Health inspection·June 28, 2023

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R73's admission Record, print date of 6/26/23, documents that R73 was admitted on [DATE] and has diagnoses of Alzheimer's Disease, Anxiety and Dementia. R73's MDS, dated [DATE], documents that R73 is severely cognitively impaired. R73's Physical Restraint Assessment, dated 6/9/23, fails to document that R69 has a (lap cushion) and the risk versus benefits of the use of a (lap cushion). This Physical Restraint Assessment documents, C. Is this device a restraint? No. If no, explain why: She id able to remove (lap cushion) several times a day when asked. It continues, D. Informed Consent Obtained with risks and benefits explained to RP (representative). On 6/26/23 at 11:30 AM, V3, Director of Nurses (DON), stated, R73 and R69 both could take off the (lap cushion) when she assessed them. (V22) should have came to me and told me. I did not know that the Physical Restraint Assessment that we fill out on the residents for the (lap cushion) needed to have the risk and benefits written. We just explain the device to the families and explain how it will help them. I really don't see any risks for the use of a (lap cushion). We use it because both of them are confused, impulsive and it makes them feel secure to have something around their waist lap area. The Physical Restraint Policy, dated 9/15/2019, documents, Procedure: 1. Physical restraint shall be used by this facility only when it is has been determined by the Interdisiplinary Care Plan Team that they are required to treat a resident's medical symptoms or as a therapeutic Care Plan Team that they are required to treat a resident's medical symptoms or as a therapeutic intervention, as ordered by a physician, and based on an overall assessment, physical restraint assessment, and the care planning process has been completed. 2. The facility shall only apply a physical restraint after obtaining the informed consent of the resident, the resident's guardian, or other authorized representative. Informed consent shall include documented information about the potential negative outcomes of the specific devices / methods use. Consents will be reviewed and renewed annually per state regulation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145783 If continuation sheet Page 2 of 11 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 145783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunrise Skilled Nur & Rehab 333 South Wrightsman Street Virden, IL 62690 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 interview, observation and record review, the facility failed to provide dining assistance and assistance with hygiene for 6 of 18 residents (R5, R8, R45, R46, R59, R64) reviewed for assistance with a activities of daily living (ADLs) in the sample of 45. Residents Affected - Some Findings include: 1. On 06/20/23 at 12:26 PM, R64 was in the dining room eating lunch. R64 got up from the table and started to walk out. V15, Certified Nurse Assistant (CNA), assisted R64 while R64 walked to her room by walking arm in arm with her. V15 asked if she needed to use the restroom, R64 stated, Yes. They both entered the room, R64 went into the bathroom. V15 did not follow R64 but closed the door leaving a small opening in the door for observation outside of the bathroom. V15 stated, She is going to the bathroom. R64 was heard using the toilet and flushing the toilet. V15 asked if R64 was finished, R64 did not say anything. V15 opened the door all the way and stated, Ok, lets go back and finish lunch. V15 entered the bathroom and got R64's arm and walked her out of the bathroom into the dining room so R64 could finish her lunch. V15 failed to remind R64 to wash her hands after using the restroom. On 06/27/23 at 10:32 AM, V3, Assistant Director of Nurses (ADON), stated, Staff should always help and remind residents to wash their hands after using the toilet. R64's admission Record, print date of 6/26/23, documents that R64 was admitted on [DATE] with diagnoses of Alzheimer's Disease and Dementia. R64's Minimum Data Set (MDS), dated [DATE], documents that R64 is severely cognitively impaired and requires extensive assistance of 1 staff member for hygiene. 2. R45's Care plan, dated 4/28/22, documents that R45 has a Self-Care Deficit As Evidenced by: Needs extensive assistance with ADLs Related to weakness, fracture, limited mobility. It continues Eating - Setup help only / Cueing required. R45's MDS, dated [DATE], documents R45 requires supervision and set up assistance for eating. On 6/20/23 at 12:48 PM, R45 sitting in recliner with meal setting on overbed table in front of resident. R45's lunch meal was setting in front of R45. R45 picked up chicken cutlet and attempted to bite it without success. R45 then set the chicken on the plate and attempted to cut the chicken with her fork. This attempt was unsuccessful. R45 again pick up chicken with the fork and attempted to bite the chicken and again was unsuccessful. R45's white plastic fork was lying on the white napkin and per R45 she could not find the knife. R45 then grabbed a hold of the plastic knife and attempted to cut the chicken without success. R45 then placed chicken on the plate and did not eat it. On 6/20/23 at 12:55 PM, R45 stated that she would have liked to eat the chicken but it was tough. R45 stated that she was not able to cut the chicken with the plastic fork or bite into the chicken. R45 stated that she could use some help but no one is here but her. On 6/27/23 at 11:00 AM, V3, Assistant Director of Nursing (ADON), stated that R45 is alert and will talk with you. V3 stated that you have to initiate it. V3 stated that she is not sure why R45 had a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145783 If continuation sheet Page 3 of 11 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 145783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunrise Skilled Nur & Rehab 333 South Wrightsman Street Virden, IL 62690 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some plastic knife. V3 stated that R45 does not have any behaviors that would cause her to need a plastic knife. V3 stated that R45 should have had a regular knife. V3 stated that she expects staff to assist the residents as they need it. On 6/27/2023 at 11:54 AM, V4, Dietary Manager, stated that he is not sure why R45 had a plastic fork. V4 stated that they have knives. V4 stated that the residents should have gotten a regular knife. 3. R5's MDS, dated [DATE], documents that R45 is cognitively intact and requires supervision and set up assistance with meal. On 6/21/2023 at 1:12 PM, during Resident Council, R5 stated that she eats in the dining room. R5 stated that the staff leave the dining room and there is no one there to ask for help. R5 stated that she needs help with cutting her meat at times and that sometimes there is no one there to ask for help. R5 stated that during those times, she just doesn't eat it. R5 stated that she would eat more if she had help. R5 stated that when they bring you the food, they ask if you need help. R5 stated that after that they are gone. R5 stated that if you find out that you do need help, no one is there. On 6/27/2023 at 11:00 AM, V3, ADON, verified that R5 needs help with her meal. The facility's Resident Council Minutes, dated 6/5/2023, documents, Once dining room is served dietary staff leave and they don't come back till its time to clean up. Don't ask if anyone needs refills or a sub. 4. On 6/21/2023 at 1:08 PM, during Resident Council, R46 stated that she eats in the dining room. R46 stated that the staff leave the dining room and there is no one there to ask for help. R46's Minimum Data Set (MDS), dated [DATE], documents that R46 is moderately impaired with no short term or long term memory impairment. 5. On 6/21/2023 at 1:10 PM, during Resident Council, R59 stated that she eats in the dining room. R59 stated that the staff leave the dining room during the meal and there is no one to ask for help. R59 stated that she doesn't need much but there are others that do. R59's MDS, dated [DATE], documents that R59 is cognitively intact with no short term or long term memory impairment. 6. On 6/21/2023 at 1:18 PM, during Resident Council, R8 stated that she eats in the dining room. R8 stated that there are multiple people that require assistance. R8 stated that R5 needs help with cutting meat and that there is no one there. R8 stated that its not just the dietary staff it's the nursing staff as well. R5 stated that they should have a monitor in the dining room. R5 stated that you don't know that you need help until you need help. R8's MDS, dated [DATE], documents that R8 is cognitively intact. The facility's ADL Support policy, dated 5/2/23, document Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145783 If continuation sheet Page 4 of 11 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 145783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunrise Skilled Nur & Rehab 333 South Wrightsman Street Virden, IL 62690 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 hygiene. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145783 If continuation sheet Page 5 of 11 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 145783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunrise Skilled Nur & Rehab 333 South Wrightsman Street Virden, IL 62690 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 ensure safe transfers for 2 of 7 residents (R59, R31) reviewed for falls in the sample 45. Findings include: 1. 06/22/23 at 8:24 AM, V7, Certified Nurse Aide (CNA), transferred R59 from her bed to her wheelchair with hands on assist. R59's Care Plan, initiated date of 6/4/21, documented R59 requires two staff with physical assistance during transfers, toileting and bathing, also, R59 has a history of falls due to weakness , limited mobility and pain. R59's Minimum Data Set (MDS), dated [DATE], documented R59 has mild impaired memory cognition. R59's Fall Risk assessment dated [DATE], documented balance problems while standing and as high risk for falls. On 6/20/23 at 9:30 AM, R59 stated she requires assistance for transferring and only one nursing staff assist and they do not put a belt around her, they just hold her arm and transfer where she needs to go. On 6/20/23 at 11:15AM, V12, CNA, stated R59 is transferred with one assist, no gait belt. On 6/22/23 at 10:32 AM, V14, Occupational Therapy, states, (R59) should be transferred with a gait belt, especially due to her body size and if she was to lose balance and go down on to the floor. 2. R31's Care Plan, dated 5/14/19, documents that R31 has Self-Care Deficit As Evidenced by: Needs extensive assistance with ADLs (activities of daily living) Related to history of L3 spinal fracture, weakness, occasional pain It continues Transfer: One person physical assistance required R31's MDS, dated [DATE], documents that R31 requires extensive assist of 1 staff for transfer. On 6/20/23 at 12:48 PM, V5, CNA, assisted R31 to the toilet, in the bathroom inside her room. V5 grabbed R31 under her left arm and pulled R31 into a standing position. R31 balance unstable, waving back and forth when attempting to stand. V5 grabbed R31 around the waist and pulled down R31's clothing and assisted R31 to sit on the toilet. At 12:57 PM, V5 grabbed R31 under the arm and assisted R31 into a standing position and assisted with cleaning R31. V5 pulled up R31's clothing and assisted R31 into her wheelchair. V5 did not apply gait belt prior to transfer and did not use during transfer. R31's gait belt was hanging on the back of the door in her room. On 6/22/2023 at 3:20 PM, V3, Assistant Director of Nurses (ADON), stated that when a staff manually transfers she expects them to use a gait belt. The facility's Gait Belt Policy, dated 10/1/22, documents It is the facilities responsibility to assure that the use of gait belts are used with all transfers and transports of a resident, to assure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145783 If continuation sheet Page 6 of 11 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 145783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunrise Skilled Nur & Rehab 333 South Wrightsman Street Virden, IL 62690 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 safety for the residents and staff. C.N.A.'s are expected to use the gait belt whenever ambulating or transferring a resident for safety of the resident and employee. Gait belts must be used when helping the resident move from the bed, chair, or commode/toilet. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145783 If continuation sheet Page 7 of 11 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 145783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunrise Skilled Nur & Rehab 333 South Wrightsman Street Virden, IL 62690 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to properly store medications, discard expired medication, and label tuberculin multi dose vial. This has the potential to effect all 78 residents living in the facility. Findings include: On [DATE] at 9:50 AM, the facility's North Wing Medication Storage Room was inspected. The medication room contained the following medication: 1. 1 open bottle of Gerikot 8.5 milligram (mg) with expiration date 4/23. 2. 1 bottle of Niacinamide 500mg with expiration date of 3/23. The refrigerator located in the North Wing Medication Storage Room was inspected. The refrigerator contained: 3. 2 Multidose Vials of Tubersol (TB) with no open date. On [DATE] at 1:57 PM, V5, Licensed Practical Nurse (LPN), stated that the tubersol was open and in use. V5 stated that the vial of Tubersol should have an open date. V5 stated that Tubersol has a different expiration date once the bottle is opened but unsure what that date is. V5 stated that placing the open date on the multidose vials tells them when the expiration date is. V5 stated that the Tubersol is not specific to one resident and is used for all the residents admitted to the facility. V5 stated that each resident is given a series of TB unless they have an allergy and that the Tubersol in the refrigerator is used for this process. V5 stated that the 1 open bottle of Gerikot 8.5mg was open and expired. V5 verified that the medication was open on [DATE]. V5 stated that the Gerikot was a stock medication and used for all residents in the facility. V5 stated that if the residents had an order and did not have an allergy, the gerikot would be used. V5 stated that the bottle of Niacinamide 500mg was expired. V5 stated that this medication must have been brought in by a family because he did not recognize the brand. V5 stated that the expired medication should be destroyed. On [DATE] at 3:15 PM, V3, Assistant Director of Nursing (ADON), stated that the TB has a different expiration date when opened. V3 stated that she expects her staff to label the multidose vials when opened with an open date. V3 stated that the expired medication should be destroyed and not kept in the medication storage room. V3 stated that the stock medication and the multi dose vial of TB are used for all residents as long as they have an order and don't have an allergy. The facility's Storage of Medication policy, dated [DATE], documents that the facility stores all drugs and biologicals in a safe, secure, and orderly manner. 4. Discontinued, outdated, or deteriorated drugs or biologicals are returned tot he dispensing pharmacy or destroyed. The Resident Census and Condition of Residents form (CMS 672), dated [DATE], documents that the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145783 If continuation sheet Page 8 of 11 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 145783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunrise Skilled Nur & Rehab 333 South Wrightsman Street Virden, IL 62690 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 0761 facility has 78 residents living in the facility. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145783 If continuation sheet Page 9 of 11 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 145783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunrise Skilled Nur & Rehab 333 South Wrightsman Street Virden, IL 62690 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview, observation and record review, the facility failed to perform hand hygiene before donning gloves, in between glove changes and after removing gloves for 3 of 14 residents (R17, R21, R69) in the sample of 45. Residents Affected - Few Finding include: 1. On 6/20/23 at 11:23 AM, V19, Certified Nurse Aide (CNA), and V22, CNA, assisted R69 out of her wheelchair and walked her from the dining room to her bathroom to use the restroom. Once in the bathroom, R69's pants, hip protectors and incontinent brief were pulled down. R69 was assisted onto the toilet. R69's incontinent brief was soiled with urine. V19 used washed cloths to cleanse the perineal and rectal area. When V19 would finish wiping, she would place the soiled cloths onto the back of the toilet seat. Once the care was finished, the soiled cloths were left on the back of the toilet seat. V19 and V22 walked R69 out of her room to the dining room. At the beginning of incontinent care, V19 and V22 donned gloves without hand hygiene, during care V19 changed gloves 3 times without hand hygiene between. V22 changed gloves 2 times without hand hygiene in between. At the end of care, V19 removed her gloves without hand hygiene and assisted R69 to the dining room. On 6/27/23 at 10:28 AM, V3, Assistant Director of Nurses (ADON), stated, Staff should always wash their hands before donning gloves, in between glove changes and after they remove the gloves. V3 further stated that soiled linens should not be left on the toilet seat. 2. On 6/21/23 at 3:10 PM, V2, Director of Nurses (DON), entered R17's room, sanitized both hands, applied clean gloves, removed old wound dressing of clear tape, then removed dirty gloves, applied clean gloves, without benefit of hand hygiene. V2 then opened a clean package of the drainage dressing/tubing and then removed her dirty gloves, went to resident's door opened to request a waste receptacle bag, from a nearby nursing staff. She then returned to the resident's bed, applied clean gloves, without benefit of hand hygiene, opened a clean wound equipment packet, cut pieces of clear tape that was applied around the parameter of the wound of R17's left heel. V2 then measured R17's heel wound using the same gloves. V2 then removed dirty gloves, applied clean new gloves, without benefit of hand hygiene, cut pieces of the vacuum black foam which was applied to the heel wound that was open to air at this time, and being applied to the heel wound with the foam and covered with clear tape. V2 then removed her dirty gloves and applied clean gloves, without benefit of hand hygiene, with the same gloves, R17's left foot was secured with a clean new vacuum tubing that was connected to the wound vacuum pump machine. 3. On 06/22/2023 at 3:40 PM, V2, DON, performed hand hygiene, donned gown and gloves and entered R21's room with wash cloths and dressing supplies. R21's door had a sign on it documenting enhanced barrier precautions. V2 wetted the wash cloths, cleaned R21's floor that had feces on it, removed gloves, donned new gloves, exited room and returned with more gloves. At 4:00 PM V2, with a soap and wetted wash cloth, cleansed the bowel movement off the side of R21's left foot, removed gloves and donned another pair of gloves without benefit of hand hygiene. V2 took bottle of wound cleanser, sprayed left outer ankle pressure ulcer, and patted it dry. V2 removed her gloves, took santyl ointment out of the bag it was stored in and without performing hand hygiene, donned a pair of clean gloves. V2 then opened the package of calcium alginate, took scissors out of her pocket, and cut a piece to fit the R21's wound bed. V2 then applied the santyl ointment to the calcium alginate dressing, replaced the cap to the santyl ointment and then applied, with the same gloved hands, the dressing to R21's left outer ankle pressure ulcer. V2 then, doffed gloves, removed the border dressing out of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145783 If continuation sheet Page 10 of 11 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 145783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunrise Skilled Nur & Rehab 333 South Wrightsman Street Virden, IL 62690 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete package, initialed and dated it, donned gloves without benefit of hand hygiene and then placed it on R21's left outer ankle pressure ulcer. V2 removed her gloves and gown and exited R21's room. The facility's policy, Handwashing/Hand Hygiene, undated, documented,7. Use an alcohol-based hand rub containing at least 62% alcohol: or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: It continues, D. Before performing any non-surgical invasive procedures. It continues, G. Before handling clean or soiled dressings, gauze pads, ect. H. Before moving from a contaminated body site to a clean body site during resident care; I. After contact with blood or bodily fluids; J. After handling used dressing, contaminated equipment, ect; K. After contact with object (e.g., medical equipment) in the immediate vicinity of the resident; L. After removing gloves. It continues, 8. Hand Hygiene is the final step after removing and disposing of personal protective equipment. Event ID: Facility ID: 145783 If continuation sheet Page 11 of 11