Health inspection·October 22, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few Right humeral head. X-ray results show impacted transverse Fx of the humeral neck with no significant displacement. Per results, clinical correlation is requested to determine the age of the fracture. POA (Power of Attorney) notified of x-ray results and POA stated he was made aware of incident that possibly caused fracture earlier on this date. POA requesting res. be sent to hospital for further evaluation/tx (treatment.) Resident made aware of x-ray results and POA request and thanked this nurse for update. Res. stating she is in constant pain and hopes the hospital will help with the pain.R1's Progress Notes document on 10/10/25 at 11:13pm, Late entry: (local) EMS (Emergency Medical Services) arrive at approx. (approximately) 2130 (9:30PM) for transport resident to hospital.R1's ED (Emergency Department) Provider Notes from the local hospital with a date of service of 10/10/25 at 10:12pm documents that R1 presented to the Emergency department for a right humerus fracture. This document states that R1 fell at the facility out of a sit to stand lift.On 10/20/25 at 10:34am, R1 stated she could not remember how she was injured.On 10/21/25 at 11:16am, V1 (Administrator) stated on 10/11/25 they identified a failure with the incident that occurred the evening of 10/10/25 involving R1. V1 stated they immediately started an investigation as soon as they were notified of the incident and the Quality Assurance Committee immediately started to develop a plan of correction.On 10/22/25 at 12:37pm, V5 (Certified Nursing Assistant/CNA) states that R1 needed to go to the bathroom. V5 stated he was unsure how R1 transferred, so he asked her, and she told him the sit to stand. V5 stated that she transferred to the toilet with the sit to stand without incident. V5 stated when he lowered her back into her chair, it appeared she passed out. V5 stated he immediately alerted the nurse. V5 stated he was suspended while investigated, he was trained on how to find out what someone's transfer needs were and general training on transfers.On 10/22/25 at 1:03pm, V3 (Licensed Practical Nurse/LPN) stated she did not witness the incident that occurred on 10/10/25, but she was R1's nurse that day and assessed her immediately after. V3 stated that V5 had transferred R1 with the sit to stand lift, and stated she passed out when transferring her back to the wheelchair. V3 stated that R1 had no visible injuries but complained of right shoulder pain. V3 stated she immediately contacted the physician and R1's power of attorney. V3 stated pain relief and stat x-rays were ordered and R1 was sent out later when Xray results were received. V3 stated she was under the impression that everyone in the facility knew that R1 was to be transferred using a sling lift. V3 stated that R1 had right side paralysis. V3 stated if someone is unsure of how someone is to be transferred, they can reference the Kardex or they can always ask a nurse, as they can find it in the chart.On 10/21/25 at 11:14am, V2 (DON) stated if staff is unsure how to transfer a resident, they can utilize the Kardex to find the information. V2 also stated the information is in the residents' medical record in a few different places, the nursing staff can access that information. The facility policy titled, Safe Lifting and Movement of Residents with a revision date of August 2008, states in the section for the use of mechanical lifts; Mechanical lifting devices shall be used for any resident needing a two person assist. Except during emergency situations or unavoidable circumstances, manual lifting is not permitted. Prior to the survey date, the facility took the following actions to correct the noncompliance:1. The facility held a meeting with Quality Assurance Committee on 10/11/25 with V1 (Administrator) and V2 (DON) to develop a plan of Correction for the 10/10/25 incident.2. On 10/10/25 R1 was transferred with a sit to stand by V5 (CNA). V3 (LPN) called V8 (Nurse Practitioner/NP) with resident complaints of shoulder pain. Hot pack, Tylenol and x-rays ordered.3. On 10/10/25 V4 (LPN) received x-ray results, notified V8 and R1 was sent to the emergency room for evaluation for determination of age of fracture.4. On 10/11/25 R1 returned to the facility with sling to right shoulder, Norco for pain and follow-up with orthopedics.5. On 10/11/25 V5 (CNA) was suspended pending investigation.6. On (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146036 If continuation sheet Page 2 of 3 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 10/22/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 10/16/25 V5 was reinstated and received additional training on reviewing Kardex, Hoyer lift, sit to stand and having two people while using a mechanical lift.7. Starting on 10/16/25 Administrator or designee will conduct daily audits of high risk rounding form, resident Kardex, Care Plans and staff/resident transfers to ensure correct transfers lift and practice are being followed.8. QAPI (Quality Assurance and Performance Improvement) committee will continue to monitor the facilities' performance to ensure corrective actions are effective.9. Completion date systemic changes will be completed: 10/16/25. Event ID: Facility ID: 146036 If continuation sheet Page 3 of 3