Inspection·October 1, 2024

F 0600 documented evaluation of either one of them for a capacity to consent. Level of Harm - Minimal harm or potential for actual harm On 9/25/24 at 3:40 PM, V13 Social Services Director, I have not ever evaluated either of the two of them for the ability to consent to a sexual relationship. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145862 If continuation sheet Page 2 of 6 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 145862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Skilled Nsg & Rehab 910 West Polk Street Charleston, IL 61920 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document evaluations to determine cognitively impaired residents' capacity to consent to a known sexual relationship, failed to develop their policy on intimate resident behavior to include the criteria for initial evaluation and frequency with which a cognitively impaired resident's capacity to consent to an intimate relationship is to be evaluated, and to specify where and how the evaluations and determinations would be documented and maintained. This failure affects two (R1, R2) residents and has the potential to affect 22 additional cognitively impaired residents (R5 through R26) on the sample list of 26 reviewed for cognitive capacity. Residents Affected - Some Findings include: The facility policy (undated) on Intimate Resident Behavior, Privacy, and Relationships, documents the facility may utilize, as appropriate, a mental health practitioner, psychiatrist, clinical social worker, or psychologist, or primary care physician to help in the evaluation and determination of an individual's ability to provide informed consent. R2's Diagnoses List dated 9/25/24 documents R2's medical diagnoses includes Dementia. R2's Minimum Data Set (MDS) dated [DATE] documents R2 scored a 2 out of a possible 15 during a Brief Interview for Mental Status, rating R2 as severely cognitively impaired. R1's Diagnoses List dated 9/25/24 documents R1's medical diagnoses includes Dementia. R1's MDS dated [DATE] documents R1 received a score of 7 out of 15 during a BIMS, rating R1 as severely cognitively impaired. On 9/25/24 at 1:15 PM, V3, Certified Nursing Assistant (CNA), stated she had direct knowledge of R1 and R2 kissing. On 9/25/24 at 1:25 PM, V5, CNA, stated she had seen R1 and R2 hold hands, and R1 hug R2 around the neck. V5 further stated that another resident reported to V5 seeing R1 in R2's room rubbing on R2's private area (genitals) with her hand. V5 stated she did not think R2 had the capacity to consent to sexual activity. On 9/25/24 at 1:35 PM, V6 CNA, stated she did not think either R1 nor R2 had the mental capacity to form consent to sexual activity. On 9/25/24 at 1:45 PM, V7, Licensed Practical Nurse, stated, I walked into R1's room and saw R1 with his privates (genitals) exposed and R2 was playing with R1's privates (genitals) with her hand. V7 then stated, I did not do anything about it because everyone tells me they are consensual. V7 concluded by stating, I think both R1 and R2 can form consent, they always sit at the table together and I hear them talking to each other asking if the other wants to come to their room. On 9/25/24 at 2:33 PM, V11, Friend/ Power of Attorney (POA) for R2, stated, I am aware of the situation with (R2) in (R1's) room and playing with (R1's) privates (genitals). I absolutely think she (R1) is aware of what she is doing and I think she has the mental thoughts to be able to do that kind of thing and I don't think that is out of line. On 9/25/24 at 2:47 PM, V12, sister/ POA for (R1), stated, Well (R1) was capable of making that kind of decision (whether to engage in an intimate relationship) before he went into the nursing home so I would say he still is capable of making that kind of decision now. On 9/25/24 at 2:55 PM, V2, Director of Nursing, stated, I do know (R1) and (R2) are friendly, I know they used to be at another nursing home at the same time so they have known each other from back (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145862 If continuation sheet Page 3 of 6 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 145862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Skilled Nsg & Rehab 910 West Polk Street Charleston, IL 61920 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some before here, I know they sit together at the same table in the dining room, and (R2) stops by (R1's) room to ask if he is going to the dining room. V2 then stated, I do think they both are able to consent to a sexual relationship. V2 concluded by stating, As far as I know there hasn't been any formal documented evaluation of either one of them for a capacity to consent. On 9/25/24 at 3:40 PM, V13, Social Services Director, I have not ever evaluated either of the two of them for the ability to consent to a sexual relationship. On 9/25/24 at 3:40 PM, V14, Regional Director of Operations, stated, There should have been some documentation of both resident's capacity to consent to sexual activity. Going forward, we will make it as right as we can. On 9/27/24 at 10:27 AM, V14 stated, Absolutely (we should have been able to put all of the documentation of the evaluations of R1 and R2's capacity to consent to a sexual relationship in your hand when you came in to do this survey). The facility policy (undated) on Intimate Resident Behavior, Privacy, and Relationships did not include where and how the results of an evaluation of a resident's capacity to consent to a sexual relationship are to be maintained, nor was there a time interval for the evaluations to be conducted. On 9/27/24 at 2:20 PM, V14, Regional Director of Operations, stated, I don't see that our policy specifies where we would document or maintain the evaluations (of a resident's capacity to consent to an intimate relationship) but going forward we would scan them into the resident's chart. V14 further stated, We would do the evaluations quarterly, we need to set up the form in the PCC (electronic medical record format). On 9/27/24 at 2:20 PM, V17, Regional Director, stated, For now we would just have to scan the evaluations into the medical record. V17 then stated, All I see as far as frequency is as appropriate which isn't very specific. The portion of the policy which V17 referred to documents The facility will record assessment findings in appropriate documentation. There is no mention of the frequency of the assessments or evaluations. Additional residents potentially affected include: R5's MDS dated [DATE] documents R5 received a score of 3 out of 15 during a BIMS, indicating severe cognitive impairment. R6's MDS dated [DATE] documents R6 received a BIMS score of 10 out of 15, rating R6 as moderately cognitively impaired. R7's MDS dated [DATE] documents R7 received a BIMS score of 2 out of 15 during a BIMS, rating R7 as severely cognitively impaired. R8's MDS dated [DATE] documents R8 received a BIMS score of 11, indicating moderate cognitive impairment. R9's MDS dated [DATE] documents R9 received a BIMS score of 4 out of 15, indicating severe cognitive impairment. R10's MDS dated [DATE] documents R10 received a score of 3 out of 15 during a BIMS, rating R10 as severely cognitively impaired. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145862 If continuation sheet Page 4 of 6 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 145862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Skilled Nsg & Rehab 910 West Polk Street Charleston, IL 61920 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 0607 Level of Harm - Minimal harm or potential for actual harm R11's MDS dated [DATE] documents R11 received a score of 6 out of a possible 15 during a BIMS, rating R11 as severely cognitively impaired. R12's MDS dated [DATE] documents R12 could not complete a BIMS interview and was assessed by staff to be severely cognitively impaired. Residents Affected - Some R13's MDS dated [DATE] documents R13 received a score of 11 out of 15 during a BIMS, rating R13 as moderately cognitively impaired. R14's MDS dated [DATE] documents R14 received a score of 11 out of 15 during a BIMS, rating R14 as moderately cognitively impaired. R15's MDS dated [DATE] documents R15 received a score of 11 out of a possible 15 during a BIMS, rating R15 as moderately cognitively impaired. R16's MDS dated [DATE] documents R16 could not complete a BIMS interview and was rated by staff to be severely cognitively impaired. R17's MDS dated [DATE] documents R17 received a BIMS score of 3 out of 15, rating R17 as severely cognitively impaired. R18's MDS dated [DATE] documents R18 received a score of 7 out of 15 during a BIMS, rating R18 as severely cognitively impaired. R19's MDS dated [DATE] documents R19 received a score of 9 out of 15 during a BIMS, rating R19 as moderately cognitively impaired. R20's MDS dated [DATE] documents R20 received a BIMS score of 7 out of 15, rating R20 as severely cognitively impaired. R21's MDS dated [DATE] documents R21 received a BIMS score of 6 out of 15, rating R21 as severely cognitively impaired. R22's MDS dated [DATE] documents R22 received a score of 3 out of 15 during a BIMS, rating R22 as severely cognitively impaired. R23's MDS dated [DATE] documents R23 received a score of 7 out of 15 during a BIMS, rating R23 as severely cognitively impaired. R24's MDS dated [DATE] documents R24 received a score of 9 out of 15 during a BIMS, rating R24 as moderately cognitively impaired. R25's MDS dated [DATE] documents R25 received a score of 10 out of 15 during a BIMS, rating R25 as moderately cognitively impaired. R26's MDS dated [DATE] documents R26 received a score of 7 out of a possible 15 during a BIMS, rating R26 as severely cognitively impaired. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145862 If continuation sheet Page 5 of 6 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 145862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Skilled Nsg & Rehab 910 West Polk Street Charleston, IL 61920 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review, the facility failed to develop residents care plans to include an intimate relationship and the need for privacy. This failure affects two residents (R1, R2) out of 5 reviewed for care plans on the sample list of 26. Findings include: On 9/25/24 at 1:45 PM, V7, Licensed Practical Nurse, stated, I walked into R1's room and saw R1 with his privates (genitals) exposed and R2 was playing with R1's privates (genitals) with her hand. V7 then stated, I did not do anything about it because everyone tells me they are consensual. V7 concluded by stating, I think both R1 and R2 can form consent, they always sit at the table together and I hear them talking to each other asking if the other wants to come to their room. On 9/25/24 at 1:25 PM, V5, CNA, stated, I have seen R1 and R2 hold hands, and R1 hug R2 around the neck. V5 further stated, Another resident reported to me seeing R1 in R2's room rubbing on R2's private area (genitals) with her hand. The facility policy (undated) on Intimate Resident Behavior, Privacy, and Relationships documents the facility encourages residents to appropriately pull privacy curtains and close doors when engaging in behavior of a sexual nature. This same policy documents, The resident's care plan should document issues or concerns related to intimacy and sexual expression. As of 9/25/24 at 2:50 PM, neither R1's nor R2's care plan had an intimate sexual relationship and the need for privacy documented on their individual plans of care. On 9/25/24 at 2:55 PM, V2, Director of Nursing, stated, I can get a care plan fixed for (R1 and R2) about them being in a sexual relationship. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145862 If continuation sheet Page 6 of 6