Health inspection·February 18, 2026

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many micturition incontinent at times with a intervention of provide assist with toilet use as needed and provide incontinent care as needed. On 02/10/26 at 12:35PM, R3 who were alert and oriented stated that he feels that facility is very short of staff. R3 stated that he thinks staff do the best they can with the number of staff they have. R3 said that he did have a fall recently he had put on his call light and was waiting on staff to answer the call light and got inpatient and fell. R3 said that he doesn't know how long his light was on for. R3 said there are days that he will wait up to 20 minutes if not longer for staff to answer his call light. R3 said he has never had an incontinent episode waiting on staff to answer his light, but he knows if he starts to feel the urge he better start hitting the light because it is going to take them a while to answer. 3.R4's Face Sheet dated 02/17/26, documents an admission date of 06/23/24 with diagnoses in part of polyosteoarthritis, lack of coordination, and muscle weakness. R4's MDS dated [DATE], documents in Section C. a BIMS score of 15 which indicates R4 is cognitively intact. Section GG documents R4 is dependent with toileting and partial/moderate assistance with transfers. R4's Care Plan with a edit date of 11/20/25 documents a problem area of ADL Functional status/rehabilitation potential impaired transfers as evidenced by res unable to complete transfers independently related to dx: weakness and resident is at risk for injuries r/t: h of falls secondary to dx: dizziness, hx unsteady on feet, left hemiparesis with a intervention of provide assist for toileting as needed. On 02/10/26 at 10:27AM, R4 stated that they could use some more staff at the facility. R4 said that he has trouble with getting someone to help get him dressed in the morning. R4 said that it will take them forever just to help him get some clothes on. R4 said that he puts his call light on, and it takes them forever to answer the call light. R4 said that he has had an incontinent episode while waiting on staff to answer his call light to help him. R4 said he wasn't mad just wishes the facility would get more help. 4. R5's Face Sheet dated 02/17/26, documents an admission date of 06/17/25 with diagnoses in part of cerebral infarction, facial weakness, hemiplegia and hemiparesis affecting right dominant side, lack of coordination, and muscle weakness. R5's MDS dated [DATE], documents in Section C. a BIMS score of 15 which indicates R5 is cognitively intact. Section GG documents substantial/maximal assistance with toileting and transfers. R5's Care Plan with an edit date of 02/12/26 documents a problems area of ADL Functional status/rehabilitation potential impaired transfers as evidenced by resident unable to complete transfers independently related to dx: weakness and urinary incontinence resident is incontinent of bowel and bladder requires assist toilet use with a intervention of provide assist with toilet use as needed and provide incontinent care as needed. On 02/10/26 at 12:38PM, R5 stated that some days they do have enough staff and other days they do not. R5 said that she had to wait over 30 minutes at times for staff to answer her call light. R5 said that she has had an incontinent episode while she was waiting on staff to answer her call light and then needed assistance with getting cleaned up as well. 5.R6's Face Sheet dated 02/17/26, documents an admission date of 12/08/25 with diagnoses in part of muscular dystrophy, muscle wasting, muscle weakness, lack of coordination, encounter for attention to tracheostomy, dependence on respirator (Ventilator) status, and non pressure chronic ulcer of left heel and buttocks. R6's MDS dated [DATE], documents in Section C. a BIMS score of 15 which indicates R6 is cognitively intact. Section GG documents R6 is dependent for toileting and turning and repositioning.R6's Care Plan with an edit date of 12/23/25 documents ADL Functional status/rehabilitation potential impaired mobility as evidenced by difficulty moving extremities independently related to dx: weakness and resident needs lim/ext (limited/extensive) assist for activities of daily living r/t requires assist for adls. Dx of ms (Multiple Sclerosis), contractures ble (both lower extremities) with interventions of assist as needed with ADL's., assist as needed with toileting. Another problem area (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145247 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 145247 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2026 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many of Resident has impaired gas exchange r/t COPD, acute/chronic respiratory failure, trach, vent. On 02/17/26 at 2:19PM, R6 stated that she feels the facility is short of staff. R6 said that sometimes they only have one staff member like a certified nurse assistant, working on her hallway and she doesn't feel like that is an appropriate number of staff for her hall. R6 said that there are a lot of residents on her hallway including her that have ventilators and tracheostomies which is why they really need the extra people working on the hall. R6 said that anytime she needs help with turning or repositioning or even when she has an incontinent episode, they have to have two staff to help her because of all of her hoses and tubes. R6 said that when they only have one staff member working on the hallway, she will have to wait for the staff member to go to another hall and see if they can get help to turn and reposition her or help change her. R6 said that the nurses will sometimes help but they are also short and are running around trying to get their medication pass done. R6 said that she knows sometimes they don't even have a nurse on her hall because they have to work her hall and another hall, she said that they use to have a nurse on the hall all the time, now they don't anymore. R6 said that she has waited over an hour to get assistance with repositioning and getting someone to answer her call light. On 02/10/26 at 1:41PM, V10 (Certified Nurse Assistant/CNA) stated there are some days when the facility does have enough staff and other days they don't. V10 said that she has worked several of the halls at the facility by herself and she is able to get all the resident care needs done on some of those halls, but there are other halls that she is not able to get all the care needs of the residents completed. V10 said that all she can do is try to do the best she can when she is working by herself. On 02/10/26 at 2:21PM, V8 (CNA) stated that she doesn't feel like that facility has enough staff. V8 said that yesterday she worked from 6AM to 6PM on southwest hall all by herself for over 8 hours. V8 said that she wasn't able to get all of the care done for all the residents. V8 said that most of the time they are able to get all the resident care done such as turning and repositioning, incontinent care, and showers. She said it is very hard but somehow, they manage, but then there are other days they aren't able to get all of this done. V8 said when they don't have enough staff it takes them 15 minutes or longer to answer a call light and that every resident who needs to be turned and repositioned every two hours is not getting turned every two hours, it is longer. On 02/17/26 at 12:47PM, V5 (Registered Nurse/RN) said that no she doesn't think the facility has enough staff to be able to meet the resident care needs. V5 said that most nights when she works, she is able to get most of her stuff done. She said that she is pretty fast and there are other nurses who aren't as fast as her and can't get everything done. V5 said that she doesn't think they have enough CNA staff either some nights they might have enough to be able to meet the resident care needs other nights they might not. V5 said that it also depends on the night, some nights are worse than others. On 02/17/26 at 1:16PM, V11 (CNA) said that when they have call in's they figure out a way to cover the call ins and other days they just don't cover the call in's. V11 said that he lives close and is always available to come into work, but they don't call him even when they have call off's and don't get it covered. V11 said that last week was a horrible week that they had 3 call in's almost every day and didn't get most of them covered. V11 said that usually he is able to get most of the resident care done properly when they have call offs. On 02/17/26 at 1:26PM, V9 (CNA) said that somedays are better than others with staffing. V9 said that yes, they have days they are short of staff and it is hard to get all the resident care provided to them. V9 said that last week they had several days that they were short, and she had to work by herself on west hall for 4 hours. V9 said that there were times that she wasn't able to get all the resident care done such and turning and repositioning for all of the residents who needed it between trying to feed residents breakfast (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145247 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 145247 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2026 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete and trying to get them turned and repositioned and trying to provide care to them it was around 2 and 1/2 hours to 3 hours in between turns and checking on the residents. V9 said not only do they not have enough CNA's staff sometimes, but she doesn't think that they have enough nurses for the building either. V9 said that residents will also complain that they don't think they have enough nurses. On 02/17/26 at 1:35PM, V13 (CNA) said that sometimes they don't have enough staff and sometimes they do have enough staff. V13 said that when they don't have enough staff that they are able to manage to get the care done but it is very hard. V13 said that they have to borrow staff from other hallways to be able to get a resident up or sometimes turn and reposition residents. V13 said that they might have to wait for the staff to come to help so the residents might have to wait longer. V13 said that she tried to make sure all the resident care is done, but she is sure there are times it doesn't get all done because they are short of staff. On 02/17/26 at 2:31PM, V2 (Director of Nursing) said that she doesn't feel like the facility has enough nurses or CNA staff. V2 said that they keep losing staff. V2 said that they are losing staff left and right. V2 said that even V6 (Medical Doctor) is going to talk to cooperate about it. V2 said that you have staff that work three 12 hours shifts a week and now we are shaving off 8 hours of those hours and having them leave for several hours. V2 said that she and V6 feel like this is why things are getting missed because nurses are in such a hurry to try to get stuff done and they are missing things or not getting to things until later. V2 said that she doesn't feel like the facility has enough CNA's either to be able to provide adequate care to all of the residents. V2 said that they are also in a hurry to try to get as much done as they can and they might be missing things or in a rush to get things done. V2 said that she doesn't feel that they have a safe number of staff to be able to care for the residents properly. V2 said, if something happens on 1 hall after 3am we have just one nurse and 1 respiratory therapist and 2 CNA's i don't feel like they can provide adequate care especially with a specialized hall like the trach and vent unit that requires so much specialized care. V2 said not only that but they have other halls that also have a high acuity of care needs. V2 said that she doesn't feel like the nurses are able to assess the residents in a timely manner. V2 stated the residents do get assessed but it might be a little later because the nurse is in the middle of a medication pass or taking care of another resident. V2 said that she is not saying the nurses miss change in conditions of residents just that it takes them a little longer to assess some of those residents. On 02/17/26 at 3:12PM, V6 (Medical Doctor) said that yes and no the facility has enough staff to provide adequate care. V6 said that he knows that they are pushing us to talk to the facility company about getting more staffing. V6 said that they have had talks about the care of the residents with the current staffing. V6 said that it is up to the facility company to decide on the staffing of the facility. The facility policy titled Staffing with a revision date of November 2021 documents under policy The facility provides adequate staffing to meet needed care and services for our resident population and according to regulatory staffing requirements CMS (Center for Medicare and Medicaid Services), IDPH (Illinois Department of Public Health), DHS (Department of Human Services) ). Under Procedure 1. Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met and schedules adequate staff to meet or exceed individual state requirements. The daily census report dated 02/10/26 documents total number of resident in house as 47. Event ID: Facility ID: 145247 If continuation sheet Page 4 of 4