Health inspection·January 2, 2024

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on interview and record review, the facility failed to have a procedure in place for filing Grievances, understanding what a Grievance is, and implementing a system to track resolutions of a Grievance. These failures have the potential to affect all 58 residents living in the facility. Findings include: 1. On 12/18/23 at 2:07 PM, V4 (R18's wife), stated, His (R18's) cell phone came up missing. The facility knew that it was missing. Someone from the facility called me and told me that they found it in the washer and it no longer worked. No one offered to replace the phone. On 12/18/23 at 2:54 PM, V3, Social Service Director/SSD, stated she has not had any Grievance filed through resident council or any formal Grievances filed. She stated if a small problem arises, she will handle it. We will make a progress note in the chart to document the issue. V3 stated she was unaware of any phone being lost or any laundry missing. V1, Administrator, was present for the conversation, and she agreed the facility just handles things as they come up. V1 stated thatshe was unaware of R18's phone. V1 and V3 stated there is no formal process to follow up on a grievance to track if the situation has been resolved. On 12/19/23 at 8:55 AM AM, V1 stated R18's phone was found in a locked medical cart, and (V4) was notified the phone was found, and even though it went through the wash, it still works. V1 stated there is a disconnect with agency staff not communicating with facility staff. 2. On 12/18/23 at 11:31 AM , R7 stated, I have a problem with (V65, Certified Nurses Aide). The aid (V65) has an attitude. She isn't here for us. She just walks up and down the hall and doesn't do anything. She doesn't say why I don't get my shower. She just leaves. I did go to (V3, Social Service Director) and she said she would talk to (V65) and look into the showers, but I have never heard back. I am very upset about this. I talked with her (V3) last Tuesday. The aides say that I have and attitude. R7's MDS (Minimum Data Set), dated 11/01/23, documents R7 is cognitively intact. On 12/26/23 at 10:29 AM, V3 stated, (R7) did come and talk to me about (V65). (R7) thought that (V65) had an attitude with her. I found out about this at the beginning of last week (12/18/23). I had told (V1, Administrator) about the issue and suggested that (V65) work on a different hall. It was not logged as a Complaint or a official Grievance. She just wanted to talk to me about it. The facility Policy Grievances, dated 6/1/22, documents, The facility shall ensure that the resident has the right to voice grievances to the facility without discrimination or reprisal and without fear of discrimination or reprisal. Grievances shall be addressed by the facility and resolved in a timely manner. It continues, 4. Upon receipt of a grievance, the Grievance Officer (V3) or designee shall complete an investigation of the concern as soon as possible and provide appropriate follow through as required. The facility Grievance Logs for 9/2023- 12/2023 were reviewed with no Grievances filed except for 1 in 11/2023 for R28 related to a call light. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 2 of 34 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 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 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 0585 The Long Term Care Facility Application For Medicare and Medicaid, dated 12/18/23 (CMS-671), documents 58 residents reside in the facility. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 3 of 34 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 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to assess residents for fall precautions, failed to implement appropriate fall interventions, and failed to ensure resident safety during transfers, for 5 of 7 residents (R6, R8, R10, R20, R27) reviewed for falls and transfers in the sample of 44. This failure resulted in R6 having a fractured left hip and having a closed vs open reduction of her left hip with nailing surgery. The findings include: 1. R6's Face Sheet, undated, documents R6 was admitted to the facility on [DATE], with the diagnoses of Dementia, Atrial Fibrillation, Major depressive disorder, Type 2 Diabetes Mellitus (DM), and Left femur fracture. R6's Care Plan, dated 3/02/23, documents R6 is at risk for falls related to diagnosis of dementia, unsteadiness on feet, muscle wasting and atrophy, depression, incontinence and use of psychotropic medication. Interventions: 12/18/23: Staff to keep resident within view while in common area, 12/12/23: Occupy resident with meaningful distractions, 12/5/23: Observe frequently and place in supervised area when out of bed, 11/20/23: Encourage shoes while ambulating, 10/2/23: Encourage resident to stay in common areas when it is not bedtime. Redirect with activity, 9/6/23: Dycem replaced on wheelchair and cushion, 8/27/23: encourage resident with an activity while other residents are being put to bed, 8/14/23: PT (physical therapist)/OT (occupational therapist) to evaluate chair positioning, 8/14/23: Call don't fall signs placed in resident room, 6/26/23: Dycem applied to wheelchair and on top of wheelchair cushion, 4/20/23: Make sure resident is wearing grip socks while ambulating, 4/20/23: Grip tape applied to the floor in front of the toilet, 4/10/23: Make sure tennis balls are on the wheeled walker 3/2/23: Provide with wheelchair and walker, Encourage to use side rails/enablers as needed. R6's Minimum Data Set (MDS), dated [DATE], documents R6 has a severe cognitive impairment and requires extensive assistance from one to two staff members for all Activities of Daily Living (ADLs). R6 is occasionally incontinent of urine and always continence of bowel. The Facility's Fall Log, dated 6/1/23 through 12/18/23, documents R6 has had a falls on 6/21/23, 6/25/23, 7/7/23, 7/13/23, 7/20/23, 8/10/23, 8/26/23, 9/4/23, 9/25/23, 11/6/23, 12/4/23, 12/5/23, and 12/10/23. R6's admission Fall Risk Assessment, dated 3/1/23, documents R6 is a High Fall Risk. R6's Fall Risk Assessment, dated 4/24/23, documents R6 is a High Fall Risk. R6's Fall Risk Assessment, dated 7/29/23, documents R6 is a High Fall Risk. R6's Fall Risk Assessment, dated 12/4/23, documents R6 is a High Fall Risk. R6's Nursing Note, dated 4/1/23 at 6:00 PM, documents, CNA reported to nurse that resident had fallen after standing from dining room and tripped over the foot of her walker and lost her balance. CNA stated she did not hit her head. Neuros (neurological checks) and VS (vital signs) WNL (within normal limit), during assessment of LLE (left lower extremity) resident verbalized 7/10 pain to left hip. MD (Medical Doctor) made aware and gave orders to send resident to ER (emergency room) and stated to update him with results once notified of results. POA (Power of Attorney) notified as well. There (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 4 of 34 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 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 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 is no new fall intervention seen in R6's Care Plan after her fall on 4/1/23. Level of Harm - Actual harm R6's Nursing Note, dated 4/3/23 at 6:51 AM, documents, Resident found sitting on floor next to her walker in her bedroom. Residents bottom was facing the window and her legs/feet were facing the bedroom door. Resident states she was trying to go to the bathroom and her knees started to buckle so she knelt down and sit on her butt. VSS (vital signs stable) (see vitals), Head to toe assessment complete with no s/s (signs/symptoms) of rotation, deformity, shortening of limbs noted. No s/s of bruising or open wounds. Residents states, I am ok I just wanted to get to the bathroom then go eat breakfast. Educated resident on using call light for help and she verbalized understanding. Fall was witnessed by CNA (see Event) Dr. notified, and POA Notified. Residents Affected - Few R6's Social Service Note, dated 4/10/23 at 10:25 AM, documents, Root Cause Analysis: Investigation into falls on 4/3 and 4/1 were completed by the IDT (Interdisciplinary team). It was determined that on 4/1 resident was standing from breakfast with w/w (wheeled walker). Resident tripped over the flip flop décor on bottom of wheelchair. Décor was removed and replaced with tennis balls. On 4/3 resident was attempting to transfer herself to the bathroom with w/w when her legs buckled and she lowered herself to the floor. Assist resident in mornings, and make sure that she has assistance when needed due to weakness in morning. R6's Care Plan Intervention, dated 4/10/23, documents Make sure tennis balls are on the wheeled walker. R6's Nursing Note, dated 4/19/23 at 6:15 AM, documents, [Recorded as Late Entry on 04/21/2023 11:33 AM] Called to (unit) by staff to find resident laying on the floor on her back with her head down by the sink. She denies pain moves all extremities without difficulty. She does have a 0.5 cm (centimeter) skin tear noted on her Rt (right) elbow that was cleansed and Steri-strips applied. Staff reports that there were no lights on in the room when they entered the room the floor was dry and resident had regular socks on her feet with no shoes on. Resident assisted off the floor by 2 staff at this time. R6's Social Service Note, dated 4/20/23 at 11:11 AM, documents, Root Cause Analysis: Investigation into fall on 4/19/2023 was completed by the IDT. It was determined that resident fell while ambulating in her room. Make sure the resident is wearing grip socks while up ambulating. There is no new fall intervention added to R6's Care Plan after her fall on 4/19/23. R6's Nursing Note, dated 4/20/23 at 3:20 AM, documents, Resident was found sitting on the floor in the her bathroom yelling out for staff. She stated she went to get off of the stool and slipped down to the floor. Denies hitting head. Stated she landed on her buttocks and sat against the bathroom door. She complained of left hip pain immediately and leg is bent up. She will not let us straighten leg out stating the pain is absolutely horrible. Large skin tear noted to left elbow with scant amount of bleeding noted. R6's Nursing Note, dated 4/20/23 at 3:51 AM, documents, Resident did have rubber sole shoes on, floor level dry and free of clutter. She was ambulating with use of walker. Denied any dizziness or other complications. Room was well lit. R6's Social Service Note, dated 4/20/23 at 11:13 AM, documents, Root Cause Analysis: Investigation into fall on 4/20/2023 was completed by the IDT. It was determined that resident fell off the toilet while taking herself to the bathroom. Resident was sent to ER and determined that her left hip was broke. (sic) Grip tape was placed in front of toilet. R6's Care Plan Intervention, dated 4/20/23, documents, Grip tape applied to the floor in front of the toilet. On 12/20/23 at 9:35 AM, there was no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 5 of 34 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 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 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 grip tape seen in front of R6's toilet as specified in the Care Plan. Level of Harm - Actual harm R6's Nursing Note, dated 4/21/23 at 9:50 AM, documents, Called (Regional Hospital) and rec'd (received) update on resident, surgery scheduled for today at 2:30 PM, having a closed vs open reduction of left hip with nailing, not looking at discharge until next week possibly. Residents Affected - Few R6's Nursing Note, dated 6/21/23 at 9:55 PM, documents, Resident was observed on the floor on her knees leaning against the bed in an unoccupied room. There was another female Resident sitting on the side of the bed. This Resident stated she was trying to get on the bed. Two staff transferred Resident to w/c (wheelchair). ROM (range of motion) WNL x 4 extremities. No injuries noted to head or body. Noted both knees to have small pinkish area on each. Resident stated her knees hurt. Resident was moving both feet to move w/c without c/o (complaint of) or noted difficulty then ambulated to toilet from w/c with use of w/w and assist of two staff with no c/o or noted difficulty. Dr. at facility to see Resident and assessed her with NNO (no new orders). Tylenol given with no further c/o knee pain. Made RN (Registered Nurse) DON (Director of Nursing) and POA/daughter aware of this event. Will fax Dr. with an update. VS 134/64 78 20 98.0 SpO2 96% RA (room air). Not compliant with Neuros. R6's Care Plan does not have any new interventions added to the Care Plan after this fall on 6/21/23. R6's Nursing Note, dated 6/25/23 at 3:32 PM, documents, CNA's reported that resident had slid out of wheelchair in sitting area. Resident observed sitting in upright position in front of wheelchair. Resident completed ROM to all extremities without limitations or pain voiced. Resident denies pain/discomfort at this time. Resident vs WNL, resident neuros WNL to resident baseline. MD notified and POA made aware. R6's Care Plan Intervention, dated 6/26/23, documents Dycem applied to wheelchair and on top of w/c cushion. R6's Nursing Note, dated 7/7/23 at 6:53 PM, documents, Resident found on floor next to toilet. She was between the wall and toilet sitting on her buttocks holding onto the assist bar. Resident was attempting to transfer self off of the toilet. No injuries noted at this time. Denies any pain at this time. Had rubber sole shoes in place, pants were mostly pulled up chair was locked and in doorway. Daughter (Name) notified of incident. Doctor notified. Neuros started and WNL, ROM WNL. Staff educated not to leave room while she is on toilet. R6's Care Plan does not have any new interventions added to the Care Plan after this fall on 7/7/23. R6's Nursing Note, dated 7/13/23 at 9:01 PM, documents, Res (resident) noted to tip recliner over in the common room and rolled out of it onto the floor. When this nurse arrived, res was lying on her stomach with her Right arm pinned below her. 3 staff members rolled res over onto her back to assess further. ROM WNL. No rotation or shortening of extremities. VS WNL neuro checks WNL. skin tear noted to right lower arm with bruising surrounding area. Bruise noted to right elbow and to left knee. Skin tear cleansed and steri-strips applied. No other injuries noted. Res denied pain elsewhere. Assisted back to recliner. Began conversing with staff again. Continue to monitor vs with neuros per protocol. MD made aware via fax. To notify family in the morning at a more decent hour. R6's Care Plan does not have any new interventions added to the Care Plan after this fall on 7/13/23. R6's Nursing Note, dated 7/20/23 at 10:59 PM, documents, 8:10 PM Resident was observed laying on her left side on the floor beside her bed. Her w/c (wheelchair) was near her. Resident stated she was trying to get into bed. No injuries noted to head or other areas. ROM not done d/t (due to) Resident c/o pain to both hips and lower back. BS (blood sugar) 205. Resident alert and verbal. Made Dr. aware. New order given to send to ER to eval (evaluate) and tx (treat). Made POA/daughter aware. Ambulance called. Resident sent to (local hospital) ER via ambulance. Sent Face Sheet, orders and DNR (Do (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 6 of 34 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 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 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 - Actual harm Residents Affected - Few Not Resuscitate). Made RN (Registered Nurse) at (local hospital) ER aware and gave report. Administrator and RN, DON aware. R6's Care Plan does not have any new interventions added to the Care Plan after this fall on 7/20/23. R6's Nursing Note, dated 8/10/23 at 6:50 PM, documents, Resident slid out of wheelchair trying to reach for items. Fall witnessed did not hit head and just slid to floor. She did land on her buttocks with no injuries noted and no complaints of pain. ROM WNL. Daughter notified of her sliding out of her wheelchair with no injuries. Doctor notified. Will consider adding [NAME] to top of cushion to help prevent sliding. R6's Care Plan Intervention, dated 8/14/23, documents, Call Don't Fall signs placed in resident room. R6's Nursing Note, dated 8/26/23 at 8:30 PM, documents, Resident observed on floor in kitchen laying on her right side, w/c was near her feet. Resident did hit her head. ROM WNL x 4 extremities. Resident rubbed her head stating that is where she hit her head, mid left back of head. No area noted. No other injuries noted. VS 134/70 74 20 97.6 SpO2 96% RA. Made Dr. aware of this event, Resident hitting head mid left side, Coumadin use, recent INR (International Normalized Ratio). Stated to monitor and report significant changes. Aware of HS (hours sleep) meds and stated to continue with meds as ordered. Made POA/daughter aware and she agrees with Dr. Made Administrator aware. At this time a slightly elevated area is noted to mid left back of head. Area is pinkish. Resident given PRN Tylenol d/t to stating, Oh, it hurts a little, when asked if her head hurt. Denies pain anywhere else. Resident is alert and verbal. Moves all extremities with no noted difficulty or c/o. R6's Care Plan Intervention, dated 8/27/23: encourage resident with an activity while other residents are being put to bed. R6's Social Service Note, dated 8/27/23 at 2:18 PM, documents, Root Cause Analysis: Investigation into fall on 8/26/2023 was completed by the IDT team. It was determined that resident fell while attempting to ambulate. When staff is working with other residents for bed and behaviors, encourage resident with a independent activity to keep her busy. R6's Nursing Note, dated 9/4/23 at 3:33 PM, documents, Resident was found in dining room. Resident was in front of wheelchair on her left side. Resident stated she was a little sore. No shortening, ROM x 4, Neuros and vitals WNL. POA aware. Admin aware. MD faxed. Will continue to monitor. R6's Care Plan Intervention, dated 9/6/23, documents, Dycem replaced on WC and cushion. R6's Social Service Note, dated 9/6/23 at 7:48 PM, documents, Root Cause analysis: IDT completed investigation into fall on 9/4/2023. It was determined resident fell sliding out of the wheelchair, Dycem added to wheelchair. R6's Nursing Note, dated 9/25/23 at 2:02 PM, documents, Resident stated went into her room, shut the door and got up to go the bathroom. Resident was found sitting in her room on her bottom, with feet straight out. ROM unchanged. Denies any c/o pain or discomfort. Vitals within normal limits. Dr. notified of incident. POA notified. R6's Care Plan does not have any new interventions added to the Care Plan after this fall on 9/25/23. R6's Social Service Note, dated 10/2/23 at 12:05 PM, documents, Root Cause Analysis: Investigation into fall on 9/25/2023 was completed by the IDT team. It was determined that resident fell while in room attempting to transfer her self. Staff encouraged to redirect resident to common areas when not in bed, and engage her with activities. R6's Care Plan Intervention, dated 10/2/23, documents, Encourage resident to stay in common areas when it is not bedtime. Redirect with activity. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 7 of 34 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 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 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 - Actual harm Residents Affected - Few R6's Nursing Note, dated 11/6/23 at 7:45 PM, documents, Resident was sitting in wheelchair in her room at foot of bed near bathroom door. She stood up and starting walking across the room. Her legs gave out and she sat down on the floor. Her feet were bare, lights on, floor level, clean, dry and free of clutter. Could not get to resident fast enough before she fell, she did not hit her head. ROM done with no complaints of pain. No external fixation or shortening of legs noted. She did complain of general pain after a while, PRN Tylenol given with relief. MD notified and daughter to be notified. Will continue to monitor. R6's Care Plan does not have any new interventions added to the Care Plan after this fall on 11/6/23. R6's Social Service Note, dated 11/9/23 at 10:04 AM, documents, [Recorded as Late Entry on 11/20/2023 10:05 AM] Root Cause Analysis: Investigation into fall completed by the IDT. It was determined that resident fell while attempting to ambulate to the bathroom. Resident to have shoes and grip socks on while ambulating. R6's Nursing Note, dated 12/4/23 at 1:30 PM, documents, [Recorded as Late Entry on 12/04/2023 07:37 PM] Resident was in common area and was trying to transfer self into recliner and slid onto bottom. Head was not hit and no injury noted. Will pass along to nurse to make Dr. and POA aware of event. R6's Nursing Note, dated 12/5/23 at 1:50 PM, documents, Resident attempted to transfer to recliner in common area and fell to floor. Resident did not hit her head. CNA was unable to get to her in time. B/P 159/76 P 76 R 22 T 97.5 SpO2 98% ROM WNL Resident had no c/o pain. Resident was transferred up from floor to recliner. R6's Care Plan Intervention, dated 12/5/23, documents Observe frequently and place in supervised area when out of bed. R6's Nursing Note, dated 12/10/23 at 5:27 PM, documents, CNA states she heard patient yelling out. Went to assess and patient was noted in sitting position in dining room with wheelchair next to her. Writer assess patient and she stated she did not hit her head. Patient was noted in sitting position next to wheelchair. Patient was in a well lit area and appropriate fitting shoes. Patient able to move all extremities with ease. Denies pain or discomfort at this time etc. denies needing to go to the bathroom. Assist for floor to bed via (full body mechanical lift). Neuro checks WNLs. R6's Care Plan Intervention, dated 12/12/23, documents, Occupy resident with meaningful distractions. R6 was left unsupervised and found on the floor. On 12/19/23 at 9:27 AM, R6 was sitting in recliner watching movie with other residents, with no staff seen in the room. On 12/20/23 at 9:35 AM, R6 was seen sitting in her wheelchair in the dining room doing activities with staff. There were no Call Don't Fall signs posted in R6's room, and there was no grip tape in front of her toilet as specified in the Care Plan. On 12/19/23 at 10:04 AM, V5, Certified Nursing Assistant (CNA), stated, We try to keep our residents supervised to help keep them from falling, and there are interventions placed in their care plan for falls. On 12/26/23 at 10:40 AM, V6, CNA, stated, No, (R6) does not have a Dycem on her wheelchair. 2. R8's Face Sheet, undated, documents R8 was admitted to the facility on [DATE], with the diagnoses of Dementia, Overactive bladder, Dysuria, and Anxiety disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 8 of 34 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 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 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 - Actual harm Residents Affected - Few R8's Care Plan includes Problem, start date of 7/24/23, R8 is at risk for falling related to decreased mobility, generalized weakness, dementia, incontinence, psychotropic medication use. Interventions: 9/25/23: Scoop mattress added to bed, 8/14/23: Dycem added to wheelchair, 7/24/23: Ensure that commonly used or reached for items are within close proximity to R8 while in bed, Ensure familiar items are present in room such as old pictures of resident when young, with parents, etc., familiar decorations from resident's prior home, or familiar afghan/blanket on bed, Use simple sentences with ADL (Activities of Daily Living) cares including nouns and verbs only (example: Use the toilet), Utilize verbal and tactile cues. Organize supplies from left to right to provide visual stimulation with tasks and task segmentation, Use simple, familiar commands and words that are familiar to the resident (i.e. [NAME] = bathroom), Hold chair steady for R8 during transfers, Provide frequent reminders and assistance for toileting and other personal care ADL needs, Alternate Call Light, Encourage R8 to use side rails and hand rails as needed. The Facility's Fall Log, dated 6/1/23 through 12/18/23, documents R8 had falls on 6/1/23, 6/16/23, 8/11/23, and on 9/16/23. R8's Clinical Record documents R8 also had falls 3/14/23, 3/25/23, 4/2/23, 5/3/23, 5/12/23, 5/16/23, 5/17/23. R8's Care Plan did not include R8 as a fall risk with interventions until 7/24/23, after R8 had fallen nine times. R8's MDS, dated [DATE], documents R8 has a severe cognitive impairment and is dependent on staff for ADLs and is frequently incontinent of urine and occasionally incontinent of bowels. On 12/19/23 at 10:04 AM, V5, CNA, stated, We try to keep our residents supervised to help keep them from falling and there are interventions placed in their care plan for falls. R8's Nursing Note, dated 3/14/23, documents, Resident was found on floor in bed room next to his bed on his bottom. Residents back was against the bed, feet pointing to his roommates bed and resident was not in non skid socks at that present time. Resident states he slid out of bed on his bottom trying to get somewhere. Head to toe assessment completed. No apparent injuries noted. No bruising noted. No wounds or bleeding noted. No limb deformity noted. Mobility unaffected. Did c/o pain to right hip but per resident and resident POA he has prior hip surgery and has had hip pain to left hip since. Resident able to bend bilateral knees to abdomen without c/o, able to rotate and flex bilateral arms without c/o. NEURO intact (neuros started due to unwitnessed fall) Bed was at lowest position and call light was within reach. R8's Administrator Note, dated 3/19/23 at 2:43 PM, documents, Root Cause Analysis: Investigation into fall on 3/14/2023 completed by IDT (Intradisciplinary team). It was found that resident was trying to transfer himself without assistance, and fell from bed. Call don't fall signs places in residents room to remind him to call for assistance. On 12/20/23 at 9:32 AM, there was no Call don't fall signs seen in R8's room. R8's Administrator Note, dated 3/28/23 at 2:13 PM, documents, Root Cause Analysis: Investigation into fall on 3/25/2023 completed by IDT. It was determined resident was trying to stand without assistance. Make sure resident is in a supervised area, and wearing slip resistant socks. R8's Nursing Note, dated 4/2/23 at 9:29 AM, documents, Resident observed on floor facing in upright position in front of toilet. Resident voiced that he was trying to go to the bathroom and slid off of the toilet. No injuries noted. VS WNL, Neuro assessment completed with no abnormalities noted to resident baseline. ROM completed x 4 extremities without pain/discomfort. Resident denies pain at this time. MD notified, POA notified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 9 of 34 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 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 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 - Actual harm R8's Social Service Note, dated 4/10/23 at 12:06 PM, documents, Root Cause Analysis: Investigation into fall on 4/2/2023 was completed by the IDT team. It was determined that the resident was attempting to transfer himself to the bathroom. staff educated to ask resident frequently if he needs to use the bathroom in hopes to avoid resident attempting to transfer himself. Residents Affected - Few R8's Nursing Note, dated 5/3/23 at 2:48 PM, documents, Resident observed sliding from wheelchair while trying to self transfer to bed. Resident non skid socks were on, but one was turned where grippers were not in correct position. No injury noted. VSS. No c/o pain voiced. POA aware. MD notified via faxed. R8's Nursing Note, dated 5/11/23, documents, Root cause analysis: resident was attempting to transfer self and slid out of wheelchair. Resident noted to be wearing gripper socks inappropriately. Resident to wear slippers with rubber soles or shoes when up in chair. Care plan updated. R8's Nursing Note, dated 5/12/23 at 8:50 PM, documents, [Recorded as Late Entry on 5/13/2023 1:32 AM] Resident was assisted to the floor by staff. He has slumped down so far in his wheelchair his back was the only thing still in the chair. Resident was assisted to the floor by CNA before he tumbled out on his own. Staff was called to assist resident back up in wheelchair. Resident had been readjusted several times in wheelchair prior to this because he keep sliding down. No injuries noted. Doctor notified. Family will be notified. Will continue to monitor. R8's Nursing Note, dated 5/16/23 at 6:53 AM, documents, Resident was found on floor in his room. Back against the wall and stated he hit his head. No bumps noted. Resident was trying to transfer self and was reaching for shoes. Area was free of clutter and floor was dry. Resident states he should have known better. Educated resident on using call light and waiting for assistance. Resident did receive skin tear to left tricep 10 cm by 2 cm. Cleansed with wound cleanser and non-adherent pad applied and gauzed wrapped. Did use steri-strips to place some skin back together. Red mark to right shoulder. Vital signs are 97%, 98.3, 162/94, 78, 12. Does complain of head pain. Neuros are WNL. ROM x4. MD faxed. POA aware. DON (Director of Nursing) notified. Will continue to monitor. R8's Nursing Note, dated 5/17/23 at 8:29 AM, documents, Resident observed on common room area floor, reported by CNA. Resident sitting upright facing tv with wheelchair facing residents right side. Blocks noted to left side of resident on floor. BLE noted equal, ROM to X4 extremities without limitations. Resident denies pain/discomfort. Edema continues to BLE. MD made aware. R8's Nursing Note, dated 6/1/23 at 4:05 PM, documents, Resident had witness fall with no injury. ROM (range of motion) WNL (within normal limits). V/S (vital signs) WNL. Did not hit head. Assist x 2 and gait belt back to w/c (wheelchair). Son and MD made aware. R8's Nursing Note, dated 6/16/23 at 11:14 PM, documents, Resident observed on floor in BR (bathroom) at 7:30 pm. Resident stated he had to go and attempted to transfer self from w/c to toilet. Noted moderate amount of urine on floor near toilet that was not from Resident. Resident stated he hit his head possibly on the door or floor, touching the top left side of head. No noticeable injury. Resident was sitting on his buttocks slightly leaned to right side with right arm holding him up. ROM x 4 with no shortening or rotation noted. Resident did initially c/o right leg pain when he extended the right leg but was able to bend leg and pull it toward him several times with no c/o or noted difficulty. (Name) RN DON (Director of Nursing) also assessed. With assist of three Resident was transferred to his w/c with no c/o pain or discomfort. Resident then used by feet to move around in w/c without c/o pain or noted difficulty. Noted a 2 cm s/t to top of right hand. Area cleansed. Two (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 10 of 34 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 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 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 - Actual harm steri-strips applied. VS 122/74 74 18 98.0 SpO2 94% RA. Made on call (Name) AGNP (Adult-gerontolgy nurse practitioner) aware and of Resident's initial c/o right leg pain. NNO. Stated to monitor and report significant changes. Made POA/son (Name) aware. Resident later c/o of low back pain then denied stating, I guess I'll be sore by morning. Neuros continue to be WNL. Residents Affected - Few R8's Nursing Note, dated 8/11/23 at 12:18 PM, documents, Resident slid out of wheelchair onto his buttocks in dining area during lunch. Fall was witnessed by unit coordinator and 2 CNA staff. No injury noted. ROM WNL for resident. No c/o pain voiced. Neuro WNL for resident. Resident assisted to bathroom per request. MD notified via fax. LM for POA. Awaiting return call. R8's Social Service Note, dated 8/14/23 at 3:11 PM, documents, Root Cause Analysis: Investigation into fall on 8/11/2023 was completed by the IDT team. It was determined that resident slid out of chair while repositioning himself. Dycem added to wheelchair. R8's Care Plan and Intervention, dated 8/14/23, documents Dycem added to wheelchair. On 12/20/23 at 9:32 AM, there was no Dycem to R8's wheelchair seen. R8's Nursing Note, dated 9/16/23 at 12:57 AM, documents, Res rolled out of bed ROM WNL, neuro check started, no pain voiced. R8's Social Service Note, dated 9/25/23 at 9:55 AM, documents, Root cause Analysis: Investigation into fall on 9/16/2023 completed by the IDT. It was determined resident rolled out of bed. Scoop mattress was added to bed for residents safety. R8's Care Plan and Intervention, dated 9/25/23, documents Scoop mattress added to bed. 3. R10's Face Sheet, undated, documents R10 was admitted to the facility on [DATE], with diagnoses of Cerebral infarction, Hemiplegia, Dementia, COVID-19, UTI, Osteoporosis, long term use of Anticoagulants, DVT, and Right hip fracture. R10's Care Plan, dated 11/21/23, documents R10 is at risk for falling r/t generalized weakness, high fall risk medications, pain, dx of OA, hemiplegia, muscle wasting and atrophy, abnormal posture, HTN, and anemia. Interventions: Give resident verbal reminders not to ambulate/transfer without assistance, Grip strips to floor in front of recliner, place call don't fall signs in resident room and on walker and wheelchair, re-educate to call for assistance, Encourage R10 to use environmental devices such as hand grips, hand rails, etc., Therapy to educate Staff on proper transfer technique. It continues R10 requires assistance with her everyday ADLs r/t a diagnosis of dementia. Interventions: Remind R10 the importance of eating, Offer food she likes, easy food to chew, Offer to open packages, cut her food for her, Lay her supplies out left to right, Offer toothpaste within 6 inches of eye level. R10's MDS, dated [DATE], documents R10 has a severe cognitive impairment and requires extensive assistance from one or two staff members for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing, and requires supervision with set up help for eating. R10 is always incontinent of both bowel and bladder. The Facility's Fall Log, dated 6/1/23 through 12/18/23, documents R10 had a fall on 6/9/23, and 10/2/23. R10's Nursing Note, dated 4/30/23 at 8:25 PM, documents, Res slid out of wheel chair d/t leaning forward to pick up a piece of food off floor, no injuries ROM WNL, no pain voiced. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 11 of 34 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 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 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 - Actual harm Residents Affected - Few R10's Nursing Note, dated 6/9/23 at 4:24 PM, documents, Resident observed on floor in room sitting in upright position, wheelchair facing in front of resident. Resident denies pain/discomfort. ROM x all extremities without limitations. POA made aware, md notified. VS and neuros WNL. R10's Nursing Note, dated 10/2/23 at 5:35 PM, documents, MD aware of fall and states monitor and report significant changes. R10's Nursing Note, dated 10/3/23 at 9:59 AM, documents, No injuries noted from fall. Will continue to monitor. R10's Social Service Note, dated 10/4/23 at 5:51 PM, documents, Root Cause analysis: Investigation into fall on 10/2 completed by the IDT. It was determined that resident slid from bed, while attempting to transfer. Resident encouraged to call for assistance before attempting to self transfer. On 12/18/23 at 10: 20 AM, R10 was seen sitting in a recliner in living area, napping, covered with blanket, with her wheelchair next to recliner, and no staff present in the living area. On 12/19/23 at 9:27 AM, R10 was sitting in a recliner watching movie with other residents with no staff present in the room. On 12/19/23 at 10:04 AM, V5, CNA, stated, We try to keep our residents supervised to help keep them from falling and there are interventions placed in their care plan for falls. On 12/20/23 at 9:38 AM, R10's fall interventions, according to his Care plan, include verbal reminders not to ambulate without assistance, grip strips to floor in front of recliner, call don't fall signs in room, on her walker and wheelchair. R10 resting in recliner in living area, there is no sign on her walker/wheelchair, no signs posted in her room, there are no grip strips in front of her recliner, and no staff members seen. 4. R27's Face Sheet, undated, documents R27 was admitted to the facility on [DATE], with the diagnoses of Dementia, Falls, Anxiety disorder, and Blindness both eyes. R27's Care Plan, dated 4/25/23, documents R27 is at risk for falls related to di[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 12 of 34 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 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. R9's Care Plan, dated 4/12/23, documents, Problem: Resident Care Information. Category ADLs (activities of daily living)Functional Status/Rehabilitation Potential. Last Reviewed/Revised 12/13/2023 at 10:54 AM. It also documents, Approach: Bowel and Bladder: Incontinent x2 assist Incontinence Products Briefs: standard Xl (extra large) brief Offer bed pan for toileting R9's MDS, dated [DATE], documents R9 is cognitively intact, always incontinent of bowel and bladder, and dependent with toileting. On 12/18/2023 at 1:45 PM observed V10, CNA, and V11, CNA, perform incontinent care on R9. R9 was incontinent of urine. V10 and V11 assisted R9 to bed from wheelchair using a full body mechanical lift. Once in bed, V10 and V11 opened each side of R9's incontinent brief and rolled it between R9's legs. V11 then, using premoistened wipes, wiped each side of R9's peri area and inner labia. V11 and V10 then assisted R9 onto her right side, revealing a heavily urine-soaked incontinent brief. V11 then cleansed R9's left buttock and partial right buttock. V10 and V11 then rolled the soiled incontinent brief under R9. V10 then, using the same urine soiled glove, applied barrier cream to R9's buttocks and applied clean incontinent brief. V10 did not cleanse R9's entire peri area, entire right buttock, and inner thighs. On 12/20/23 at 12:23 PM, R9 stated she has accidents and wets herself. R9 stated she depends on the staff for her toileting needs. R9 stated the staff does all of the work and that she is appreciative. R9 stated she would like to be cleaned all over if she is wet. R9 stated she would assume that is what the girls do. R9 stated she doesn't like to be dirty and does not want to smell. 6. R25's Care Plan, dated 07/18/2023, documents R25 is at increased risk for skin breakdown/injury r/t incontinence and decreased mobility. It continues Approach: Provide incontinent care after each incontinence episode. It also documents Problem: R25 has a history of UTIs. It also documents Approach: Assist R25 with pericare/incontinence care as needed. R25's MDS, dated [DATE], documents R25 is severely cognitively impaired, dependent on staff for toileting, and always incontinent of bowel and bladder. On 12/19/2023 at 11:00 AM V12, CNA, assisted R25 with incontinent care. R25 was incontinent of urine. V12 pulled back R25's cover, revealing a heavily urine-soaked incontinent draw pad. The draw pad was soiled up to lower back and waist area. V12, using a premoistened wipe, cleansed each side of R25's peri area and inner labia. V12 then turned R25 on her right side, revealing a soiled pad. V12 then rolled the pad and applied the clean incontinent brief. V12 did not clean R25's entire peri area, buttocks and inner thighs. On 12/12/2023 at 12:10 PM, V2, Director of Nursing, stated she would expect the staff to clean all areas of incontinence. V2 stated she would expect the staff to cleanse the entire peri area, inner and outer labia, both buttocks, and any soiled area. The facility's, Incontinence Care policy, dated 2/04, documents Objective 1. To keep skin clean, dry, free of irritation and odor. Procedure: 7. Wash all soiled skin areas and dry very well, especially between skin folds. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 13 of 34 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 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Based on observation, interview, and record review, the facility failed to provide timely and complete incontinence and for 6 of 6 residents (R6, R8, R9, R10, R25, R29) reviewed for incontinent care in a sample of 44. 1. R6's Face Sheet, undated, documents R6 was admitted to the facility on [DATE], with the diagnoses of Dementia, Major depressive disorder, Type 2 Diabetes Mellitus (DM), and Left femur fracture. R6's Care Plan, dated 3/2/23, documents R6's Bowel and Bladder: Incontinent of bladder and bowel at times Continent/Incontinent Toileting: Every two hours to the toilet, assist of one Incontinence ProductsLarge pull-up. R6's Minimum Data Set (MDS), dated [DATE], documents R6 has a severe cognitive impairment and requires extensive assistance from one to two staff members for all Activities of Daily Living (ADLs). R6 is occasionally incontinent of urine and always continence of bowel. On 12/18/23 at 12:38 PM, R6 was taken to her room in her wheelchair by V5, Certified Nursing Assistant (CNA), who assisted R6 to stand up and ambulate to the restroom, and placed R6 on the toilet. R6's incontinence brief was wet with urine. V5 put gloves on and removed R6's wet brief and pants. A clean brief and pants were put on R6's lower legs. V5 assisted R6 to stand up, and as R6 held onto her walker, V5 reached from behind R6 and wiped once between R6's legs, threw the wipe away, then reached again between R6's legs and wiped once, then pulled R6's brief and pants up, all while using the same gloves with no hand hygiene done. There was no wiping of R6's buttocks, groins or other areas, and no drying prior to applying new incontinence brief. 2. R8's Face Sheet, undated, documents R8 was admitted to the facility on [DATE], with the diagnoses of Dementia, Overactive bladder, Dysuria, and Anxiety disorder. R8's Care Plan, dated 3/13/23, documents R8's Bowel and Bladder: Continent at times at night he may be incontinent Continent/Incontinent Toileting: Assist x one, Every two hours Incontinence Products- wears large pull-ups. Provide frequent reminders and assistance for toileting and other personal care ADL needs. R8's MDS, dated [DATE], documents R8 has a severe cognitive impairment and is dependent on staff for ADLs and is frequently incontinent of urine and occasionally incontinent of bowels. On 12/19/23 at 11:45 AM, R8 was sitting at dining room table. R8 stated several times he wanted to go to restroom. R8 was finally assisted to his room by V9, CNA. A sit-to-stand device was used to get R8 to stand out of his wheelchair, and placed R8 onto the toilet. During the transfer, R8 stated he can't wait any longer and is urinating at this time. V9 assisted R8 to the toilet, pulled R8's pants down, and his wet brief was unfastened and removed. When R8 was finished, V9 applied a new brief on R8, assisted him to stand back up, and fastened the clean brief without any cleaning or wiping done. V9 assisted R8 back to his wheelchair and then back to the dining room for lunch. V9 did not offer to wash R8's hands after using the toilet and prior to eating. 3. R10's Face Sheet, undated, documents R10 was admitted to the facility on [DATE], with diagnoses of Cerebral infarction, Hemiplegia, Dementia, Urinary Tract Infection (UTI), Osteoporosis, and a Right hip fracture. R10's Care Plan, dated 11/2/23, documents R10's Bowel and Bladder: Incontinent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 14 of 34 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 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 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 0690 Continent/Incontinent Toileting: x one assist, Incontinence Products - Med pull-up with large contour pad. Level of Harm - Minimal harm or potential for actual harm R10's MDS, dated [DATE], documents R10 has a severe cognitive impairment and requires extensive assistance from one or two staff members for transfers, dressing, toilet use, personal hygiene, and bathing. R10 is always incontinent of both bowel and bladder. Residents Affected - Some On 12/18/23 at 12:55 PM, R10 was assisted back to her bed, with a strong smell of urine and feces. V7, CNA, came in to do peri-care on R10. R10's pants were pulled down, which showed loose stool in her pants. R10's brief was unfastened and tucked between her legs. V7 wiped R10's groins once each, then using same wipe, wiped once down middle of her vagina and pushed that wipe between R10's legs. As R10 was rolled over, V7 noticed loose stool was up R10's back and all over her buttocks. V7 began wiping R10's stool, and asked to get another CNA to assist her. V7 used soiled gloves and pulled the sheet over R10 while she waited for help. V6, CNA, entered to assist and wiped R10's groins once, used same cloth, and wiped R10's vagina once. R10 was rolled to her right side and V7 began to wipe R10's back, and anal area. Using the same gloves, V7 put a new incontinent brief and bed pad down, then applied barrier cream to R10's anal area. R10 started to have more loose stool and was allowed to finish her bowel movement (BM). Both CNAs doffed their gloves, gathered soiled linen and trash bags without gloves on, then left the room without doing hand hygiene. On 12/18/23 at 1:18 PM, V6 and V7 went back into R10's room to clean her up after her BM. R10's brief was tucked between her legs, R10 was rolled to her right side, and her anal area was briefly wiped, and her soiled incontinence brief was pulled out from under her. Using the same soiled gloves, V7 applied a new incontinence brief and bed pad to the bed. There was no further wiping of R10's vagina, groins, or buttocks after her BM. V7 used the same soiled gloves to pull resident up in bed. V7 doffed her gloves, covered R10, then exited the room without hand hygiene done. 4. R29's Face Sheet, undated, documents R29 was admitted to the facility on [DATE], with the diagnoses of Dementia, Type 2 DM, Cardiac Pacemaker, Chronic Kidney Disease, Major depressive disorder, Anxiety disorder, and a Left femur fracture. R29's Care Plan, dated 1/9/23, documents R29's Bowel and Bladder: one assist for Continent/Incontinent Toileting: Incontinent of bowel and bladder, Incontinence Products - Med pull-up. R29's MDS, dated [DATE], documents R29 requires extensive assistance from one staff member for toileting, dressing, personal hygiene, and bathing. R29 is frequently incontinent of both bowel and bladder. On 12/19/23 at 10:17 AM, R29, was on the toilet requesting assistance, as she had a large amount of loose stool, both in her incontinence brief and in the toilet. V6, CNA, entered to assist R29. R29 was attempting to clean herself up, but had stool all over herself, including her hands. V6 unfastened R29's incontinence brief and tucked it between her legs. R29's pants were wet and soiled with loose stool, and were removed by V6. After V6 gathered the soiled pants and incontinence brief to put in a plastic bag, V6 went out of the restroom to a dresser drawer in R29's room to gather more supplies with the same soiled gloves on. V6 then applied a gait belt around R29, and a clean brief and pants were put on R29's lower legs, all with the same soiled gloves on. V6 assisted R29 to stand up and hold onto her walker while V6 wiped stool off R29's back, buttocks, and anal area. V6 reached between R29's legs and wiped from front to back with a lot of stool seen on the cloths/wipes; one dry washcloth used to reach between R29's legs once more, then brief and pants pulled up with same soiled (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 15 of 34 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 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 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 0690 Level of Harm - Minimal harm or potential for actual harm gloves on. R29's groins and/or vagina was not thoroughly wiped. R29's shirt had stool on the bottom of the shirt, which was pulled down over her clean pants, while V6 stated she had to change her shirt because it had stool on it. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 16 of 34 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 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 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 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 consecutive 8 hour Registered Nurse (RN) coverage in the facility. This has the potential to affect all 58 residents residing in the facility. Residents Affected - Many Findings include: On 12/22/23 at 11:30 AM, the Nursing Working staffing schedule from October 2023 through December 2023 was reviewed with V2, Director of Nursing. The facility did not have consecutive 8-hour RN coverage for the following days: 10/26/2023, 10/29/23, 11/4/2023, 11/7/23, 11/8/23, 11/11/23, 11/20/23, and 12/14/2023. On 12/26/2023 at 10:00 AM V1, Administrator, stated V2 and V14, Registered Nurses, are managers and the managers do not clock in. V2 stated there is not a way to tell what actual days V2 and V14 worked. On 12/29/2023 at 9:05 AM, V1 stated she is currently using agency to assist with staffing. V1 stated V2 does not work the floor. V2 stated she is actively seeking and hiring her own staff. The Long Term Care Facility Application For Medicare and Medicaid (CMS-671), dated 12/18/23, documents 58 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 17 of 34 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 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. 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 food at palatable temperature for 3 of 3 residents (R7, R22, and R49) reviewed for meal service in the sample of 44. This failure has the potential to affect all residents in the facility. Residents Affected - Many Findings include: 1. On 12/21/23 at 11:17 AM, with a calibrated metal stemmed thermometer, the steam table temperatures were taken. The [NAME] beans were 169.0 degrees Fahrenheit (F), gravy 154.2 degrees F, Hamburgers 133.7 degrees F, diced Turkey 142.3 degrees F, Sweet potatoes 150.6 degrees F, pureed green beans 135.6 degrees F. The service was started at 11:35 AM. On 12/21/23 at 12:16 PM, the hall trays left the kitchen. On 12/21/23 at 12:30 PM, the last meal tray (test tray) was served. The following temperatures were taken using the same calibrated metal stemmed thermometer. The ground chicken was at 110.8 degrees F. It tasted oily and cold. The pureed chicken was at 112.0 degrees F. It tasted cold, was very salty, and did not taste like chicken. The diced turkey was at 108.5 degrees F. It tasted cold, chewy, and oily. The sweet potatoes were at 104.4 degrees F and tasted cold. The green beans were at 106.9 degrees F and tasted cold. The pureed green beans were at 100 degrees F and tasted cold. On 12/21/23 at 11:55 AM, V16, Dietary Manager, stated she has received complaints of cold food, and the facility is now using domed lids. V16 stated, Hopefully, that helps. On 12/26/23 at 1:03 PM, V16 stated the temperatures of the test tray were too cold. 2. R49's Face Sheet, print date of 12/26/23, documents R49 was admitted on [DATE], and has a diagnosis of mild cognitive impairment. R49's Minimum Data Set (MDS), dated [DATE], documents R49 is cognitively intact. On 12/18/23 at 10:50 AM, R49 stated the food has no flavor and is sometimes cold. 3. R7's Face Sheet, print date of 12/26/23, documents R7 was admitted on [DATE], and has a diagnosis of Alzheimer's Disease. R7's MDS, dated [DATE], documents R7 is cognitively intact. On 12/18/23 at 11:31 AM, R7 stated, The food is horrible. It's cold most of the time. 4. R22's Face Sheet, print date of 12/27/23, documents R22 was admitted on [DATE], and has a diagnosis of hypertension. R22's MDS, dated [DATE], documents R22 is cognitively intact. During the resident council meeting on 12/19/23 from 1:00 PM until 2:00 PM, R22 stated, The food tastes horrible, portions are small, not all hot meals are served hot. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 18 of 34 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 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 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 0804 The facility failed to provide a policy on serving temperatures. Level of Harm - Minimal harm or potential for actual harm The Long Term Care Facility Application For Medicare and Medicaid (CMS-671), dated 12/18/23, documents 58 residents reside in the facility. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 19 of 34 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 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 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 interview, observation, and record review, the facility failed to maintain the kitchen in a clean an sanitary manner, have hand hygiene products available, throw away expired food, and cover, label, and date left over food to prevent foodborne illness. These failures have the potential to affect all 58 residents residing in the facility. Findings include: On 12/18/23 at 10:00 AM during initial tour of the kitchen the following were noted. 1. On 12/18/23 at 10:00 AM, the kitchen was entered. V17, Dietary Aide, was operating the dish machine. V17 was questioned where the hand sink was located in the kitchen , V17 stated, Over there and pointed to a sink that was 2 feet away. The hand sink was filled with soiled cleaning towels. V17 was questioned if there was another hand sink in the kitchen, V17 stated, Around the corner. This surveyor went to that hand sink and washed her hands. While washing hands, V16, Dietary Manager, came and introduced herself. This surveyor, in the presence of V16, tried to obtain paper towels to dry hands. The dispenser did not have any towels in it. V16 attempted to open the dispenser. V16 was unable to. V16 stated she would get some paper towels and left the kitchen. This surveyor went to the first hand sink that was observed to get paper towels; the dispenser was empty. This surveyor went back to second hand sink, and V16 was standing there with no paper towels. V16 was questioned if she was getting paper towels; V16 failed to answer. V16 stood there looking at this surveyor until this surveyor told V16, We have waited long enough. My hands have air dried now. V16 stated she thought this surveyor dried her hands with the other dispenser towels. V16 was told the other dispenser was empty. 2. The wall refrigerator in the main kitchen was observed. The refrigerator bottom had obvious milk and juice spills. The lip of the floor and the door had multiple dried spills of milk and juice. 3. The griddle table was observed. The shelf under the griddle had debris, dust, and grease build up. 4. The Steam Oven drip tray had approximately 3.5 inches of water/grease in it. The tray and the table that it was stationed on had grease and debris accumulation. 5. The rolling sugar storage bin lid had a build up of dried spills and debris on the top of it. The stainless steel end of shelf cap that the sugar container sat next to had multiple grease stains and food particles dried onto it. 6. The griddle, oven, and steam oven stainless steel vent hood and backsplash had multiple areas of grease build up resulting in streaks running from the top of the stainless steel to the bottom. 7. The walk-in refrigerator was observed. There were: 2 facility prepared cups of pears with no covering; 2 facility prepared cups of cottage cheese, pudding, and salad with no label of when prepared; an open package of multiple American cheese slices, ham and turkey lunch meat, which were not dated as to when opened and loosely wrapped; a storage container of Chicken Broth had an expiration date of 12/10/23, white gravy of 12/15/23; a second large container of gravy was made on 12/4/23, with no expiration date; a large container of left over ham chunks, large container of Jello fluff, and a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 20 of 34 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 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 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 large stainless steel bowl of a tannish liquid substance. At that time V16 stated, I think it might be eggs, but the lighting is bad in here. There was also a container of a red diced food which V16 stated, I think beets, that was not labeled as to what it was,when it was made, or when it expired. There was a large box of sweet potatoes on the bottom shelf of the cooler, with a 20 pound box of ground beef on top of it. The ground beef had defrosted and leaked onto the lid of the sweet potatoes, leaving it damaged and visibly contaminated with juices from the beef. V16 was questioned about storage of the thawing ground beef, V16 stated, Well the sweet potatoes should be on the other side (of the cooler). They shouldn't be here. Hamburger (ground beef) should not be on top of them. V16 moved the box of ground beef, removed the soiled lid, exposing approximately 45 sweet potatoes, 8 of which had obvious liquid drainage on them, V16 removed 6, exposing the bottom of the box which had wet and dried drainage on it. V16 stated she was going to throw those (6) potatoes away. At this time, V16 was informed the entire box had been contaminated with the beef juices. 2 - 12 ounce cans of evaporated milk were covered with wrap. The cans had been punctured, but the metal lid was still in place. There was no date of opening on the cans or wrap. 8. The walk- in Freezer was observed. An approximate 20 pound box of chicken patties was directly placed on the floor. There was an approximately 5 pound freezer burnt piece of meat lying in the corner. It was lying on the shelving unit support in the corner. It was not labeled. V16 stated no items should be on the floor of the freezer, and she did not know what the piece of meat was that was lying on the support on the floor. 9. The dry storage area was observed. There was a hall cart that was used to pass snacks and drinks stored. The cart had a removable clear plastic tub on top of it. The tub had an obvious white liquid floating in 1/2 of the bottom of the tub. V16 was questioned why this cart was in the dry storage, V16 stated, It is a hall cart and it has not been washed yet. They are new they didn't know to take it to get it washed. 10. The kitchen floor was littered with food debris, grease and sticky spots in walkways and under cabinets. On 12/18/23 at 10:15 AM, V16 stated, Food is only good for 7 days after it was made, everything should have a date on it when it was made, when it expires and what it is. On 12/18/23 a 3:55 PM, V1, Administrator, stated, All foods should be labeled. Those sweet potatoes should have all been thrown out. The whole box was contaminated. On 12/19/23 at 9:18 AM, V1, stated, I know it's a little late, but all kitchen staff stayed and cleaned the kitchen all night. All kitchen staff are being in serviced on sanitation. I was in that kitchen for 4 years before. It was bad. I can't believe how dirty it was, but it is clean today. V1 stated, All staff have food handler and next Wednesday they are getting the Dietary Manager training. 11. On 12/21/23 at 11:40 AM, V21, Cook, was observed with his bare hands, serving the food, going to the walk in refrigerator and getting an onion, returning to the line, getting a cutting board and a knife, cutting the onion, returning the onion to walk in refrigerator, coming back to line, getting a hamburger bun from the bun bag and then making a cheeseburger with the onion. V21 then continued to do meal service from the steam table. At the end of the steamtable there is an approximate 2 foot by 2 foot counter attached to the steamtable. There is a large container with no lid of thick white liquid. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 21 of 34 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 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 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 On 12/21/23 at 12:10 PM, V21 was questioned what was in the container. V21 stated, It's left over white gravy from the morning cook. She didn't put it away. V21 was questioned how he handles left overs, V21 stated, After meal service, I turn off the steam table and then I go on break. While I am gone the food is cooling down. When I come back and the food is cool enough, I cover it, label it, date it and then put it in the refrigerator. Residents Affected - Many On 12/26/23 at 1:03 PM, V16, stated staff should only touch food with clean hands that had just been washed. V16 stated left over food should be cooled down within a 4 hour window and temperatures should be taken while cooling down. The policy Food Storage and Labeling Procedure, date 9/22, documents, Food Storage: Store food in containers intended for food. Food should be stored in a clean, dry location. Store all food at least 6 inches off the floor. Keep all food covered in a re-sealable bag or container or the original container, of applicable. Labeling of Refrigerated Foods: The label should include: 1. Product name: Even if you can see the product/ leftover through the plastic wrap or lid, you must label the container or re-sealable bag with the product name. 2. Date: Document the date that the produce is placed in the refrigerator. 3 Discard Date: Count 7 days from the date you are placing the item in the refrigerator. 4. Staff Initials: Every label must include the initials of the staff member preparing the item / left over to be refrigerated. The policy Cleaning and Sanitizing Work Surfaces and Equipment Procedure, dated 8/19, documents, Clear work surface tables of food, food crumbs, dirty utensils, used cutting boards,etc. (ecetra). Clear equipment such as grill, slicer, mixer, etc. of food and food crumbs. The Long Term Care Facility Application For Medicare and Medicaid (CMS-671), dated 12/18/23, documents 58 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 22 of 34 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 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and record review, the QA&A (Quality Assurance Committee) failed to recognize an infection control problem, and the QAPI (Quality Assurance Performance Improvement) committee failed to perform a Performance Improvement Plan (PIP) regarding an infection control problem. This failure has the potential to affect all 58 residents residing in the facility. Finding include: On 12/27/23 at 10:20 AM, V1 (Administrator) was questioned if the committee had recognized the infection control issue of isolation, identifying an outbreak, and tracking and trending of infections. V1 stated, We really never have discussed infection control because we haven't had issues until the last month. We had COVID in October, then in December, and then this GI (Gastrointestinal) issue. On 12/27/23 at 10:25 AM, V1 stated the facility does not have a PIP (Performance Improvement Plan) in writing, but they do them verbally. The Quality Assurance Committee policy, dated 8/20, documents, Quality Assurance Committee is utilized to: Identify areas of concerns. Detect trends or patterns that signal potential areas of risk. Detect trends or patterns that signal potential areas of risk. Involve staff in developments of action plans related to monitoring results, thereby enhancing staff commitment to and involvement in measures to promote compliance. Evaluate the effectiveness of past and present actions taken to remedy deficiencies. Provide managers with objective information to guide decision making. The QAPI Plan, dated 11/14/22, documents, Direction of QAPI Activities: 1. Identifying and prioritizing problems based on performance indicator data. Ensuring that corrective actions address gaps in the system and are evaluated for effectiveness. It continues, PIP's will be documented continuously during execution. The Long Term Care Facility Application For Medicare and Medicaid (CMS-671), dated 12/18/23, documents 58 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 23 of 34 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 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 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 - Immediate jeopardy to resident health or safety On 12/19/23 at 10:17 AM, R29 was on the toilet requesting assistance, as she had large amount of loose stool, both in her brief and in the toilet. V6, Certified Nursing Assistant (CNA), entered to assist R29. R29 was attempting to clean herself up, however, had stool all over herself, including her hands. V6 unfastened R29's brief and tucked it between her legs. R29's pants were wet and soiled with loose stool, and were removed by V6. After V6 gathered the soiled pants and brief to put in a plastic bag, V6 went to a dresser drawer in R29's room to gather more supplies with the same soiled gloves on. V6 then applied a gait belt around R29, a clean brief and pants on her lower legs, all with the same soiled gloves on. V6 assisted R29 to stand up and hold onto her walker while V6 wiped stool off R29's back, buttocks, and anal area. V6 reached between R29's legs and wiped from front to back with a lot of stool seen on the cloths/wipes, one dry washcloth used to reach between R29's legs once more, then brief and pants pulled up with same soiled gloves on. R29's shirt had stool on the bottom of the shirt, which was pulled down over her clean pants, while V6 stated she had to change her shirt because it had stool on it. Residents Affected - Many The Gastrointestinal Log, dated 12/2023, fails to document R29 having symptoms of diarrhea. On 12/18/23 at 10:20 AM, R10 was sitting in a recliner in the living area, napping, covered with blanket, wheelchair next to the recliner, and no staff present. On 12/18/23 at 12:55 PM, R10 was assisted back to her bed, with a strong smell of urine and feces. V7, CNA, came in to do peri-care on R10. R10's pants were pulled down which showed loose stool in her pants. R10's brief was unfastened and tucked between her legs. V7 wiped R10's groins once each, then using same wipe, wiped once down middle of her vagina, and pushed that wipe between R10's legs. As R10 was rolled over, V7 noticed loose stool was up R10's back and all over her buttocks. V7 began wiping R10's stool and asked to get another CNA to assist her. V7 used soiled gloves and pulled the sheet over R10 while she waited for help. V6, CNA, entered to assist and wiped R10's groins once, used same cloth and wiped R10's vagina once. R10 was rolled to her right side and V7 began to wipe R10's back, and anal area. Using the same gloves, V7 put a new incontinent brief and bed pad down, then applied barrier cream to R10's anal area. R10 started to have more diarrhea and was allowed to finish her bowel movement (BM). Both CNAs doffed their gloves, gathered soiled linen and trash bags without gloves on, then left the room without doing hand hygiene. On 12/18/23 at 1:18 PM, V6 and V7 went back into R10's room to clean her up after her bowel movement. R10's brief was tucked between her legs. R10 was rolled to her right side and her anal area was briefly wiped, and her soiled incontinence brief was pulled out from under her. Using the same soiled gloves, V7 applied a new incontinence brief and bed pad to the bed. There was no further wiping of R10's vagina, groins, or buttocks after her BM. V7 used same soiled gloves to pull resident up in bed. V7 doffed her gloves, covered R10, then exited the room without hand hygiene done. The Gastrointestinal Log, dated 12/2023, documents R10 as having diarrhea beginning on 12/5/23, and R10 was not put on isolation. On 12/21/2023 at 9:25 AM, R160 stated she was having diarrhea. R160 stated she feels weak and sick to her stomach. On 12/21/2023 at 9:40 AM, R37 stated she has had diarrhea for the last couple of days. R37 stated she has told the staff. R37 stated she has not been on any isolation precautions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 24 of 34 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 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 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 - Immediate jeopardy to resident health or safety Residents Affected - Many On 12/21/2023 at 9:23 AM, R56 stated she has had diarrhea yesterday and today. R56 stated she just goes in the toilet and flushes. On 12/21/2023 at 9:33 AM, R52 stated she is nauseated and unsure why. R52 stated she has not had any diarrhea. R52 stated that she was in her room with the door closed, and was isolated, and not sure why. On 12/21/2023 at 12:30 PM, V15, Medical Director, stated he was the Medical Director for the facility. V15 stated he was notified of residents having GI symptoms. V15 stated he would have not been notified of every resident that had the symptoms, because he is not everyone's physician. V15 stated he was not aware of specific number of residents and staff with the GI symptoms. V15 stated if there was an outbreak, he would be notified. V15 stated he is not sure what that number is, and the facility would have the specifics. V15 stated he would expect the facility to contact the health department and follow their recommendations. V15 stated he would expect the facility to communicate the recommendations to him. When asked why the residents were only tested for COVID? V15 stated during this time, COVID had more GI symptoms than respiratory. V15 stated there are more than COVID respiratory infections, there is RSV and Flu as well. V15 stated it takes time for norovirus results to come back. V15 stated, The first step with residents with GI symptoms would be isolation. The resident should be in isolation. It would start there. V15 stated he had 1 resident with IV therapy recently but is unsure, due to not having the chart, if this was because of the nausea or vomiting or poor intake. The facility's policy Infection control, dated 12/17/2019, did not address what type of infection control procedures should be implemented regarding Gastroenteritis. Centers for Disease Control and Prevention (CDC) 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, last updated July 2023 documents Documented LTCF (long-term care facilities) outbreaks have been caused by various viruses (e.g., influenzas virus, rhinovirus, adenovirus, norovirus and bacteria (e.g., group A streptococcus, B. Pertussis, non-susceptible S. pneumoniae, other MDROs (multi drug resistant organisms, and Clostridium difficile). Thes pathogens can lead to substantial morbidity and mortality and increased medical cost; prompt detection and implementation of effective control measures are required. The Guidelines documented Contact Precautions also apply where the presence of excessive wound drainage, fecal incontinence, or other discharges from the body suggest an increased potential for extensive environmental contamination and risk of transmission. The Guidelines documented healthcare personnel caring for patients on Contact precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning PPE (personal protective equipment) upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g., VRE, C. difficile, noroviruses and other intestinal tract pathogens; RSV). The Immediate Jeopardy that began on 12/3/23 was removed on 12/21/23 when the facility took the following actions: 1. The facility's DON, V2, completed an audit of all residents for signs and symptoms of infection, including GI illness. 2. The facility's Administrator, V1, completed an audit of all staff to ensure no one is currently working with signs and symptoms of any infection, including GI illness, and the employee infection log is completed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 25 of 34 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 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 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 - Immediate jeopardy to resident health or safety Residents Affected - Many 3. Facility infection control policies were reviewed by Regional Nurses, V50 and V51, to ensure it is acceptable with Standards of Practice. 4. V1, Administrator, V2, DON, and Infection Preventionist were in serviced by Regional Nurses, V50 and V51, regarding policies 01.11 Infection Control, 3.29 Categories of Transmission based precautions, 3.45 Standard Precautions. This in-servicing included how to identify an outbreak, track, and trend an outbreak to prevent further infection, implementing contact precautions, isolating affected residents, using personal protective equipment, and educating staff on preventing the spread of infection, including Gastroenteritis. 5. Facility initiated in-servicing all staff, concerning policies 01.11 Infection Control, 3.29 Categories of Transmission based precautions, 3.45 Standard Precautions. This in-servicing includes reporting signs and symptoms of infection, including Gastroenteritis prior to reporting to work, use of PPE and contact isolation. No staff will be allowed to work without in-servicing. 6. All nurses will be in serviced by V2 or designee regarding completing an assessment (Infection tracker event) for any resident displaying signs and symptoms of infection, including Gastroenteritis, at the time symptoms are exhibited. 7. The DON/or designee will be responsible for tracking all infections moving forward. 8. The Administrator/Designee will audit 3 employees weekly for 1 month to ensure staff is not working while symptomatic of Gastroenteritis and then ongoing. 9. The facility's DON/Infection Preventionist will review infection tracker events 3 times per week for 1 month to ensure reporting and treatment of infections as well as tracking and trending of infections. From 12/26/23 through 12/29/23, the survey team validated the removal of the immediacy by interviewing V6, V9, V11, V18, V30, V43, V48, V55, V57, about the in-services they received related to the types of isolation, use of PPE, when to assess resident for signs of infection, who to notify of an infection and when to call off. V34, V56, V58, V59 all stated they were in-serviced on when to call off from work and how long they need to stay off work. R3's, R6's, R8's, R27's, R43's and R54's rooms were observed with isolation signage and carts. The facility audits, in-services and policies were reviewed. Based on observation, interview, and record review, the facility failed to implement a system to track and trend infections, and failed to implement infection control procedures including isolation precautions and personal protective equipment (PPE) to prevent the spread of infection. These failures resulted in 23 residents devloping Gastroenteritis, including 8 residents (R10, R29, R32, R37, R41, R52, R56, R160) currently experiencing Gastroenteritis in the facility. These failures have the potential to affect all 58 residents in the facility. The Immediate Jeopardy began on 12/3/23, when R56 developed Gastroenteritis and the facility failed to implement isolation precautions including personal protective equipment. Subsequently, 22 other residents have developed Gastroenteritis. On 12/21/23 at 2:52 PM, V1, Administrator, V2, Director of Nursing, V14, Infection Preventionist, and V51, Regional Director, were notified of the Immediate Jeopardy. The surveyors confirmed by observation, interview, and record review, the Immediate Jeopardy was removed on 12/21/23, but noncompliance remains at Level Two because additional time is needed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 26 of 34 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 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 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 to evaluate the implementation and effectiveness of the in-service training. Level of Harm - Immediate jeopardy to resident health or safety Findings include: The employee call off log documented on 11/27/23, V22, Dietary Aide, called off work because of Gastrointestinal symptoms. Subsequently, from 11/27/23 to 12/15/23, 23 staff developed Gastroenteritis. Residents Affected - Many The facility's Infection Control Tracking documented on 12/3/23, R56 developed Gastroenteritis symptoms, and no isolation precautions were implemented. From 12/3/23 to 12/21/23, 23 additional residents developed Gastroenteritis including R5, R7, R9, R10, R16, R20, R23, R25, R28, R29, R30, R31, R32, R37, R41, R44, R45, R50, R52, R54, R56, R111, R160. During the survey, R10, R29, R32, R37, R41, R56, R160 were experiencing gastroenteritis. On 12/18/23 through 12/21/23, there was no signage on the doors indicating any of the residents were on contact isolation. R32's Nurse's Note, dated 12/10/2023 at 9:28 PM, documents, 7pm Resident's urine is dark. Decreased urine output. States she has not drank much fluids today d/t (due to) it upsets her stomach. VS (Vital Signs) 134/68 (blood pressure) 74 (pulse) 20 (respiration) 97.0 (temperature) SpO2 (oxygenation saturation) 95% RA (room air). Made on call (V61, Nurse Practitioner, NP)) aware. Gave order for Saline IV 1 L (liter) at 75 ml (milliliter) per hour and Zofran (nausea medication) 4 mg (milligram) every one tab every four hours for n/v (nausea/ vomiting). R32's Nurse's Note, dated 12/11/2023 at 12:29 AM, documents, IV continues. Resident was incontinent of a large loose stool at 9 pm. Resident given PRN (as needed) Zofran at 7:15 pm for c/o (complaint of) nausea. Urine color improving. Resident has drank a little water. R32's Nurse's Note, dated 12/11/2023 at 2:39 AM, documents, Linens changed after earlier incontinent loose stool. R32's Nurses Note, dated 12/11/2023 at 11:16 PM, documents, Resident BS (blood sugar) 552 at HS (hour of sleep). Emesis x 1, milk with pieces of mandarin oranges. Zofran given. Made (V62, NP) aware. Stated to continue with sliding scale as ordered for BS (blood sugar) over 400. Monitor and report. Also made aware of emesis, recent IV fluids, and loose stools. Novolog sliding scale given as ordered. Will monitor. R32's Nurse's Note, dated 12/11/2023 at 11:19 PM, documents,10:30 pm Emesis x one. Resident diet 7-Up given with effectiveness. R32's Nurse's Note, dated 12/12/2023 at 10:13 AM, documents, Resident noted to have elevated blood glucose at 556 this AM. while still refusing to eat. Insulin given and MD (Medical Doctor) notified, rechecked after 30 minutes and blood glucose was 507. Resident continues to feel nauseous and refusing to eat. MD stated to send out to ER (Emergency Room) for evaluation r/t (related to) elevated blood glucose. POA (Power of Attorney) aware of sending out to ER for evaluation. R32's Nurse's Note, dated 12/12/2023 at 03:32 PM, documents, Resident back from ER visit. No new orders at this time. Resident received IV fluids and insulin in ER. Encourage fluids and monitor blood glucose. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 27 of 34 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 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 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 - Immediate jeopardy to resident health or safety Residents Affected - Many R32's Nurse's Note, dated 12/13/2023 at 9:41 AM, documents, Resident states she is feeling just a little better today. Zofran given for nausea. AM blood glucose was low at 56, gave large glass of juice and she ate her breakfast sausage, rechecked and it was 119. Continued to encourage to increase fluids at this time. R32's Nurse's Note, dated 12/16/2023 at 2:05 AM, documents, Resident c/o (complaint of) nausea at HS (hour of sleep/bedtime). Gave PRN Zofran with effectiveness. HS BS 92. Offered snack but Resident stated, 'I don't need it'. Resident encouraged to eat and drink fluids. Covid test: negative. R32's Nurse's Note, dated 12/16/2023 at 11:35 AM, documents, Resident states that she still does not feel well and does not feel like getting up out of bed at this time, she is very nauseous, so Zofran was given at this time. R32's Nurse's Note, dated 12/18/2023 at 1:58AM, documents, Resident continues to feel nauseated and achy, refused her meds and meals. Requested ice water only. (Indwelling urinary catheter) patent, Tylenol given prn as ordered. MD aware and has given orders to monitor blood Glucose closely. R32's Nurse's Note, dated 12/19/2023 at 10:57 AM, documents, Fax sent to MD regarding resident, she has a 102.2 fever, and diarrhea. PRN Tylenol given. awaiting response from MD. R32's Nurse's Note, dated 12/19/2023 at 03:04 PM, documents, Labs received and Potassium is 5.2 and sodium is 129. Call placed to (V62) with results. (V62) states to send resident to ER. Ambulance called and arrived to facility within minutes. Resident does express she wants to go. Resident is a diabetic and is not well controlled. Resident continues with diarrhea and fever despite Tylenol. Urine is dark yellow draining per catheter. Resident is heading to ER now. R32's Nurse's Note, dated 12/19/23 at 6:22 PM, documents, Spoke to (Local Hospital) who reported that resident is being transferred to (Regional Hospital). Only dx (diagnosis) at this time: Hyperglycemia. On 12/19/23 at 10:50 AM, R32's room was entered with V8, Licensed Practical Nurse, LPN, to administer Acetaminophen for a fever of 102.5 degrees. R32 was being cleaned up of an incontinent episode of diarrhea. R32's room had an extreme foul odor related to the stool. There was not an isolation cart containing personal protective equipment or isolation precaution signage outside of R32's room. On 12/19/23 at 10:40 AM, V8 stated R32 has had loose stool and nausea for the last 3 weeks, and the doctor is aware. R16's Nurse's Note, dated 12/09/2023 at 9:25 PM, documents, Called to room at this time, resident having another emesis. T (Temperature) 98.1 P (Pulse) 120 R (Respirations) 20 BP (Blood Pressure) 178/97 O2 (Oxygenation) 92 @ 2L(Liters). Call made to on call dr. for (V42) at this time. On call doctor recommended resident to go to (Local Hospital) to get fluids. Call then made to make POA aware and she agreed to have resident taken to ER for evaluation and treatment. 911 called at 9:30pm. R16's Nurse's Note, dated 12/10/2023 at 12:20 AM, documents, Call received at this time from (Local Hospital) in regard to resident being sent back to facility. Stated hospital nurse gave resident fluids and Zofran. All testing came back negative. Resident diagnosed with Gastroenteritis. Order received for Zofran 4mg q (every) 4-6hr per rectum if unable to take orally PRN. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 28 of 34 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 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 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 - Immediate jeopardy to resident health or safety R16's Nurse's Note, dated 12/22/2023 at 3:47 PM, documents, CNA notified writer that resident has had an episode of diarrhea, isolation has been started. No fever at this time. resident has no complaints at this time. POA aware, administrator aware, MD was faxed to notify. The Gastrointestinal Log, dated 12/2023, documents R16 began to have emesis on 12/9/23, and was not put on isolation when symptoms of gastroenteritis began. Residents Affected - Many R41's Nurse's Note, dated 12/06/2023 at 11:56 PM, documents, 11:30 pm Moderate amount of loose stool x 1. VS 138/64 74 20 97.1 SpO2 97% RA. Covid test negative. Resident given clear soda. PRN Imodium given. Resident given Tylenol at HS med pass for c/o general discomfort. Will make (V15, Medical Director) aware. R41's Nurse's Note, dated 12/07/2023 10:52 PM, documents, NA (Nurse Aide) reported that she had an episode of vomiting, temperature is 99.5. R41's Nurse's Note, dated 12/11/2023 at 1:49 AM, documents, Two loose stools x two with PRN Imodium. Fluids encouraged. No emesis or c/o nausea. T 97.6. No c/o voiced. R41's Nurse's Note, dated 12/16/2023 at 12:14 AM, documents, Resident's Imodium 2 mg one tab after every loose stool with a max of three times/day continues as needed per (V15), is aware of numerous loose stools with foul odor and is also aware of coccyx being red and irritated with barrier cream being applied. Notes: monitor and report significant changes. The Gastrointestinal Log, dated 12/2023, documents R41 began to have nausea and diarrhea on 12/7/23, and was not put on isolation. On 12/20/23 at 1:58 PM, V6, Certified Nurse Assistant (CNA), stated, (R41) had diarrhea yesterday. She hasn't had any today. V6 stated the (GI bug) went on for about 2 weeks. On 12/20/23 at 2:08 PM, V18, LPN, stated R56 had GI issues recently. On 12/20/23 at 12:10 PM, V16, Dietary Manager, stated, I am the only one (of kitchen staff) that has not had the GI bug. Employees that were sick needed to be symptom free for 24 hours with a doctor's note before they came back. On 12/21/23 at 9:10 AM, V27, Cook, stated he did have Gastrointestinal symptoms and he needed to stay home for 24 hours after he was symptom free. On 12/20/23 at 10:15 AM, V14, Infection Preventionist, was questioned about the GI (Gastro-Intestinal) Bug that has been in the building, V14 stated, I can't figure it out. I don't know where it is coming from. We have had to give some IV (Intravenous Fluids). The doctor did not want any testing done. I have not contacted the County Health Department because I don't know how. (V1, Administrator) is the one who calls them. V14 stated she is tracking the GI issues in the facility. The November and December Monthly Antibiotic Control log was reviewed at this time. This log failed to document any GI issues. A copy of V14's tracking was requested at this time. On 12/20/23 at 2:20 PM, V14 stated the facility does not have any residents that are currently having symptoms of nausea, vomiting or diarrhea. V14 stated, The last resident was (R32) and she went to the hospital yesterday (12/19/23), so there are no current residents. It started around the 5th (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 29 of 34 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 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 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 - Immediate jeopardy to resident health or safety (12/5/23), the main part was the 8th through the 11th (12/8/23 - 12/11/23). V14 stated the two residents that needed IV fluids while having GI symptoms were (R32) and (R41) (R41 did not require fluids). V14 stated R32 needed fluids twice. On 12/21/23 at 10:15 AM, V14 stated, Employees who contracted the GI bug had to be symptom free for 24 hours before returning to work. Residents Affected - Many On 12/20/23 at 10:28 AM, V1, stated, I did not report to the County Department of Health. It was not the flu (Influenza Virus), RSV (Respiratory Syncytial Virus) or COVID. The doctor was not ordering any tests. Why would I? V1 was asked if she had considered the Norovirus, V1 stated, No. On 12/21/23 at 10:00 AM, V1 stated, When the residents were experiencing nausea, vomiting, or diarrhea the residents stayed in their room until they were symptom free for 24 hours. The staff wore masks because we were on COVID precautions, they wore gloves and used frequent hand washing. We did not require gowns while caring for the residents or put isolation signs or carts outside of room. At this time, we do not have any current cases. We had 2 residents receive IV fluids (R32 and R41) (R41 did not require IV fluids) and 2 residents were sent to the hospital because of it (R32 and R16). We do not have a specific GI policy and procedure. We use the basic infection control policy. On 12/21/23 at 12:00 PM, V2, Director of Nursing, (DON), stated, If a resident was having symptoms, they had to be in the room for 24 hours until they were symptom free. We did COVID tests and notified their primary care provider. Once notified, they (doctors) just said to monitor. We did not have any specific isolation just general isolation. The doctors never gave an order regarding the type of isolation or for isolation. We did in-service for hand washing. Employees that were ill stayed home until they were symptom free. On 12/20/23 at 1:45 PM, V20, Local Health Department Registered Nurse, stated, I was not aware that (the facility) was having an outbreak of Gastroenteritis. I would have expected them to notify us. I would have contacted them to see if they needed anything from us. I would have told them to pull the guidance from the IDPH (Illinois Department of Public Health) website, do they need help understanding it? I would expect contact isolation to be put in place, PPE (Personal Protective Equipment) by doors, signage on doors, testing of the stool to determine what bug is going around. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 30 of 34 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 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 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 Based on interview and record review, the facility failed to establish an infection prevention and control program that reduces the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use for 5 of 5 residents (R9, R23, R36, R50, R210) reviewed for antibiotic stewardship in the sample of 44. Residents Affected - Some 1. The Facility's Monthly Infection Log for the month of October 2023 does not document an organism causing R9's infection. The log documents No for culture and organism is blank. The log also documents R9 was treated with the antibiotic Keflex. R9's Physician Order Sheet (POS), not dated, documents cephalexin capsule; 500 mg; amt: 1 tab (tablet); oral Special Instructions: give 500 mg (milligrams) by mouth twice a day x 7 days starting at 8:00am on 10/07/2023. R9's Medication Administration Record (MAR) for the month of October 2023 documents that R9 received 5 of 14 doses of Cephalexin 500mg. It also documents that R9 received 14 of the 14 doses of Macrobid 100MG. 2. The Facility's Monthly Infection Log for the month of October 2023 does not document an organism causing R210's infection. The log documents No for culture and organism is blank. The log also documents R210 was treated with Cefdinir. R210's October MAR, documents that R210 received 7 doses of Cefdinir. 3. The Facility's Monthly Infection Log for the month of November 2023 does not document an organism causing R36's infection. The log documents No for culture and organism is blank. The log also documents R36 was treated with Keflex. R36's November MAR, documents that R36 received 15 doses of Keflex. 4. The Facility's Monthly Infection Log for the month of November 2023 does not document an organism causing R50's infection. The log documents No for culture and organism is blank. The log also documents that R50 was treated with Macrobid. R50's November MAR, documents that R50 received 13 doses of Macrobid. 5. The Facility's Monthly Infection Log for the month of November 2023 does not document an organism causing R23's infection. The log documents No for culture and organism is blank. The log also documents that R23 was treated with Keflex. R23's November MAR, documents that R23 received 15 doses of Keflex. On 12/26/2023 at Approximately 10:30 AM, V14 (Infection Preventionist) stated that the Monthly Antibiotic/Infection Control Log is how she tracks and trends infections and antibiotic use. V14 stated that log is filled out with the information that she has. On 12/29/2023 at 9:03 AM, V1 (Administrator) stated that she expects the antibiotic stewardship to be performed per policy. V1 stated that she expects the logs to be completed so that the antibiotic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 31 of 34 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 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 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 Level of Harm - Minimal harm or potential for actual harm usage and infections tract and trended. V1 stated that this would help with preventing the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotics. The facility's Antibiotic Stewardship Policy, dated 12/18/19, documents that the purpose of the program is to reduce inappropriate use of antibiotics, improve resident outcomes and lessen adverse events. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 32 of 34 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 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 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 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on record review and interview, the facility failed to ensure the required abuse training was complete for 6 of 6 employee records reviewed for abuse. This failure has the potential to affect all 58 residents residing in the facility. Findings include: 1. A Review of V30's, Certified Nurse Aide, (CNA), employee required education records began on 12/21/23 at 1:21 PM. V30's Individual Employee Training Record documents V30's hire date was 11/22/22. V30's Individual Employee Training Record did not indicate completion of Abuse training for 11/22/2022 through 12/21/23. 2. A Review of V44's, CNA, employee required education records began on 12/21/23 at 1:21 PM. V44's Individual Employee Training Record documents V44's hire date was 11/29/21. V44's Individual Employee Training Record did not indicate completion of Abuse training for 11/29/2022 through 12/21/23. 3. Review of V60's, CNA, employee required education records began on 12/21/23 at 1:21 PM. V60's Individual Employee Training Record documents V60's hire date was 10/2/18. V60's Individual Employee Training Record did not indicate completion of Abuse training for 10/2/2022 through 12/21/23. 4. Review of V63's, CNA, employee required education records began on 12/21/23 at 1:21 PM. V63's Individual Employee Training Record documents V63's hire date was 10/18/2018. V63's Individual Employee Training Record did not indicate completion of Abuse training for 10/18/2022 through 12/21/23. 5. Review of V64's, CNA, employee required education records began on 12/21/23 at 1:21 PM. V64's Individual hire date was 12/20/22. V64's Individual Employee Training Record did not indicate completion of Abuse training for 12/20/2022 through 12/21/23. 6. Review of V10's, CNA, employee required education records began on 12/21/23 at 1:21 PM. V10's Individual hire date was 12/21/22. V10's Individual Employee Training Record did not indicate completion of Abuse training for 12/21/2022 through 12/21/23. On 12/21/2023 at approximate 1:21 PM, V2 (Director of Nursing) stated the Individual Employee Training Record is where the documentation of the required 12 hour education for abuse would be for each employee. On 12/29/2023 at 9:07 AM, V1 stated she expects the staff have all required in-services and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 33 of 34 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 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 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 0947 education. Level of Harm - Minimal harm or potential for actual harm The Abuse Policy, dated 11/28/2019, documents new employee orientation shall include training on abuse and neglect prohibition. It also documents at least annually, the facility will in-service on Abuse Prohibition, including reporting obligations of the employees. Residents Affected - Many The Long Term Care Facility Application For Medicare and Medicaid (CMS-671), dated 12/18/23, documents 58 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 34 of 34