Health inspection·March 26, 2024

F 0684 Level of Harm - Actual harm R5's physicians orders contain order, dated 2/1/2024, for physical therapy recertification orders skilled physical therapy I time a week for 4 weeks to include therapeutic exercises therapeutic activities neuromuscular reeducation gait training electrical stimulation ultrasound short wave diathermy per plan of care. Residents Affected - Few On 3/21/2024 at 1:00 PM, R5 stated he is supposed to be getting therapy, but hasn't gotten any therapy for a month. R5 stated he has lost all the strength that he has gained, and now he will have to start all over again whenever he begins to get therapy again. R5 stated he requires therapy because of his cerebral palsy. 3.R1's physicians orders contain order, dated 2/9/2024, for PT (Physical Therapy) to eval and treat. 4. R3's physicians orders contain order, dated 2/12/2024, for physical therapy clarification order skilled physical therapy 4 times a week for 4 weeks to include therapeutic exercise therapeutic activities neuromuscular re-education gait training electrical stimulation ultrasound short wave diathermy per plan of care. 5. R8's physicians orders contain order, dated 2/9/2024, for physical therapy and occupational therapy clarification order skilled physical therapy 5 times a week for 4 weeks to include therapeutic exercise, therapeutic activities neuromuscular reeducation, gait training, electrical stimulation ultrasound short wave diathermy for diagnosis of weakness. 6. R9's physicians orders contain order, dated 2/19/2024, for physical therapy 3 times a week for 4 weeks, therapeutic exercise therapeutic activities neuro re-ed manual techniques gait training and estim. On 3/21/2024 at 11:00 AM, V1 (Administrator) stated, Therapy services ended on 2/17/2024, and a new company starts soon. The new therapy company was in this week. V1 stated she is not sure if she has anyone with therapy orders right now. On 3/21/2024 at 11:10 AM, V2 (Business office Manager) stated they do not have therapy services, and it has been about a month since therapy was here. V2 stated they have a new therapy company that is starting soon. On 3/21/2024 at 12:20 PM, V1 stated there are 6 residents with orders for therapy that are not receiving therapy services. On 3/21/2024 at 12:40 PM, V3 (Licensed Practical Nurse) stated the facility has not had therapy services for about a month now. V3 stated R1, R3, R4, R5, R8, and R9 had an order to hold therapy services, dated 2/18/2024, for one week. Since, those residents still have not received therapy even though there are doctor's orders for therapy. V3 states, Corporate has not let us know the status of therapy servicing starting up again. We have no idea when those residents will begin receiving therapy services again. On 3/21/2024 at 2:30 PM, V6 (Licensed Practical Nurse) stated there have been no therapy services since the middle of February. Observations of no therapy staff in building on the date of 3/21/2024 11:00 AM-3:30 PM. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145478 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 145478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nokomis Hc & Senior Living 505 Stevens Street Nokomis, IL 62075 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to provide the services of a Director of Nursing on a full-time basis, and a Registered Nurse for 8 consecutive hours a day. This failure has the potential to affect all 31 residents in the facility. Findings include: On 3/21/2024 at 11:00 AM, V1 (Administrator) stated they do not have a Full time Registered Nurse on duty. V1 stated V5 (Director of Nursing) is not here today either. On 3/21/2024 at 12:20 PM, V1 stated V5 is not in the facility 40 hours a week, and does not remember the last time V5 was in the facility. On 3/21/2024 at 12:40 PM, V3(Licensed Practical Nurse) stated V5 is the DON of record for the facility, but she has not been in the facility for 40 hours a week. On 3/21/2024 at 2:00 PM, V2 (Business Office Manager) stated V5 hasn't been in the facility for weeks now, and V5 is the only RN here. On 3/21/2024 at 2:30 PM, V6 stated the facility rarely has a Registered Nurse working. The facility's Nursing staffing scheduled reviewed with no full time Director of Nursing and no Registered Nurse for the month of February and March 2024. On 3/21/2024 at 11:00 AM, V1 stated the current census of facility is 31. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145478 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 145478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nokomis Hc & Senior Living 505 Stevens Street Nokomis, IL 62075 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 0774 Help the resident with transportation to and from laboratory services outside of the facility. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to provide transportation from the emergency room where R2 received laboratory services for one of three (R2) residents reviewed for transportation to and from the source of service. Residents Affected - Few Findings include: R2's face sheet, dated 3/21/2024, documents an admission date of 2/16/2024, and diagnoses that include hemiplegia, dysarthria and cerebral infarction. R2's progress note, dated 3/8/2024 at 11:55pm, documents, Local hospital emergency nurse called facility at 8:44pm and said (R2) would be returning. Local hospital nurse called facility back at 2056 and stated facility would have to set up transfer and gave local ambulance number. Notified (V3) at 9:00pm due to unknown to who can drive the van and knowing (R2's) transfer status and not being eligible for ambulance transfer through insurance. At 9:28pm ambulance service worker called facility asking for approved payment for (R2). The hospital had called and set it up and ambulance had a crew at the hospital waiting. Notifed (V3) who stated facility was not able to approve payment and said everyone who is approved to drive the van either said no or had not answered (V3) yet. (V3) asked if family maybe available to transport. called emergency contact #1 and it went straight to VM (voice mail). then called emergency contact #2 and emergency contact #1 answered on that number and said he was in Decatur and couldn't give (R2) a ride but if (R2) still needed a ride in the AM he would. at 10:48pm (V3) informed that maintenance man to pick (R2) up in AM and hospital aware. Hospital then called back at 11:20pm and inform that the physician on shift is going to report facility to state for abandonment if (R2) is not picked up now. R2's progress note, dated 3/9/2024 at 09:12am, documents, (R2's) family called inquiring about why Hospital called them stating that facility had abandoned the (R2) there. The hospital had called family multiple times as well as the facility and had explained that facility did not have transport at the time. Family requested that facility call them once (R2) is back in the facility. R2's progress noted, dated 3/9/2024 at 9:53am, documents, (R2) returned from local Hospital at approx 9:45am. (R2) stated hospital did not feed him breakfast, ,dietary brought (R2) something to eat. updated family on (R2') return and condition. R2's hospital records dated 3/8/2024 document laboratory services and radiology services were provided during emergency room visit. On 3/21/2024 at 12:20 PM, V1 (Administrator) stated R2 went to the hospital on the evening of 3/8/2024 and the hospital called wanting to send (R2) back later that evening. V1 stated the facility did not have anyone to drive the transport van that evening, but the following morning, R2 was picked up from the hospital by the facility transport van and returned to the facility. On 3/21/2024 at 12:40 PM, V3 (Licensed Practical Nurse)stated, (R2) went to the hospital on the evening on 3/8/2024 and the hospital called wanting to send (R2) back to the facility, and wanted to know if the facility would pay for ambulance transfer. V3 stated she could not make that authorization to pay for transport. V3 stated she made multiple calls to several staff to find a driver for the van to pick up R2 from the hospital, but wasn't able to find someone to pick R2 up until the morning of 3/9/2024 from the hospital. V3 stated R2 returned to the facility on the morning or 3/9/2024. V3 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145478 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 145478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nokomis Hc & Senior Living 505 Stevens Street Nokomis, IL 62075 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 0774 stated the family was not able to transport R2 to the facility either. Level of Harm - Minimal harm or potential for actual harm Facility provided medical transportation cost policy, dated 7/2018, documents, facility will provide medical transportation when the facility's vehicle is able to accommodate the trip. Medical transportation will be a private expense billed to the resident. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145478 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 145478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nokomis Hc & Senior Living 505 Stevens Street Nokomis, IL 62075 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 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, and interview, the facility failed to provide therapy services for 6 of 6 residents (R1, R3, R4, R5, R8, R9) reviewed for therapy services. Residents Affected - Some Findings include: On 3/21/2024 at 11:00 AM, V1 (Administrator) stated, Therapy services ended on 2/17/2024, and a new company starts soon. The new therapy company was in this week. V1 stated she is not sure if she has anyone with therapy orders right now. On 3/21/2024 at 11:10 AM, V2 (Business office Manager) stated they do not have therapy services, and it has been about a month since therapy was here. V2 stated they have a new therapy company that is starting soon. On 3/21/2024 at 12:20 PM, V1 stated there are 6 residents with orders for therapy that are not receiving therapy services. On 3/21/2024 at 12:40 PM, V3 (Licensed Practical Nurse) stated the facility has not had therapy services for about a month now. V3 stated, (R1), (R3), (R4), (R5), (R8), and (R9) had an order to hold therapy services dated 2/18/2024 for one week. Since those residents still have not received therapy even though there are doctor's orders for therapy. Corporate has not let us know the status of therapy servicing starting up again. We have no idea when those residents will begin receiving therapy services again. On 3/21/2024 at 2:30 PM, V6 (Licensed Practical Nurse) stated there have been no therapy services since the middle of February. Observations of no therapy staff in building on the date of 3/21/2024 11:00 AM-3:30 PM. R1's physicians orders contain order, dated 2/9/2024, for PT (Physical Therapy) to eval and treat. R3's physicians orders contain order, dated 2/12/2024, for physical therapy clarification order skilled physical therapy 4 times a week for 4 weeks to include therapeutic exercise therapeutic activities neuromuscular re-education gait training electrical stimulation ultrasound short wave diathermy per plan of care. R4's physicians orders contain order, dated 2/22/2024, for may have physical therapy/occupational therapy/speech therapy as determined by intradisciplinary team recommendation. R5's physicians orders contain order, dated 2/1/2024, for physical therapy recertification orders skilled physical therapy I time a week for 4 weeks to include therapeutic exercises therapeutic activities neuromuscular reeducation gait training electrical stimulation ultrasound short wave diathermy per plan of care. R8's physicians orders contain order, dated 2/9/2024, for physical therapy and occupational therapy clarification order skilled physical therapy 5 times a week for 4 weeks to include therapeutic exercise, therapeutic activities neuromuscular reeducation, gait training, electrical stimulation ultrasound short wave diathermy for diagnosis of weakness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145478 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 145478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nokomis Hc & Senior Living 505 Stevens Street Nokomis, IL 62075 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 Level of Harm - Minimal harm or potential for actual harm R9's physicians orders contain order, dated 2/19/2024, for physical therapy 3 times a week for 4 weeks, therapeutic exercise therapeutic activities neuro re-ed manual techniques gait training and estim. Facility provided contract from new therapy company, dated 3/13/2024. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145478 If continuation sheet Page 7 of 7