Health inspection·October 8, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The policy Abuse Prohibition and Reporting, dated 11/28/2019, documents, Policy: The facility actively prohibits resident abuse, neglect, corporal punishment, involuntary seclusion, misappropriation of property, injuries of unknown source, exploitation and use of any physical or chemical restraint not required to treat residents symptoms. Purpose: To protect residents from any kind of abuse such as verbal, mental, physical, including corporal punishment, involuntary seclusion, neglect, misappropriation of property exploitation and use of any physical or chemical restraint not required to treat residents symptoms. 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 10/08/2024 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 - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to investigate a fall and provide a new progressive fall prevention intervention in place for 1 of 3 (R1) in the sample of 8. Findings include: R1's Face Sheet, 10/7/24, documents R1 was admitted on [DATE], and has diagnoses of Cerebral infarction due to embolism of right middle cerebral artery and Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R1's Minimum Data Set, dated [DATE], documents R1 is cognitively intact, requires supervision with dining, moderate assistance with bed mobility, and is dependent on staff for transfers. R1's Nurses Note, dated 09/20/2024 07:34 PM, documents, Resident found lying on left side in dining room by aide at 1905. Resident stated he was reaching for a napkin and slid out of his wheelchair. Resident assessed by nurse. Resident A&O (alert and orientated) x4. No injuries noted at time of fall. No c/o (complaint of) pain or discomfort at this time. ROM WNL (range of motion within normal limits). R1's Electronic Medical Record fails to document a fall investigation or a progressive intervention to prevent further falls for R1's fall on 9/20/24. On 10/7/24 at 10:35 AM, R1 stated he has had some falls. He stated while reaching for things, he gets to close to the edge of the wheelchair seat, and falls out of the wheelchair. On 10/7/24 at 11:09 AM, V1, Administrator, stated there was not a fall investigation done, and R1 did not have a progressive fall intervention put into place after this fall. V1 stated the nurse did not notify management of the fall or put the fall into a fall event note. V1 further stated the fall policy is located in the Emergency Care Procedure policy. The Emergency Care Procedure, dated 4/3/2018, fails to documents a fall investigation should be done and a new fall prevention intervention should be put in place. 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 10/08/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to secure narcotics upon delivery from pharmacy for 4 of 4 residents (R3, R4, R5, R6) reviewed for pharmacy storage. Findings include: On 10/3/24 at 8:06 AM, V1, Administrator, stated, The pharmacy delivered medications and the nurse signed off they were delivered. In the morning, when the nurse went to load the medication into the STAT safe, the Tylenol with codeine was not there. We were unable to find the medications. I don't know if they were taken or if they were even in the order. The nurse was immediately put on suspension. I notified the police department and the DEA (Drug Enforcement Agency) was notified. At the end of investigation, I did terminate the nurse for not following our policy of accepting delivery of medications from the pharmacy. On 10/3/24 at 1:07 PM, V2, Director of Nurses, stated, It takes 2 nurses to load medication into the STAT safe. Pharmacy had delivered the medications between 12 and 1 AM. There where 2 nurses here, but one was agency, and she did not have a log in. The agency nurse should have called me because I could have got her one, but she didn't. The pharmacy delivery was locked in the medication room. In the morning, 2 nurses loaded the medications that were present. Later, I got a notification from the pharmacy that the Tylenol with codeine had not been loaded yet. That is when it was discovered the Tylenol with codeine was delivered. The nurse said she did not review the order she signed for, and she did not take the Tylenol with codeine. The pharmacy says they delivered it. The nurse was terminated for not following our policy. The Tylenol with codeine was stock medication. No residents at this time have an order for it, but we like to have it on hand so if it is ordered we can give it timely. 1. R3's face Sheet, print date of 10/3/24, documents R3 was admitted on [DATE]. This Face Sheet fails to document R3 has an allergy to Tylenol or Codeine. 2. R4's Face Sheet, print date of 10/7/24, documents R4 was admitted on [DATE]. This Face Sheet fails to document R4 has an allergy to Tylenol or Codeine. 3. R5's Face Sheet, print date of 10/8/24, documents R5 was admitted on [DATE]. This Face Sheet fails to document R5 has an allergy to Tylenol or Codeine. 4. R6's Face Sheet, print date of 10/7/24, documents R6 was admitted on [DATE]. This Face Sheet fails to document R6 has an allergy to Tylenol or Codeine. The facility supplied Codeine Allergy list, undated, fails to document R3, R4, R5 and R6 have a codeine allergy. The facility reported final report, dated 8/9/24, documents, A full audit of the STAT-Safe Inventory was completed by (V2) and another RN (Registered Nurse) to assure that the medication had not been misplaced into a different drawer. All four medications carts and both med (medication) rooms were also inspected. The medication was not located. It continues, (V11, RN) was terminated from her (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 10/08/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete position as a bedside Registered Nurse at (the facility) due to her not following protocols on checking in narcotics and verifying that they are secured. The Pharmaceutical Procedures, dated 1/5/23, documents Purpose: 1. To provide the appropriate control of procurement, distribution, administration, and utilization of drugs to the facility. VII. Emergency Medication Supply Convenience Drug Boxes or Automated Convenience Box fails to document the procedure to accept medication deliveries and the procedure to load the STAT safe with medication 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 10/08/2024 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 - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to wear Personal Protective Equipment (PPE) for 2 of 3 residents (R2, R8) reviewed for COVID in the sample of 8. Residents Affected - Few Findings include: 1. R2's Face Sheet, print date of 10/7/24, documents R2 was admitted on [DATE]. R2's Progress Note, dated 09/24/2024 09:57 AM, documents, Resident has cough with no production, nasal congestion, body aches, and overall fatigue. Res (resident) was covid-19 tested via rapid test and results were positive. POA (Power of Attorney) notified. Faxed MD (Medical Doctor) to notify and request Paxlovid per res request. Res placed in isolation at this time. On 10/3/24 at 12:19 PM, V8, Certified Nurse Aide (CNA), went to R2's and R7's room with 2 lunch plates. The door has signage documenting a N95 mask, gown, gloves, and eye protection must be worn. There is an isolation cart with supplies outside the door. V8 donned a N95 mask, gloves, and a gown. V7 entered the room without eye protection. On 10/3/24 at 1:25 PM, V8 was questioned why she did not wear eye protection, V8 stated, Honestly, I forgot. They are not coughing or anything. 2. R8's Face Sheet, print date of 10/7/24, documents R8 was admitted on [DATE]. R8's Progress Note, dated 10/5/24, documents, Resident reports to writer that she has been dry heaving for the last 2 days and just doesn't feel well. CNA reports to this nurse that resident has really been coughing. Rapid covid test done and is positive. On 10/7/24 at 9:29 AM, V9, Registered Nurse (RN), was observed entering R8's room. V9 was observed at the bedside talking with R8. V9 was only wearing a surgical mask. The door has signage documenting a N95 mask, gown, gloves, and eye protection must be worn. There is an isolation cart with supplies outside the door. On 10/7/24 at 9:31 AM, V9 was questioned why she did not don a N95, gown, gloves, or eye protection, V9 stated, I did. I just took them off. On 10/7/24 at 9:33 AM, V3, Infection Prevention Nurse, stated all staff should wear a gown, gown, gloves, eye protection, and a N95 mask while caring for covid positive resident. The policy COVID-19, dated 8/28/23, documents, Residents with symptoms consistent with COVID-19: c. Contact Droplet precautions (N95 respirator) with eye protection will be initiated. The policy Infection Control, dated 12/17/2029, documents, Transmission -Based Precautions: The purpose of isolation techniques is to protect the resident and personnel from infection and to halt the spread of the infectious agent. Emphasis will be placed on isolating the disease not the resident. All isolation precautions will fall into one of the following categories: 1. Airborne Precautions 2. Contact Precautions 3. Droplet Precautions. It continues, Gowns are worn by all personnel when they enter a strict isolation room and by those coming in direct contact with residents who require (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 10/08/2024 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 airborne, droplet, and contact (if necessary) precautions. It continues, Gloves, disposable in nature, will be worn unless sterile gloves are necessary. 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 7 of 7