Inspection·May 6, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent physical abuse to 1 of 5 residents (R4) reviewed for abuse in the sample of 10. Findings include: 1. R4's face sheet dated, 4/22/2024, documents R4 has a diagnosis of unspecified dementia , unspecified severity, with agitation. R4's Minimum Data Set (MDS), dated [DATE], documents R4 has severe cognitive impairment. R4's event report, dated 4/16/2024 at 9:19AM, documents a purplish-black bruise measuring 3 Centimeters (CM) x 3CM. R4's event report documents unknown activity during bruise. On 4/22/2024 at 3:02 PM, V14, Certified Nursing Assistant (CNA), stated he was assigned to R4 as 1:1 on 4/15/2024. V14 stated he was assigned to R4 for his whole shift.V14 stated R4 was pretty calm, but did get restless. V14 stated they made a couple of laps around the facility with R4 in transfer chair. V14 stated they remained outside in the court yard from 2 PM-5:30 PM because R4 was restless. V14 stated at one time he did try to stand up, but sat back down. V14 then stated they stayed outside until 5:00PM, then came in for supper. V14 stated he toileted R4 after supper and he did not void. V14 stated R4 was in recliner in his room at 7:45PM. V14 stated R4 would start to stand up saying looking for his car then would sit back down. V14 stated, If (R4) was trying to get out of the chair, I did kind of lay my hand across his chest . On 4/22/2024 at 2:05 PM, V15, CNA stated she was walking past R4's room on 4/15/2024. V15 stated it was on the evening shift, she worked 2-10 PM, and it was before supper. V15 stated she saw V14, CNA, sitting on R4's bed and R4 was sitting in chair. V15 stated V14 had his hand on R4's upper extremity/chest, so R4 could not get up. V15 stated she reported this to V18, Licensed Practical Nurse (LPN). On 4/23/2024 at 1:51 PM, V16, CNA, stated she had taken care of R4 for a short time. V16 stated R4 would get agitated and did a lot of wandering, and would try to elope from the facility. V16 stated he would try to go into R8's room across the hall. V16 stated she was working on 4/15/2024 during the evening shift . V16 stated V14, CNA, was providing 1:1 care for R4. V16 stated V14 had taken R4 outside, and when they came back in the facility at approx 3:30-4:00PM, V14 was pushing R4 down the hall in wheelchair, and R4 planted his feet, so the chair would not move. V16 stated V14 then pulled up R4's legs, cradled feet, and pushed R4 into his room. V16 stated she observed R4 trying to get out of his recliner. V16 stated V14 had his hands on R4's forearms so he cannot get out of the chair. V16 stated V14 was restraining R4 from walking. V16 stated she reported her observations to V18, LPN. On 4/24/2024 at 12:02 PM, V1, Administrator, stated R4 did have a bruise on his arm. V1 stated she concluded V14 was using tactile touch approach to keep R4 from falling, as R4 is a fall risk and had falls. The facility policy Abuse Prohibition and Reporting (Elder Justice Act) dated, revised 11/28/19, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 2 of 7 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 05/06/2024 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 0600 documents the facility actively prohibits resident abuse, including injuries of unknown source and use of any physical restraint not required to treat resident symptoms. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 3 of 7 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 05/06/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an allegation of abuse in a timely manner for 1of 5 residents (R4) reviewed for abuse in the sample of 10. Findings include: 1. R4's face sheet, dated 4/22/2024, documents R4 has a diagnosis of unspecified dementia , unspecified severity, with agitation. R4's Minimum Data Set (MDS), dated [DATE], documents R4 has severe cognitive impairment. R4's event report, dated 4/16/2024 at 9:19AM, documents a purplish-black bruise measuring 3 Centimeters (CM) x 3CM. R4's event report documents unknown activity during bruise. On 4/22/2024 at 3:02 PM, V14, Certified Nursing Assistant (CNA), stated he was assigned to R4 as 1:1 on 4/15/2024. V14 stated he was assigned to R4 for his whole shift. V14 stated R4)was pretty calm, but did get restless. V14 stated they made a couple of laps around the facility with R4 in a transfer chair. V14 stated they remained outside in the court yard from 2 PM-5:30 PM because R4 was restless. V14 stated at one time, he did try to stand up but sit back down. V14 then stated they stayed outside until 5:00PM then came in for supper. V14 stated he toileted R4 after supper and he did not void. V14 stated R4 was in recliner in his room at 7:45PM. V14 stated R4 would start to stand up, saying he was looking for his car, then would sit back down, V14 stated, If (R4) was trying to get out of the chair, I did kind of lay my hand across his chest . On 4/22/2024 at 2:05 PM, V15, CNA, stated she was walking past R4's room on 4/15/2024. V15 stated it was on the evening shift, she worked 2 PM-10 PM, and it was before supper. V15 stated she saw V14, CNA, sitting on R4's bed, and R4mwas sitting in the chair. V15 stated V14 had his hand on R4's upper extremity/chest so R4 could not get up. V15 stated she reported this to V18, Licensed Practical Nurse (LPN). On 4/23/2024 at 1:51 PM, V16, CNA, stated she had taken care of R4 for a short time. V16 stated R4 would get agitated and did a lot of wandering, and would try to elope from the facility. V16 stated he would try to go into R8's room across the hall. V16 stated she was working on 4/15/2024 during the evening shift. V16 stated V14, CNA, was providing 1:1 care for R4. V16 stated V14 had taken R4 outside, and when they came back in the facility at approx 3:30-4:00PM, V14 was pushing R4 down the hall in wheelchair and R4 planted his feet, so the chair would not move. V16 stated V14 then pulled up R4's legs, cradled feet and pushed R4 into his room. V16 stated she observed R4 trying to get out of his recliner. V16 stated V14 had his hands on R4's forearms so he cannot get out of the chair. V16 stated V14 was restraining R4 from walking. V16 stated she reported her observations to V18, LPN. On 4/24/2024 at 12:02 PM, V1, Administrator, stated R4 did have a bruise on his arm. V1 stated she concluded V14 was using tactile touch approach to keep R4 from falling, as R4 is a fall risk and had falls. The facility did not provide any documentation that an investigation was initiated on 4/15/2024 when staff reported to nurse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 4 of 7 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 05/06/2024 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 0609 On 4/26/2024 at 12:56 PM, V1, Administrator, stated abuse is to be reported immediately Level of Harm - Minimal harm or potential for actual harm The facility policy Abuse Prohibition and Reporting (Elder Justice Act) dated, revised 11/28/19, documents the facility employee or agent who becomes aware of alleged abuse or neglect of a resident should immediately report the matter to the facility administrator or designee. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 5 of 7 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 05/06/2024 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to initiate a timely and thorough investigation in response to allegations of abuse concerning residents for 1of 5 residents (R4) reviewed for abuse in the sample of 10. Residents Affected - Few Findings include: 1. On 4/22/2024 12:56 PM, V1, Administrator, stated the undated, unsigned white sheet of paper in the abuse folder for R4 titled (staff) interview was her notes/timeline of her interview with V14. The white sheet has no times on it. On the piece of paper it is documented an employee from shift key had provided 1:1 to R4; there is no statement in the packet, nor was that employee interviewed. V1 was asked by surveyor how she could do a complete investigation without the alleged abuser written statement. V1 stated she does not have written statement yet. V1 stated V13, Infection Control Nurse did send her pictures from phone. R4's abuse investigation packet does not have a written statement or interview from V13. R4's abuse investigation packet failed to document any type of interviews with any staff or residents except for V14, CNA. V1 stated how she concluded there was no abuse when written statements from staff documenting V14 was holding R4 down was after talking to V14, she determined V14 was using tactile cues. On 4/22/2024 2:05 PM, V15, CNA (Certified Nursing Assistant), stated she was walking past R4's room on 4/15/2024 on the evening shift; she worked 2-10 PM, and it was before supper. V15 stated she saw V14, CNA, sitting on R4's bed, and R4 was sitting in a chair. V15 stated V14 had his hand on R4's upper extremity/chest so R4 could not get up. V15 stated she reported this to V18, Licensed Practical Nurse (LPN). On 4/22/2024 at 3:02 PM, V14, CNA, stated he was off sick 4/10 and 4/11. V14 stated he was off 4/12/-4/14 and returned to work on 4/15/2024 2-10 PM shift. V14 stated he was notified on 4/16 he was off pending investigation, and was called he could return to work on 4/20. V14 stated he had not been asked to provide a written statement prior to today. . On 4/23/2024 at 1:51 PM, V16, CNA, stated she was working on 4/15/202,4 and during the evening shift, V14, CNA, was providing 1:1 care for R4. V16 stated V14 had taken R4 outside, and when they came back in the facility at approx 3:30-4:00PM, V14 was pushing R4 down the hall in a wheelchair and R4 planted his feet, so the chair would not move. V16 stated V14 then pulled up R4's legs, cradled feet and pushed R4 into his room. V16 stated she observed R4 trying to get out of his recliner. V16 stated V14 had his hands on R4's forearms so he could no get out of the chair. V16 stated V14 was restraining R4 from walking. V16 stated she reported her observations to V18, Licensed Practical Nurse (LPN). V16, CNA, stated she wrote out a statement. V16 stated she was never interviewed or questioned by anyone in regards to her statement. V16 stated , I never heard anything else. On 4/22/2024 at 12:56 PM, V1, Administrator, stated she did not interview staff and other residents. On 4/22/2024 at 12:56 PM, V1, Administrator, stated allegations of abuse are to be reported immediately. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 6 of 7 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 05/06/2024 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The facility Abuse Prohibition and Reporting (Elder Justice Act) dated, revised 11/28/2019, documents investigation- interviews with all involved parties or potential witnesses will be completed. The policy documents if possible at least two interviewers shall be present for each witness interview. The policy documents at least one interviewer shall take notes. The policy documents signed statements from those persons who saw or heard information pertinent to the incident shall be obtained. Statements shall be taken from the suspect, the person making the accusations, the resident abused or neglected (if cognitive level permits), other staff or residents who may have witnessed the incident, and any other person who may have information related to the incident. The policy documents the administrator shall keep copies of all notes from the interviews conducted by the administrator or other facility interviewer in the course of the investigation. The administrator shall be responsible for supervising the investigation. Event ID: Facility ID: 145837 If continuation sheet Page 7 of 7