Inspection·November 19, 2024

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3) On 11/13/2024 at 12:33 PM, V14 (R3's Family Member) stated her and (R3's) other family member is unhappy with the inconsistent care (R3) received at the facility, which is why (R3) is being moved out of the facility today. V14 stated she would come to visit (R3) and (R3) would smell terrible and look like staff never bathe (R3) or brushed her hair and teeth. V14 stated she discussed the issues regarding (R3's) care with V2 (DON) and (V2) stated she would make sure (R3) would receive showers on Thursdays and Sunday. V14 stated she asked V2 for the shower sheets on (R3), and V2 could never produce the shower sheets. On 11/13/2024 at 10:02 AM, shower sheets were requested for R3 for the past 14 days and no shower sheet was available for 10/30/2024. Documenting R3 only received one shower for the last week in October. 4) R12's MDS dated [DATE] documents she was cognitively intact for decision making of activities of daily living. On 11/14/2024 at 1:32 PM, R12 stated there have been issues with not getting their showers, and they are supposed to be trying to fix it. They have talked about it at the resident council Meeting Minutes. R12's Shower Sheets were reviewed for the past 14 days and document she was only receiving one shower a week. Resident Council Meeting Minutes dated 11/14/2024 documents, Showers not timely manner. On 11/14/2024 at 1:13 PM, V2 (DON) stated they had some complaints related to residents not getting their showers and they were trying to fix the system. The Undated Bath. Shower Tub Policy documents: The date and time the shower/tub bath was performed. The name and title of the individual(s) who assisted the resident with the shower/tub bath. All assessment data (e.g., any reddened areas, sores, etc., on the resident ' s skin) obtained during the shower/tub bath. How the resident tolerated the shower/tub bath. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken. The signature and title of the person recording the data. Reporting Notify. The Resident Right Policy with a revision date of 11/18 documents, Your facility must be safe, clean, comfortable and homelike. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145497 If continuation sheet Page 2 of 5 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 145497 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Three Springs Sr Living & Rhab 161 Three Springs Road Chester, IL 62233 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 ensure a Registered Nurse (RN) was working in the facility for at least 8 consecutive hours a day, 7 days a week. This failure has the potential to affect all 66 residents living in the facility. Findings include: On 11/12/2024 at 9:04 AM, Staffing schedules were requested from the facility for the past 14 days. On 11/14/2024 at 9:33 AM, staffing schedules were reviewed and does not document any RN working on Wednesday 10/30/2024, Thursday 10/31/2024, Saturday November 2, 2024, Sunday November 3, 2024, and Monday 11/4/2024. Five of the 14 days reviewed does not documents any RN coverage. On 11/14/2024 at 2:45 PM, V1 (Administrator) stated, We have a census of 66 residents. I did not realize the RN coverage for the Director of Nursing only counted as half. We have another RN that works but she did not work this past weekend. V2 (Director of Nursing) did not work last weekend either. On 11/13/2024 at 2:55 PM, V2 (Director of Nursing) stated that currently the facility has two RN's me and V20 (RN). I know they are trying to hire more RN's. The Facility Assessment, dated 2024 documents, Licensed nurses providing care (Licensed Practical Nurse, Registered Nurse, staffing plan based on current Census, skilled census x 3.8, intermediate census x 2.5 total /45% days, 35% evenings, 20% nights. 25% of each shift= nurse hours. The Facility Staffing Policy dated 10/2017 documents, Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services. The Facility's Daily Census Sheets dated 11/12/2024 documents a total of 66 residents living in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145497 If continuation sheet Page 3 of 5 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 145497 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Three Springs Sr Living & Rhab 161 Three Springs Road Chester, IL 62233 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the Facility failed to ensure infection control surveillance was being followed for residents experiencing vomiting and/or diarrhea. This has the potential to affect all 66 residents living in the facility. Residents Affected - Many Findings include: On 11/12/2024 at 9:35 AM, V1 (Administrator) stated, they had a few residents that were experiencing vomiting and diarrhea a few weeks ago but they were good now. On 11/13/2024 at 2:32 PM, V3 (Infection Control Specialist) stated, I started working here on 10/25/2024. I have not taken the course yet and do not have my certification. We have a census of 66 and we had 11 residents experience emesis and/or loose stools. Of those eleven residents three were sent out to the hospital. I reached out to Corporate, and they told me to test everyone for flu and COVID which I did, and everyone was negative. I was never instructed to put anyone on contact isolation and/or notify the health department. I did not do any surveillance and/or tracking my rooms. Staff members also got whatever it was, and I personally was really sick, but it only lasted 24 hours. I was not tracking staff members. Whatever it was, it seemed to go away as quickly as it came. We did have had a couple of call offs from staff for nausea and vomiting. On 11/14/2024 at 10:30 AM, a list of test results was requested for all of the residents tested for COVID and flu. On 11/14/2024 at 10:41 AM, active daily surveillance from 10/14/2024 to 11/14/2024 was requested. A system for preventing, identifying, and reporting and controlling infections for the outbreak was requested. On 11/14/2024 at 3:00 PM, The Facility provided a Sheet, undated (a floor plan), which does not identify each resident, it does not document any interventions that facility was implementing with the exception of the COVID and Flu vaccines. 4 of the rooms were documented as receiving the COVID/Flu vaccine, of the 11 residents displaying symptoms of diarrhea and/or vomiting. On 11/14/2024 at 3:02 PM, V3 stated, I do not have the test results for (R3) or (R11), I did not test them. On 11/14/2024 at 3:10 PM, V3 stated, I went through all of the call offs, and here is a list of staff members I think called off because of the stomach bug. On 11/19/2024 at 8:38 AM, V23 (Infection Control Specialist for Hospital) and V22 (Medical Director) stated, If two or more residents are experiencing symptoms then I would expect the facility to contact the Local Health Department and (V22) who in return would then notify me so we could start surveillance. (V22) and I were never notified of the outbreak in the facility. I would consider more than two people outbreak. Tracking staff is important as well to look at the call offs and if staff are experiencing the same symptoms and how it affects the facility. Surveillance is important in tracking trends and monitoring what is happening in the facility and the community. The Surveillance for Infections Policy with a revision date of September 2017 documents, The Infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145497 If continuation sheet Page 4 of 5 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 145497 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Three Springs Sr Living & Rhab 161 Three Springs Road Chester, IL 62233 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. In addition to collecting data on the incidence of infections, the surveillance system is designed to capture certain epidemiologically important data that may influence how the overall surveillance data is interpreted; for example, focused surveillance data may be gathered for residents with a high risk for infection or those with a recent hospital stay. The Facility's Daily Census Sheets dated 11/12/2024 documents a total of 66 residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145497 If continuation sheet Page 5 of 5