Inspection·March 19, 2024

F 0825 2.) R2's undated Face Sheet documents R2 admitted to facility on 2/5/24. Level of Harm - Minimal harm or potential for actual harm R2's Minimum Data Set (MDS) dated [DATE] documents R2 as modified independent for decision making skills. Residents Affected - Some R2's Physician Order Sheet (POS) dated March 2024 documents a physician order starting 2/12/24 and discontinued on 2/23/24 for Skilled Physical Therapy five times per week for four weeks to include therapeutic exercises, therapeutic activities, neuromuscular reeducation, and gait training. This same POS documents a physician order starting 2/12/24 and discontinued on 2/23/24 for Skilled Speech Therapy five times per week for four weeks for cognitive communication re-training. On 3/19/24 at 12:15 PM V3 (R2's) family member stated R2 admitted to facility after a hospital stay. V3 stated R2 was supposed to receive therapy to regain strength. V3 stated R2 was receiving Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST) up until 2/16/24. V3 stated the facility called and informed V3 that the facility would no longer have any rehabilitation services after 2/18/19. V3 stated, We (family) were shocked that we were not given any notice. That is the only reason (R2) went to that facility was to get therapy. It definitely caused a delay for (R2) as far as her cognition and physical strength are concerned. 3.) R3's undated Face Sheet documents R3 admitted to facility on 12/29/2023. R3's Minimum Data Set (MDS) dated [DATE] documents R3 as cognitively intact. R3's Physician Order Sheet (POS) dated March 2024 documents a physician order starting 1/30/24 and discontinued 3/9/2024 for Physical Therapy Recertification Order for Skilled Physical Therapy five times per week for four weeks to include therapeutic exercise, therapeutic activities, neuromuscular reeducation, and gait training. This same POS documents a physician order starting 1/25/24 and discontinued on 3/9/24 for Skilled Occupational Therapy (OT) five times per week for four weeks for therapy exercise, neurological reeducation, manual, group, therapy activities, self-care and wheelchair management. On 3/19/24 at 11:15 AM R3 lying in bed in room. R3 stated, I went to the hospital on [DATE] and from there I came to this facility. I came here for therapy. I started to receive Physical and Occupational Therapies and then they (facility) came in and said the therapy department would not be back. They told me this on a Friday in the middle of February. They said I would not be receiving therapy until they could get a new company. They came back and told me that a new company was supposed to start 3/1/24 but that did not occur. I came here for therapy. I was supposed to get therapy to get stronger to go back home. This has been a big problem for me. I haven't walked in years, but I have enough strength in my legs to stand. (V4) Certified Occupational Therapy Assistant (COTA) told me I was doing very well standing with (V4). I have not stood since therapy left. The staff make me use a total body mechanical lift for all transfers. They (staff) told me it is too dangerous for me to stand with them without therapy present. I can't wait to get home, but this has been a definite setback. Not getting therapy means that I am losing strength that I worked so hard to get. I must stay here for months longer than I was supposed to. It has really affected my mental state because I just lay in this bed all day worrying about how much strength I am losing because I am not able to get any therapy. 4.) R4's undated Face Sheet documents R4 admitted to facility on 1/23/2020. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145370 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 145370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sullivan Healthcare & Senior Living 11 Hawthorne Lane Sullivan, IL 61951 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 0825 R4's Minimum Data Set (MDS) dated [DATE] documents R4 as severely cognitively impaired. Level of Harm - Minimal harm or potential for actual harm R4's Physician Order Set (POS) date March 2024 documents a physician order starting 2/9/24 and discontinued 3/9/24 for Skilled Speech Therapy five times per week for four weeks for Dysphagia management. This same POS documents a physician order starting 2/9/24 and discontinued 3/9/24 for Skilled Occupational Therapy three times per week for four weeks for self-care, neurological reeducation, therapy exercises, therapy activities, manual, group and wheelchair management. This same POS documents a physician order for Skilled Physical therapy five times per week for four weeks to include therapeutic exercise, therapeutic activities, and neuromuscular reeducation. Residents Affected - Some On 3/19/24 at 11:50 AM R4 sitting in reclining wheelchair in dining room. R4 responded, 'No' when asked if has been getting therapy services. On 3/19/24 at 11:30 AM the facility therapy office/gym was locked. On 3/19/24 from 8:10 AM-4:00 PM no therapy employees were present at facility. On 3/19/24 at 9:00 AM V1 Administrator stated the previous therapy services company stopped providing all therapies on 2/18/24. V1 Administrator stated the facility has not been able to offer or provide any type of therapy services since 2/18/24 and is working on regaining therapy services as soon as possible. On 3/19/24 at 12:45 PM V4 Certified Occupational Therapy Assistant (COTA) stated therapy services ceased at facility on 2/18/24. V4 COTA stated V4 had 10 residents she saw for Occupational Therapy services the week of 2/12/24-2/16/24. V4 COTA stated all of those 10 residents were not finished with their therapy services when the therapy company ceased to provide services on 2/18/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145370 If continuation sheet Page 3 of 3