Health inspection·June 12, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm medication. V6 stated it is the night shift nurse's responsibility to return expired medications to the pharmacy. V6 stated the Asprin bottles were stock meds and not resident specific. On 06/12/25 at 12:36 PM, V2 (Director of Nursing) stated the pharmacy checks the medication storage room and the medication carts monthly. Residents Affected - Many On 06/12/25 at 02:06 PM, V1 (Administrator) stated the nursing staff should be checking expiration dates for medications in the medication storage room and medication cart. V1 stated the pharmacy does not provide any documentation stating they checked for expired medications, and she just found out they only spot check the medication cart and medication storage room for expired medications. A facility policy dated 10/27/2014, titled Consultant Pharmacist Services Provider Requirements documents under Procedures, F. Specific activities that the consultant pharmacist performs includes, but is not limited to: 4) Ensure that the medication storage areas are examined monthly, and the medication carts quarterly for proper storage and labeling of medications, cleanliness, and removal of expired medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146036 If continuation sheet Page 2 of 4 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 146036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shawnee Senior Living 1901 13th Street Herrin, IL 62948 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure proper hand hygiene was performed before assisting dependent residents with eating and while serving residents glasses for 4 of 8 residents (R10, R58, R72, and R88) observed for dining in a sample of 51. Findings include: On 06/10/25 at 12:30PM, V7 (Certified Nurse Assistant/CNA) was noted to be assisting R88 with eating. V7 used her right hand and would pick up R88's spoon and give him a few bites. V7 then put down R88's spoon she then touched her face then both of her hands and then she picked up R58's spoon with her right hand and started to give R58 a couple of bites of her food. V7 then put down R58's spoon and then picked up R88's spoon and started assisting R88 with several bites. No hand hygiene was observed at anytime during this observation. 1. R88's admission record dated 06/12/25, documents an admission date of 04/01/25 with diagnoses in part of critical illness myopathy, chronic motor or vocal disorder, gastro-esophageal reflux disease without esophagitis, age-related physical debility, personal history of traumatic brain injury, unspecified abnormal involuntary movements, and lack of coordination. R88's MDS (Minimum Data Set) dated 04/07/25 documents in Section C a BIMS (Brief Interview for Mental Status) score of 14 which indicates cognitively intact. Section GG documents eating as dependent. R88's Care Plan with a revision date of 04/22/25 documents a focus of R88 has a ADL (Activities of Daily Living) self-care performance deficit r/t (related to) a traumatic brain injury. This focus area includes a intervention of: Eating R88 is dependent on staff for eating during meals. On 06/12/25 at 1:00PM, R88 stated that the CNA's (Certified Nurse Assistant's) must assist him for all meals. R88 stated that the CNA' s will usually assist him with eating along with another resident at the same time. R88 stated that he has never seen a CNA perform hand hygiene of any kind such as washing hands or using a hand sanitizer after they assist the other resident with a bite and then switch over to give him a bite. 2. R58's admission record dated 06/12/25, documents an admission date of 05/02/25 with diagnoses in part of zoster without complications, paroxysmal atrial fibrillation, dysphagia, need for assistance with personal hygiene, and anorexia. R58's MDS dated [DATE] documents in Section C a BIMS score of 01 which indicates R58 is cognitively impaired. Section GG documents supervision or touching assist with eating. R58's Care plan with a revised date of 04/21/25 documents a focus area of, R58 has a ADL self-care performance deficit activity intolerance fatigue. This focus has an intervention of: Eating R58 is able to eat with supervision/cues. On 06/10/25 at 12:50PM, V7 (CNA) stated that she did not perform hand hygiene at anytime when she was assisting R88 and R58. V7 said that anytime you touch anything or switch from assisting one (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146036 If continuation sheet Page 3 of 4 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 146036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shawnee Senior Living 1901 13th Street Herrin, IL 62948 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident to the other that you should perform hand hygiene such as washing hands or using a hand sanitizer. V7 said she forgot to bring her hand sanitizer and that she was more worried about assisting R88 and R58 with their meals and she forgot all about hand hygiene. On 06/10/25 at 12:29pm, R72 and R10 were being assisted by V4 (Restorative CNA). V4 was continuously observed from 12:29pm to 12:38pm, no hand hygiene was observed being performed by V4. V4 was alternating between assisting R72 and R10 with eating. V4 was also grabbing their glasses by the rim and continue to assist them with eating and did not perform hand hygiene. V4 was observed touching the table and touching the residents during this observation. 3. R10's admission record documents an admission date of 01/22/2020, with the following diagnoses: senile degeneration of the brain, Parkinson's disease, and unspecified dementia. R10's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) of 3, indicating R10 is severely cognitively impaired. Section GG-Functional Abilities documents that R10 requires substantial/Maximum assistance for eating. R10's current care plan documents, requires assist with all adls (activities of daily living) r/t (related to) cerebral vascular accident, Parkinson's and dementia. 4. R72's admission record documents an admission date of 09/18/2024 with the following diagnoses: unspecified dementia and lack of coordination. R72's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) of 2, indicating R72 is severely cognitively impaired. Section GG-Functional Abilities documents that R72 requires supervision or touching assistance for eating. R72's current care plan documents, The resident has an ADL self-care performance deficit r/t (related to) activity intolerance, confusion, dementia, fatigue. With an intervention of, .requires supervision from staff for eating during mealtimes. On 06/11/25 at 12:37pm, V4 (Restorative CNA) stated she did not recall whether she sanitized in between residents while assisting with lunch. On 06/12/25 at 11:23am, V15 (Dietary Manager) stated staff should not grab cups by the top where residents drink from. On 06/12/25 at 03:13pm, V2 (DON/Director of Nursing) stated her expectation would be for staff to perform hand hygiene in-between direct contact with residents. Facility policy titled, Handwashing/Hand hygiene with a revision date of August 2008 documents in general guidelines, use of an alcohol-based hand rub for all of the following situations: . before direct contact with residents . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146036 If continuation sheet Page 4 of 4