (Certified Nursing Assistant/CNA) was walking with R129 into the dining room. V5 stated I have my hands full, she (R129) likes to wander. On 08/6/24 between 10:15 am - 11:00 am, R129 was observed independently ambulating throughout halls and common areas. On 08/06/24 at 12:35 PM, R129 was seated in the dining room in a straight back chair. R129 does not have a departure alert system safety bracelet on R129's ankles or wrist. On 8/6/24 at 12:55 pm V2 (Director of Nursing) stated (R129) needs a (departure alert system) bracelet. The facility has ordered some, but they have not come in yet. I am not sure what the delay is. V2 acknowledged R129 has been exit seeking. V2 confirmed R129 had actually gotten out of the building (7/26/24). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145836 If continuation sheet Page 6 of 12 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 08/09/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 8/6/24 at 1:05 pm, V1 (Administrator) provided a (private name) supply sheet dated 7/26/24 that documented Resident Transmitter with Band, Waterproof and stated the form V1 provided was the purchase order for R129's (departure alert system) bracelet. Surveyor identified the on the form V1 provided, that it does not say R129's safety device was ordered. What the form documents is as follows: Dear (V9 Maintenance Director), Thank you for giving me the opportunity to quote the products listed below. The product listed was documented as Resident Transmitter with Band, Waterproof price of three $621.53. On 8/7/24 at 9:30 am V1 (Administrator) stated It turned out that the (departure alert system) bracelet for (R129), had not been ordered. That sheet I gave you (8/6/24 at 1:05 pm) was just a quote (noted above). I thought that was an actual order. (R129) should have had one right away. I got her one yesterday from a sister facility. She has it one on now. On 8/7/24 at 10:15 am V12 (R129's Family Member) returned call. V12 stated She (R129) had gotten out of our home four times. A couple times all the way to a busy street. A neighbor (unidentified) brought her (R129) home. I tried changing the locks. I tried everything to keep her safe. On 8/7/24 at 12:15 pm an exit door alarm had sounded at the end of the hall. V13 (Transportation Department) intervened. V13 walked with R129 down the hallway. V13 stated (R129) wanders all over the place. I was just bringing her back from the other hall, she was trying to exit and set off the alarm. On 8/7/24 at 12:22 pm V8 (Housekeeper) stated V8 working in the hall on 7/26/24, heard the door alarm sound. V8 went right away and found (R129) had gotten out of the building. On 8/7/24 at 1:15 pm V14 (LPN) stated I was the nurse the day (R129) exited the building. She did not get far. The door alarmed and one of the staff (V8 Housekeeper) brought her in (from outside the building). She (R129) was not upset. I did not do a full head to toe assessment. I looked her over briefly, she was her normal self. We got her a snack right away. She stays busy and wanders a lot. We have to give her activities to do to keep her attention diverted. I did not call her husband. I notified him when he came in that day. I asked him what kind of things she like to do. He said she likes to fold towels. He said the hospital had her doing that and it kept her distracted. She was in the hospital before ever admitting here. I told (V2) from the get-go, that (R129) needed a (departure alert system bracelet). I reported she (R129) exited the building that day too. (R129) definitely needs to have a (departure alert system bracelet). I thought V2 was going to get her one. We did not have one in the facility for her to even use. On 8/7/24 at 2:40 pm V2confirmed R129 was supposed to have a (departure alert system bracelet) on, post elopement of 7/26/24, and that the (departure alert system) safety bracelet was the only intervention post R129's elopement of 7/26/24. V2 also stated R129 should have had a (departure alert system bracelet) on when she was admitted [DATE], because R129's family member V12 had alerted the facility R129 'had eloped from home'. The facility Elopement Prevention Policy dated October 2006 documents the following: Policy: It is the policy of (Private Corporation Name) to provide a safe and secure environment for all residents. To ensure this process, the staff will assess all residents for the potential for elopement. Determination of risk will be assigned for each individual resident and interventions for prevention be established in the plan of care to minimize the risk for elopement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145836 If continuation sheet Page 7 of 12 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 08/09/2024 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 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 Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week for 10 days in a total of 39 days reviewed. This failure affects 25 residents residing in the facility. Findings include: The Long-Term Facility Application for Medicare and Medicaid form CMS 671 dated August 7, 2024 documents the census for the facility as 25 residents. Reviewing the facility's nurse assignment sheets for the months of July and August 2024. The facility had 10 days out of the 39 days reviewed which did not document RN time of 8 hours per day. The facility did not have a RN working at least 8 consecutive hours a day on 7/6/24, 7/7/24, 7/13/24, 7/14/24, 7/20/24, 7/21/24,7/27/24, 7/28/24, 8/3/24 and 8/4/24. V2 (Director of Nurses) confirmed on 8/8/24 at 12pm, Yes, this is correct we do not have the RN coverage for the weekends. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145836 If continuation sheet Page 8 of 12 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 08/09/2024 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 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** Based on observation, interview and record review the facility failed to implement timely infection control precautions for a resident positive with bacteria in the urine, provide Personal Protective Equipment (PPE) to ensure effective infection control when caring for residents, provide designated trash receptacles in resident room, ensure staff wore appropriate PPE during direct care, and implement a room change for a resident to prevent potential cross contamination. These repeated failures were ongoing 08/04/24-08/06/24. These failures affected two of two residents (R7 and R19) reviewed for infection control on the sample list of 28. Residents Affected - Few Findings include: On 08/06/24 between 10:00 and 11:00 am, R7 and R19 had a sign posted on their bedroom door that stated enhanced barrier precautions. There was no signage for contact isolation precaution. There were no PPE (Personal Protective Equipment) supplies set up of outside R7 and R19's room. There were no designated receptacles in R7 and R19's room for discarding soiled PPE after removal. R7 was not in their shared room. R19 was asleep in their shared bedroom. On 08/06/24 at 11:03 AM V3 (Licensed Practical Nurse/LPN) stated (R7) is on Contact isolation precautions as of today, for ESBL (Extended spectrum beta-lactamase, bacteria) in (R7's) urine. Her (R7's) roommate (R19) will be moved to room (specific room number) when the roommate (R19) wakes up. The facility Resident Infection Control Antimicrobial Log dated August 2024 documents R7 had a house acquired infection (HAI), an onset of ESBL infection in R7's urine on 8/4/24 and was started on Augmentin (antibiotic) twice daily for five days. The same log documents R7 requires isolation precautions. The facility Resident Infection Control Antimicrobial Log dated July 2024 documents R19 had a recent HAI urinary tract infection of a Non-MDRO (Multidrug-resistant Organisms) organism, with an onset date of 07/19/24 that required antibiotic treatment of Amoxicillin 500 milligrams twice a day for seven days. R7's Current diagnoses list documents the following: Alzheimer's Disease, Unspecified. R7's Minimum Data Set, dated [DATE] documents R7 has a Brief Interview of Mental Status score of 05 out of a possible 15, indicating severe cognitive impairment. R7's Health Status Note: dated 08/04/2024 at 09:13 am documents the following: Note Text: (V19 Nurse Practitioner) notified of urine culture results. NO's (new order) rec'd (received) for Augmentin 500/125 (milligram) BID (twice a day) x5 D (days). On 8/6/24 at 1:05 pm V3 (LPN) reviewed R7's culture and sensitivities result and stated, (R7's) Urine was collected on 8/1/24 and final results showed ESBL on 8/4/24. Augmentin was started 8/4/24. Her Primary Care Physician Office (V6) just called me this morning with the results (final). I don't know what the delay was. V3 also stated I was not working. (R7) should have been on contact isolation immediately and (R19) moved to another room. They have both been using the same bathroom. I put a bedside commode in (R7's) room now. V3 also stated the CNA (V7 Certified Nursing Assistant) should have been wearing PPE while giving (R7) a shower this morning. We did clean the shower chair immediately following (R7's) shower. (R7) has a depends (incontinence brief) on now to prevent any accidents. She has a history of dribbling, though she uses the toilet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145836 If continuation sheet Page 9 of 12 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 08/09/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 8/8/24 at 11:07 am R7 was in the shower room at the sink, fully dressed with wet hair. V7 (CNA) stated she was getting ready to dry R7's hair. There was a pile of wet towels on the floor of the shower stall. There was one small trash receptacle next to the sink. There was no sign of soiled PPE in the trash receptacle. V7 stated I just completed (R7's) shower and I did not wear PPE, because (R7) does not have a catheter or a pressure ulcer, so I don't have to wear PPE. Just gloves are all. V7 then stated I did not know she (R7) had ESBL in her urine. I would have worn full PPE. We are supposed to wear a gown and eye protection when there is a possible chance of urine splashing. On 8/8/24 at 1:05 pm V18 (Infection Preventionist) stated the following: When V18 came in Monday (8/5/24), R7 had been started on an antibiotic. We discussed this in morning meeting. I got it on the infection control log. V18 also stated All nursing staff are aware they must put on PPE during personal care. The CNA (V7) CNA that gave (R7) a shower should have had on a gown, gloves and eye protection on. The facility policy Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) Updated: July 12, 2022 documents the following: Key Points: 1. Multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. 2. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. 3. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: *Wounds or indwelling medical devices, regardless of MDRO colonization status Infection or colonization with an MDRO. 4. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care. 5. Standard Precautions, which are a group of infection prevention practices, continue to apply to the care of all residents, regardless of suspected or confirmed infection or colonization status. The same policy documents: Implementation: When implementing Contact Precautions or Enhanced Barrier Precautions, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. To accomplish this: Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves). Make PPE, including gowns and gloves, available immediately outside of the resident room. Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145836 If continuation sheet Page 10 of 12 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 08/09/2024 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 0880 the room). Level of Harm - Minimal harm or potential for actual harm Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. Residents Affected - Few The same policy directs staff to implement Contact Precautions that include: Don gloves and gown before room entry and doff before room exit: change before caring for another resident. (Face protection may also be needed if performing activity with risk of splash or spray). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145836 If continuation sheet Page 11 of 12 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 08/09/2024 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Some 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 a minimum of 80 square feet of floor space per resident bed. This failure affects 23 residents (R1 through R11, R13, R14, R17 through R24, R26, and R179) on the sample list of 28. Findings include: Historical room size documentation and actual measurements demonstrate the facility's rooms 101 through 111, 201 through 210, and 301 through 311 do not provide 80 square feet per resident bed. Rooms 101 through 111 and 201 through 210 provide 73 square feet per resident bed, and rooms 301 through 311 provide 78 square feet per resident bed. On 8/6/24 at 11:30 AM, V1, Administrator, stated, I am aware of the undersized rooms. It is every room except for the back hall (400 hall). We get the tag every year and then we have to go through the process of applying for a waiver because there isn't anything we can do about it. The facility's Declaration of Room Sizes dated as revised 8/1/21 documents rooms 101 through 111, 201 through 210, and 301 through 311 do not meet the requirements for 80 square feet per resident bed. The Medicare/ Medicaid Certification and Transmittal dated from the most recent annual survey 7/19/2023, maintained at the State Survey Agency Regional Office, documents all 80 beds in the facility are certified Title 18 (Medicare) or Title 19 (Medicaid). The facility's Room Roster dated 8/5/24 documents (R1 through R11, R13, R14, R17 through R24, R26, and R179) reside in the undersized resident rooms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145836 If continuation sheet Page 12 of 12