Inspection·February 11, 2026

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R38's Physician Order, dated 1/27/26, documents Lower extremities elevated on pillows above heart level to reduce edema/drainage as resident will allow. One time a day for preventative and as needed for preventive. R38's Physician Order, dated 2/2/26, documents Santyl External Ointment 250 Unit/GM (gram). Apply to RLL (right lower extremity)/foot slough topically every dayshift for wounds. R38's Physician Order, dated 2/5/26, documents Cleanse R (right) foot with wound cleanser and normal saline. Pat dry. Weak Betadine-soaked gauze between toes daily and PRN (as needed). R38's Wound Healing Center Physician Orders, dated 2/2/26, documents Cleanse wound(s) with Normal Saline, Soap and Water, Wash with soap and water with dressing changes. Right lower leg/foot: Santyl to slough areas, dry and rolled gauze/ace wrap. Right foot (toes 1-5): Betadine to toes, weave gauze between toes. Left dorsal foot: Xeroform, dry and rolled gauze/ace wrap. Apply ace wraps to knees. R38's Medication Administration Record (MAR)-Treatment Administration Record (TAR), dated February 2026, documents Santyl External Ointment 250 UNIT/GM (Collagenase), Apply to RLL/foot slough topically every dayshift for wounds and is documented as completed on 2/3/26, 2/4/26, and 2/5/26. On 2/5/26 at 1:40 PM, V2, Director of Nursing (DON), was observed providing wound care to R38. V2 stated the wound nurse is off today and she is doing wound assessments today, so she will be the one doing wound care on R38. All supplies are already on bedside table with old bilateral leg dressings off. V2 used NS and 4X4 gauze to wipe R38's left foot, then wiped R38's left toes. V2 put Xeroform over the open area on top of R38's left foot, then covered the foot with 4X4 gauze and wrapped with rolled gauze from toes up the leg to the knee. V2 then wrapped R38's leg with ace wrap. R38's right leg from just above his ankle to his toes were oozing serosanguinous fluid and blood, appearance as very swollen, reddened, with white patches and open sores throughout the lower leg and foot. V2 used NS and 4X4 gauze to wipe R38's right toes, foot, and ankle areas. V2 then wiped Betadine between R38's right toes and top of his foot. V2 then got Xeroform and applied to the top of R38's foot. R38 stated I had an appointment two days ago and they are not using that stuff (Xeroform) anymore. They changed it to Santyl. R38 showed V2 the orders from the wound physician which documents to use Santyl to right lower leg/foot. V2 stated Well, I will have to correct the orders then. and continued to apply the Xeroform. V2 left the Xeroform on the foot and applied an absorbent sponge dressing to R38's foot, then wrapped with rolled gauze and ace wrap from toes up to just below the knee. When asked what the nurses have been doing the past couple of days, R38 stated They used the Santyl like the order said. They even took the yellow copy of the orders when I got back from the appointment, so I know they have the orders. On 2/5/26 at 2:15 PM, after finishing R38's wound care, V2 stated You know I looked at the orders before I went in there and there was no Santyl order. I see the new orders, and I guess the nurse never put the new order in after his appointment. On 2/5/26 at 2:25 PM, V2 returned and stated, I looked and the Santyl order was already in there from 2/2/26, but they did not discontinue the original order for Xeroform. The facility's Skin Condition Assessment & Monitoring-Pressure and Non-Pressure, dated 12/2025, documents in part To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other non-pressure skin conditions and assuring interventions are implemented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146026 If continuation sheet Page 2 of 6 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 146026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at Sangamon Valley 3400 West Washington Springfield, IL 62711 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide sufficient staffing to provide safe and timely care for residents reviewed for sufficient staffing in the sample of 32. This failure has the potential to affect all 126 residents living in the facility.Findings include: On 2/9/26 at 2:00 PM, V2, Director of Nursing (DON), stated their normal staffing pattern is the following: Day and Evening Shifts have 6 Nurses total: 1 on 100-hall, 1 on 200-hall, 1 on 300-400 halls, 1 on Grace North, 1 on Grace South, and one split/floater. V2 stated there are 12 Certified Nursing Assistants (CNAs) total: 2 on 100-hall, 2 on 200-hall, 3 split the 300 and 400-halls, and 5 on Grace Points. V2 stated the Night Shift has 4 Nurses total: 1 on 100-hall, 1 on 200-hall, 1 on 300-400 halls, and 1 that splits the Grace Point units. V2 stated the Night shift CNAs have 8 total - 3 on 100-200 halls, 2 on 300-400 halls, and 3 on Grace Point units. V2 stated they use agency as needed but first they try to get regular staff in, then the charge nurse covers, then the on-call manager covers, and finally the scheduler covers for call-ins.On 2/2/26 at 9:40 AM, R38 stated he is incontinent at times, uses his call light and it depends on who is working because some will answer it timely, while others take a while, especially if not enough people working. R38 stated some days there is enough staff and some days not, and the nights and/or weekends are usually short. R38 stated it's too easy for them to call off. R38's Minimum Data Set (MDS), dated [DATE], documents R38 is cognitively intact.On 2/2/26 at 10:26 AM, R154 stated there is not enough staff. R154 stated he does not know what was going on past weekend as he had asked for a stool softener in the morning and did not get one until that evening. Stated the CNA would report have to find a nurse. R154's MDS, dated [DATE], documents R154 is cognitively intact. On 2/2/26 at 11:00 AM, R1 seen sitting in wheelchair with full body mechanical lift device sling under her. R1 stated the staff use that to transfer her, sometimes only with one person because they don't have enough people. R1's MDS, dated [DATE], documents R1 is cognitively intact.On 2/2/26 at 11:01 AM, R42 stated his oxygen wasn't working and V7, CNA, stated she would let his nurse know then left. V8, LPN, came to the room a minute later and stated she would have to switch R42's oxygen from the tank to the concentrator because the tank was empty. V8 stated R45 wasn't getting ready to leave anywhere when he had been brought back a while ago to his room, but she wasn't notified his oxygen was low. V8 stated it's not an excuse but the CNAs have 16 residents each and she has 32 and that's why stuff like this happens.On 2/2/26 at 11:46 AM, After both CNAs and the Nurse was in R130's room for approximately 30 to 45 minutes, other residents were waiting to be taken to the dining room for lunch, one call light was seen on and unknown how long it has been on. Both CNAs began taking residents to the dining room while lunch had already begun. R130's MDS, dated [DATE], documents R130 has a severe cognitive impairment.On 2/2/26 at 12:00 PM, V14, CNA, state Today, and usually every day, the 300-hall has one CNA and one nurse, the 400-hall has two CNAs, and they share the nurse. It always seems like we are short staffed. We have most of our residents that require assistance with transfers, a lot of (full body mechanical lift device) transfers that take two people, and we have residents with behaviors and need closely watched. It's hard to be everywhere, watch everyone, and help everyone with just two of us.On 2/5/26 at 8:55 AM, V12, CNA, stated The staffing is terrible here, we are really short of staff. It has always been like this but since the new owners took over, they have been cutting things thin. Today we only have two of us on 400-hall and 1 on the 300-hall. It makes it hard to get things done when most of the residents need assistance with transfers. The call lights take longer to answer because we are busy with the residents.On 2/5/26 at 10:55 AM, R1 sitting in wheelchair next to her bed with soft touch call light on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146026 If continuation sheet Page 3 of 6 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 146026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at Sangamon Valley 3400 West Washington Springfield, IL 62711 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many bedside table and within reach. R1 stated she put her call light on, and it was answered once by someone who told her they would let her aide know. R1 stated that was 20 minutes ago and no one has come back in. R1 stated she needs to have a bowel movement (BM) and needs someone to put her on a bedpan. R1 put her call light back on and waited. No staff was seen in the hallway or at the desk. V14 answered the call light at 10:59 AM, shut the light off and told resident she must wait for V12 to get back from break. R1's MDS, dated [DATE], documents R1 is cognitively intact.On 2/5/26 at 11:02 AM, V12 was seen returning from break and assisted another resident to the restroom.On 2/5/26 at 11:07 AM, R1 stated I don't get upset with the staff because they are busy and trying the best they can. When I can't hold it any longer and have an accident, it is embarrassing and that upsets me because I don't like doing that.On 2/5/26 at 11:10 AM, Both V12 and V14 stated This is what we are talking about, it takes two of us to help these residents when a lot of them are (full body mechanical lift device) transfers. There is not enough staff here to take care of these residents.On 2/5/26 at 11:13 AM, Both V12 and V14 was then seen assisting another resident from her bed to her wheelchair.On 2/5/26 at 11:15 AM, V14 left that resident's room and failed to tell V12 about R1 waiting for a bedpan. On 2/5/26 at 11:18 AM, When V12 was exiting that room, V12 was advised that R1 has been waiting for a bed pan. V12 had V14 assist her with R1.On 2/5/26 at 11:21 AM, V12 and V14 finally in with a full body mechanical lift device assisting R1 from her wheelchair to her bed. R1 was then lowered to the bed, sling removed and R1 was placed on a bedpan. It was approximately an hour since R1 initially put her light on. On 2/10/26 at 9:35 AM, V31, CNA Supervisor, stated I am given a set number of CNAs to have working each shift. If our census goes up, they may add one or two. I have had just about everyone complain that they need more staff to take care of the residents here, but I can't do anything about it until the census goes up and it gets approved, that's our guidelines I have to follow. When advised that when all staff are in one room assisting a resident, there is no one else around answering call lights, assisting the residents, or the case that was observed, no one to take the residents to the dining room when time to eat. V31 stated I saw that too.On 2/10/26 at 10:40 AM, V26, Mobile Director of Nursing (DON), stated The only nurses working here work the night shift and that is by choice. We are hiring RNs and trying to get some more in and even have referral bonuses for staff. I thought some of the managers were RNs and were in house covering, but now I see they are LPNs.On 2/10/26 at 10:45 AM, V33, CNA, stated We don't have enough people working here. Having two CNAs covering one hall is not enough. The residents call lights are delayed and I have seen residents saturated in urine because we can't get to them in time. There are a lot of residents that need two-person assists like today, my rooms I am covering there are five (full body mechanical lifts) that require two staff members. The other CNA working with me (V14) also has five (full body mechanical lifts) so we have to work together to get these ten residents up and down. That takes a lot of time away from other residents. We just can't get to everyone when they need us.On 2/10/26 at 10:50 AM, V16, LPN, stated The staffing is horrible here. There are not enough CNAs to take care of all the resident needs. When asked about RNs working, V16 stated There are mainly LPNs working, at least days and evenings. The LPNs basically run this building.The Facility's Resident Council Meeting minutes, dated 9/2/25, documents in part Dietary: being served on time, need more staff.The Facility's Resident Council Meeting minutes, dated 12/2/25, documents in part Residents would like to invite the new DON and ADON to the January meeting: re. Call Lights, shower schedules, medications. The Facility's Resident Council Meeting minutes, dated 1/6/26, documents in part Call lights times being long on 2-10 PM shift.On 2/10/26 at 1:12 PM, V1, Administrator, stated they do not have a staffing policy and that they follow Federal Guidelines.The Department of Health and Human Services, Centers for Medicare & (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146026 If continuation sheet Page 4 of 6 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 146026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at Sangamon Valley 3400 West Washington Springfield, IL 62711 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 0725 Medicaid Services, Long-Term Care Facility Application for Medicare and Medicaid, dated 2/2/26, documented that there were 126 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: 146026 If continuation sheet Page 5 of 6 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 146026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at Sangamon Valley 3400 West Washington Springfield, IL 62711 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 0908 Keep all essential equipment working safely. 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 maintain enough batteries for the mechanical lifts for 1 of 4 residents (R154) reviewed for essential equipment in the sample of 32. Findings include:On 2/2/2026 at 10:26AM R154 in bed with mechanical lift sling underneath him. R154 stated they are supposed to get me up. R154 stated Certified Nursing Assistant (CNA) came in and said the mechanical lift doesn't work so she is going to tell therapy. R154 stated I guess she is going to pass it off on therapy. On 2/2/2026 10:51 AM V3, and V4 CNA enter room with mechanical lift. R154 stated I have to be at dialysis at 11:00AM. V3 and V4, CNA transferred R154 from bed to wheelchair with mechanical lift.On 2/2/2026 at 10;34AM, V14, CNA stated V3, CNA is going upstairs to get a battery for the lift as the battery is dead. V4, CNA stated the mechanical lifts are not broke. V4 stated the facility does not have enough batteries for the lift.On 2/5/26 at 11:20 AM, V12, CNA left the floor to get a battery for the full body mechanical lift device that was sitting in front of R1's room. V12 stated Most of the time there is only 1 or 2 batteries available to use. A couple of weeks ago, no one could find a battery, and I think there was only 1 or 2 for all the halls to share.R154's face sheet dated 2/9/2026 documents a diagnosis in part end stage renal disease, dependence on renal dialysis and congenital complete absence of left lower limb. R154's Care plan dated 1/27/2026 documents R154 has an Activity of Daily Living (ADL) self-care performance deficit related to weakness, absence limb, End stage renal disease (ESRD), fractured ulna. R154's care plan documents the intervention dated 1/26/2026; transfer: the resident requires Hoyer lift to transfer between two surfaces. R154's Minimum Data Set (MDS) dated [DATE] documents R156 is cognitively intact. On 2/10/2026 at 10:58AM V1 Administrator stated the facility has 14 mechanical lifts and 12 batteries. V1, stated 2 of the 12 batteries need fuses. V1 stated she would expect the facility to have enough batteries for the mechanical lifts. V1 stated the facility does not have a specific policy for maintenance of equipment, but would expect the facility to follow manufacturer guidelines. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146026 If continuation sheet Page 6 of 6