Health inspection·April 9, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. 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 access to a hand washing sink for two residents (R21, R12) of 18 residents reviewed for accommodation of needs in a sample list of 47. Residents Affected - Few Findings Include: 1. R21's electronic health record diagnosis list, printed on 4/3/24 at 3:05 PM, documents the following diagnoses: Chronic Obstructive Pulmonary Disease, History of Falling, Right Knee Pain, Abnormal Gait and Mobility, Unsteadiness on Feet, Neuropathy, Muscle Weakness, and Anxiety Disorder. R21's Minimum Data Set, dated [DATE] documents R21 is cognitively intact and uses a wheelchair for mobility. On 4/2/24 at 4:00 PM, R21 stated I have to use the sit-to-stand lift to go to the toilet and it's tight in there, but we manage. I'd really like to use the sink to wash my hands and face, comb my hair and brush my teeth, I can't get my wheelchair anywhere close to the sink. I like to do as much as I can for myself. The sink is observed to be between a wall and a cabinet and does not have enough space to roll a wheelchair under it. R21 is sitting in a wide wheelchair. 2. R12's electronic health record diagnosis list printed on 4/4/24 includes the following diagnoses: Parkinson's Disease, Unsteadiness on Feet, and Abnormal Gait and Mobility. R12's Minimum Data Set (MDS) dated [DATE] documents R12 is cognitively intact and uses a walker and wheelchair for mobility. On 4/2/24 at 11:00 PM, R12 stated his room does not accommodate his needs as he uses a wheelchair and his bathroom is crowded and he can't get to the sink . The sink is observed to be between a wall and a cabinet and does not have enough space to roll a wheelchair under it. R21 is sitting in a wheelchair. On 4/4/24 at 11:00 AM, V1 Administrator confirmed there is not enough space to wheel a wheelchair up to the sinks in (R12 and R21's) rooms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145883 If continuation sheet Page 2 of 17 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 145883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piatt County Nursing Home 1111 N State St Monticello, IL 61856 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on observation, interview, and record review the facility failed to ensure the right to be free from physical and verbal abuse by staff. R45, who resides on the dementia unit, was subjected to physical and verbal abuse on three separate occasions by V13 Certified Nurse's Assistant. R45's hands and chest were bruised, R45 was fearful showing emotional symptoms following the incidents as evidenced by increased behaviors with cares, making more sudden abrupt startled movements when approached by caregivers. These failures affect one (R45) of six residents reviewed for abuse on the sample list of 47. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 1/9/24 when V13 Certified Nurse's Assistant verbally abused R45 during a shower, V13 was suspended from work 3/13/24. V1 Administrator was notified of the Immediate Jeopardy on 4/4/24 at 10:00 AM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 4/4/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of their Removal plan and Quality Assurance monitoring. Findings include: R45's careplan dated 8/24/20 documents R45 has a diagnosis of Dementia with behavioral disturbance, Anxiety, and Chronic pain. This care plan documents R45 has a history of becoming combative with cares and has care planned interventions to stop care and re-approach when combative. On 4/3/24, R45's right hand had faded bruising between the pointer finger and thumb. The facility's Allegation/Summary conclusion dated 3/19/24 documents on 3/13/24 at approximately 1:45 PM during a team meeting, V16 CNA (Certified Nurse's Assistant) made the comment to the group that V13, CNA was mean to (R45) and suggested that a bruise seen on (R45's) hand was from Where (V13) was holding her down. V7, CNA then added she witnessed an incident the week prior where V13 threatened R45 after R45 became aggressive during care. On 4/3/24 at 8:37 AM, V9 CNA stated V13's tone was very aggressive with the residents. A couple months ago, on 1/9/24, I was giving R45 a shower. R45 was becoming combative so I asked V13 for help. R45 made a noise and then said, oh poo. V9 stated V13 then got in R45's face and meanly said, Oh Poo! back to R45 and then hissed like a snake in R45's face very aggressively. On 4/2/24 at 3:21 PM, V7 CNA stated on 3/6/24 at 5:30 PM, V13 CNA and I went into R45's room. V7 stated they were transferring her to bed and changing her. V7 stated they were talking to R45 and we were trying to get R45's shirt off but it wasn't working and she was tensed up. V7 stated V13 then tried to force her to take the shirt off without saying anything. V7 stated this caused R45 to try to fight her and R45 began to punch and scratch V13. V7 stated V13 then grabbed both of R45's wrists and pinned them against her chest and got face to face to R45 and was touching nose to nose and said, I will snap your wrists if you wont's let us get you to bed. I will snap your legs. V7 stated they then hooked her up to the mechanical lift and got R45 in the bed. V7 stated V7 took R45's pants off. V7 stated as they were trying to change R45, V13 kept pinning R45's arms to her chest. V7 stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145883 If continuation sheet Page 3 of 17 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 145883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piatt County Nursing Home 1111 N State St Monticello, IL 61856 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 once they were done V13 took a blanket and threw it on her (R45). Level of Harm - Immediate jeopardy to resident health or safety On 4/3/24 at 8:33 AM, V7 CNA stated after the 3/6/24 incident with V13, R45 was scared. V7 stated during the incident R45 appeared scared, her eyes were great big. V7 stated after that, during cares R45 would flinch (making sudden startled movements) and she still does. V7 stated, I really feel like she still remembers and is now more combative. Residents Affected - Few V16's undated witness statement documents on 3/12/23, V16 CNA was helping V13 CNA with getting R45 up. R45 was hitting at V16's face and V13 then pinned R45's arms to her chest and said stop hitting or I will break your arms. Attempts were made to contact V16 for interview, however V16 was unable to be reached. The facility's census sheet dated 4/1/24 documents R45 resides on the Dementia unit. The facility's daily staffing sheet documents V13 worked on the Dementia unit on 25 occasions between 1/9/24 and 3/12/24. V13's Employee Termination Form dated 3/19/24 documents, On March 6th (2024), (V13) verbally abused a resident (R45) by using profanity and physically threatened her during care. and On March 13th (V13) held the same resident's hands down hard enough to bruise her hand and wrist, as well as leaving a small bruise on the resident's chest. She also cursed and threatened the resident during this incident. On 4/3/24 at 12:00 PM, V1 Administrator stated V13 was terminated for the physical and verbal abuse of V13. V1 stated V13 did have bruising as a result of this abuse. The Immediate Jeopardy that began on 1/9/24 was removed and the deficient practice corrected on 4/4/24 when the facility took the following actions to remove the Immediacy and correct the noncompliance: 1. On 3/13/24, V13 Certified Nurse's Assistant was suspended by V1 Administrator pending an investigation, V13 was terminated from employment on 3/19/24. On 3/22/24, V39 Unit Coordinator was also terminated from employment by V1 Administrator. 2. On 3/19/24, V1 Administrator reported the abuse to the county sheriff's office. 3. On 4/4/24, V2 Director of Nursing updated R45's care plan with new interventions. 4. On 4/4/24, V2 inserviced the Nurses, CNAs, and activity staff on interventions for when R45 becomes combative during care. 5. On 4/3/24, V30 Social Service Director completed risk of abuse assessments on all residents in the facility. 6. On 4/4/24, V30 and V3 ADON updated care plans for the residents who were newly identified as at risk for abuse. 7. On 4/4/24, V2 inserviced the Nurses, CNAs, and activity staff on interventions for when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145883 If continuation sheet Page 4 of 17 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 145883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piatt County Nursing Home 1111 N State St Monticello, IL 61856 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 residents becomes combative during cares. Level of Harm - Immediate jeopardy to resident health or safety 8. On 3/13/24, V1 Administrator, V2 Director of Nursing, V30 Social Service Director re-evaluated the abuse policy and procedures. Residents Affected - Few 9. On 3/13/24, 3/14/24, and 4/4/24, V26 Administrative Assistant and V40 Human Resource Specialist re-educated all staff on the facility protocol for reporting abuse, the types and signs of abuse, and the facility's abuse prevention policy and procedures. 10. On 3/14/24, V1 Administrator developed a quality assurance plan to ensure continuing education of all staff on facilities abuse reporting procedure, skills for identifying and preventing abuse, and how to manage an incident of abuse. This process began on 3/14/24, the audit has been completed weekly, on 3/21/24, 3/28/24 and 4/4/24. 11. On 4/4/24, V2 Director of Nursing developed a quality assurance plan to ensure continuing CNA and Nurse education on interventions with residents who are combative or resistant with care. 12. On 4/4/24, V2 Director of Nursing developed a quality assurance plan to ensure continuing compliance with the updating of care plan interventions for residents who are combative with care. The facility presented an abatement plan to remove the immediacy on 4/4/24 at 2:11PM. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions on 4/4/24 at 2:41 PM. The facility presented a revised abatement plan on 4/4/24 and the survey team accepted the abatement plan on 4/4/24 at 4:07 PM. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145883 If continuation sheet Page 5 of 17 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 145883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piatt County Nursing Home 1111 N State St Monticello, IL 61856 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 Based on observation, interview, and record review the facility failed to follow it's abuse prohibition policy by failing to report allegations of abuse to the facility Administrator and prevent further resident abuse. These failures affected three (R45, R35, and R69) of six residents reviewed for abuse on the sample list of 47. These failures have the potential to affect all 24 residents (R66, R77, R70, R3, R47, R55, R20, R74, R9, R59, R76, R45, R62, R79, R19, R8, R35, R10, R69, R61, R5, R65, R36, and R32) residing on the Dementia unit. Residents Affected - Some Findings include: The facility's Abuse Prohibition policy dated 8/22/16 documents all residents have the right to be free from verbal and physical abuse. This policy documents the definition of physical abuse as, the infliction of injury on a resident that occurs other than by accidental means. This policy documents the definition of verbal abuse as, the use by an employee or agent of oral, written or gestured language that includes disparaging and derogatory terms to a resident or within his or her hearing or seeing distance, regardless of the resident's age, ability to comprehend or disability. This policy also documents that, A facility employee or agent who becomes aware of alleged abuse or neglect of a resident shall immediately report the matter to the facility administrator. 1. R45's careplan dated 8/24/20 documents R45 has a diagnosis of Dementia with behavioral disturbance, Anxiety, and Chronic pain. This care plan documents R45 has a history of becoming combative with cares and has care planned interventions to stop care and re-approach when combative. On 4/3/24, R45's right hand had faded bruising between the pointer finger and thumb. V16's Employee Termination Form dated 3/19/24 documents V13 was terminated for verbally and physically abusing R45 on 3/6/24 and 3/12/24. On 4/3/24 at 8:37 AM, V9 Certified Nurse's Assistant (CNA) stated V13 was verbally abusive to R45 on 1/9/24 and she did not report it to V1, Administrator. On 4/2/24 at 3:21 PM, V7 CNA stated on 3/6/24 at 5:30 PM, V13 was physically and verbally abusive to R45 and that she did not report it to V1, Administrator. V16's undated witness statement documents on 3/12/23, V16 CNA witnessed V13 physically abuse R45 and documents V16 did not report it to V1, Administrator. On 4/3/24 at 12:00 PM, V1 Administrator stated V9, V7, nor V16 reported the verbal and physical abuse of R45 inflicted by V13 on 1/9/24, 3/6/24, and 3/12/24. V1 stated the Administrator is supposed to be notified immediately of all abuse allegations. The facility's staffing sheets document V13 worked on the Dementia unit on which R45 resides on 1/10/24, 1/15/24, 1/16/24, 1/18/24, 1/20/24, 1/21/24, 1/24/24, 1/30/24, 2/3/24, 2/4/24, 2/6/24, 2/7/24, 2/12/24, 2/13/24, 2/17/24, 2/21/24, 2/26/24, 2/27/24, 3/2/24, 3/3/24, 3/5/24, 3/6/24, 3/11/24, and 3/12/24 (16 shifts after the first instance of abuse occurred on 1/9/24). On 4/3/24 at 10:30 AM, V26 Administrative Assistant stated V13 works mostly on the Dementia unit and can provide care to all residents on this unit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145883 If continuation sheet Page 6 of 17 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 145883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piatt County Nursing Home 1111 N State St Monticello, IL 61856 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 The facility's census sheet dated 4/1/24 documents R66, R77, R70, R3, R47, R55, R20, R74, R9, R59, R76, R45, R62, R79, R19, R8, R35, R10, R69, R61, R5, R65, R36, and R32 reside on the Dementia unit. 2. On 4/01/24 at 9:30 AM, R35 stated someone bent her thumb back last night. The facility's Abuse Report dated 4/5/24 documents that on 3/31/24 there was a physical altercation between R35 and R69 and that V1 was not notified of this altercation until the next day. On 4/4/24 at 9:41 AM, V1 Administrator stated there was a physical altercation between R35 and R69 last night (3/31/24). V1 stated no one reported the altercation to him. V1 stated the Administrator is supposed to be notified immediately. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145883 If continuation sheet Page 7 of 17 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 145883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piatt County Nursing Home 1111 N State St Monticello, IL 61856 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 - Immediate jeopardy to resident health or safety Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on observation, interview, and record review the facility failed to report repetitive instances of verbal and physical abuse of a resident (R45) by V13 Certified Nurse's Assistant and failed to report a resident to resident physical altercation to the facility's Administrator. These failures resulted in V13 having continued access to R45 in which V13 provided direct cares and in the further instances of verbal and physical abuse of R45 by V13. As a result of this abuse R45's hands and chest were bruised and R45 displayed emotional symptoms of residual harm as evidenced by flinching(making sudden startled movements) and increased behaviors with cares. These failures affected three (R45, R35, and R69) of six residents reviewed for abuse on the sample list of 47. This failure has the potential to affect all 24 residents (R66, R77, R70, R3, R47, R55, R20, R74, R9, R59, R76, R45, R62, R79, R19, R8, R35, R10, R69, R61, R5, R65, R36, and R32) residing on the Dementia unit. These Failures resulted in an immediate jeopardy. The Immediate Jeopardy began on 1/9/24 when V16 Certified Nurse's Assistant failed to report an incident of abuse to V1 Administrator after witnessing V13 verbally abuse R45 during a shower. V1 Administrator was notified of the Immediate Jeopardy on 4/4/24 at 10:00 AM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 4/4/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of their Removal plan and Quality Assurance monitoring. Findings include: 1. R45's careplan dated 8/24/20 documents R45 has a diagnosis of Dementia with behavioral disturbance, Anxiety, and Chronic pain. This care plan documents R45 has a history of becoming combative with cares and has care planned interventions to stop care and re-approach when combative. On 4/3/24, R45's right hand had faded bruising between the pointer finger and thumb. V16's Employee Termination Form dated 3/19/24 documents V13 was terminated on 3/13/24. This form documents that V16 verbally and physically abused R45 on 3/6/24 and physically abused R45 on 3/13/24 in which R45 was bruised. On 4/3/24 at 8:37 AM, V9 CNA stated V13 was verbally abusive to R45. V9 stated V9 did not report the abuse to V1 Administrator. V9 stated this occurred on 1/9/24. On 4/2/24 at 3:21 PM, V7 CNA stated on 3/6/24 at 5:30 PM, V13 was physically and verbally abusive to R45. V7 stated V7 did not report the abuse to V1 Administrator because she was scared of V13. On 4/3/24 at 8:33 AM, V7 CNA stated after the 3/2/24 incident with V13, R45 was scared. V7 stated during the incident R45 appeared scared, her eyes were great big. V7 stated after that, during cares R45 would flinch and she still does. V7 stated, I really feel like she still remembers and is now more combative. V16's undated witness statement documents on 3/12/23, V16 CNA witnessed V13 physically abuse R45. This statement documents V16 was afraid to say anything about the abuse V16 witnessed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145883 If continuation sheet Page 8 of 17 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 145883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piatt County Nursing Home 1111 N State St Monticello, IL 61856 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 - Immediate jeopardy to resident health or safety Residents Affected - Some On 4/3/24 at 12:00 PM, V1 Administrator stated V1 was not aware of the verbal and physical abuse of R45 by V13 that occurred on 1/9/24, 3/6/24, and 3/12/24 because the CNAs who witnessed the abuse did not report the abuse to him. V1 stated the abuse did occur and R45 was bruised as a result. The facility's staffing sheets document V13 worked on the Dementia unit on which R45 resides on 1/9/24, 1/10/24, 1/15/24, 1/16/24, 1/18/24, 1/20/24, 1/21/24, 1/24/24, 1/30/24, 2/3/24, 2/4/24, 2/6/24, 2/7/24, 2/12/24, 2/13/24, 2/17/24, 2/21/24, 2/26/24, 2/27/24, 3/2/24, 3/3/24, 3/5/24, 3/6/24, 3/11/24, and 3/12/24 (24 shifts after the first instance of abuse occurred on 1/9/24). On 4/3/24 at 10:30 AM, V26 Administrative Assistant stated V13 works mostly on the Dementia unit and can provide care to all residents on this unit. The facility's census sheet dated 4/1/24 documents R66, R77, R70, R3, R47, R55, R20, R74, R9, R59, R76, R45, R62, R79, R19, R8, R35, R10, R69, R61, R5, R65, R36, and R32 reside on the Dementia unit. 2. On 4/01/24 at 9:30 AM, R35 stated someone bent her thumb back. R35's left thumb appeared a little bigger then the other. The facility's Abuse Report dated 4/5/24 documents V1 Administrator was made aware of an allegation of abuse on 4/1/24. This report documents upon investigation, R35 and R69 did have a physical altercation on the evening of 3/31/24. This report documents that the on-call nurse was notified but not V1, Administrator. On 4/4/24 at 9:41 AM, V1 Administrator stated there was an altercation between R35 and her room mate. V1 stated V1 was not immediately notified of the incident. The facility's Abuse Prohibition policy dated 8/22/16 documents all residents have the right to be free from verbal and physical abuse. This policy also documents that, A facility employee or agent who becomes aware of alleged abuse or neglect of a resident shall immediately report the matter to the facility administrator. The Immediate Jeopardy that began on 1/9/24 was removed and the deficient practice corrected on 4/4/24 when the facility took the following actions to remove the Immediacy and correct the noncompliance. 1. On 3/13/24, V13 Certified Nurse's Assistant was suspended by V1 Administrator pending an investigation, V13 was terminated from employment on 3/19/24. On 3/22/24, V39 Unit Coordinator was also terminated from employment by V1 Administrator. 2. On 3/19/24, V1 Administrator reported the abuse to the county sheriff's office. 3. On 4/4/24, V2 Director of Nursing updated R45's care plan with new interventions. 4. On 4/4/24, V2 inserviced the Nurses, CNAs, and activity staff on interventions for when R45 becomes combative during care. 5. On 4/3/24, V30 Social Service Director completed risk of abuse assessments on all residents in the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145883 If continuation sheet Page 9 of 17 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 145883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piatt County Nursing Home 1111 N State St Monticello, IL 61856 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 - Immediate jeopardy to resident health or safety Residents Affected - Some 6. On 4/4/24, V30 and V3 ADON updated care plans for the residents who were newly identified as at risk for abuse. 7. On 4/4/24, V2 inserviced the Nurses, CNAs, and activity staff on interventions for when residents becomes combative during cares. 8. On 3/13/24, V1 Administrator, V2 Director of Nursing, V30 Social Service Director re-evaluated the abuse policy and procedures. 9. On 3/13/24, 3/14/24, and 4/4/24, V26 Administrative Assistant and V40 Human Resource Specialist re-educated all staff on the facility protocol for reporting abuse, the types and signs of abuse, and the facility's abuse prevention policy and procedures. 10. On 3/14/24, V1 Administrator developed a quality assurance plan to ensure continuing education of all staff on facilities abuse reporting procedure, skills for identifying and preventing abuse, and how to manage an incident of abuse. This process began on 3/14/24, the audit has been completed weekly, on 3/21/24, 3/28/24 and 4/4/24. 11. On 4/4/24, V2 Director of Nursing developed a quality assurance plan to ensure continuing CNA and Nurse education on interventions with residents who are combative or resistant with care. 12. On 4/4/24, V2 Director of Nursing developed a quality assurance plan to ensure continuing compliance with the updating of care plan interventions for residents who are combative with care. The facility presented an abatement plan to remove the immediacy on 4/4/24 at 2:11 PM. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions on 4/4/24 at 2:41 PM. The facility presented a revised abatement plan on 4/4/24 and the survey team accepted the abatement plan on 4/4/24 at 4:07 PM. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145883 If continuation sheet Page 10 of 17 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 145883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piatt County Nursing Home 1111 N State St Monticello, IL 61856 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to prevent falls by ensuring a residents personal safety alarm was in working order, using an inappropriate sized mattress on a residents bed and failed to ensure a residents fall interventions were in place. This failure affects three (R19, R35, and R27) of five residents reviewed for falls on the sample list of 47. Findings include: 1.) R19's nurse's notes written by V4 Licensed Practical Nurse dated 3/10/24 at 2:41 PM, documents R19 was found on the floor laying on her stomach. R19 was noted to have a contusion above the right eyebrow. R19 was sent to the emergency room for an evaluation. On 4/02/24 at 11:43 AM, V4 stated on 3/10/24 she had just got done with lunch and she heard someone say that someone was on the floor. V4 stated she ran out there and R19 was laying on the floor on her side and the right side of her face was bleeding. V4 stated she sent her our due to her being on a blood thinner. On 4/2/24 at 11:49 AM, V5 Activity Aide stated R19 fell around 12:45 PM, stated she was on the other side of the dining room. V5 stated R19's chair alarm did not sound. On 4/2/24 at 11:58 AM, V6 Certified Nursing Assistant (CNA) stated V6 entered the dining room after R19 fell and they found that her alarm was not sounding. On 4/2/24 at 12:00 PM, V7 CNA, stated upon entering the dining room after R19 fell the alarm was not sounding. The alarm was changed out after that. On 4/2/24 at 2:42 PM, V2 Director of Nursing stated on the day of her fall her chair alarm did not alarm. A kinked wire caused the malfunction. We used the alarm to notify us when she is getting up. 2.) R35's Incident report dated 2/6/24 at 12:30 PM documents R35) was being turned by two CNA's (Certified Nurse's Aides) to right side in bed while providing care. The mattress fell out from under (R35) due to an incorrectly sized frame. The incident report also documents (R35's) bed frame was switched out by maintenance due to equipment needing repair. There is no documented injury to (R35). On 4/4/24 at 1:00 PM V2, Director of Nursing stated Maintenance took (R35's) Bariatric bed out for repair and put the Bariatric mattress on a regular bed. The mattress was too big and this caused a fall hazard. It was immediately corrected. 3.) R27's undated Medical Diagnosis list documents R27's medical diagnoses as Dementia, Abnormalities of Gait and Mobility, Muscle Wasting and Atrophy, Osteoarthritis of Knee, Muscle Weakness, Difficulty in Walking and Heart Failure. R27's Minimum Data Set (MDS) dated [DATE] documents R27 as cognitively intact. This same MDS documents R27 depends on two staff member and a total body mechanical lift for transfers. R27's Care Plan interventions dated 11/22/23 documents R27 uses a bed alarm, a full mattress at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145883 If continuation sheet Page 11 of 17 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 145883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piatt County Nursing Home 1111 N State St Monticello, IL 61856 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 bedside when in bed. This same careplan documents an intervention dated 12/13/22 that R27 utilizes a total body mechanical lift with two staff for transfers. R27's Fall Risk Assessment documents R27 as a high fall risk. R27's Nurse Progress Note dated 3/31/2024 at 2:13 AM documents (R27) is awake at 2:00 AM and has been seated near the nurses station since 10:00 PM (3/30/24) because she was attempting to get out of bed and needed closer supervision. R27's Nurse Progress Note dated 3/31/24 at 7:03 AM documents (R27) was placed in her bed and then changed by (V24) Certified Nurse Aide (CNA) around 4:20 AM this morning (3/31/24). Once (V24) CNA stepped out to grab the total body mechanical lift and seek assistance, (R27) rolled out of bed. (R27) was found on her Left side and it is unclear if she had hit her head or not since it happened while (V24) CNA momentarily stepped out of the room. R27's Fall Investigation dated 3/31/24 documents R27 was found on the floor of her room after being left alone momentarily on 3/31/24 at 4:40 AM. This same investigation documents (R27) was at the nurses station from 10:00 PM (3/30/31) to 4:20 AM (3/31/24) being supervised due to other attempt to get out of bed earlier in the evening (3/30/24). This same investigation documents R27's call light was within five to ten feet of R27 (at time of fall). This same investigation documents (R27) was placed in her bed, incontinence care was given by (V24) Certified Nurse Aide (CNA) around 4:20 AM on 3/31/24. Care was complete and (V24) CNA left the room to get a second assist for total body mechanical lift to get (R27) up in chair. When (V24) returned, (R27) was on the floor. (R27) stated she was trying to go home . (R27) was observed on her Left side next to the bedside table and it is unclear if she had hit her head. (R27) was confused and unable to determine if she hit her head. On 4/3/24 at 3:00 PM, V2 Director of Nurses (DON) stated (V24) was assisting R27 to get up for the day just prior to R27's fall. V2 stated R24 had a fall mat in place prior to her fall but V24 CNA removed the fall mat and then left R27's room to retrieve the total body mechanical lift to transfer R27 from her bed to her wheelchair. V2 DON stated The rooms are tight so it would be difficult to bring in the total body mechanical lift prior to removing the fall mat. V2 DON stated V24 CNA could have gotten another person to assist 'but we (facility) just don't have enough staff for that'. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145883 If continuation sheet Page 12 of 17 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 145883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piatt County Nursing Home 1111 N State St Monticello, IL 61856 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R28's undated Face Sheet documents R28 admitted to facility on 12/10/2018. R28's Minimum Data Set (MDS) dated [DATE] documents R28 is moderately cognitively impaired. R28's Physician Order Sheet (POS) dated April 2024 documents R28's medical diagnosis as Huntington's Disease, Bipolar Disease, Anxiety Disorders and Dysphagia. This same POS documents a physician order starting 1/26/21 with no end date listed for Bupropion Hydrochloride (HCL) Extended Release (ER) 100 milligrams (mg) twice daily for Depression. This same POS documents a physician order starting 7/15/23 with no end date for Risperidone 1 milligram (mg) daily for Huntington's Disease and a separate physician order starting 7/14/23 with no end dated for Risperidone 2 milligrams (mg) daily for Huntington's Disease. This same POS documents a physician order starting 8/7/21 with no end date for Trazodone 25 milligrams (mg) daily for Insomnia. R28's Note to Attending Physician/Prescriber dated 8/2/23 documents (R28) has been receiving Trazodone 25 milligrams (mg) once daily for Insomnia since 11/2019. Dose reduction attempts should be made for sedative/hypnotic medications at least twice in the first year and then yearly to ensure drug effectiveness with minimal side effects. This same report documents V33 Physician responded by checking a pre-printed response of Condition is not well controlled. Documentation of the specific clinical rational for your declination is required per Centers For Medicare and Medicaid Services (CMS). R28's Note to Attending Physician/Prescriber dated 9/6/23 documents (R28) has been receiving Bupropion Sustained Release (SR) 100 milligrams (mg) twice daily for Depression since it was increased 1/2021. Dose reduction attempts should be made for anti-depressant medications at least twice in the first year and then yearly to ensure drug effectiveness with minimal side effects. This same report documents V33 Physician responded by checking a pre-printed response of Condition is not well controlled. Documentation of the specific clinical rational for your declination is required per Centers For Medicare and Medicaid Services (CMS). The facility was unable to provide documentation of R28's pharmacy recommendation for a gradual dose reduction. On 4/2/24 at 1:00 PM V2 Director of Nurses stated the facility is supposed to attempt to reduce the dosage of Psychotropic medications. V2 DON stated the facility is unable to provide documentation of any reduction attempts for R28. V2 DON stated the facility discussed this problem at the last Quality Assurance Improvement Plan (QAPI) meeting in March. V2 DON stated We (facility) knew this was a problem, we just had not come up with a plan to try to fix this problem yet. Based on observation, interview, and record review the facility failed to support the appropriate use of psychopharmacologic medications for residents, failures include: completing residents' psychotropic medication assessments, determine the cause of residents' behaviors considering nonpharmacological interventions, providing parameters for the use of as needed (PRN) antianxiety medication, and providing a rational for duplicative therapy nor required gradual dose reductions for residents receiving psychotropic medications. These failures affects two (R19, R28) of six residents reviewed for psychotropic medication use on the sample list of 47. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145883 If continuation sheet Page 13 of 17 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 145883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piatt County Nursing Home 1111 N State St Monticello, IL 61856 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 0758 Findings include: Level of Harm - Minimal harm or potential for actual harm The facility's psychotropic medication policy dated 03/2021 states, 2. The facility supports the appropriate use of psychopharmacologic medications that are therapeutic and enabling for residents suffering from mental illness. 3. The facility supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of environmental, medical, and/or behavioral interventions, as well as psychopharmacological medications can be utilized to meet the needs of the individual resident. 4. The facility supports the goal of determining the underlying cause of residents having difficulty sleeping so the appropriate treatment of environmental or medical interventions can be utilized prior to psychopharmacological medication use. 5. Efforts to reduce dosage or discontinue of psychopharmacological medications will be ongoing, as appropriate, for the clinical situation. Residents Affected - Few 1.) On 4/01/24 at 12:15 PM, during lunch meal, R19 was lethargic and tearful asking what is wrong with me? R19 was attempting to feed self but unsuccessful causing tearfulness. On 4/01/24 at 11:39 AM, V44 (R19's family member) stated she feels R19 is overmedicated and as a result, not eating well. V44 states R19 is sleeping all day and night. R19's PASSAR (Preadmission Screening and Resident Review) dated 2/28/24 documents there no Serious Mental Illness or Intellectual/Developmental Disability. R19's Electronic Medical Record documents R19 was admitted on [DATE] with the following diagnoses: Depression, Anxiety, Dementia without Behavioral Disturbance, Psychotic Disturbance, and Mood Disturbance. This Medical record documents R19 was admitted to the facility for treatment of a Urinary Tract Infection. R19's admission orders dated 2/29/24 documents an order for Escitalopram (antidepressant) 20 milligrams by mouth once daily for anxiety. R19's physician order dated 3/1/24 documents an order for Ativan 0.5 milligrams by mouth as needed every two hours PO as needed for anxiety/restlessness. This order does not include parameters or nonpharmacological interventions that should be utilized prior to it's use. R19's medical record does not include a psychotropic assessment or that an attempt was made to determine the underlying cause for R19's behaviors for the use of the Escitalopram or Ativan. R19's physician's order dated 3/3/24 documents an order for Risperidone 0.25 milligrams every morning for anxiety. R19's psychotropic medication assessment dated [DATE] does not include what nonpharmacological interventions were attempted prior to ordering the Risperidone. R19's physician order dated 3/21/24 documents an order for Trazodone (antidepressant) 25 milligrams by mouth every night for depression. R19's medical record does not include a psychotropic medications assessment for the use of the Trazodone or a rational for the duplicative therapy for the use of the Escitalopram and Trazodone. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145883 If continuation sheet Page 14 of 17 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 145883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piatt County Nursing Home 1111 N State St Monticello, IL 61856 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 0758 Level of Harm - Minimal harm or potential for actual harm On 4/02/24 at 1:50 PM, V2 Director of Nursing stated that a psychotropic medications assessment was not completed when R19 admitted to the facility or after the Trazodone was added. V2 stated there are no parameters listed for the use of the Ativan. V2 stated there is no documentation of what nonpharmacological interventions were attempted prior to the use of the psychotropic medications. V2 stated there is no explanation for the duplicative therapy for the antidepressants. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145883 If continuation sheet Page 15 of 17 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 145883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piatt County Nursing Home 1111 N State St Monticello, IL 61856 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 implement antibiotic stewardship practice for residents by ordering prophylactic antibiotics. This failure affects two residents (R60, R35) reviewed for antibiotic stewardship on the sample list of 47. Residents Affected - Few Findings Include: R35's Physician's Order Summary dated 4/3/24 includes a physician's order for Cephalexin Oral Tablet 250 MG (Cephalexin) Give 1 tablet by mouth one time a day for Urinary Tract Infection. This order is documented as initiated 6/17/23 and has been given continually since that date. R35's March Medication Administration Record (MAR) documents (R35) was given Macrobid Oral Capsule 100 MG 1 capsule by mouth two times a day related to Urinary Tract Infection from 3/3/24 to 3/21/24 . There is no documentation to support a Urine Culture and Sensitivity has been performed in the entire time (R35) has been given these antibiotics. There is no documentation to support (R35) has a physician's order to be evaluated by a Urologist the entire time (R35) has been given these antibiotics. R60's Physician's Order Summary dated 4/3/24 includes a physician's order for Cephalexin Oral Capsule 250 MG (Cephalexin) Give 1 capsule by mouth one time a day related to personal history of Urinary Tract Infections. This medication has been given continually since 6/22/23. There is no documentation to support a Urine Culture and Sensitivity has been performed in the entire time (R60) has been given this antibiotic. There is no documentation to support (R60) has a physician's order to be evaluated by a Urologist the entire time (R60) has been given this antibiotics. There is no documentation to support the physician ordering antibiotics for R60 nor R35 has been consulted as to the efficacy of prolonged antibiotic therapy without culture and sensitivity. On 4/3/24 at 3:30PM V2, Director of Nursing stated the Medical Director orders prophylactic antibiotics and I am aware of the guidelines, but we have to follow his orders. The facility's Antibiotic Stewardship policy dated 1/19/19 states Antibiotic usage and outcome data will be collected and documented using a facility approved surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility wide Antibiotic Stewardship through the Quality Assurance Process. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145883 If continuation sheet Page 16 of 17 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 145883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piatt County Nursing Home 1111 N State St Monticello, IL 61856 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 interview and record review, the facility failed to monitor and maintain Certified Nursing Assistant (CNA) required twelve hours of inservice training per year to ensure continued competence. This failure has the potential to affect all 82 residents residing in the facility on the sample list of 47. Findings include: V20's training record documents, V20's Continuing Education Hours completed for 2023 total 7.00 hours. V27's training record documents, V27's Continuing Education Hours completed for 2023 total 11.50 hours. V28's training record documents, V28's Continuing Education Hours completed for 2023 total 11.50 hours. On 4/04/24 at 10:15 AM, V2 Director of Nursing states V2 is aware of the required Certified Nursing Assistant (CNA) requirement of 12 hours of annual education. V2 indicates V15, Wound Nurse, is responsible for monitoring CNA education and informing those CNA's that are in need of completing education hours. V2 acknowledges V2 and V15 are aware that several CNA's do not have the required 12 continuing education hours for 2023. V2 confirmed V20, V27, and V28 training record documentation for 2023. The facility's Long Term Care Application for Medicare and Medicaid dated 4/1/24 signed by V1 Administrator documents there are 82 residents residing in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145883 If continuation sheet Page 17 of 17