Health inspection·August 1, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few not.R2's Verification of Incident Report date of incident 7/11/2025 at 9:00 AM, Resident rolled out of bed at 9 AM. Resident sent to ER (emergency room) there. ER was called for a status updated and was made aware of fractures. Immediate Action: Nurse Practitioner in building and assessed. Extra dose of Norco provided for pain management. Bolsters added to resident mattress. POA (Power of Attorney), IDPH and Ombudsman notified. Summary of investigation: Resident had a fall after rolling out of bed. Resident was seen by the wound nurse and wound NP prior to rolling out of bed. Resident was ready to get up for the day, wound nurse notified CNA (Certified Nurse's Assistant) that resident was ready to get up. When aide entered room, resident was observed on the floor. CNA notified nurse who immediately assessed. No altered skin integrity noted. Does complaint of pain to right elbow and right ankle. Resident was able to move all extremities himself with no issues, rotated ankles and moved his arms and bending them at the elbows, resident denies hitting his head. Wife was present in the room at the time of the incident and states he did not hit his head. Resident was assisted up off the floor with (mechanical lift). Placed in bed, aid got him ready for dialysis then assisted to wheelchair via (mechanical lift). Primary care NP (Nurse Practitioner) was making rounds, who also assessed resident. NP ordered an extra dose of Norco to be given and ordered for one to be sent with resident to dialysis. Resident lays on a low loss mattress, and when he rolled over, the air in the mattress went to the opposite side, causing him to roll out of bed. Bolsters were placed on air mattress for boundary awareness and as a safety intervention. CP (Care Plan) updated. Transportation driver reported that the resident had no complaints on the ride to dialysis. Once at the dialysis, resident complained of pain to BLE (bilateral lower extremities), dialysis then sent resident to the ED (emergency department). Nurse called the ED for status update, and they confirmed resident did have a fracture of the left and right distal tibia as well as the 2nd metatarsal. Resident was admitted to the (hospital) for further evaluation.R2's Hospital Records dated 7/11/2025 R2 had a mechanical fall and suffered from an acute left distal tibial diaphysis fracture; Acute left distal fibular fracture; Acute fracture of the distal right tibial diaphysis and acute fracture of the neck of the 2nd metatarsal of the right foot and was admitted to the ortho bed and neurology was consulted for management. R2's Progress Notes dated 7/25/2025 at 7:04 PM, Note Text: Resident returned from Hospital. Resident asked to lay dawn. Resident was (mechanical lift) into bed with assist of 2. Resident became very agitated and yelled hey watch my legs! Don't move them! Resident is in the sling appropriately, staff guided him into bed. Was provided by reassurance in a calming voice by nurse in room and let resident know that he is safe and ok. Resident hollered no it's not ok!On 7/29/2025 at 4:00 PM, R2 stated, I use to be at another facility and at that facility I developed wounds on my back and buttocks. When I got here, two staff members, I am not sure of their names came into my room to change my dressings. They had me roll to the side and slide down so they can get to the wounds better. They pulled me towards the end of the bed and had me roll to my left side. After the nurse was done, she left the room. The other staff (not sure of her name) she was changing the linen because of the drainage from the wound, and I was still laying on my left side and the bed was high up in the air because they just finished doing the treatment. The girl changing the sheets said she needed a draw sheet because it was dirty from the wound draining on it. She said she would be right back. I was holding on to the bar and was on my left side waiting. The staff left the room, but I waited as long as I could, and I just could not hold on any longer and when I let go, I fell from the bed being up high in the air to the floor. I just couldn't hold on any longer. I think the staff forgot about me. They came back and put me on one of those (mechanical lifts) and put me back into the bed. I was in a lot of pain. My wife shared a room with me, and she saw the whole thing too. I was in the hospital for two (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145783 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 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 - Actual harm Residents Affected - Few weeks and had 2 breaks in the right leg and one break in the left leg. Both of my legs were broken. I get dialysis on Mondays, Wednesday and Friday. I feel like they should not have left me like that and should have sent me to the hospital right away. They gave me some pain medicine but when I got to dialysis it was so bad they sent me out to the hospital and that is when I found out I had broken both of my legs. On 7/29/2025 at 4:12 PM, R4, wife and roommate of R2, stated I was in the room at the time they were treating (R2), and he fell out of bed. The nurse left the room as soon as (R2's) treatment was done. They were changing (R2's dressing). When the nurse was done, she left the room. The other girl was changing the sheets. (R2) was on his side and was holding on to the bar. The girl left the room, and she said she would be right back but (R2) waited and waited and he could not hold on any longer and the bed was up really high, and he fell and broke both of his legs with one leg have two fractures. After he fell, they came in and used that machine to put him back into bed and then later the Nurse Practitioner came and looked at him and gave him pain medication.On 7/30/2025 at 10:42 AM, V8, Hospital Social Service Worker stated, (R2) was admitted to the hospital on [DATE] and he had an extended admission and was not discharged until 7/25/2025. So, he was here for a while. I was the consultant towards the end of this visit and (V9, Palliative Care Social Worker) was with him when he was first admitted . (R2) told me he had a pressure ulcer on his back and buttocks and was receiving care from the wound Nurse and they had his bed high in the air. (R2) stated he was rolled to his side, and he grabs onto the side rails. The lower rail was missing on the bed. The Nurse member left the room because she was done with the treatment. The agency staff told him she would be right back because she was changing the sheets and needed a drawsheet and left the room with him on his side, no lower bed rail and she did not reposition him. He said he waited and waited but she did not come back, and he could no longer hold on and he fell from the bed in the high position to the floor.On 7/30/2025 at 11:01 AM, V9, Hospital Palliative Social Worker stated, When I first saw (R2) at the hospital he told me they were doing a dressing change on him, and he had rolled to his side and was holding on to the side rail. The bed was in the high position because of the treatment. The bottom side rail was missing on the bed. He said the nurse had finished the wound treatment and the agency CNA was cleaning up the sheets and she did not put him back on his back, and she told him she would be right back and left the room because she wanted to get a drawsheet. His wife was in the room with him. The CNA did not come back and (R2) said he became weak and could not hold on any longer and he fell off the bed between the bed and wall. Staff then came in and checked on him and even the NP came in to see him. They asked him if he was hurt and put him in a (mechanical Lift) and transferred him to his wheelchair, gave him some pain medicine and eagerly rushed him off to dialysis. (R2) said he was in shock and when he got to dialysis the nurse there said his color was off and asked if he was feeling okay and he said he was in a lot of pain and had fallen and they sent him to the hospital where he was admitted . (R2) had two broken legs, 2 breaks in the left leg, and one break in the left leg.On 7/30/2025 at 11:48 AM, V2, Director of Nursing stated, (V7, Registered Nurse, RN) was the person responsible for (R2's) fall report. She wrote it up and investigated. I know we asked (R4, wife and roommate) if (R2) had hit his head and she said no. I was not present at the time of the fall. I know the Nurse Practitioner (V18) was here and she went and put eyes on (R2) so we could do an intervention, and we put boosters on his bed. That is all I know you will have to talk to (V7). If staff are doing treatment and put the bed up, I would expect staff to put the bed down after the treatment is finished. I would expect staff to never leave any resident unattended or left laying on their side. I would expect staff to reposition the resident, so they are safe, go and get what they needed and then return. I would not expect staff to leave a resident with the bed up, laying (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145783 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 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 - Actual harm Residents Affected - Few on their side. This is the first I am learning of it.On 7/30/2025 at 11:47 AM, Dialysis center called back and read V10's, Dialysis Center's Registered Nurse, RN, notes from that day. The notes document, Patient arrived to dialysis with complaints for pain to BLLE (bilateral lower extremities). Patient stated he fell out of bed prior to coming to the facility and the bed was elevated. Pain too high to do treatment. EMS (emergency medical services) called to transport. 911 was called. On 7/30/2025 at 2:13 PM, V10, Dialysis RN stated, We got a call from the (Facility) telling us (R2) had fall and that he was still going to make his appointment. When (R2) arrived, he was grimacing, and I could tell he was in a lot of pain, so I called 911 just to be safe.On 7/30/2025 at 12:56 PM V7, Registered Nurse, RN/Floor Nurse stated I am the one that made the incident report for (R2's) fall. I did ask (R2) and (R4) because they share a room if (R2) hit his head and they said no. I did not get any statements from them. It's all in the report. I remember the CNA came and got me and told me (R2) was on the floor and she said he had rolled out of bed. I went and assessed him, and he said he was having pain in his arm and ankle. I got another CNA, and he said he could move his ankles. We used the (mechanical lift) and put him back into his wheelchair. I asked him if he was hurting anywhere else and he said he was alright. He then said he didn't feel like going to dialysis and I told him it was important not to miss any days. We then sent him out to dialysis, and I found later he had injured himself. Nobody ever told me anything else. I didn't get any written statements from anybody. I just thought he fell out of bed.On 7/30/2025 at 1:26 PM, V4, Agency Certified Nurse's Aide, CNA, stated, We were passing out breakfast trays. The Wound nurse was in (R2's) room providing treatment and then she walked out. I grabbed the breakfast tray and asked the Wound Nurse if they were done. I asked her if she could give (R2) his food. I looked in the room a little later and no staff was in the room. The resident was laying on his left side and the bed was not down and was high up and even then, I knew he was a fall risk. The Wound Nurse was not in the room, and he was in up high, and I went to try and find the Wound Nurse and she was on her phone on the other hall. Then I heard a loud help, help and help. I saw the wound nurse and asked why she would leave the bed all the way up and he fell, and he was yelling. The Wound nurse left the bed all the way up, and the other nurse and I said why would she do that. The Wound Nurse was the last one in the room. Why did she tell him to hold on to the bed? The Wound Nurse was the last person in that room. Me and the other CNA found him on the floor.On 7/30/2025 at 2:14 PM, V16, CNA stated, I was working the day (R2) fell. (R2) had just had his wounds done. The Wound Doctor and the ADON (Assistant Director of Nursing) were doing the treatments. His bed was up high, and he was on his side. His wife was in the room too. Me and (V4) found (R2) after he had fallen. The bed was still up high. (V7, Registered Nurse/Floor Nurse) came and assessed him and looked him over. We were told to use the (mechanical lift) and put him in his wheelchair. He said he was in a lot of pain. (R2) did not want to go to dialysis. The Nurse Practitioner told him how important dialysis was for him and send him some pain medicine to take with him because he said he didn't want to go and was hurting. She said he might have some bruising and would be sort and she sent him some pain medication. On 7/31/2025 at 9:50 AM, R2 was wearing plastic splints/boots with Velcro on the side that goes up to the knee on both legs.On 7/31/2025 at 3:32 PM, V6, Medical Director stated, I would expect staff to always lower residents' bed after raising the bed. I am not sure how (R2) landed but I know he did have some broken bones. No fall is ever good for any resident. The bed should always be lowered. On 7/31/2025 at 3:11 PM, R2's bed was placed in the high position with V17, Maintenance Director and the V3, Assistant Director of Nursing, ADON. The bed was measured from the high position to the floor and measured 36 inches. R2's bed has a low air mattress on it.On 7/31/2025 at 3:12 PM, R2 was asked if the (V3) was the staff that left him alone in the room (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145783 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 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 - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete with his bed high and said she would return and he replied no, he thinks it was the agency CNA (certified nursing assistant). He was not sure, but it was not (V3). On 7/31/2025 at 3:13 PM, V3, stated, (V4) was the person in the room with us when we were doing treatment. This is the first I am learning the bed was high and (R2) was left lying on his side waiting for staff to return and he was not able to hold and a fell. I would expect staff to always put the bed down. (R2) has a remote so he can move his bed up and down. I did not realize staff left (R2) unattended and left the room.On 7/31/2025 at 4:12 PM, R2 stated that he fell from this bed with the same mattress, but after his fall the (Facility) added the bolsters.The Fall Policy with a revision date of 9/7/2023 documents, To provide staff with guidelines for investigating reporting and recording, Accidents and Incidents. All accidents/incidents involving a resident shall require an incident report. The interdisciplinary team (IDT) will complete an investigation to determine root cause and implement appropriate interventions. The MDS nurse shall update the Care Plan with implemented interventions and communicate interventions with line staff. Event ID: Facility ID: 145783 If continuation sheet Page 5 of 5