Health inspection·May 4, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cerebral infarction. R2's facility assessment dated [DATE] showed severe cognitive impairment and requires total staff assistance with bed mobility, transfers, locomotion, dressing, eating, toilet use, and personal hygiene. The same assessment showed R2 is always incontinent of urine and bowel. On 5/2/23 at 9:19 AM, V5 and V11 (Certified Nurse Aides) provided incontinence care to R2 while she was lying in bed. V5 and V11 removed the wet incontinence brief and rolled R2 from side to side while cleansing her. V5 and V11 removed R2's nightgown and put a fresh gown on her. R2 was naked and fully exposed to the window that was next to the bed. The window looked out to the front entry and a set of windows where a group activity was occurring. On 5/4/23 at 8:50 AM, V2 (Director of Nurses) stated window curtains should be closed while personal care is happening. It is especially important because all the resident rooms are on the main floor, and someone can easily see into the rooms. It does not feel good to be naked and exposed. Cognition levels make no difference. The curtains provide dignity and should be pulled closed during all cares. The undated Residents' Rights for People in Long-Term Care Facilities pamphlet (Produced by the Illinois Department of Aging) states: Your medical and personal care are private. Facility staff must respect your privacy when you are being examined or given care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145727 If continuation sheet Page 2 of 19 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 05/04/2023 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R79's admission Record, printed by the facility on 5/3/23, showed she had diagnoses including Alzheimer's disease with early onset, major depressive disorder, and anxiety disorder. R79's baseline Care Plan dated 4/18/23, showed she was dependent on 2 staff members for toileting and bathing. The care plan showed R79 was dependent on one staff for dressing. The care plan also showed R79 was a high fall risk and had poor safety awareness. The Care plan did not identify a restraint, a lap buddy or a table/tray. Residents Affected - Few On 5/2/23 at 10:23 AM R79 was observed sitting in a low hospice geriatric chair in the common area, by the nurse's station. A tray was attached to the front of R79's geriatric chair. V15 (Hospice CNA-Certified Nursing Assistant) took R79 to give her a shower. After the shower, R79 was placed back into the low hospice geriatric chair and the tray was placed back on the chair. On 5/3/23 R79 was observed sitting in the dining room during the breakfast and lunch meals with the tray attached to her geriatric chair. The only time R79 was observed without the tray attached to her geriatric chair on 5/2/23 and 5/3/23 was when staff were providing incontinent care for her, or she was being provided a shower. On 5/2/23 and 5/3/23 a magazine was seen sitting on R79's tray table for a brief period. The magazine was open on both observations, however R79 was not looking at the magazine, or turning pages in the magazine. On 5/2/23 at 12:18 PM V1 (Administrator) said R79 has the table for activity purposes, she is a very busy person and likes to do things constantly. V1 said R79 is new to the facility and on hospice. V1 said hospice suggested they use the table to allow R79 to keep activities on the table top within reach. On 5/3/23 at 9:43 AM, V18 and V19 (R79's family) said the table attached to her low hospice geriatric chair was new. V19 added that last Wednesday when they came in, there was a cushion that went in front of R79 and under the arms of the chair (lap buddy). Both V18 and V19 said they think the tray table may be due to R79's frequent falls in the previous facility. V19 said R79 fell in the previous facility and had to have hip surgery. V18 said R79 would keep scooting forward and try to get up out of the chair. On 5/03/23 at 1:15 PM, V13 Nurse Practitioner-NP) said the table attached to R79's chair was definitely a restraint. V13 said the table is not the same as a lap buddy pad. V13 said the tray table is a hard table not a padded cushion. V13 said the tray would be a restraint and would need to have an order and a rationale for it. V13 said R79 did not have that when she came in to facility. V13 said a lap buddy pad and a hard tray are not the same thing. On 5/03/23 at 1:33 PM, V12 (Therapy Rehab Director) said R79 was not evaluated by the therapy department. V12 said R79 was on hospice when she was admitted . We did not have anything to do with the table on her chair. On 5/04/23 at 9:30 AM, (Director of Nursing-DON) said R79 would not be able to get out of the chair on her own with the tray. V2 said R79 would not be able to take the tray off. The tray is not a lap buddy pad. V2 said there should be an assessment, an order and a rationale for the restraint use. V2 said there should also be a signed consent for the restraint. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145727 If continuation sheet Page 3 of 19 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 05/04/2023 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R79's Physician's Order Sheet (POS), signed by R79's physician on 4/19/23, showed the following order: 4/25/23 Lap buddy pad may be used for patient comfort. No order for a tray/table restraint was listed on the POS. The Physical Restraint/Enabler Consent document in R79's paper medical record was not filled out and there was a line drawn through the document going from the right side in a downward motion to the left side of the document. The Physical Enabler/Restraint Use/Reduction Evaluation located in R79's paper medical record was not filled out and there were lines on page 2 and page 4 of the forms going from one side of the page down to the other side of the page. The facility was in the process of initiating electronic medical records for the facility. R79's electronic medical record was reviewed. There was no order for a table/tray restraint and no signed consent for the restraint in R79's orders tab, miscellaneous tab, or assessment tab. R79's Medication Record, provided by the facility on 5/4/23, showed Fax out re (regarding) lap buddy order. No information regarding a tray table was listed on R79's Medication Record. R79's Order Summary Report for active orders as of 5/3/23, showed no order for a Geri-chair tray table. R79's Medication Administration Record from 5/1/23-5/31/23 showed no order for a Geri-chair tray table. R79's Hospice Binder contained six pages in the binder: an In-Home Medical Group Order Form for Hospice Evaluation dated 4/14/23, a hospice form showing R79's name, date admitted to hospice and information on when the facility staff should call hospice with their number listed on the form. Another one of the forms provided a list of the Hospice Interdisciplinary Team and their contact numbers. Another form in the binder showed the Procedure for Death of a Hospice Patient in a Nursing Home. Another form was the Hospice' admission Order Set. The admission Order Set did not contain an order for a geri-chair tray table. The last document was the hospice Nursing Progress Notes. The notes did not mention anything about a geri-chair tray table. The facility's policy and procedure titled Physical Restraint/Enabler Policy, with a revision date of 7/24/18, showed Definition of a Physical Restraint: Physical restraints (are) 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: bed rails, self-release waist restraints, soft waist restraints, lap top cushions, vest restraints, Geri-chair with tray table, arm restraints, leg restraints, personal alarms and hand mitts . The policy showed Procedure: 1. Complete Physical Enabler/Restraint Use/Reduction Evaluation. 2. Obtain verbal and/or written consent from resident/legally responsible party (May obtain verbal consent until able to receive written consent). 3. Document in nurse's notes the date, time, and which type of consent obtained prior to physical restraint being applied. 4. Obtain M.D. (Doctor) order for restraint or adaptive device/enabler. The order must include: Specific medical/physical reason, type of restraint/enabler, release and reposition at least every two hours, and when to be used .15. Document in nurse's notes type of restraint being used and resident's response to the physical restraint. 16. 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. 17. After initial documentation, all physical restraints require quarterly documentation regarding the type of physical restraint (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145727 If continuation sheet Page 4 of 19 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 05/04/2023 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few used, resident's response to the physical restraint, and if any reduction plan has been attempted. 18. Initiate Restraint Elimination/Reductions Program ninety days from application. Based on observation, interview, and record review the facility failed to identify the use of physical restraints and failed to follow their policy for restraints for 2 of 2 residents (R2, R79) reviewed for physical restraints in the sample of 13. The findings include: 1. R2's face sheet printed on 5/3/23 showed diagnosis including but not limited to rhabdomyolysis (severe muscle breakdown), dementia, multiple sclerosis, epilepsy, gastrostomy status, and history of cerebral infarction. R2's facility assessment dated [DATE] showed severe cognitive impairment and requires total staff assistance with bed mobility, transfers, locomotion, dressing, eating, toilet use, and personal hygiene. The same assessment showed R2 is always incontinent. The assessment showed R2 was not using any type of physical restraint. On 5/2/23 at 9:36 AM, R2 was transferred from the bed to her wheelchair using a mechanical lift. V5 and V11 (CNAs-Certified Nurse Aides) reclined the high back wheelchair slightly and clipped a seat belt around R2's waist. At 11:38 AM, R2 was still in the wheelchair with the seat belt clipped across her waist. V5 approached and wheeled R2 down the hall and set her in the front foyer. The seat belt remained clipped around her waist. On 5/2/23 at 12:24 PM, V1 (Administrator) stated there are no restraints used in the building. The facility Matrix for Providers form supplied at entrance did not indicate any physical restraint use for R2 or R79. R2's active physician orders dated 5/3/23 showed an order for: Seat belt in cushion wheelchair. The order had no rationale for the use. R2's working paper chart care plan showed a focus area related to falls. A handwritten intervention dated 10/16/19 (3+ years ago) stated: ok to have seat belt in wheelchair as enable for positioning due to dx of MS (diagnoses of multiple sclerosis). There were no interventions related to release time or monitoring. On 5/3/23 at 11:24 AM, V13 (Nurse Practitioner) stated she was unaware R2 had a seat belt and there was no reason for it. V13 said R2 has severe dementia, requires total care, and absolutely could not remove it herself. V13 said any resident with a restraint requires a physician order, consent, and documentation of why it is needed. V13 said the facility protocol needs to be followed. V13 said she had no knowledge of who ordered the belt use from 2019 and possibly the therapy department would know. At 11:32 AM, V13 observed R2's wheelchair with seat belt and said, Yes, this is definitely not needed. Maybe it just came with the custom wheelchair and staff are using it because it is there. (R2) is always reclined back in her chair so the belt would serve no re-positioning purpose. She does not fall forward or move in the wheelchair. On 5/3/23 at 11:38 AM, V12 (Physical Therapist/Rehab Director) stated R2 tends to lean to the side while in her wheelchair but does have enough lateral support to keep herself upright. R2 does not have a problem rolling forward and the seat belt is not a therapy intervention. R2 does not need a seat belt for positioning in the wheelchair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145727 If continuation sheet Page 5 of 19 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 05/04/2023 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 0604 Level of Harm - Minimal harm or potential for actual harm On 5/4/23 at 8:52 AM, V2 (Director of Nurses) stated a physical restraint is anything that stops movement or freedom for a resident. V2 said she would consider a seat belt a restraint. It stops the resident from moving while in the chair. V2 said a consent and physician order are needed. Routine reassessments are required to ensure the need for use is still there. V2 said the misuse of physical restraints have a high risk of injury and can be undignified for a resident. Residents Affected - Few On 5/4/23 at 9:10 AM, V1 (Administrator) said a restraint is any device that prevents a resident from moving the body. V1 said R2's seat belt is not a restraint because she needs it for re-positioning. V1 was asked who determined it was for repositioning and replied, I don't know. V1 said she has seen R2 and there is no possibility she could remove the belt herself. V1 said there is probably no reason for it. V1 said there should be a consent, assessment for the need, doctors order, quarterly reviews and how it should be used. All those items are important to ensure safety and that it is being used appropriately for the resident. V1 said restraints have the potential to cause entrapment, injury, and emotional stress. On 5/4/23 at 11:33 AM, V1 and V2 stated there was no documentation of R2's seat belt consent, physician order with reason for use, assessments, or attempt to reduce the use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145727 If continuation sheet Page 6 of 19 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 05/04/2023 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 ensure ADL (Activities of Daily Living) care was provided for 1 of 1 resident (R19) reviewed for activities of daily living in the sample of 13. Residents Affected - Few The findings include: R19's face sheet printed on 5/3/23 showed diagnoses including but not limited to Huntington's Disease, muscle weakness, insomnia, gastrostomy status, and dysphagia. R19's facility assessment dated [DATE] showed no cognitive impairment and staff assistance needed for bed mobility, transfers, locomotion, dressing, eating, toilet use and personal hygiene. R19's ADL report for April 2023 showed total staff dependence for oral hygiene. On 5/2/23 at 9:52 AM, R19 was seated in a wheelchair in her room. R19 was alert and able to nod yes or no in answer but was non-verbal. R19's teeth, tongue, and lips were covered with a yellowish, crusty substance. R19's call light was lying on the floor, underneath her bed. At 9:55 AM, V5 (Certified Nurse Aide) said R19 can express her needs and uses the call light to ask for help. She needs help with transfers, incontinence care, and basically everything. She is aware of her surroundings and can express her needs with yes or no nods. At 12:28 PM, R19 was in her wheelchair and the call light was still in same position. At 3:20 PM, R19 was in bed and the call light was over her head. On 5/3/23 at 8:56 AM, R19 was asleep in bed. The call light was above her head, next to the pillow. At 11:54 AM, V3 (Registered Nurse) supplied liquid nutrition to R19 via her G-tube. R19's lips, teeth, and tongue were still caked with a yellowish, dried substance. V3 stated she should be getting oral care every shift. It is not getting done. R19 had a terrible lip sore from chapped lips last week and it was likely caused by lack of oral hygiene. V3 said R19 is very alert and just has a speech issue. V3 said R19 uses the call light when she needs assistance with any of her ADLs. The facility was unable to supply any documentation related to oral care being provided to R19. The facility Oral Care/Toothbrushing policy review dated 3/20/23 states: Policy-To provide adequate oral hygiene for all residents. 17. Repeat procedure as frequently as necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145727 If continuation sheet Page 7 of 19 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 05/04/2023 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 document an assessment of a pressure area and develop a care plan for 1 of 1 resident (R21) reviewed for pressure ulcers in the sample of 13. Residents Affected - Few The findings include: R21's admission Record, printed by the facility on 5/4/23, showed she was admitted to the facility on [DATE] with diagnoses including anemia, muscle spasm, malignant neoplasm of exocervix (the outer part of the cervix that opens into the vagina), obstructive (a condition in which urine cannot flow, either partially or completely, through the ureter, bladder or urethra due to some type of obstruction) and reflux uropathy (a condition in which the kidneys are damaged by the backward flow of urine into the kidney). R21's facility assessment dated [DATE] showed she was cognitively intact. The assessment showed R21 required extensive assist of two staff members for bed mobility and dressing, extensive assist of one staff member for personal hygiene, and was dependent on two staff members for toileting and transfers. The assessment also showed R21 had a limitation to her range of motion on one side of her upper and lower extremities. On 5/3/23 at 10:53 AM, V3 (Registered Nurse-RN) said R21 had a pressure ulcer on her buttocks. V3 said it started out as a shear and developed into a pressure injury. R21's Skilled Progress Notes from 4/1/23-5/3/23 did not show an assessment of the wound on R21's buttocks. R21's paper chart medical record did not have any assessment of R21's wound on her buttocks. R21's electronic medical record did not have any assessment of a pressure wound to R21's buttocks in the miscellaneous tab, assessment tab, or progress notes tab. The facility's Treatment Administration Record (TAR) binder was reviewed with no assessment for the pressure area on R21's buttocks in the tab marked with R21's name. R21's TAR (located in the binder) showed an order dated 4/20/23, Apply duoderm to left buttock every 72 hours and as needed for dressing failure. No assessment of the left buttocks was listed on the TAR. This surveyor asked V1 (Administrator) for the first assessment and the most recent assessment of the wound to R21's buttocks. On 5/4/23 at 7:50 AM, V6 (Licensed Practical Nurse-LPN/MDS Nurse) was asked to let this surveyor know when she was going to do the dressing change for R21 so an observation of the wound could be done. V6 agreed to the request. At 8:55 AM, V1 (Administrator) was asked to provide the first assessment for R21's pressure injury to her left buttocks, and the most recent assessment. At 10:40 AM, V1 said they were not able to locate any assessments for R21's pressure injury. At 10:48 AM, V6 said she had already changed the dressing for R21 because the dressing had come off. V6 said she assessed the area and updated the doctor. V6 said the order was changed to (barrier cream) and leave open to air, due to the area healing well. At 10:52 AM, V6, V16 and V17 (Certified Nursing Assistants-CNAs) rolled R21 onto her left side. R21 had two small open red areas to her left inner buttocks. When V6 pressed the area lightly, R21 said Ouch. V6 said the area was not healed, but it is healing well. V6's assessment and any written correspondence with R21's doctor on 5/4/21 regarding R21's pressure injury was requested. R21's Order Summary Report, showing active orders as of 5/4/23, showed an order for duoderm CGF (control gel formula) dressing (a flexible, waterproof dressing that forms a gel-like covering used to protect the open area and prevent infection). the order showed Apply to left inner buttock every 3 days and as needed for wound care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145727 If continuation sheet Page 8 of 19 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 05/04/2023 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few All R21's care plans were reviewed with no care plan for risk of skin alteration or pressure injury listed for R21. R21's Progress Note dated 5/4/23 at 10:42 AM, entered by V6, showed: Communication with Physician. pressure area to inner left buttock healing. Wound measures 0.5 centimeters (cm) length x 0.2 cm width. 100% epithelial tissue. Area 100% blanchable. The note showed R21's Physician gave a new order to discontinue duoderm at this time and resume the previous treatment of calmoseptine ointment (barrier cream) to the area every shift. Keep area free of pressure when able. R21's Progress Note dated 5/4/23 at 10:43 AM, entered by V6, showed: Communication with Physician. Pressure area to left inner buttock healing. Previous area of shear. Wound measures 0.2 centimeters (cm) length x 0.3 cm width. 100% epithelial tissue. 100% blanchable. The note showed R21's Physician gave a new order to discontinue the duoderm at this time and resume the previous treatment of calmoseptine ointment (barrier cream) every shift. Keep free of pressure when able. The facility's undated policy and procedure titled Decubitus Care/Pressure Areas showed: the purpose of the policy was to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer, once identified. The Procedure showed: 1. Upon notification of skin breakdown, a Newly Acquired Skin Condition report will be completed and forwarded to the Director of Nurses. 2. The pressure area will be assessed and documented on the Treatment Administration Record (TAR). 3. Complete all areas of the TAR. i) Document size, stage site, depth, drainage, color, odor, and treatment (upon obtaining from the physician). ii) Document the stages of the pressure ulcer as follows: a) Suspected Deep tissue injury .b) Stage I .c) Stage II .d) Stage III .e) Stage IV .iii) Document the color .5. Documentation of the pressure area must occur upon identification and at least once each week on the TAR. The assessment must include: i) Characteristic (i.e., size, shape, depth, color, presence of granulation tissue, necrotic tissue, etc.) ii) Treatment and response to treatment .8. Initiate problem on care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145727 If continuation sheet Page 9 of 19 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 05/04/2023 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 transfer a high fall risk resident safely and failed to ensure a resident did not hold smoking materials for 2 of 2 residents (R10, R82) reviewed for safety in the sample of 13. The findings include: 1. R10's face sheet printed on 5/3/23 showed diagnoses including but not limited to metabolic encephalopathy, muscle weakness, difficulty walking, unsteadiness on feet, and altered mental status. R10's facility assessment dated [DATE] showed total dependence on staff for transfers and toilet use. The same assessment showed R10 is always incontinent of urine and bowel. R10's Fall Risk assessment dated [DATE] showed a high risk for falls. The facility supplied fall log showed R10 has fallen five times within the last three months. On 5/2/23 at 9:02 AM, V5 and V7 (CNAs-Certified Nurse Aides) entered R10's room and wheeled her to the bathroom. V5 assisted R10 to stand and pivot to the toilet while holding her arm. V5 assisted R10 back into her wheelchair in the same manner after using the toilet. At no time was the gait belt, which was hanging on R10's door, put on her waist. V5 was questioned about the lack of gait belt and said she did not use the belt because there were grab bars in the bathroom. V5 said R10 can stand well without the gait belt so she does not use it for toileting. V5 said if R10 was transferring outside of the room then she would use it. V5 said R10 has had falls in the past but is doing pretty good now so the belt isn't needed. On 5/3/23 at 11:47 AM, V12 (Physical Therapist) said R10 needs help with transfers. Her cognition is not good, and she has poor safety awareness. V12 said gait belts are necessary to prevent falls. V12 said R10 is declining physically and mentally due to her disease processes. On 5/4/23 at 9:00 AM, V2 (Director of Nurses) stated gait belts are used for all resident transfers and ambulation. They are necessary for safety and to reduce falls. Gait belts reduce the chance of a resident being hurt from a fall. V2 said anyone who needs assistance with transfers or ambulation requires a gait belt. The facility Fall Prevention policy revision dated 12/09 states under the fall prevention interventions: 11. Transfer with proper number of assist and gait belt. The facility Transfer Belts/Gait Belts policy revision dated 12/17/12 states under the policy section: GAIT BELTS ARE MANDATORY. 2. R82's face sheet printed on 5/3/23 showed an admission date of 2/28/23 and diagnoses including but not limited to complex febrile convulsions. On 5/2/23 at 3:27 PM, R82 was lying on her stomach in bed and dressed. R82 had three packs of cigarettes on the bed next to her and one pack on her nightstand. R82 was asked where she keeps her lighter and matches and replied, With me. R82 was asked to show this surveyor where she keeps them but (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145727 If continuation sheet Page 10 of 19 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 05/04/2023 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 closed her eyes and refused to speak. Level of Harm - Minimal harm or potential for actual harm On 5/2/23 at 3:45 PM, R82 was outside smoking while being supervised by V3 (Licensed Practical Nurse). Residents Affected - Few On 5/3/23 at 2:17 PM, V3 (LPN) said we do go out with her (R82) each time she smokes. She needs supervision. We do not hold her lighter or matches at the nurse station. I am not sure where she keeps them, but yesterday she pulled a lighter out of her own pocket. So yes, she is keeping them in her room someplace. At 2:28 PM, V14 (CNA) said R82 does need staff supervision to go outside and smoke. V14 stated R82 has her cigarettes and lighter with her each time he is with her. V14 said she keeps them in her coat pocket. On 5/3/23 at 2:37 PM, R82's chart was reviewed by this surveyor and V2 (DON) for a smoking assessment and care plan for safe smoking. None were located. At 3:02 PM, V1 (Administrator) reviewed R82's chart and was also unable to locate the documents. V1 said the smoking assessment is necessary to ensure a resident is safe to smoke. On 5/4/23 at 9:15 AM, V1 (Administrator) said residents are not allowed to hold their own smoking materials. It is a fire and safety hazard to themselves and others. V1 said R82 does need supervision to smoke and there is no reason she should have smoking items in her room. That is not safe, and the items should be locked in a med room until R82 wants to smoke. The facility supplied a Resident Smoking Assessment for R82 dated 5/3/23 (same day as survey). The assessment showed R82 was permitted to smoke per facility policies and procedures. The undated facility Smoking Policy states under the guidelines section: 2. Residents .may not keep his/her smoking materials. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145727 If continuation sheet Page 11 of 19 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 05/04/2023 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 have an order for dialysis on a resident's Physician's Order Sheet (POS) and failed to develop a dialysis care plan for 1 of 1 resident (R 81) reviewed for dialysis in the sample of 13. Residents Affected - Few The findings include: R81's admission Record, printed by the facility on 5/4/23 showed R81 was admitted to the facility on [DATE] and had diagnoses of end stage renal disease, chronic kidney disease, depression, muscle weakness, major depressive disorder, type II diabetes mellitus, and other disorders of electrolyte and fluid balance. R81's facility assessment dated [DATE] showed he was cognitively intact and required extensive assist of two staff members for bed mobility and toileting. The assessment showed R81 was dependent on staff members for transfers, dressing and bathing. The assessment also showed that R81 was receiving dialysis. On 5/2/23 at 1:18 PM, R81 was in his room, sitting in his wheelchair. R81 said he had just got back from having dialysis at an outside facility. R81's Physician's Orders do not show an order for dialysis. R81's Baseline Care plan dated 4/14/23 does not show that R81 receives dialysis and does not list the location of the dialysis center, the days R81 receives dialysis, or the site on R81's body that he receives dialysis through. The Baseline Care Plan does not identify what to monitor for after R81 returns from dialysis, who and when to call if there are any concerns or provide information on any instructions prior to R81 receiving dialysis (i.e., what medications to give prior, what medications to hold prior to dialysis, etc.). On 5/04/23 at 9:40 AM, V2 (Director of Nursing-DON) said if a resident is receiving dialysis, there should be an order located in the Physician's Orders. The order should identify the days for dialysis, the location of dialysis, and what to monitor for post dialysis. V2 said there are things that need to be monitored when they receive dialysis, for their safety. V2 said there should also be a care plan in place for dialysis to guide staff in the care of a dialysis patient. The facility's policy and procedure titled Dialysis, with a review date of 3/17/23, showed the different types of dialysis. The policy that was provided listed things that are important to monitor for in a resident with an access site for dialysis. The policy provided by the facility did not address making sure there is an order for dialysis, including the days dialysis is scheduled. The policy that was provided also did not address developing a care plan for the care of the dialysis patient. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145727 If continuation sheet Page 12 of 19 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 05/04/2023 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 0727 Level of Harm - Minimal harm or potential for actual harm 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 was on duty at least 8 hours a day. This had the potential to affect all 29 facility residents. Residents Affected - Many The findings include: The facility's 5/3/23 Resident Census and Conditions of the Resident's form showed there were 29 facility residents. On 05/03/23 at 02:27 PM, V10 Licensed Practical Nurse (LPN) said she had been working at the facility since February. V10 said she works part time as needed on Sundays and during the month of April 2023 there were no Registered Nurses (RNs) or Administration staff present. On 05/03/23 at 03:55 PM, V9 LPN said she works as needed and during the month of April 2023 there were no RNs working while she was there. On 05/04/23 at 09:44 AM, V1 Administrator was shown the April 2023 nursing schedule. V1 said you're right and acknowledged there were no RNs scheduled to work any Sunday in April. V1 said she worked 4 hours on a Sunday in April but that doesn't cover all those days. The facility's schedule showed no RNs scheduled to work on 4/2, 4/9, 4/16, 4/23, and 4/30/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145727 If continuation sheet Page 13 of 19 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 05/04/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R83's admission Record, printed by the facility on 5/3/23, showed she was admitted to the facility on [DATE]. R83's facility assessment dated [DATE] showed she is cognitively intact. On 5/02/23 at 9:40 AM, R83 was sitting in her room. V20 (R83's husband) was also in her room. V20 said the facility still has not received R83's Norco from the pharmacy and they are only able to give her the pain medication because he brought in a bottle that she had prior to coming to the facility. V20 was concerned that the supply he brought into the facility was getting low and the facility still has not received the pain medication from the pharmacy. R83 said she always has pain but the Norco helps with the pain. On 5/02/23 at 10:30 AM, V3 (Registered Nurse-RN) said in order to fill R83's Norco prescription, the pharmacy has to have an e-script. V3 said the facility only has a paper script from the hospital. V3 said she would call the pharmacy and see if they ever received the e-script from the hospital. V3 said she could not get the pain medication out of the C-box (a box containing controlled medications that is provided by the pharmacy) for R83 because there is no e-script. V3 said R83 has been receiving Norco for pain because V20 brought in a bottle of Norco to the facility for her. On 5/02/23 at 1:22 PM, V20 came to the conference room and asked this surveyor what she found out about R83's Norco. This surveyor informed V20 that V1 (Administrator) and V2 (Director of Nursing) were asked to look into it and update him and R83. This surveyor also informed V20 that she had spoken with V3 and she said the pharmacy has to have an e-script in order to fill the Norco and that V3 said she was going to call the pharmacy and see where they were at. ON 5/03/23 at 3:06 PM, V3 said when she (V3) came in on Saturday (4/29/23), R83 had about 5 pills that her husband had brought in for her. V3 showed this surveyor the reconciliation sheet that showed on 4/29/23 there were 6 Norco 5/325 mg pills for R83. V3 said she called the pharmacy and they said they would only accept an e-script from a doctor's office and not a paper script that was sent from the facility. V3 said she called the doctor's office that prescribed the Norco at the hospital and left a message. V3 said it was the weekend so there was no one at the doctor's office. V3 said on Monday the hospital doctor's office called back and said they did not feel comfortable sending an e-script for the Norco because they were the hospitalist that just happened to be working that day at the hospital. V3 said the hospitalist said that it would have to be the facility's doctor that sends an e-script over to the pharmacy. V3 said she called R83's doctor on Tuesday to get an e-script sent to the pharmacy. V3 said she is not sure why the nurse that was on duty Monday did not call the facility's doctor to get the e-script sent on Monday. V3 said she (V3) could have called the facility's doctor on Saturday to get the order for the Norco but she was waiting until she got the declination from the prescribing physician at the hospital. V3 said the facility received R83's Norco from the pharmacy last night (Tuesday 5/2/23). On 5/04/23 at 9:44 AM, V2 (DON) said R83 was admitted to the facility on [DATE] and her Norco 5-325 was delivered to the facility on 5/2/23 in the evening. V2 said that is not acceptable. V2 said with the e-script, the doctor needs to send it to the pharmacy. V2 said knowing it was the weekend, and they were not going to probably be able to contact the physician from the hospital that ordered the pain medication. The nurse on duty should have either called the resident's Primary Care Physician or the facility's Medical Director to have an e-script sent to the pharmacy so R83's medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145727 If continuation sheet Page 14 of 19 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 05/04/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some would have arrived in a timely manner. V2 stated, It is not up to the family to make sure the residents' medications are available. That is all on us. R83's Order Summary Report for active orders as of 5/3/23, showed an active order for Norco 5-325 mg one tablet every 4 hours as needed for pain. That order showed a start date of 5/1/23. R83's April 2023 Medication Administration Record PRN (as needed) Medication Information sheet, dated 4/27/23, showed an order on 4/27/23 for Norco 5-325 mg every 4 hours as needed for pain. R83's Care Plan dated 5/3/23 showed she is taking pain medication related to back pain. R83's Controlled Substance Proof of Use form started with 6 Norco 5-325 milligram (mg) pills documented on the form on 4/30/23. The form showed 10 more Norco 5-325 mg pills were brought in on 5/2/23 when R83 only had 1 Norco left. V3 identified the source of the Norco 5-325 as V20 bringing in for R83. The Pharmacy Delivery Receipt dated 5/2/23 showed 30 Norco 5-325 mg tablets were delivered to the facility at 6:15 PM for R83 on 5/2/23. The facility's undated policy and procedure titled Pharmacy Medication Procurement was reviewed. the facility's Controlled Substances policy and procedure, with a review date of 3/16/23 was reviewed. The facility's policy and procedure titled Conformance with Physician Medication Orders, with a reviewed date of 9/27/17 was reviewed. None of the three previously listed policies addressed what to do if there is a problem or issue getting prescribed medications from the pharmacy (i.e., notify the Director of Nursing, the resident's Physician, or the facility's Medical Director). Based on observation, interview, and record review, the facility failed to ensure controlled medications were reconciled in a manner to prevent diversion for 3 of 3 residents (R79, R4, R13) reviewed for medication storage in the sample of 13 and failed to ensure a resident's pain medication was available for use for 1 of 1 resident (R83) reviewed for pain medications in the sample of 13. The findings include: On 05/02/23 at 08:53 AM, during the medication storage task with V3 Registered Nurse (RN) there were three boxes in the medication refrigerator. One box had R79's information on the label and included a sealed 15 milliliter (ml) bottle of morphine sulfate 100 milligrams (mg) per 5 ml oral solution and a sealed 30 ml bottle of lorazepam 2 mg per ml oral solution. Neither bottle had a reconciliation form to show it was controlled and accounted. A second box had R4's information on the label and contained a sealed 5 ml bottle of morphine sulfate 20 mg per ml oral solution and a sealed 5 ml bottle of lorazepam 2 mg per ml oral solution. Neither bottle had a reconciliation form to show it was controlled and accounted. A third box labeled with R13's information contained a sealed bottle of morphine sulfate 100 mg per 5 ml oral solution. This bottle did not have a reconciliation form to show it was controlled and accounted. On 5/2/23 at 9:00 AM, V3 said there aren't any count (reconciliation) sheets for the above medications, and they're not counted each shift. Morphine and lorazepam are both controlled drugs and should be counted. It's important to count controlled medications every shift because otherwise they can disappear and we wouldn't know. V3 said the boxes are comfort kits brought by hospice. On 05/03/23 at 12:56 PM, V1 Administrator said controlled medications should be reconciled to avoid (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145727 If continuation sheet Page 15 of 19 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 05/04/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some diversion. When a controlled drug comes in, the nurse confirms the quantity, starts a reconciliation sheet and it is confirmed and counted at each shift change and each dose is signed out. The facility's 3/16/23 Controlled Substances Policy showed at the time a controlled substance is delivered, the charge nurse and the delivery person will count the controlled substance together to verify the count. If the controlled substance count is correct, a control sheet for each prescription will be initiated. The control sheet will contain: the residents name, ordering physician's name, issuing pharmacy, name and strength of the drug, quantity received, and date and time received. All schedule II drugs must be administered and recorded on a disposition sheet. The drugs in other schedules deemed necessary for control are placed under the same restrictions as schedule II drugs by the pharmacist. The drugs in schedule II (and those in other schedules which have been restricted and stored in the controlled substances cabinet) will be counted and reconciled by the nurse coming on duty and the nurse that is going off duty. 1. R79's face sheet showed admission to the facility on 4/18/23. R79's diagnosis included Alzheimer's disease, major depressive disorder, anxiety disorder, hypertension, and atrial fibrillation. R79's physician order sheet showed a 4/19/23 order for hospice to evaluate and treat. This physician order sheet does not have a current order for morphine sulfate oral solution or lorazepam oral solution. 2. R4's face sheet showed admission to the facility on 4/20/22. R4's diagnosis included heart failure, Type 2 diabetes, morbid obesity, depression, anxiety disorder, sleep apnea, and chronic obstructive pulmonary disease. R4's physician order sheet showed a 4/3/23 order for hospice to evaluate and treat. This physician order sheet does not have a current order for morphine sulfate oral solution or lorazepam oral solution. 3. R13's face sheet showed admission to the facility on [DATE]. R13's diagnosis included dementia, polyneuropathy, heart failure, major depressive disorder, and hypertension. R13's physician order sheet does not show an order for hospice or morphine sulfate oral solution. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145727 If continuation sheet Page 16 of 19 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 05/04/2023 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 0882 Level of Harm - Minimal harm or potential for actual harm Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on interview and record review, the facility failed to have an Infection Preventionist. This failure had the potential to affect all 29 facility residents. Residents Affected - Many The findings include: The facility's 5/3/23 Resident Census and Condition of Residents form showed 29 residents in the facility. On 05/03/23 at 09:53 AM, V6 MDS nurse said she was unable to locate her Infection Preventionist (IP) Certificate. At 09:55 AM, V1 Administrator said she could not produce her IP certificate. On 05/04/23 at 08:50 AM, V1 said she it's important to have an IP on staff to monitor and track illnesses trends for infectious diseases, minimize the risk of the spread of infection, and to monitor immunizations to prevent complications. The facility's 4/11/22 Infection Control Surveillance and Monitoring Policy showed the facility shall employ at a minimum, a part-time Infection Control Preventionist. The facility's 3/3/23 Infection Preventionist Job Description showed the Infection Preventionist (IP) is accountable for decreasing the incidence and transmission of infectious diseases between residents, staff, visitors and community. The IP maintains current knowledge of federal, state and local regulations and ensures that the facility leaders are informed of appropriate issues. Understands and complies with infection control, safety and OSHA (Occupational Safety and Health Administration) procedures and regulations. Participates in external reporting to CDC (Centers for Disease Control and Prevention) NHSN (National Healthcare Safety Network) system, and other post acute care specific quality organization. Authority and responsibility for ensuring appropriate intervention and education occurs with staff, volunteers and medical staff when healthcare infection trends, outbreaks or non-compliance to infection control/OSHA are identified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145727 If continuation sheet Page 17 of 19 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 05/04/2023 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 ensure residents were offered immunization for influenza and pneumonia and failed to obtain historical immunization data for 3 of 5 residents (R21, R79, R81) reviewed for immunizations in the sample of 13. Residents Affected - Few The findings include: On 05/03/23 at 03:08 PM, V8 Regional Director of Operations said there were no consents, historical data, or evidence of immunization for pneumonia or influenza being offered for R21, R79, and R81. On 05/04/23 at 08:50 AM, V1 said she it's important to ensure residents have their immunizations or at least offered and up to date. If residents are not immunized there is an increased risk of them becoming ill, an increased for spreading disease, and making them more susceptible to complications of infectious diseases. The residents live in a high risk environment and being immunized decreases their likelihood of getting flu & pneumonia. The resident immunization review in the infection control task revealed the facility had no influenza or pneumonia history, data, or evidence of offering the vaccines to R21, R79, or R81. The facility's 1/23/20 Immunization of Residents Policy showed the facility will offer immunizations and vaccinations that aid in the prevention of infectious diseases. The facility will explain to the resident, resident's guardian or the resident's Durable Power of Attorney for Health Care at the time of admission, the importance of vaccination against common illnesses such as pneumonia and influenza. Verify the date of the last vaccination. Obtain proof of Pneumococcal and Influenza vaccination for residents when able. Assess all newly admitted residents' pneumococcal and influenza vaccination status upon admission and record last known immunization on the resident's immunization record. Offer the PCV13 or PPSV23 (pneumonia vaccines) as indicated utilizing the Pneumococcal vaccination algorithm unless contraindicated. Offer the pneumococcal vaccination within 30 days of admission. The Centers for Disease Control (CDC) and Prevention algorithm showed to administer pneumococcal vaccination to adults age [AGE] and older if no immunocompromising condition present. Adults age [AGE]-64 with specified immunocompromising conditions (including renal failure) were include in another algorithm recommending vaccination. 1. R21's face sheet showed a [AGE] year-old female admitted to the facility on [DATE]. Diagnosis included sepsis, hypertension, malignant neoplasm of exocervix, and obstructive uropathy. R21's physician orders showed a order for influenza and pneumococcal immunization. R21's medical record had no influenza or pneumococcal immunization data. The facility's immunization report had no information on R21's immunization status for flu or pneumonia. 2. R79's face sheet showed a [AGE] year old female admitted to the facility on [DATE]. Diagnosis included Alzheimer's disease, major depressive disorder, anxiety disorder, and hypertension. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145727 If continuation sheet Page 18 of 19 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 05/04/2023 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 R79's physician order sheet showed an order for influenza and pneumococcal immunization. Level of Harm - Minimal harm or potential for actual harm R79's medical record had no influenza or pneumococcal immunization data. The facility's immunization report had no information on R79's immunization status for flu or pneumonia. Residents Affected - Few 3. R81's face sheet showed a [AGE] year old male admitted to the facility on [DATE]. Diagnosis included end stage renal disease, depression, hypertension, Type 2 diabetes, repeated falls and benign prostatic hyperplasia. R81's physician order sheet showed an order for influenza and pneumococcal immunization. R81's medical record had an immunization record. The influenza and pneumococcal information was blank. The facility's immunization report had no information on R81's immunization status for flu or pneumonia. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145727 If continuation sheet Page 19 of 19