Health inspection·December 9, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on interview and record review the facility failed to answer call lights in a timely manner. This failure has the potential to affect all 76 residents who reside in the facility. The Facility's Call Lights: Accessibility and Timely Response policy dated August 2025 documents the purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure an appropriate response. All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. The Facility's Grievance Log documents that on 8/6/25 R2 complained about long call lights. The conclusion of the grievance was Leader Rounding/re-education. On 12/9/25 at 11:00 AM R2 stated The call lights have not gotten any better, if anything they are getting worse. They (staff) tell me they will be back and they don't come back. I routinely wait an hour to have my call light answered. The Facility's Grievance Log documents that on 11/19/2025 R11 complained that a CNA (Certified Nurse Aide) turned off her call light and left without helping her. The conclusion of the grievance was CNA counseled. On 12/9/25 at 11:30 AM R11 stated Getting your call light answered around here is ridiculous. I usually wait at least an hour after I have turned it on, and if they do come they turn it off and say they are coming back and don't come back.On 12/9/25 at 12:10 PM R3 stated Call lights are never answered very quickly. Since (the state agency representative) got here on Friday we are getting our call lights answered very quickly. Managers are answering call lights and they never do that. They (management) knows your watching the call lights so they have posted extra people to answer them. It would be wonderful if our call lights were answered like this all the time. On 12/9/25 at 12:15 PM R9 stated Call lights stay on for at least an hour if not more every time. On 12/9/25 at 9:30 AM R10 stated I have a lot of trouble getting them (staff) to answer my call light. I've timed it before at one hour 30 minutes. Sometimes they (staff) come in and say they are coming right back in and then they don't. I don't think they should turn it off if they aren't going to help us. On 12/5/25 at 2:00 PM V3 (Ombudsman) stated we have a lot of resident complaints coming from (the facility). The call lights have been an ongoing issue, I have witnessed it myself. I was there visiting someone and their call light was on for over an hour and when I went to the desk they said they were going to send someone and never did. I had to go back up to the desk and ask for help and stand and wait for someone to come with me. On 12/5/25 at 12:00 PM V8 (R5 Family Member) stated that if he turns on her call light it usually takes about an hour, which is too long. On 12/9/25 at 12:00 PM V9 (R8 Family Member) stated I am here multiple times a week. Getting anyone to help you is almost impossible. If I turn on her light I know we are waiting at least an hour if not more. Sometimes I just go find someone but then you have to stay with them until they come because they will say they are coming but then don't. I was timing her call lights one night, I got very upset at an hour and a half Page 1 of 4 145703 145703 12/09/2025 Silvis Center for Nursing Rehab & Care 1455 Hospital Road Silvis, IL 61282

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many so I had to quit doing that. Friday and today (the call lights) are being answered very quickly. I have seen people out of their offices that I have never seen out of their offices before.On 12/9/25 at 12:15 PM V10 (Visitor) stated she comes to visit multiple residents who have become friends of hers. V10 stated The call light situation for all of my friends is awful. Call light times are always at least an hour. But everyone is telling me that when (state agency representative) is in the facility everyone is helping answer the lights so they are getting answered much quicker. The Resident Census Report dated 12/5/25 lists 76 residents currently reside at the facility. 145703 Page 2 of 4 145703 12/09/2025 Silvis Center for Nursing Rehab & Care 1455 Hospital Road Silvis, IL 61282

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to serve their posted menu on a consistent basis. This failure has the potential to affect all 76 residents who reside in the facility.The Facility's Dietary Manager Job Summary documents it is the the Dietary Manager's responsibility to plan menus with the dietitian that meet the nutritional needs of residents in accord with recommended dietary allowances and state and federal regulations. Prepares standard recipes and daily production sheets from each menu cycle for dietary staff who prepare food-as applicable. Ensures menus are available to all residents and posts in readily accessible places in facility. The Facility's Dietary Manager Job Summary also documents the Dietary Manager is responsible to order food economically and efficiently only from sources approved or considered satisfactory by Federal, state or local authorities. Maintains sufficient inventory of supplies. establishes effective system to [NAME] inventory and secure storage areas. On 12/5/25 during lunch multiple residents (R2,R3, R12,R13,R14 and R15) were voicing frustration with their deli meat sandwiches. Residents overhead saying it was supposed to be a grilled cheese with tomato soup, who eats a regular sandwich with tomato soup?On 12/9/25 at 10:30 AM R2 stated Since this new company took over they (kitchen staff) never make what they put on the menu. We find out at the time of the meal that we aren't getting what we were supposed to because someone ordered wrong or something. That is ok every once in a while, people make mistakes. This is not someone making a mistake, this is a company trying to save money. It is awful and no one is listening. Breakfast has no meat ever, if meat is on the menu I guarantee you it will be switched to eggs the day of the meal. On 12/9/25 at 11:00 AM R3 stated We never know what we are going to have, it just depends on what they order. And they sure aren't generous with their portions. This new company are real penny pinchers. On 12/5/25 at 11:15 AM R12 stated the food quality and quantity has gone down since a new company took over the facility. It's like no one cares about the food anymore. The food used to be pretty decent. Now we never know what we are getting. Whatever (V5/Dietary Manager) remembers to order. On 12/5/25 at 11:20 AM R13 stated I have had it with the kitchen in this place. They never serve what they say they are going to. We have the same things over and over even when the menu says we should be getting different foods. On 12/5/25 at 11:25 AM R14 stated The kitchen has gone so downhill. They serve the same basic things over and over again. I don't think i will ever eat Tilapia again in my life. On 12/5/24 at 11:30 AM R15 stated No one cares about the food. We just get whatever they have. It has no rhyme or reason. And we usually don't find out the menu has changed until we get our plate. The Facility's Week 4/ 11-23-25 through 11-29-25 document on Sunday lunch the dessert was changed from Brownie to Pudding. On the same Sunday Dinner was planned to be Kielbasa with Pierogies (Dumpling). The Pierogies were changed to noodles.The same week on Tuesday for breakfast the Waffle was changed to Pancake. Tuesday lunch the Cucumber Salad was changed to tossed salad. The same week on Wednesday breakfast the Egg Burrito was changed to a Hard Boiled Egg. Wednesday lunch the Turkey with Herbs was supposed to be served with Parslied [NAME] and that was changed to [NAME] Pilaf. The Cake/Icing that was planned for dessert was changed to ice cream. Wednesday Dinner time Broccoli cuts were changed to Squash. The same week on Thursday breakfast the Cheddar Egg Bake was changed to Scrambled Eggs and the muffin was changed to an English muffin. Thursday lunch was supposed to be a Chicken Salad sandwich with corn chowder, but it was changed to Chicken Salad sandwich with corn. Thursday dinner was supposed to be served with Cinnamon Scalloped Peaches and it was changed to diced peaches.The same week on Friday the Tilapia was to be served with Scandinavian vegetables and it was changed to mixed 145703 Page 3 of 4 145703 12/09/2025 Silvis Center for Nursing Rehab & Care 1455 Hospital Road Silvis, IL 61282

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many vegetables. The same week on Saturday the lunch was supposed to be Chicken Tenders with French Fries and it was changed to Patty of Chicken and Tator Tots. Saturday dinner was supposed to be served with a dinner roll and was served with a slice of bread instead. The Facility's Week 1/11-30-25 through 12-6-25 documents that on Sunday breakfast the Sausage Patty on the menu was substituted with scrambled eggs. Sunday lunch was supposed to be served with Tapioca Pudding and was served with Vanilla Pudding instead. Sunday Dinner was supposed to be a Pork Roast and was changed to Ham. The same week on Monday lunch the Cucumber Salad was substituted with a Tossed Salad. Monday Dinner was supposed to be served with Bread sticks and was served with Texas Toast instead. The same week on Tuesday breakfast the Breakfast Casserole was substituted with Cheesy Eggs.The same week on Wednesday breakfast the French Toast was substituted with Eggs Your Way. Wednesday lunch was supposed to be a Hamburger on a Bun with Corn Chowder and Cake/Icing, the substitute was Hamburger on a Bun with corn and Pudding. The same week on Thursday dinner was supposed to be served with a Brownie and was served with Pudding. The same week on Friday breakfast the Sausage and Gravy was substituted with Pancakes. Friday lunch was supposed to be a Grilled Cheese Sandwich with Tomato soup, and it was substituted with a Deli Meat Sandwich with Tomato soup. Friday supper was supposed to be a Fish Breaded Filet and was substituted with Tilapia.The same week on Saturday lunch was supposed to be Chicken Salad sandwich, French Onion Soup, Broccoli Salad, Dinner Roll and Pineapple, it was substituted with Lasagna Italian Style with peas, Bread Sticks and Chocolate Pudding. Saturday dinner was supposed to be Lasagna Italian Style with peas, Bread Sticks and Chocolate Pudding, it was substituted with Chicken Salad sandwich, French Onion soup and soup crackers. The Facility's Week 2/12-7-25 through 12-13-25 documents that Sunday breakfast was supposed to be served Bacon and it was substituted with a Hard Boiled Egg. Sunday lunch was supposed to be a Ham Steak with Baked Sweet potato and it was substituted with Turkey and Rice. The same week on Monday lunch was supposed to be a Quesadilla, Black Beans and Corn, it was substituted with Enchilada Casserole with Lettuce, Tomato and Onion. The same week on Tuesday breakfast was supposed to be a Hard Cooked Egg, Cereal of Choice and Danish, it was substituted with scrambled eggs and toast. On 12/9/25 at 1:00 PM V1 (Administrator) acknowledged that the dietary staff sometimes cannot get the food that is on the menu. V1 stated sometimes it just isn't available for order so we have to switch it around. V1 stated that she did not feel like this was done frequently. V1 confirmed that the menus are made 6 months ahead of time. The Facility's Resident Census Form dated 12/5/25 documents 76 residents currently reside in the facility. 145703 Page 4 of 4