Inspection·June 28, 2024

F 0584 Level of Harm - Potential for minimal harm Residents Affected - Some better than others, it is still warm everywhere especially the dining room, but the temps are better today than over the weekend. On 6/26/2024 at 10:50 AM, V2 (Maintenance Director) started down North (300) Hall to temp the rooms. V2 was asked how often the rooms are temped and he stated, I temp them once a day in the mornings about this time every day, Monday through Friday. V2 was then asked who temps the rooms on the weekends and he stated, Nobody temps on the weekends. V2 was asked to provide the temp logs for the month of June, and V2 stated, I keep a log, but the log only shows that the temperature checks were done and not the actual temperatures of the areas. I don't keep a log of the temperature results. V2 was observed checking the temperatures of each resident's room on all halls, the hallways, nurses' station, the dining room, and the activity room. The highest temperature was 81.3 degrees in the dining room and the low was 62 degrees in R12 and R13's room at the end of the [NAME] (200) Hall. All the other rooms were mostly in the higher 70's. V2 stated that V1 (Administrator) has reached out to the local Heating and Air company and is awaiting a time for them to come and check the whole facilities air system out. V2 stated the main problem is that the roof is concrete and so is the flooring so that makes it hard to cool. V2 stated the big units on the roof are froze up and leaking through the vents so the PTAC units are not keeping up with the heat. V2 stated they are trying to keep the facility cool with portable Air conditioners, turning the PTAC units to the lowest setting of 62 degrees, and using fans. V2 stated the temperatures are better today than they were yesterday but could not recall the temperatures from 6/25/2024. On 6/26/24 at 10:55 PM, the website Weather Underground (https://www.wunderground.com/history/daily/us/il/) historical data documents a temperature of 79 degrees with 74% humidity. This indicates that the temperature inside the facility in the dining room was warmer than the temperature outside. A Daily Temperature Checks log for June 2024 provided by V2 documents a checkmark that the temperature checks were completed for June 1st through June 25th, including the weekends, and contains V2's initials as the inspector. There are no actual temperatures recorded on the log. On 6/26/2024 at 11:32 AM, V1 (Administrator) stated he was aware of the issues with the air conditioners. V1 stated he called Monday (6/24/2024) to the local Heating and Air Service and was told they would get to them as soon as they could. V1 stated he was going to call them back and try to get an estimated time. V1 stated he was going to have them go through the whole facility and look at all the units including all the PTAC units. V1 stated he would get an estimate for replacing the PTAC's that are not working properly and the big units on the roof. V1 stated the units on roof are frozen and that is why they are leaking through the vents in the hallways. At 12:35PM, V1 stated the local Air Conditioner repair service will be at the facility at 7:00AM tomorrow (6/27/2024). On 6/27/2024 at 11:00 AM, V10 (Director of Nursing) was asked when she was first notified of the issues with the air conditioners. V10 stated I found out on Monday when I came in to work. V10 stated nobody notified her over the weekend. V10 stated nobody notified V1 either of the issues over the weekend. V10 stated she noticed the increase in temps on Monday, 6/24/2024. V10 stated no residents were affected by the heat. V10 stated they should have reached out to me or V1 over the weekend. V10 stated the equipment failure is not something she deals with, and she only deals with the clinical issue in the facility. V10 stated she has never seen the procedure titled Heat Index. On 6/26/2024 at 1:55 PM, V11 (Assistant Director of Nursing) stated I know the air conditioner units have not worked right this summer. V11 stated that V1 and V10 (Director of Nursing) have put in 2 new units so far. V11 stated that V1 has put in a request to fix the air conditioners but the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145247 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 145247 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doctors Nursing & Rehab Center 1201 Hawthorn Road Salem, IL 62881 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 0584 Level of Harm - Potential for minimal harm Residents Affected - Some requests have not been approved by Corporate yet. V11 states the dining room is the warmest room and the residents still want to go out there. V11 stated none of the residents have complained to me about the heat and yesterday was hotter than today. On 6/26/2024 at 10:50 AM, V2 (Maintenance Director) was observed checking the temperature in R1's room. The room temp was 78 degrees F (Fahrenheit). R1's air conditioner unit in his room has the thermostat set at 62 degrees F, and the unit is running at this time. On 6/26/2024 at 12:05 PM, R1 was observed sitting in his chair in his room. R1 stated the temperature in his room is better than the day before. R1 stated my air conditioner unit is not working properly and it runs nonstop, and it is still warm in here. R1 stated he is not having any difficulty breathing or any issues from the heat at this time. R1 stated he didn't notice a big difference in the temps from the weekend compared to today but does know the temps weren't as hot as yesterday (6/25/2024). R1 denies feeling sick from the heat. R1 stated he was uncomfortable yesterday when the room was much warmer than today. On 6/26/24 at 10:55 AM, R2's room temperature was checked by V2 and was 76 degrees F (Fahrenheit). R2's air conditioner unit was not running, and thermostat set at 74 degrees F. On 6/26/2024 at 12:11 PM, R2 stated her room temperature is good today. R2 states she likes the temperature around 75 degrees, that temp is good for her because if it is too cold it makes her hurt more. R2 stated yesterday (6/25/2024) it was warmer in my room than normal . R2 said My room was not as comfortable as I would have liked yesterday. A little too warm. R2 stated when I go through the dining room to go to therapy the dining room has been really hot. I prefer to eat in my room anyway, so I don't eat down there. On 6/26/24 at 11:40 AM, V2 was observed checking the temperature in R3's room on the North (300) hall. R3's room temperature was 78 degrees F (Fahrenheit). R3's air conditioner unit was set on 62 degrees and noted to be running. R3 was dressed in light weight clothing. R3 was asked how the temperatures have been in her room for the last few days, R3 replied well, it is not very cool in here now. The last couple of days have been miserable for me. R3 then stated it is not as bad today as it was yesterday (6/25/2024), that day was hot. On 6/26/2024 at 9:59 AM, R4 was observed sitting in her room watching her bird feeder. R4 was asked if her room has stayed cool lately, and R4 stated It's been hot, and I talked to (V1 Administrator) and he said, corporate is coming in hopefully to fix it. R4 stated my unit is running but it is not cooling the room. R4's thermostat was observed to be set at 69 degrees but the unit was observed blowing out warm air. R4 did have a fan in her room that was running. R4 stated that yesterday was warmer than it is right now, and stated it was hot yesterday. R4 also stated the past weekend was warm as well but not as bad as yesterday (6/25/2024). At approximately 11:10AM V2 checked temp in R4's room and the temp was 76 degrees and the air conditioner unit was running. On 6/26/2024 at 10:08 AM, R8 was observed sitting in the dining room. R8 was asked if he was comfortable in the dining room and he stated well, the last 2 days have been too hot for me. R8 stated he wished they would get the air conditioners fixed soon. R8 was asked if he had the option to eat in his room and he stated yes, if I wanted to but I always eat here in the dining room. It was really hot yesterday (6/25/2024). Its better today. On 6/26/24 at 11:10 AM, V2 was observed checking the room temperature in R9's rom. R9's room temperature at that time was 75 degrees. On 6/26/2024 at 2:20 PM, R9 stated it is a cooler than it was yesterday in here, yesterday was really warm. My unit ran all day and night but didn't keep it cool enough. R9's air conditioner unit was observed to be running and the thermostat was set at lowest (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145247 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 145247 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doctors Nursing & Rehab Center 1201 Hawthorn Road Salem, IL 62881 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 0584 Level of Harm - Potential for minimal harm Residents Affected - Some setting of 69 degrees. R9 stated it is better today though. R9 stated she didn't feel bad or anything yesterday just a little too warm for her, just uncomfortable. R9 was alert and oriented at the time of the interview. On 6/27/2024 at 4:00 PM, V1 was asked about the status of the repairs for the air conditioners, V1 stated the units on the roof all need serviced, the problem is that the Freon that they need is no longer available, so the serviceman must order the Freon that is compatible. There are some PTAC units that will need to be serviced, and he is getting an estimate for replacing the existing older units in the rooms. The serviceman was able to repair the outside unit that supplies air to the nurses 'station and another one outside that will help cool the dining room. V1 stated the units had not been serviced in a while and there had not been a scheduled maintenance check on the units, so this is what caused the issues, but he has set up repairs, servicing with the local repairman and now they will be on a scheduled service plan for all the heating and air units at the facility going forward. This will also put them on a priority list for any issues, so if the heating or air units go down, they will get fixed more rapidly. The facility policy titled Extreme Weather-Heat or Cold (undated) documents, It is the policy of this facility to protect our residents, staff, and others who may be in our facility from harm during emergency events. To accomplish this, we have developed procedures for specific hazards which build on the cross-cutting strategies in our continuity of operations plan. The priority of this facility to minimize the stress our residents could experience form extreme temperatures related to weather events. To mitigate this risk, we rigorously maintain our systems of heating, ventilation and air conditioning and generator. The facility policy titled Heat Index (undated) documents the following under Procedure: Individuals are prone to heat illnesses when they remain in hot or humid weather for an extended period. If the facility reaches a heat index/apparent temperature of 80° Fahrenheit implement the following actions and/or treatments: Move individual{s) to cool area. Keep individual away from direct or indirect sunlight. Utilize electric fans circulate air. Close blinds. Monitor residents for liquid need. Notify Director to ensure measures for air condition repair and resident care are being followed. According to historical climate data found on the website Weather Underground (https://www.wunderground.com/history/daily/us/il/), the highest temperature and humidity levels were recorded for the following dates: 6/22/24 (Saturday) at 2:15 PM a temperature of 94 degrees and 42% humidity level, 6/23/24 (Sunday) at 3:15 PM a temperature of 89 degrees and 50% humidity level, 6/24/24 (Monday) at 4:55 PM a temperature of 90 degrees and 43% humidity level, and 6/25/24 (Tuesday) at 1:35 PM a temperature of 98 degrees and 41% humidity level. Based on the historical data provided from the Weather Underground website and the National Oceanic and Atmospheric Administration's (NOAA) National Weather Service Heat Index chart, the heat index for the following dates are: 6/22/24 97 degrees, 6/23/24 91 degrees, 6/24/24 91-93 degrees, and 6/25/24 105 degrees. The National Weather Service (https://www.weather.gov/safety/heat-ww) Hazardous Weather Outlook, issued for the county that the facility is located in, dated 6/22/24, 6/23/24, 6/24/24, and 6/25/25 all document that hot and humid conditions ae expected to lead to heat index values near 105 degrees and a heat advisory remains in effect. The facility roster dated 6/26/24 documents that R1-R47 reside on the [NAME] (200) hall, North (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145247 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 145247 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doctors Nursing & Rehab Center 1201 Hawthorn Road Salem, IL 62881 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 0584 (300) hall, and Southwest (400) hall that were affected by the non-functioning air conditioning units. Level of Harm - Potential for minimal harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145247 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 145247 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doctors Nursing & Rehab Center 1201 Hawthorn Road Salem, IL 62881 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 0807 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. Based on interview, observations, and record review the facility failed to provide water and other fluids to meet the residents needs and preference for 18 out of 47 residents (R1, R2, R3, R4, R6, R7, R8, R9, R10, R15, R20, R22, R24, R26, R30, R33, R37, and R46) reviewed for hydration in a sample of 47. The findings include: On 6/26/2024 at 10:08 AM, R7 was observed sitting in her room visiting with family. There was no waster pitcher or other fluids available in R7's room. At 12:05 PM on the same date, there were still no water pitcher or other fluids available observed in R7's room. On 6/26/2024 at 11:40 AM, there was no observation of a water pitcher or any other liquids to drink in R3's room. R3 was asked where her water pitcher was and she stated, I don't have one. R3 stated I drink what I get on my meal trays normally. R3 is alert and oriented at this time. On 6/26/2024 9:59 AM and 12:00 PM, R4 was observed siting in her room. There was no water pitcher observed in R4's room at the time of the observations. On 6/26/2024 at 12:05 PM, R1 is an alert and oriented male sitting up in chair in his room. R1 does not have a water pitcher in his room. R1 was asked if he had access to liquids and he said, on my meal trays. R1 stated he normally doesn't have a water pitcher in his room. R1 stated They don't keep a water pitcher at my bedside. R1 stated he doesn't always have a water pitcher every day. R1 is alert and oriented at this time. R1's Care Plan dated 6/13/24 documents a problem area of constipation and includes an approach of encouraging and providing adequate fluids as indicated. On 6/26/2024 from 12:10 PM to 1:00 PM, the rooms of R8, R10, R15, R20, R22, R24, R26, R30, R33, R37, and R46 were observed with no water pitcher or other fluids available to drink. On 6/26/2024 at 12:25PM, R2 was observed with an over bed table in front of her with a water pitcher half full of water. The water pitcher was warm to touch. R2 was asked when her water pitcher was last filled with fresh ice water and she stated, it hasn't been filled today and the water is warm, I can't drink that. On 6/26/2024 at 3:00 PM, R2 was observed sitting up and had a water pitcher with ice and water noted in the pitcher. R2 stated they came and filled it just a little bit ago. First time today. R2 is alert and oriented at this time. On 6/26/24 at 12:27 PM, R8 was observed sitting in the dining room. R8 stated that he doesn't have a water pitcher in his room but he is going to ask to for one after lunch. R8 was alert and oriented at the time of the interview. On 6/26/2024 at 2:20 PM, R9 was observed sitting up in bed. R9's water pitcher was out of R9's reach and contained no water or liquids in the pitcher. On 6/26/2024 at 2:50 PM, R6 was observed sitting in her room with a book. R6 had a water pitcher within reach with ice water in it. R6 stated they came and filled these up just a few minutes ago, first time today. R6 is alert and oriented at this time. On 6/27/2024 at 9:45 AM, R6 was observed sitting in her room working on a puzzle book. R6 stated I have cold ice water, it was surprising. R6 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145247 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 145247 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doctors Nursing & Rehab Center 1201 Hawthorn Road Salem, IL 62881 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 0807 stated the water pitchers don't usually get filled this early. Level of Harm - Minimal harm or potential for actual harm On 6/26/2024 at 1:55 PM, V11 (Assistant Director of Nursing) stated she expects the staff to refresh the residents water every 4 hours right now. Residents Affected - Some On 6/27/2024 at 11:00 AM, V10 (Director of Nursing) was asked about hydration/passing of water for the residents, V10 stated there are 3 of us that make morning rounds and we check water pitchers too, V11, the Treatment Nurse as well as myself. When V10 was asked if she would expect water pitchers be filled for the residents before 1:30PM, V10 stated yes. V10 was then asked if she knew why this wasn't done on 6/26/2024, she stated I guess because I wasn't here. The facility policy titled Hydration dated December 2016, documents it is the policy of (name of company) to provide residents with adequate fluids, including water and other liquids that are consistent with resident needs and preferences and sufficient to maintain resident hydration. Procedure step 2 documents Staff will offer fluids on a routine basis. This will be in addition to the fluids offered on the meal tray. The facilities Emergency Operations and Plan Manual (undated), under the section titled Heat Index documents Individuals prone to heat illnesses when they remain in hot or humid weather for an extended period. If the facility reaches a heat index/ apparent temperature of 80 degrees Fahrenheit implement the following actions and/or treatments .monitor residents for liquid need. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145247 If continuation sheet Page 7 of 7