Health inspection·February 9, 2022

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 2/8/22 at 9:21 am, V2, Director of Nursing (DON) said the seatbelt is to keep R21 in his chair. R21 cannot remove the belt when staff ask, R21 just does it when he wants to do it. V2 also said there has been no quarterly assessment for R21's use of restraint and no reduction attempts for least restrictive device to be used for R21 that she knows of since she's been the DON in the facility (August 2021). 2. On 2/7/22 at 2:22 PM, V4 CNA (Certified Nursing Assistant) was preparing to transfer R20 into bed from his wheel chair. R20 was pointing to the seat belt that was fastened over his lap. R20 was motioning to V4 to unfasten his seat belt. R20 was not able to remove the fastened seat belt himself. On 2/8/22 at 12:16 PM, V2 DON (Director of Nursing) was interviewed in regards to the reason for R20's seat belt. V2 said she was not aware that R20 had a seat belt. At 3:34 PM, V2 said she could not find the consent or assessment for R20's seat belt. V2 said the seat belt was care planned. R20's Care Plan started on 1/15/18 shows, [R20] is non ambulatory since having a CVA (cerebrovascular accident). He is wheel chair bound and requires assistance with all ADLS (Activities of daily living) related to right hemiparesis. 10/16/19- Ok to have seat belt in custom wheelchair as enabler for positioning related to diagnosis of CVA with hemiparesis and poor sitting balance. R20's Physician Orders Sheet for 2/22 does not included an order for a seat belt in R20's wheel chair. The facility's Physical Restraint/Enabler Policy revised 7/24/18 shows, To allow residents to be free of physical restraints which are not required to treat the resident's medical symptoms or as a therapeutic intervention. Physical restraints shall not be used for the purpose of discipline or convenience. Physical restraints is any manual method or physical or mechanical device, equipment, or material attached or adjacent to the resident's body, which the individual cannot remove easily and which restricts freedom of movement or normal access to his or her body. A device that may constitute a physical restraint may include, but is not limited to self-release waist restraint. Procedure: Complete physical enabler/restrain use/reduction evaluation. Obtain verbal and/or written consent from resident/legally responsible party. Obtain MD (Medical Doctor) order for restraint or adaptive device/enabler. Place physical restraint problem on the resident's care plan. The care plan must address the duration, type, and circumstances under which the restraint can be used. After initial documentation, all physical restraints require quarterly documentation regarding the type of physical restraint used, resident's response to the physical restraint, and if any reduction plan has been attempted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145727 If continuation sheet Page 2 of 15 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 145727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Polo Rehabilitation & Hcc 703 East Buffalo Polo, IL 61064 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide incontinence care for residents who need extensive assistance, and failed to provide oral care for three of 14 residents (R20, R12, and R17) in the sample of 14. Residents Affected - Few The findings include: 1. On 2/7/22 at 2:22 PM, V4 CNA was performing incontinence care for R20. R20's mechanical lift sling was wet. R20's buttocks and frontal peri area was reddened. V4 did not place any protective cream to R20's buttocks. V4 said staff on third shift got R20 out of bed. R20's Care Plan with a start date of 1/15/18 shows, [R20] is at risk for skin breakdown related to immobility, right hemiparesis with contractures to right hand/wrist, diabetes, and episodes of bladder incontinence. Frequently gets rash like area near coccyx and back of upper thighs. R20's MDS (Minimum Data Set) dated 1/1/22 shows R20 requires extensive assist in bed mobility and total assistance in toilet use and personal hygiene. R20 is always incontinent of stool. 2. On 2/7/22 at 2:58 PM, V4 CNA performed incontinence care to R12. The back of R12's pants were wet and the bottom of R12's shirt was wet. R12's incontinence brief was saturated with dark yellow urine. There was a strong urine smell. R12's buttocks were reddened. There was stool in R12's buttocks. V4 said R12 was last changed before breakfast. R12's MDS dated [DATE] shows R12 is rarely/never understood and R12's cognitive skill for daily decision making is severely impaired. R12 requires total assistance in toilet use and personal hygiene. R12 is always incontinent of bowel and bladder. 3. On 2/7/22 at 10:31 AM, R17 had thick, tan, dry skin to her bottom lip. There were no fluids at R17's bedside. At 12:50 PM, the thick, tan, and dry skin was still noted to R17's lips. V5 RN (Registered Nurse) said the CNAs (Certified Nursing Assistants) perform oral care on the residents. V5 said she did not know when the last time R17 received oral care. R17's MDS dated [DATE] shows R17 is not cognitively intact. R17 receives nutrition via feeding tube and R17 requires total assistance with toilet use and personal hygiene. On 2/9/22 at 9:50 AM, V10 CNA said incontinence care is done every two hours and as needed. Oral care is done in the morning because it is a part of morning care. Oral care is done at least once a shift and as needed. On 2/8/22 at 12:16 PM, V2 DON (Director of Nursing) said incontinence care is done at least every two-three hours. It is important to do incontinence care in order to keep residents' buttocks from breaking down. The facility's Perineal Cleansing policy reviewed 12/17 shows, To eliminate odor; to prevent irritation or infection and to enhance resident's self-esteem. The facility's Oral Care for Unconscious or NPO (nothing by mouth) status resident policy dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145727 If continuation sheet Page 3 of 15 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 145727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Polo Rehabilitation & Hcc 703 East Buffalo Polo, IL 61064 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 0677 1/2018 shows, To provide adequate oral hygiene for the unconscious or NPO status resident as necessary. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145727 If continuation sheet Page 4 of 15 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 145727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Polo Rehabilitation & Hcc 703 East Buffalo Polo, IL 61064 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure a resident's feet were not up against a foot board to prevent redness, and failed to ensure dressings were maintained for three wounds for two of 14 residents (R12, R20) reviewed for quality of care in the sample of 14. Residents Affected - Few The findings include: 1. R12's Report of Monthly Weight and Vitals sheet shows R12 is 74 inches long (Over six feet tall). R12's Physician Orders Sheet dated 2/1/22-2/28/22 shows, Float heels while in bed. R12's Progress Notes dated 8/5/21 shows, [R12] is a tall man and could benefit from a longer bed and/or foot board. On 2/7/22 at 12:00 PM, R12's legs were bent and his feet were pressed up against the foot board of his bed. At 2:58 PM, during incontinence care, R12's feet were still pressed up against the foot board of his bed. V4 CNA (Certified Nursing Assistant) said that R12 used to have a longer bed, but something broke on it. On 2/8/22 at 11:51 AM, R12's legs were bent and his feet were pressed up against the foot board of his bed. V20 RN (Registered Nurse) said that the 2nd and 3rd toe on R12's right foot are reddened. On 2/8/22 at 12:12 PM, V2 DON (Director of Nursing) said R12 had a different bed that was about three inches longer, but the was a part that quit working on his bed. V2 said the part has been ordered and in the meantime the facility put R12 into a bariatric bed which is shorter. V2 said R12's previous bed broke sometime last week. V2 said the staff need to keep pulling R12 up in his bed so that his feet aren't up against the foot of his bed. V2 said, I told the staff today to put a blanket at the end of his bed so his feet don't rub on the foot board. On 2/08/22 at 1:17 PM, V21 Maintenance supervisor said R12 head of bed stopped working. V21 said the bed stopped working on 2/1/22 or 2/2/22. V21 said V1 Administrator ordered the new part on 2/3/22. V21 said R12 was given the bariatric bed because R12 needed a longer bed, and a bariatric bed is longer than a standard bed. V21 thought the bariatric bed was 3-4 inches shorter than R12's previous bed. 2. R20's Wound Care Assessment and Individualized Treatment plan shows R20 has a full thickness wound to his left thigh, right thigh, and buttocks. It shows orders for a gauze island dressing to all three wounds changed daily. On 2/7/22 at 2:22 PM, V4 CNA (Certified Nursing Assistant) performed incontinence care to R20. V4 removed three gauze island dressings that were intact to R20's left and right upper thighs and R20's coccyx area. V4 did not notify the nurse at the time. V4 then proceeded to another resident's room to perform incontinence care. R20's Care Plan started 1/15/18 shows, [R20] is at risk for skin breakdown related to immobility, right hemiparesis with contractures to right hand/wrist, diabetes, and episodes of bladder incontinence. Frequently gets rash like area near coccyx and back of upper thighs. Care Plan dated 1/3/19 shows, Treatment per MD (medical doctor). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145727 If continuation sheet Page 5 of 15 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 145727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Polo Rehabilitation & Hcc 703 East Buffalo Polo, IL 61064 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 2/9/22 at 9:50 AM, V10 CNA said CNAs are not allowed to remove wound dressings. V10 said the nurse should remove the dressing and if the dressing is soiled, V10 reports it to her nurse. On 2/08/22 at 2:09 PM V2 DON said CNAs are only to remove wound dressings if they are no longer intact. If the CNAs remove a dressing, they should tell the nurse as soon as they are done so the nurse can put a new dressing on. The facility's Skin Condition Monitoring policy revised 11/18 shows, It is the policy of this facility to provide proper monitoring, treatment, and documentation of any resident with skin abnormalities. The facility's Preventative Skin Care Policy revised 1/18 shows, It is the facility's policy to provide preventative skin care through repositioning and careful washing, rinsing, drying, and observation of the resident's skin condition to keep them clean, comfortable, well groomed, and free from pressure ulcers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145727 If continuation sheet Page 6 of 15 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 145727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Polo Rehabilitation & Hcc 703 East Buffalo Polo, IL 61064 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 0688 Level of Harm - Minimal harm or potential for actual harm Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, interview, and record review the facility failed to ensure a resident with a contracture had a splint applied for one of three residents (R12) reviewed for contractures in the sample of 14. Residents Affected - Few The findings include: On 2/7/22 at 12:00 PM, R12's right hand was contracted and had no splint in place. At 2:58 PM R12 still did not have a splint in place. On 2/8/22 at 11:51 AM, R12 did not have a splint in place to his right hand. V7 CNA (Certified Nursing Assistant) said R12 has a splint that he uses periodically, but V7 did not know when R12's splint is applied. On 2/8/22 at 12:16 PM, V2 DON (Director of Nursing) said, R12 has a splint that get put on for up to six hours once or twice a day per therapies orders. V2 said therapy does not see R12 anymore but did instruct staff how to put the splint on. Placing the splint should be a part of the CNAs get up plan in the morning. V2 said R12's splint should be placed on in the morning. V2 said there is no way to document that the splint is in place. The staff just know to put it on when they get him [R12] dressed in the morning. There were no orders for the splint placement on R12 in his physician orders or treatment administration record. A note done by V22 COTA (Certified Occupational Therapist Assistant) shows, Hand splint: Position the splint under [R12's] right forearm, wrist, and hand. Apply straps to splint, then wrap with ace wrap. [R12] can wear splint for four hours, twice daily to prevent contractures. R12's Care Plan does not include any information in regard to R12's contractures or splints. On 2/9/22 at 9:00 AM, V2 said she obtained an order on 2/8/22 for R12 splint and placed the order in R12's Treatment Administration Record. The facility's Splints/Appliances policy revised 9/08 shows, A resident who has a contracture, or has a likelihood of developing a contracture, caused by a physical condition and requires further evaluation will be assessed by the Occupational Therapist for a splint/appliance as ordered by the resident's physician. Once the splint is received, the resident's hand/wrist area will be washed, rinsed and dried well before application. The Occupational Therapist will provide nursing with a schedule for the application and removal of the splint, subject to physician order. The program will be identified on the residents care plan including the problem, approaches, and goals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145727 If continuation sheet Page 7 of 15 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 145727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Polo Rehabilitation & Hcc 703 East Buffalo Polo, IL 61064 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to reposition residents in a safe manner and failed to ensure fall prevention interventions were in place to a resident with previous falls and high risk for falls for three of 14 residents (R12, R7, R14) reviewed for safety in the sample of 14. The findings include: 1. R7's Physician Orders dated 2/1/22-2/28/22 shows R7 was admitted to the facility on [DATE] with diagnoses including: Seizures, weakness, multiple sclerosis, neurogenic bladder, and spastic paraparesis. R7's MDS (Minimum Data Set) dated 1/17/22 shows total dependence of two staff for bed mobility. R7's MDS shows that R7 has a limited range of motion to both upper and lower extremities. R7's Care Plan started 2/21/17 shows R7 is at risk for falls related to multiple sclerosis with spastic paraparesis and generalized weakness. R7's Care Plan does not address R7's current ADLs assistance needs. R7's care plan does not reflect that R7 currently uses a mechanical lift for transfers. On 2/7/22 at 1:42 PM, V4 CNA was providing incontinence care to R7. R7 had a difficult time turning onto his right side. There were no other staff members in the room assisting with bed mobility for R7. 2. R12's Fall Risk assessment dated [DATE] shows R12 is a high fall risk. R12's Physician Orders dated 2/1/22-2/28/22 shows R12 was admitted to the facility on [DATE] with diagnoses including: Stroke, daystar, hemiplegia, dysphagia, and fracture dislocation of left ankle. R12's MDS dated [DATE] shows R12 requires extensive assistance of two people for bed mobility and R12 has limited range of motion on one side of his lower extremities. R12's Care Plan started 8/6/21 shows R12 is at risk for falls related to hemiplegia and recent stroke. Use additional assist as needed when resident is not feeling well, feeling weak or dizzy. On 2/7/22 at 2:58 PM, during incontinence care, R12 had a difficult time turning onto his left side. R12's right side was flaccid from a previous stroke. V4 said R12 would be able to turn better with side rails on his bed. 3. R14's Physician Orders dated 2/1/22-2/28/22 shows R14 was admitted to the facility on [DATE] with diagnoses including: Visual hallucinations, depression, glaucoma, dementia, and left hip fracture. R14's Fall Risk assessment dated [DATE] shows R14 is a high risk for falls and has multiple falls. R14's Progress Notes show the most recent fall was 12/13/21. R14's Care Plan dated 7/31/2020 shows, [R14] is at a high risk for falls. Keep call light within (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145727 If continuation sheet Page 8 of 15 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 145727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Polo Rehabilitation & Hcc 703 East Buffalo Polo, IL 61064 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reach at all times. Personal Alarm: Laser alarm when in bed; pressure pad alarm in wheelchair or when sitting in recliner. 12/23/2020 Bed pad alarm replaced due to falling out of bed and alarm found to not being in working order. On 2/07/22 at 11:00 AM, R14 was in her reclining chair. There was an alarm device that was on her dresser unplugged. R14's call light was attached to her bed not within reach of R14. On 2/08/22 at 12:16 PM, V2 DON said that R14 does not use a chair alarm. V2 said that R14's call light should be within reach. The facility's Fall Prevention Policy revised 11/10/18 shows, To provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. Fall Prevention Interventions: Side rails, personal alarm, pressure alarm for chair, positioning in bed, transfer with proper number of assist and gait belt, call light within reach. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145727 If continuation sheet Page 9 of 15 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 145727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Polo Rehabilitation & Hcc 703 East Buffalo Polo, IL 61064 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a urinary indwelling catheter was kept below the level of the bladder for one of two residents (R20) in the sample of 14. The findings include: R20 Physician Orders dated 2/1/22-2/28/22 shows R20 was admitted to the facility on [DATE] with diagnoses including: Sepsis, kidney stones, right hemiparesis, and urinary tract infection (UTI). On 2/7/22 at 2:22 PM, V4 CNA (Certified Nursing Assistant) lifted R20's urinary drainage bag above the level of R20's bladder while she was pulling the bag through R20's pants. There was dark urine in R20's urinary drainage bag. R20 placed the urinary drainage bag on top of R20's bed while she finished cares. On 2/9/22 at 9:50 AM, V10 CNA said the catheter bag should be kept below the level of the resident's bladder. The facility's Catheter Care policy revised 12/8/10 does not include interventions to keep the urinary drainage bag below the level of the bladder. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145727 If continuation sheet Page 10 of 15 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 145727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Polo Rehabilitation & Hcc 703 East Buffalo Polo, IL 61064 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview and record review the facility failed to to ensure psychotropic medications had a duration end date for 2 of 5 residents (R22, R6) reviewed for unnecessary medications in the sample of 5. The findings include: On 02/08/22 AM, at 9:11 AM, review of R22's Physician Order Sheet (POS) show, R22 has an order of : Order date: 1/14/22 - Xanax (anti-anxiety psychotropic medication) 0.25 mg BID as needed for anxiety, no stop date/duration. On 02/08/22 at 08:41 AM, review of R6's POS show R6 has an order of: Order date, 9/9/21-Lorazepam (anti-anxiety psychotropic medication) give 0.25mg every 2 hours as needed for agitation, with no stop date/duration. On 2/8/22 at 12:36 PM, V2 Director Of Nursing (DON) said she knew psychotropic medications need to have stop dates. The facility policy entitled Psychotropic Medication dated 11/17 show, PRN orders for psychotropic medications- time limitations 14 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145727 If continuation sheet Page 11 of 15 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 145727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Polo Rehabilitation & Hcc 703 East Buffalo Polo, IL 61064 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 2. On 2/7/22 at 9:44 AM, V6, License Practical Nurse (LPN) was the nurse working in the Covid Unit. V6 had four residents in the Covid unit and Isolation unit, R3, R19 (both COVID positive) and R4, R77 (both PUI). V6 was wearing a surgical mask under her N95 mask. V6 said she prefers to put her surgical mask first then apply the N95 mask. V6 said that was how she wears her PPE. V6 was also the nurse working in the B wing (non-isolation unit). Residents Affected - Many On 2/7/21 at 12:31 PM, V2 (DON) said it does not matter to her how staff wear their mask, they can put surgical mask under the N95 or over the N95. V2 said she would rather have staff wear a surgical mask and a N95 over it, research has not shown there is a difference. On 2/8/21 at 2:36pm PM, V8 (Regional Nurse) said staff should not put anything under the N95 mask so not to break the seal to prevent the spread the infection particularly COVID-19. A facility document entitled CDC Respirator-On with training date of 3/8/21 show Do not allow anything between your face and the respirator. (N95 Mask). Based on observation, interview and record review the facility failed to ensure all staff wearing a N95 mask were medically cleared and fit tested prior to wearing a N95 and failed to ensure N95 masks were worn appropriately to prevent the spread of COVID-19. The facility failed to ensure staff removed their gloves and washed their hands to prevent the spread of infection. This applies to all 29 residents that reside at the facility. The findings include: The Resident Census and Conditions of Residents (Form CMS 672) dated 2/8/22 shows that there were 29 residents residing in the facility. The undated facility provided COVID-19 Positive Staff list shows that an outbreak started on 12/9/21 when an employee tested positive for COVID-19. The undated facility provided COVID-19 Positive Residents lists shows that 17 additional residents tested positive on 12/9/21. 1. On 2/8/22 at 2:00 PM, V12, Certified Nursing Assistant (CNA) had a N95 mask on. V12 had facial hair coming out the bottom of his mask obstruction the seal of the mask. On 2/8/22 at 2:00 PM, V12 said that he has never been fit tested for a N95 mask. On 2/8/22 at 2:04 PM, V10 (CNA) said that she has not been fit tested to use a N95. V10 said that they have multiple kinds and can just pick which one they want to use based on comfort. On 2/8/22 at 2:16 PM, V6 (Licensed Practical Nurse) said that she has never been fit tested to use a N95 mask or did a medical questionnaire or had a medical evaluation. The schedule for 2/8/22 shows that she was taking care of residents on the COVID unit. On 2/8/22 at 2:36 PM, V8 (Regional Director of Clinical Operations) said that she brought a testing supply kit to the facility a couple months ago before their outbreak started. V8 said that V2 (Director of Nursing) said that it has not been done yet. V8 said that it is important for staff to be fit tested and have a medical evaluation to make sure the fit is appropriate to help prevent staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145727 If continuation sheet Page 12 of 15 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 145727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Polo Rehabilitation & Hcc 703 East Buffalo Polo, IL 61064 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 from contracting COVID-19 or spreading it. Level of Harm - Minimal harm or potential for actual harm On 2/9/22 at 9:20 AM, V1 (Vice President of Operations) said that they have had access to fit testing since 2020 so he is not sure why the facility has never done it. Residents Affected - Many The facility's Respiratory Protection Program updated on 12/2020 shows, Employees assigned to jobs/tasks requiring the use of a respirator will: Complete the required questionnaire for medical clearance and participate in a medical examination if necessary. Adhere to facility policies on facial hair to ensure respirator seals properly. Attend training and respirator fit testing as required in the RPP (Respiratory Protection Program). 3. On 2/7/22 at 2:22 PM, V4 CNA (Certified Nursing Assistant) transferred R20 into bed via mechanical lift. The mechanical lift sling was wet. V4 performed incontinence care to R20. V4 wiped and dried R20's front side and lifted R20's shirt without changing her gloves or performing hand hygiene. V4 changed her gloves, then wiped the stool from R20's buttocks, dried R20's buttocks, and pulled R20's urinary drainage bag through his pants without changing her gloves or performing hand hygiene. 2. On 2/7/22 at 2:58 PM, V4 CNA performed incontinence care to R12. V4 said R12 was last changed before breakfast. R12's back of his pants and bottom of his shirt were wet. R12's incontinence brief was saturated with dark urine. There was a strong urine smell noted. V4 wiped R12's front peri area, turned R12, wiped the stool from R12's buttocks, touched the clean pad, and touched R12's clean incontinence brief and did not change her gloves or perform hand hygiene. 3. On 2/7/22 at 1:42 PM, V4 performed incontinence care for R7. There was urine in R7's incontinence brief. V4 wiped R7's front peri area, placed a clean depends on the bed, wiped the stool from R7's buttocks, put the clean incontinence brief under R7, and turned R7 onto his back without changing gloves or performing hand hygiene. On 2/08/22 at 12:16 PM, V2 DON (Director of Nursing) said gloves should be changed and hand should be washed prior to touching clean items. The facility's Perineal policy reviewed 12/17 shows, The basic infection control concept for peri-care is to wash from the cleanest to the dirtiest area and remember to change or remove gloves and wash hands when going from working with contaminated items to clean items. The facility's Hand Hygiene policy reviewed 12/7/18 shows, All staff will wash hands, as washing hands as promptly and thoroughly as possible after resident contact and after contact with blood, body fluids, secretions, excretions, and equipment or articles contaminated by them is an important component of the infection control and isolation precautions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145727 If continuation sheet Page 13 of 15 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 145727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Polo Rehabilitation & Hcc 703 East Buffalo Polo, IL 61064 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to offer and administer pneumococcal conjugate vaccine (PCV13) and Pneumococcal polysaccharide vaccine (PPSV23) for 4 of 5 residents (R4, R6, R12 and R17) reviewed for immunizations in the sample of 14. Residents Affected - Some The findings include: 1. R12's Face Sheet shows that he was admitted to the facility on [DATE]. R12's Immunization Record shows, Unknown for Pneumococcal record. On 2/9/22 at 9:30 AM, V2 (Director of Nursing) said that she spoke to R12's Power of Attorney today and they would like vaccine series started. 2. R6's Face Sheet shows that she was admitted to the facility on [DATE]. R6's Immunization Record shows, Unknown for Pneumococcal record. 3. R4's Face Sheet shows that he was admitted on [DATE]. R4's Immunization Record shows that she received PPSV23 on 11/3/20. There is no documentation that she received the PCV13 dose. 4. R17's Face Sheet shows that she was admitted to the facility on [DATE]. R17's immunization Record shows that she received PPSV23 on 10/17/17. There is no documentation that she received PCV13 dose. On 2/7/22 at 1:24 PM, V2 (Director of Nursing) said that a resident's Pneumococcal immunization status is asked upon admission and the resident is offered the vaccine if they have not had it. V2 said that all residents need the PCV13 and PPSV23 vaccine. The Facility's Immunization of Residents Policy revised on 9/2017 shows, Offer the PCV13 and PPSV 23 as indicated utilizing the Pneumococcal vaccination algorithm unless contraindicated .Offer the Pneumococcal vaccination within 30 days of admission . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145727 If continuation sheet Page 14 of 15 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 145727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Polo Rehabilitation & Hcc 703 East Buffalo Polo, IL 61064 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 0886 Perform COVID19 testing on residents and staff. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to test an unvaccinated employee for COVID-19 twice a week as required for a high community transmission rate. This has the potential to affect all 29 residents that reside at the facility. Residents Affected - Many The findings include: The Resident Census and Conditions of Residents (Form CMS 672) dated 2/8/22 shows that there were 29 residents residing in the facility. The undated facility provided COVID-19 Positive Staff list shows that an outbreak started on 12/9/21 when an employee tested positive for COVID-19. The undated facility provided COVID-19 Positive Residents list shows that 17 additional residents tested positive on 12/9/21. On 2/7/22 at 1:24 PM, V2 (Director of Nursing) said that they are doing twice a week testing on all staff members due to the community transmission rate being high and they are in an outbreak that started on 12/9/21. V2 said that they have had high community transmission since she started at the facility in August. The facility's Staff/Physician/Visitors COVID-19 Vaccination List dated 1/17/22 shows that V11(Certified Nursing Assistant) is unvaccinated. V11's Employee Time Card printed on 2/7/22 shows that she worked 17 times from 11/16/21 to 1/25/22. V11's COVID-19 testing shows that she was tested on [DATE] and not tested again until 1/25/22. V11 had COVID-19 testing on 1/30/22 and no other testing was provided for after 1/30/22. V11's Employee Time Card shows that she worked 2/5/22 and 2/6/22. The facility's undated COVID-19 Positive Staff list does not show that V11 has had COVID-19 within the last 90 days. On 2/8/22 at 9:00 AM, V9 (Staff that keeps track of testing) said that she does not have any other documented testing for V11 between 11/16/21 and 1/25/22. The facility's Testing of Staff and Residents Policy revised on 10/29/21 shows, Routine testing should be based on the Facility County Level of Community Transmission Level of COVID-19 Community Transmission High (Red) Minimum Test Frequency for Unvaccinated Staff Unvaccinated staff twice weekly . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145727 If continuation sheet Page 15 of 15