Health inspection·March 5, 2025

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 3/3/25 at 11:43 AM R5 was lying in bed with her eyes open. R5 was unable to answer questions appropriately. A perimeter defining mattress was on the bed, and (R5's) right side of bed was up against the wall. On the opposite side of the bed (left side), a body pillow was tucked underneath the fitted sheet, next to R5's left side. R5 was not visible from the doorway due to the height of the body pillow. On 3/3/25 at 12:21 PM R5 was lying in bed in a gown sleeping with the head of bed slightly raised. R5's bed remained pushed up against the right side of the wall with a body pillow tucked underneath the fitted sheet, next to R5's left side. R5 was not visible from the doorway due to the height of the body pillow. On 3/4/25 at 9:30 AM R5 was lying in bed with her eyes open. A body pillow remained tucked underneath R5's fitted sheet, next to R5's left side and the right side of R5's bed remained pushed up against the wall. R5 was not visible from the doorway due to the height of the body pillow. On 3/3/25 at 12:29 PM V5/CNA (Certified Nursing Assistant) verified a body pillow was being utilized underneath R5's fitted sheet on the left side of R5's bed. V5/CNA stated, A body pillow is underneath the fitted sheet on the left side of (R5's) bed to prevent (R5) from getting out of bed or rolling out of bed. (R5) tries to climb down to the end of her bed to get out of the bed since the body pillow prevents her from getting out of the bed. When (R5) tries to climb to the bottom of her bed to get out, (R5's) bed alarm goes off alerting us that (R5) is trying to get up. On 3/3/25 at 2:45 PM V11/CNA verified a body pillow was being utilized underneath R5's fitted sheet on the left side of R5's bed. V11/CNA stated, The body pillow was placed on the left side of (R5's) bed to prevent (R5) from getting up or rolling out of bed and falling. On 3/3/25 at 2:26 PM V13/Restorative Registered Nurse stated, I oversee the resident's fall interventions along with a daily team. (R5's) falls since 12/26/24 has had five falls from self-transferring out of bed or rolling out of bed. (R5) has had a body pillow on the left side of (R5). We (facility staff) just replaced the pillow due to the pillow not being firm enough to prevent (R5) from getting up. We also put (R5) on a concave mattress, low bed, a fall matt that alarms, and a bed alarm. (R5's) bed is against the right wall. All these interventions are to keep (R5) from getting out of bed unsupervised and harming herself. If (R5) had increased supervision or one-on-one of staff that would keep (R5) from falling. I know now that these fall interventions, including the body pillow, concave mattress, low bed, and alarms are being used to restrain (R5) and a restraint assessment has not been completed for these interventions. On 3/5/25 at 9:26 AM V1/Administrator stated, The staff are not supposed to be putting the body pillow underneath the fitted sheet and restraining R5 to the bed. I will have to educate the staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146068 If continuation sheet Page 2 of 24 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 146068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Acres Nursing Home 19130 Sunny Acres Road Petersburg, IL 62675 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to request a PASRR (Pre-admission Screening and Resident Review) for one of one resident (R10) reviewed for PASRR in a sample of 35. Findings Include: R10's admission Record documents that R10 was admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Vascular Dementia, Unspecified Severity, With Other Behavioral Disturbance, Major Depressive Disorder, and Anxiety Disorder. R10's MDS (Minimum Data Set) Assessment, dated 1/30/25, documents R10 is cognitively intact, has no hallucinations or delusions, has no physical/verbal/or other behaviors directed at others, and does not reject care. R10's Medical Record does not include evidence of the facility obtaining R10's PASRR Level I prior to admission to the facility. On 3/3/25 at 2:24 PM, V1/Administrator stated the facility had not obtained a level I PASRR for R10. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146068 If continuation sheet Page 3 of 24 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 146068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Acres Nursing Home 19130 Sunny Acres Road Petersburg, IL 62675 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to refer a resident to the PASRR (Preadmission Screening and Resident Review) State Agency to obtain a Level II PASRR after being diagnosed with a Mental Illness for one of one resident (R10) reviewed for Mental Illness in the sample of 35. Residents Affected - Few Findings Include: R10's admission Record documents that R10 was admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Major Depressive Disorder and Anxiety Disorder. R10's Diagnoses Listing documents R10 was diagnosed with Delusional Disorder (a serious mental illness) on 11/24/23. R10's current Physician Orders documents R10 has an order for Quetiapine (Antipsychotic medication) 12.5 mg (milligrams) by mouth at bedtime related to Delusional Disorders. R10's Medical Record does not include evidence of the facility obtaining R10's PASRR Level II after being diagnosed with Delusional Disorder. On 3/3/25 at 2:24 PM, V1/Administrator stated the facility does not have a level II PASRR for R10. V1 stated, It was never requested. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146068 If continuation sheet Page 4 of 24 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 146068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Acres Nursing Home 19130 Sunny Acres Road Petersburg, IL 62675 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 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review the facility failed to develop a Care Plan for oxygen use for one of 18 residents (R185) reviewed for care plans in the sample of 35. Residents Affected - Few Findings include: The Resident Care policy dated 11/2017 documents A Comprehensive person-centered care plan shall be developed and implemented to meet the resident's preferences and goals, and address the residents medical, physical, mental, and psychosocial needs, while honoring resident rights to choose. This care plan shall include goals, measurable objectives, and interventions to meet identified resident needs. The comprehensive care plan may be completed in conjunction with the admission MDS (Minimum Data Set), or within the first 48 hours of stay. If completed as replacement for the baseline care plan, the comprehensive care plan must be modified based on information gathered during completion of the admission MDS (Minimum Data Set) assessment, as well as ancillary assessments and observations. The modified Comprehensive care plan must be completed by day 21 of the residents stay. All plans of care must be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly assessment. R185's admission Record dated 9/28/23, documents R185 has a diagnoses which included, Parkinson's Disease with Dyskinesia, Dementia in Other Diseases Classified Elsewhere, Unspecified Severity, with Anxiety, Restlessness and Agitation. R185's Physicians Orders printed 3/4/25, documents Oxygen at two liters as needed to keep oxygen saturation above 91 percent. Order date 2/3/25. R185's Care Plan printed 3/5/25 does not include an oxygen care plan. On 3/4/25 at 2:34 PM, V13/Restorative Registered Nurse stated (R185) uses oxygen as needed. V13 also verified that R185 does not have an oxygen plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146068 If continuation sheet Page 5 of 24 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 146068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Acres Nursing Home 19130 Sunny Acres Road Petersburg, IL 62675 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 a resident's fingernails (R36's) were kept trimmed and cleaned and ensure a resident (R32) received a shower or bath at least once a week for two of two residents (R32 and R36) reviewed for ADLs (Activities of Daily Living) in the sample of 35. Residents Affected - Few Findings include: 1. The facility's Nail Care Policy dated 9-8-2005 documents, Nails and feet need special attention to prevent infection, injury, and odors. Long or broken nails may scratch the skin or snag clothing. Routine nail care may include cleaning, filing, or cutting. R36's current Care Plan documents R36 is at risk for an ADL self-care deficit related to the diagnosis of Multiple Sclerosis, Osteoporosis, and Hypertension. On 03/03/25 at 10:36 AM and 03/04/25 at 9:25 AM R36 was sitting in her room in a wheelchair. During these times, all R36's fingernails were long, jagged, and had brown matter underneath. R36 stated, I cannot remember last time my nails were clipped and cleaned. On 03/04/25 at 9:25 AM V12 (CNA/Certified Nursing Assistant) stated, Eww! (R36's) nails need cleaned and trimmed. (R36's) nails should be trimmed with every bed bath. 2. R32's Face Sheet documents R32 is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Acute and Chronic Diastolic Congestive Heart Failure, Acute and Chronic Respiratory Failure with Hypoxia, Muscle Weakness, need for Assistance with Personal Care, Chronic Obstructive Pulmonary Disease with Acute Exacerbation, Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Lymphedema, and Primary Generalized (Osteo) Arthritis. R32's Brief Interview for Mental Status/BIMS dated 2/21/25 documents a BIMS of 15 (cognition intact). R32's MDS (Minimum Data Set) Assessment documents R32 has an upper extremity impairment on one side, requires partial assistance of staff for showers, and requires substantial assistance of staff for personal hygiene. R32's Care Plan printed 3/3/25 documents (R32) is at risk for ADL (activity of daily living) Self Care Performance Deficit r/t (related to) weakness. Interventions: Bathing -requires 1 (one) staff participation with bathing. R32's Bathing Task printed 3/4/25 documents that R32's days for bathing are on Tuesdays and Fridays. R32's Skin Monitoring Shower Review dated 1/1/25 through 1/31/25 documents R32 did not receive a shower or bath from 1/4/25 through 1/24/25. On 3/3/25 at 10:45 AM R32 stated, I don't get bathed as often as I would like. There is no consistency with bathing. It all depends on when the staff have time. I went for over a week without a shower when I had influenza. I was not given a bed bath either. I have only refused one shower and that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146068 If continuation sheet Page 6 of 24 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 146068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Acres Nursing Home 19130 Sunny Acres Road Petersburg, IL 62675 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 was when it was below zero outside, and the shower room gets cold. I like to be kept clean. Level of Harm - Minimal harm or potential for actual harm On 3/5/25 at 10:30 AM V1/Administrator stated, The facility does not have a policy on how often showers should be offered. We (the facility) follow the standard and residents should get a shower once a week or as requested. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146068 If continuation sheet Page 7 of 24 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 146068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Acres Nursing Home 19130 Sunny Acres Road Petersburg, IL 62675 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow a physician ordered treatment for one of one resident (R32) reviewed for skin alterations in the sample of 35. Residents Affected - Few Findings include: The Wound Policy dated 3/28/24 documents It is the policy of this facility to provide nursing standards for assessment, prevention, treatment, and protocols to manage residents at any level of risk for skin breakdown and for wound management. Procedure: Wound- an area of skin impairment or damage which has been manifested or resulted other than by pressure for which treatment and/or observation is provided until such time as that area has resolved by healing. Treatment continues per physician's orders until the wound and/or ulcer is healed. R32's Face Sheet documents R32 is a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses which included Acute and Chronic Diastolic Congestive Heart Failure, Acute and Chronic Respiratory Failure with Hypoxia, Muscle Weakness, need for Assistance with Personal Care, Chronic Obstructive Pulmonary Disease with Acute Exacerbation, Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Lymphedema, and Primary Generalized (Osteo) Arthritis. R32's Brief Interview for Mental Status/BIMS dated 2/21/25 documents a BIMS of 15 (cognition intact). R32's Physician Order printed 3/3/25 documents Cleanse wound on umbilical area of abdomen, pack wound and undermined area with collagen and apply calcium alginate with silver using a single piece, cover with gauze island dressing every day shift for wound healing. Start date 2/10/25. R32's Treatment Administration Record (TAR) dated 2/1/25 - 2/28/25 documents Cleanse wound on umbilical area of abdomen, pack wound and undermined area with collagen and apply calcium alginate with silver using a single piece, cover with gauze island dressing every day shift for wound healing. Start date 2/10/25. This same TAR documents R32's treatment was not signed as being done on 2/13, 2/17, 2/20, 2/26, and 2/28/25. On 3/3/25 at 10:45 AM R32 stated that the abdominal dressing changes are not done as ordered on her abdominal wound. On 3/5/25 at 1:38 PM, V1/Administrator and V4/Registered Nurse both verified that according to R32's TAR, R32's abdominal dressing was not done daily as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146068 If continuation sheet Page 8 of 24 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 146068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Acres Nursing Home 19130 Sunny Acres Road Petersburg, IL 62675 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, interview, and record review the facility failed to develop and implement services to maintain and/or improve range of motion limitations and failed to develop a care plan to address limitations in range of motion for two of two residents (R3 and R36) reviewed for limitations in range of motion in the sample of 35. Findings include: 1. R3's MDS (Minimum Data Set) Assessments dated 1-3-25 and 10-4-24 document R3 is cognitively intact, has functional limitations in range of motion to both sides of the lower extremities, and does not receive passive or active range of motion restorative programs. R3's current Physician's Order Sheets document R3 has the diagnosis of Muscle Weakness. R3's Contracture Risk Evaluation dated 1-3-25 documents R3 is at high risk of developing contractures. R3's current Care Plan does not include a plan of care to address R3's limitations in range of motion. On 3-3-25 at 10:18 AM R3 was sitting in a wheelchair with her legs elevated. R3 stated she cannot move her legs on her own and staff do not do range of motion exercises with her. 2. R36's MDS Assessments dated 12-3-24 and 10-2-24 document R36 has functional limitations in range of motion to one side of the upper and lower extremities and does not receive passive or active range of motion restorative programs. R36's current Physician's Order Sheets documents R36 has the diagnoses of Muscle Weakness, Muscle Wasting and Atrophy, and Multiple Sclerosis. R36's Contracture Risk Evaluation dated 12-30-24 documents R36 at moderate risk of developing contractures. R36's current Care Plan does not include a plan of care to address R36's limitations in range of motion. On 3-3-25 at 10:46 AM R36 was sitting in a wheelchair. R36's right foot was pointed inward. R36 stated the staff does not do range of motion exercises with her. On 3-4-25 at 9:25 AM V12 (CNA/Certified Nursing Assistant) stated, I do not believe (R3 or R36) get range of motion exercises or restoratives. On 3-4-25 at 10:05 AM V13 (Restorative Nurse) stated, (R3 and R36) do not receive range of motion restoratives and do have limitations in range of motion. (R3 and R36) have not had a care plan developed to address their limitations in range of motion. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146068 If continuation sheet Page 9 of 24 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 146068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Acres Nursing Home 19130 Sunny Acres Road Petersburg, IL 62675 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 provide adequate supervision to prevent falls for one of one resident (R5) reviewed for falls in the sample of 35. Findings include: The facility's Fall Assessment and Management Policy, dated 6/2024, documents Policy: It is the policy of this facility to assess each resident's fall risk on admission, quarterly, and with each fall. This will help facility an interdisciplinary approach for care planning to appropriately monitor, assess, and ultimately reduce injury risk. Factors related to the risk will be addressed and care planned. R5's MDS (Minimum Data Set) assessment dated [DATE] documents R5 is severely cognitively impaired. R5's Fall Investigations dated 10/15/24 to 1/13/25 document R5 has had six falls out of bed during this timeframe with three of these falls resulting in either bruising or skin tears. On 3/3/25 at 11:43 AM R5 was lying in bed with her eyes open. R5 was unable to answer questions appropriately. A perimeter defining mattress was on the bed, and R5's right side of bed was up against the wall. On the opposite side of the bed (left side), a body pillow was tucked underneath the fitted sheet, next to R5's left side. R5 was not visible from the doorway due to the height of the body pillow. On 3/3/25 at 12:21 PM R5 was lying in bed in a gown sleeping with the head of bed slightly raised. R5's bed remained pushed up against the right side of the wall with a body pillow tucked underneath the fitted sheet, next to R5's left side. R5 was not visible from the doorway due to the height of the body pillow. On 3/4/25 at 9:30 AM R5 was lying in bed with her eyes open. A body pillow remained tucked underneath R5's fitted sheet, next to R5's left side and the right side of R5's bed remained pushed up against the wall. R5 was not visible from the doorway due to the height of the body pillow. On 3/4/25 at 2:26 PM V13/Restorative Registered Nurse stated, I oversee the resident's fall interventions along with a daily team. (R5's) falls since 12/26/24 has had five falls from self-transferring out of bed or rolling out of bed. (R5) has had a body pillow on the left side of her we just replaced due to the pillow not being firm enough, a concave mattress, low bed, and a fall matt that alarms, and a bed alarm. (R5's) bed is against the right wall. All these interventions are to keep (R5) from getting out of bed unsupervised and harming herself. If (R5) had increased supervision or one-on-one of staff that would keep (R5) from falling. On 3/5/25 at 9:26 AM V1/Administrator stated, You cannot see (R5) in her room while (R5) is lying in bed from the hallway because of (R5's) roommates' recliner. (R5's) roommate likes to get up quite a bit, and there was no other way to rearrange (R5) and her roommates' room. (R5's) body pillow also contributes to staff not being able to supervise (R5) while in bed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146068 If continuation sheet Page 10 of 24 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 146068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Acres Nursing Home 19130 Sunny Acres Road Petersburg, IL 62675 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R79's Face Sheet documents R79 is a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Chronic Kidney Disease, Stage 3, and Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms. R79's MDS (Minimum Data Set) Assessment documents R79 has an indwelling urinary catheter. On 3/3/25 at 11:30 AM, R79 was lying in bed sleeping. The bed was in the low position with the urinary catheter bag hanging on the side of the bed. Half of the urinary catheter bag was on the floor folded under the bed. On 3/3/25 at 3:03 PM, R79's bed was in the low position with half of the urinary catheter bag resting on the floor. On 3/4/25 at 8:27 AM, R79's bed was in the low position with half of the urinary catheter bag on the floor. On 3/4/25 at 1:47 PM, V4/Registered Nurse/Infection Preventionist stated that R79's urinary catheter bag should never be touching the floor. Based on observation, interview, and record review the facility failed to properly keep the catheter bag off the floor for one resident (R79) and failed to change gloves, perform hand hygiene, and perform indwelling urinary catheter care per facility policy for one resident (R39) for two of three residents (R39 and R79) reviewed for urinary catheters in the sample of in the sample of 35. Findings include: The facility's Catheter Care-Female, dated 8/1/05, states To cleanse the meatus and adjacent catheter. Cleanse area of insertion of catheter into meatus using a clean washcloth prepared with soap and water or perineal care cleanser. Cleanse downward from top to bottom on one side, and then repeat on the other side using a clean washcloth. Cleanse catheter tubing one and a half to two inches down from insertion site. Rinse well with clean cloths, following same procedure as for washing. Dry with a clean towel. The Urinary Catheter Insertion Competency- Key (un-dated) documents Catheter bag must be placed so that no part of the bag touches the floor or is attached to a movable area of the chair or bed such as a bed rail or reclinable footrest. 1. On 03/04/2025 at 12:44 PM, V16 (CNA/Certified Nursing Assistant) was preparing catheter care for R39. V16 donned gloves and began R39's indwelling catheter care. During catheter care, V16 used a warm soapy washcloth and washed R39's meatus doing downward swipes and not folding the washcloth to the clean parts. V16, did not obtain another washcloth to rinse R39's meatus. With the same gloves and without washing her hands, V16 then placed a clean adult brief on R39. V16 did not wash R39's catheter tubing after cleansing R39's perineum area. On 03/04/2025 at 1:00 PM, V16 stated, I should have had multiple wash clothes that were soapy, non-soapy, and dry while performing (R39's) catheter care and changed my gloves and washed my hands in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146068 If continuation sheet Page 11 of 24 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 146068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Acres Nursing Home 19130 Sunny Acres Road Petersburg, IL 62675 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 between touching dirty to clean. V16 verified she should have cleansed the catheter tubing during R39's catheter care. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146068 If continuation sheet Page 12 of 24 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 146068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Acres Nursing Home 19130 Sunny Acres Road Petersburg, IL 62675 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to date oxygen tubing and a humidifier bottle for one of one resident (R185) reviewed for oxygen in the sample of 35. Residents Affected - Few Findings include: The Oxygen Administration policy dated 1/28/25 documents To administer oxygen in conditions in which insufficient oxygen is carried by the blood to the tissues. Procedure 12. Nasal cannulas, oxygen tubing, humidifiers and reservoirs will be tagged with date and initials of date changed. 14. Guidelines for changing respiratory equipment will be as follows: a. Oxygen tubing weekly. b. Humidifier bottles weekly. R185's Physicians Orders printed 3/4/25, documents Oxygen at two liters as needed to keep oxygen saturation above 91 percent. Order date 2/3/25. On 3/3/25 at 10:42 AM, R185 was lying in bed sleeping. R185's oxygen tubing and humidifier bottle were not labeled with the date or initials. On 3/3/25 at 11:28 AM, V4/Registered Nurse/ verified R185's oxygen tubing and humidifier bottle were not labeled with the date or initials. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146068 If continuation sheet Page 13 of 24 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 146068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Acres Nursing Home 19130 Sunny Acres Road Petersburg, IL 62675 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to administer a prescribed opioid medication to keep resident's pain controlled, failed to perform a pain assessment while the resident was not receiving her prescribed opioid medications, and failed to notify the physician of the need for a refill order and complaints of increased pain for one of one resident (R32) reviewed for pain in the sample of 35. These findings resulted in R32 experiencing stress and excruciating pain for over a week, that radiated to the neck and jaw. Residents Affected - Few Findings include: The Facility's Management of Pain Policy dated 4/4/12 documents Our mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. The purpose of this policy is to accomplish that mission through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and involvement. We will achieve these goals through: Promptly and accurately assessing and diagnosing pain. Monitoring treatment efficacy and side effects. Using pain medication judiciously to balance the residents desired level of pain relief with the avoidance of unacceptable adverse consequences. A standard format for assessing, monitoring and documenting pain in both cognitively intact and cognitively impaired residents will be utilized. As part of a comprehensive approach to pain assessment and management, pain will be considered the fifth vital sign at the facility, along with temperature, pulse, respiration, and blood pressure. For the purpose of this policy, pain is defined as Whatever the experiencing person says it is, existing whenever the experiencing person says it does. Procedure 1. Resident/Family Involvement Upon admission, all residents and families will receive the facility handout, A Message of Care to our Residents and Families - Facts about pain, encouraging residents to report pain early so pain management can be more effective. Residents will be asked to periodically measure satisfaction related to pain and its management. 2. Physician Communication and Involvement - Pain will be assessed and managed in a timely fashion, especially if it is a recent onset. The physician will be notified of resident's complaint of pain when not relieved by medication as ordered by the physician. Thorough communication with the physician will ensure an appropriate pain management plan. Pain Screening- By receiving input from someone who knows the resident well, pain management can be more specific to the resident. If the resident scores five or above on the pain questionnaire the comprehensive pain assessment must be completed. The United States Food and Drug Administration Safety Communication Website article dated 4/9/19 documents, Opioid's are a class of powerful prescription medicines that are used to manage pain when other treatments and medicines cannot be taken or are not able to provide enough pain relief. Rapid discontinuation can result in uncontrolled pain. R32's Face Sheet documents R32 is a [AGE] year-old female admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Primary Generalized (Osteo) Arthritis, Neuropathy, and GERD (Gastroesophageal Reflux Disease). R32's current Care Plan documents (R32) is at risk for pain related to arthritis, neuropathy, GERD. Goal: (R32) will not have an interruption in normal activities due to pain through the review date. Interventions: Administer analgesia as ordered and monitor effectiveness of pain medications used. Evaluate the effectiveness of pain interventions utilized, both medical and non-medical. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146068 If continuation sheet Page 14 of 24 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 146068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Acres Nursing Home 19130 Sunny Acres Road Petersburg, IL 62675 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 0697 Level of Harm - Actual harm on functional ability and impact on cognition. Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. Monitor/record/report to Nurse (R32's) complaints of pain or requests for pain treatment. Notify physician if interventions are unsuccessful or if current complaint is a significant change from (R32's) past experience of pain. Residents Affected - Few R32's MDS (Minimum Data Set) Assessment, dated 2/21/25, documents R32 is cognitively intact. This same MDS documents R32 frequently had pain or was hurting in the last five days that occasionally made it hard to sleep, occasionally limited her day-to-day activities due to pain, and rated her worst pain as a seven out of ten. R32's Progress Note dated 2/23/25 at 11:41 AM documents Fentanyl Transdermal Patch 72 Hour 100 MCG (microgram)/Hr (hour) apply 1(one) patch trans dermally in the afternoon every 3 (three) days for chronic pain and remove per schedule. Waiting for signed order from doctor. R32's Medication Administration Record (MAR) dated 2/1/25 through 2/28/25 documents Fentanyl Transdermal Patch 72 Hour 100 MCG/HR. Apply one patch trans dermally in the afternoon every three day(s) for chronic pain and remove per schedule. Start date 9/11/24. This same MAR documents R32 did not receive her scheduled Fentanyl Transdermal Patch 100 MCG/HR from 2/17/25 through 2/24/25. The pain assessment documents that R32 rated her pain at a level five or above eight times between 2/17/25 through 2/25/25. R32's Electronic Medical Record and Progress Notes dated 2/17/25 through 2/25/25 (dates R32's pain was rated above a five) includes evidence of only one comprehensive pain evaluation being completed on 2/21/25 during this timeframe. R32's Pain Evaluation dated 3/21/25 documents R32 was experiencing pain frequently over the past five days, rated at a level seven (indicating the pain was as bad as it could be). This same Evaluation documents no new care plan interventions or clinical suggestions were made to address R32's pain. On 3/3/25 at 10:45 AM, R32 stated I wear a pain patch and on 2/17/25 I did not get my new patch. I kept asking the staff and nothing was done about it. I was told at one point that they needed to get a physician's order. I don't know if it was not followed up on or what happened. On 2/25/25 I was so upset because it had been well over a week that I had waited for the pain patch to be replaced. I was having stabbing pain in my neck and jaw I think from the stress from the amount of pain I was under. I thought I was having a heart attack. I was hurting and frustrated that no one would help me get my medication. I was in excruciating pain for over a week. I didn't get the patch until 2/25/25. On 3/4/25 at 11:35 AM, V21/Pharmacist stated We did not get a request to refill (R32's) Fentanyl patch until 2/24/25. The last time the order was filled was 1/13/25 which should have lasted a month. On 3/4/25 at 11:51 AM, V22/R32's Primary Care Physician's Nurse stated 2/24/25 was the first time we were notified that (R32) needed the order for her fentanyl patch. Our office should have been notified of the need for (R32's) Fentanyl Patch refill before (R32) ran out. On 3/5/25 at 8:50 AM, V1 (Administrator) stated, When (R32) was out of her Fentanyl Patch somebody should have reached out to (R32's) physician to get the refill order or to see if the patch could have been pulled from back-up. The staff should have let the physician know that (R32) was in pain and see if there was something else, we (the facility) could do to control (R32's) pain. (R32) should not have had to go without her Fentanyl Patch. The staff should have contacted me or (V2/Director of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146068 If continuation sheet Page 15 of 24 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 146068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Acres Nursing Home 19130 Sunny Acres Road Petersburg, IL 62675 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 0697 Level of Harm - Actual harm Residents Affected - Few Nursing) when the Fentanyl Patch was not available so one of us could have followed up on it. There is no documentation that the physician, me, or (V2) were notified of (R32) going without her scheduled Fentanyl Patch or (R32's) complaints of pain from 2/17/25 to 2/25/25. During the timeframe of 2/17/25 to 2/25/25 we had agency staff taking care of (R32) and were not familiar with (R32). I think that is why there was no follow-up. Any pain rating above a seven indicates pain that is as bad as it can be. On 3/5/25 at 9:00 AM V18 (CNA/Certified Nursing Assistant) stated, Every time I would take (R32's) meal tray into her between 2/17/25 to 2/25/25, (R32) would complain of pain and say to me, I just do not understand why they (the staff) are not getting me my pain patch and I have to go this long in pain. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146068 If continuation sheet Page 16 of 24 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 146068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Acres Nursing Home 19130 Sunny Acres Road Petersburg, IL 62675 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow a physician's order to reduce an anti-psychotic medication for one resident (R17) and failed to document behaviors and diagnoses to justify the use of anti-psychotic medications for four of six residents (R5, R10, R17, R64) reviewed for anti-psychotic drug use with the diagnosis of Dementia in the sample of 35. Findings include: The Psychotropic Medication policy dated 11/28/17 documents, Intent: Residents are free from unnecessary psychotropic medication use. Psychotropic medication is any drug that affects brain activity associated with mental processes and behavior. These medications include but not limited to 1) Antianxiety 2) Antidepressant 3) Antipsychotic. These medications are to be given to treat a specific condition/medical symptom that is diagnosed and documented in the clinical record. Specific condition/medical symptoms alone are not enough to justify pharmacological use. An evaluation must be done to determine other possible physical, mental, behavioral, and psychosocial needs. B) Dose, Duration, Monitoring 1) Evaluation of pharmacological ongoing effectiveness towards therapeutic goal. 2) Evaluation of the effectiveness of the non-pharmacological approaches prior to medication administration. 3) Quarterly evaluation or more frequent if needed to determine if a reduction is warranted. C) Gradual Dose Reduction (GDR). 1) Resident's should receive the lowest effective dose of psychotropic medication for the resident's physical, mental, and psychosocial well-being. 2) GDR is to be attempted within the first year in two separate quarters, (with at least one month between attempts), unless clinically contraindicated. 1. R17's Current Order Summary Report dated 3-3-25 documents, Order date 9-18-24: Seroquel 25 mg (milligrams) 1.5 tablets (37.5 mg) at bedtime related to unspecified Dementia, unspecified severity, with agitation. R17's Pharmacy Requisition signed by V17 (R17's Physician) documents V17 ordered R17's Seroquel to be reduced from 37.5 mg every night to 25 mg every night. R17's MDS (Minimum Data Set) assessment dated [DATE] documents R17 does not have behaviors that put others or himself at risk for physical injury or illness. R17's current electronic Physician's Order document, Seroquel Oral Tablet 25 MG Warning: Increased mortality in elderly patients with dementia-related psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Quetiapine is not approved for the treatment of patients with dementia-related psychosis, suicidal thoughts, and behavior. On 3-3-25 from 11:30 AM through 12:20 PM R17 was sitting in a high-back chair in the dining room. R17 was exhibiting no behaviors during this time. On 3-3-25 at 10:15 AM V5 (CNA/Certified Nursing Assistant) stated, (R17) does not have any behaviors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146068 If continuation sheet Page 17 of 24 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 146068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Acres Nursing Home 19130 Sunny Acres Road Petersburg, IL 62675 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm On 3-3-25 at 10:51 AM V15 (R17's Family Member) stated, (R17) has not been having behaviors for a very long time. (R17) in the past had a behavior of urinating in spots he was not supposed to. On 3-3-25 at 2:15 PM V10 (RN/Registered Nurse) stated, (R17) does not have any behaviors. (R17) just gets anxious at times and tried to slide down the seat of his chair. Residents Affected - Some On 3-4-25 at 1:30 PM V4 (RN) stated, I am responsible for monitoring all of the residents' psychotropic drug use. (R17's) Seroquel was supposed to be reduced from 37.5 mg to 25 mg every night on 1-31-25. I missed the order. (R17) only has anxiety. (R17's) behaviors and diagnoses do not justify the use of Seroquel. 2. R64's current Order Summary Report dated 3-3-25 documents, Order Date: Seroquel 25 mg one tablet in the morning related to Dementia with Psychotic Disturbance and Unspecified Behavioral Syndromes Associated with Physiological Disturbances and Physical Factors. R64's MDS assessment dated [DATE] documents R64 has no behaviors and does not have behaviors that put others or herself at risk for physical injury or illness. This same MDS documents R64 has not had a physician documented gradual dose reduction attempt. R64's current electronic Physician's Order documents, Seroquel Oral Tablet 25 MG Warning: Increased mortality in elderly patients with dementia-related psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Quetiapine is not approved for the treatment of patients with dementia-related psychosis, suicidal thoughts, and behavior. On 3-3-25 at 10:30 AM R64 was sitting in a wheelchair coloring in a book. R64 was polite and was not exhibiting behaviors at this time. On 3-4-25 at 1:30 PM V4 (RN) stated, (R64) only has a behavior once or twice a month of getting anxious. (R64) does not have behaviors that put herself or others at risk for harm or injury. (R64) does not have a diagnosis or behaviors to warrant the use of Seroquel. 3. R10's admission Record documents that R10 was admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Vascular Dementia, Unspecified Severity, With Other Behavioral Disturbance, Major Depressive Disorder, Anxiety Disorder, and Delusional Disorders. R10's MDS Assessment, dated 1/30/25, documents R10 is cognitively intact, has no hallucinations or delusions, has no physical/verbal/or other behaviors directed at others, and does not reject care. This same MDS documents R10 receives an antipsychotic medication. R10's current Physician Orders documents R10 has an order for Quetiapine (Antipsychotic medication) 12.5 mg/milligram by mouth at bedtime related to Delusional Disorders. R10's Care Plan, dated 3/3/25, documents R10 has a history of hallucinations with use of antipsychotic medication. R10's Behavior Tracking for September 2024 through February 2025 documents that R10 had one behavior of cursing at others, one time refusing care, twice accusing others, three times expressing frustration/anger at others, and four times of agitation not directed at others. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146068 If continuation sheet Page 18 of 24 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 146068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Acres Nursing Home 19130 Sunny Acres Road Petersburg, IL 62675 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm R10's Physical Device/Psychoactive Medication Initial and Quarterly Evaluation dated 1/30/25 documents Please indicate any appropriate diagnosis/indications that contribute to the use of antipsychotic medication: 6. expressions or indications of distress that are significant to the resident 12. dementia with behavior disorder. 13. behaviors that interfere with judgment. Psychotropic Medication Order Quetiapine 12.5 mg every day at bedtime. Residents Affected - Some On 3/4/25 at 8:28 AM, R10 was lying in bed asleep. R10 had no behaviors at this time. On 3/5/25 at 11:16 AM, R10 was sitting in her room doing a word search. R10 was calm and pleasant. R10 stated that she does not have any hallucinations or delusions. On 3/4/25 at 8:28 AM, V9/Licensed Practical Nurse stated that R10 does not bother any residents or staff and is not a harm to herself. On 3/4/25 at 10:10 AM, V13/Restorative Nurse stated that she has not seen R10 be a harm to staff/residents or be a harm to herself. On 3/5/25 at 11:21 AM, V24/Social Services stated that R10 hallucinates and sees things that are not there. V24 also stated that R10 is not a harm to herself or others. 4. R5's admission Record, dated 3/5/25, documents R5 was admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Insomnia, Anxiety Disorder, Muscle Weakness, Hallucinations, Cognitive Communication Deficit, Poly-Osteoarthritis, Major Depressive Disorder, and Dementia with Agitation. R5's MDS (Minimum Data Set) assessment dated [DATE] documents R5 is severely cognitively impaired. R5's Order Summary Report dated 3/3/25 documents, Order date 6/21/24: Seroquel 50 mg 1.5 tablets (75 mg) two times daily related to Dementia, unspecified severity, with agitation. R5's current electronic Physician's Order document, Seroquel Oral Tablet 50 MG Warning: Increased mortality in elderly patients with dementia-related psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Quetiapine is not approved for the treatment of patients with dementia-related psychosis, suicidal thoughts, and behavior. On 3/3/25 at 11:43 AM R5 was lying in bed with her eyes open. R5 was unable to answer questions appropriately. R5 had no behaviors observed at this time. On 3/3/25 at 12:21 PM R5 was lying in bed sleeping. R5 had no behaviors observed at this time. On 3/4/25 at 9:30 AM R5 was lying in bed with her eyes open. R5 had no behaviors observed at this time. On 3/4/25 at 1:50 PM V4/Registered Nurse stated, (R5) does not have behaviors or a diagnosis to justify the use of Seroquel. (R5's) only behavior is trying to get up out of bed, especially at night. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146068 If continuation sheet Page 19 of 24 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 146068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Acres Nursing Home 19130 Sunny Acres Road Petersburg, IL 62675 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to properly cleanse a food thermometer before use and between foods when checking steam table food temperatures, ensure a hairnet was worn correctly in the kitchen, label and date open food items in refrigerators and dry food storage areas, ensure freezers contained internal thermometers and thermometers in working condition, use dishwasher temperature testing strips that reflect the required dish surface temperature, check the surface temperature daily to ensure dishes reach the required temperature during the rinse cycle of a high temperature sanitation dish machine, and ensure juice and coffee dispensers in the main dining room were clean and free from buildup and slime. These failures have the potential to affect all 85 residents residing in the facility. Findings include: The facility's Food and Nutrition Services Manager Job Description (undated), documents Job Summary: Production and service of high-quality meals; organize, supervise, and train dietary employees; purchase food and supplies; provide a sanitary and infection free environment; participate in the assessment process; write care plans; prepare menus; make decisions. This job description also documents Essential Job Functions: Supervise the receiving and storage of food. Supervise food preparation and service. Maintain high sanitation standards. Ensure maintenance of equipment. Supervise cleaning procedures to ensure safe and sanitary conditions are maintained within the food service department, including kitchen, dining room, and freezers. The facility's Personal Hygiene: Illness, Shoes, Hair Restraints policy, dated 2/2022, documents Employees shall use effective hair restraints such as hats, hair coverings or nets, beard restraints and clothing that cover body hair that are designed and worn to effectively keep their hair from contacting exposed food, and clean equipment. Anyone entering a kitchen or serving area will have their hair restrained and/or a beard guard. This will be worn throughout the time in the kitchen and when handling food. On 3/3/25 10:50 AM, V7 (Dietary Manger) entered the facility's kitchen and placed a hairnet on her head. Throughout the entire kitchen tour, steam table temperature checks and freezer/fridge walk through, V7 had her hair partially covered in a hair net with approximately six to eight inches of ponytail uncovered and hanging on her shoulder, outside of the hairnet. On 3/3/25 at 10:55 AM, V7 took a food thermometer out of her shirt pocket, rinsed the thermometer probe under tap water for approximately two seconds and then took a paper towel and wiped it dry. V7 then proceeded to check steam table food temperatures of Chicken Breasts, Cheesy Rice, Mixed Vegetables, [NAME] Beans, Ground Chicken, Pureed Chicken, Pureed Rice, and Pureed [NAME] Beans. In between each food temperature, V7 wiped the thermometer probe off with the original dry paper towel and then inserted the probe into the next item. On 3/3/25 at 11:05 AM, upon completing steam table temperatures, V7 confirmed that the thermometer should be wiped with a food safe sanitizing wipe or alcohol wipe between foods. V7 stated Yes, when staff do temperatures they should use the cleansing wipes. Normally I would, but I didn't know where those were at. The facility's Food Labeling and Dating policy, dated 2/2022, documents Labeling and dating food is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146068 If continuation sheet Page 20 of 24 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 146068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Acres Nursing Home 19130 Sunny Acres Road Petersburg, IL 62675 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many important to assure foods are used in a timely manner. Proper food labeling includes: name of product, date stored and in some cases, the time of the day. The food must be labeled and dated if it is removed from its original container. Leftover foods placed in a container must be cooled down properly, labeled and dated. On 3/3/25 at 11:10 AM, the kitchen reach-in refrigerator contained a large tub of lettuce with a lid that was not labeled or dated. At this time V7 confirmed that the tub should be labeled and dated and now needs to be discarded because it wasn't labeled. On 3/3/25 at 11:12 AM, the kitchen's dry food storage room contained two bags of spiral pasta, one bag of dried milk, one bag of breadcrumbs, and two plastic containers of cereal (out of original package), that all were opened and undated. Directly outside of the dry food storage room was a rack containing packages of breads. This rack contained two loaves of wheat bread, one package of hot dog buns and one package of cinnamon bread, all packages were open and undated. V7 confirmed that this time that the opened dry storage food items and breads should all be dated with the dates the items were opened. On 3/3/25 at 11:15 AM, the facility's walk-in refrigerator contained a large container of ham salad, labeled beets. At this time, V7 confirmed the container does not contain beets and does not have a label for what is inside. In this same refrigerator another large metal container with several sandwiches insides was covered with foil, without a label or date. V7 stated It's ham salad sandwiches and the container should have been labeled and dated. On 3/3/25 at 11:17 AM, the facility's upright walk-in freezer contained a thermometer inside with a broken center and an unreadable temperature recording. At this time, V7 confirmed the thermometer is broken and not readable. On 3/3/25 at 11:19 AM, the facility's large chest freezer contained several bags of vegetables and did not have an internal thermometer. V7 stated I know there was one (thermometer) in here, but it's not in here now. I don't know why. The facility's Heat Sanitizing Log procedure, dated 2/2022, documents Wash temperature, 150 degrees Fahrenheit. Rinse/Sanitize temperature, 180 degrees Fahrenheit. If temperatures are not 150 or 180, notify your manager immediately. The facility's Dishwasher testing strip (undated), documents 71 degrees Celsius/ 160 degrees Fahrenheit. If center (of testing strip) is black, then correct temperature has been achieved. On 3/3/25 at 11:20 AM V8 (Dietary Aide) stated he is the one who checks the dishwasher temperatures each day and stated, It is a high-temp dishwasher. V8 stated he records the outside temperature of the digital reading to check the temperature during a dishwashing cycle. V8 denied using any strips or surface level thermometers during the dish cycle and stated, It isn't broken (outside thermometer) because it's a new machine and gives us the temperature recording on the outside. At this time V8 located some temperature testing strips. V8 stated I forgot we had these. V8 then confirmed that the strips will turn black when they reach a temperature of only 160 degrees. On 3/3/25 at 11:25 AM, the juice machine in the facility's main dining room contained orange slime, a bright red gel-like substance and smeared slime like debris on the underside plastic casing of the machine, where the juice spout nozzles are located. At this time the coffee machine dispenser (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146068 If continuation sheet Page 21 of 24 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 146068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Acres Nursing Home 19130 Sunny Acres Road Petersburg, IL 62675 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many nozzles and surroundings on the machine's underside, contained dried brown splatters and debris. V7 and V8 both stated those areas on both machines should be cleaned in the evening, but the cleaning is not documented anywhere, to prove it is ever completed. On 3/3/25 at 11:28 AM, V7 stated Staff should be wearing hairnets in the kitchen to contain their hair. V7 confirmed her ponytail is not fully in her hairnet and stated I don't usually go in the kitchen. I am usually out in the dining room or in my office. The facility's Long Term Care Application for Medicare and Medicaid dated 3/3/25 and signed by V1 (Administrator) documents 85 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146068 If continuation sheet Page 22 of 24 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 146068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Acres Nursing Home 19130 Sunny Acres Road Petersburg, IL 62675 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 Observation, Interview, and Record Review the facility failed to complete hand hygiene between residents receiving medications, follow Enhanced Barrier Precautions during direct resident cares, and dispose of soiled washcloths in a sanitary manner for five of 25 residents (R6, R27,R30, R39, R47) reviewed for infection control in the sample of 35. Residents Affected - Some Findings include: The facility's Medication Administration policy, dated 1/11/10, documents Objective: To provide accuracy during medication pass to assure quality for residents. Procedure: Wash hands according to facility protocol. Wash prior to medication pass, after administering eye preparations and after removing gloves and when hands become soiled. The Facility's Enhanced Barrier Precautions Protocol Policy, revised 4/8/24, documents, Enhanced Barrier Precautions expands the use of Personal Protective Equipment (PPE) beyond situations in which exposure to blood and body fluids is anticipated, refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of Multi-Drug-Resistant Organisms (MDROs) to staff hands and clothing. If Enhanced Barrier Precautions are required, a sign should be placed outside the resident's room to assist in educating staff, residents, and visitors on appropriate personal protection. When required, Enhanced Barrier Precautions apply to everyone caring for the resident. This same policy documents, Hand hygiene practices must be followed. Personal Protective Equipment, PPE (e.g., gloves and gowns) should be used during high-contact resident care activities. Examples of high-contact resident care activities requiring gowns and glove use include: Dressing, Providing Hygiene, Device Care or use for urinary catheter, and feeding tube. 1. On 3/5/25 at 3/5/25 9:08 AM, V23 (Licensed Practical Nurse), administered medications to R27 in her room. After administering the medications, V23 picked up R27's television remote and programmed R27's television channel by pushing buttons on the remote control. V23 then handed the remote back to R27 and exited the room. V23 then unlocked her medication cart and began preparing medications for R30. V23 entered R30's room at 9:14 AM and administered her medications. R30 stated to V23 that she had gotten sick with a large amount of emesis this morning and she hadn't felt very well throughout the night. V23 took the empty medication cup from R30 and discarded it in the trash. Upon completion of medications, V23 exited R30's room, unlocked her medication cart, prepared and then administered R47's medications in R47's room. Throughout the medication administration V23 did not complete hand hygiene between residents rooms, before or after administering medications. On 3/5/25 at 9:25 AM, V23 exited R47's room and walked over to a wall hand sanitizer pump in the hallway. V23 stated Typically I have the sanitizer bottle in my medication cart and I don't know where it is today. Typically I sanitize my hands a lot, especially if I touch a resident. 2. R6's Physician Order Sheet, dated 3/5/25, documents R6 has a gastrostomy tube. On 03/03/2025 at 10:45 AM R6's room did not have an Enhanced Barrier Precaution sign outside or inside of R6's room. On 03/03/2025 at 10:46 AM, V13 (Restorative RN/Registered Nurse) verified R6 did not have an Enhanced Barrier sign on her door and stated she did not know R6 should be in Enhanced Barrier Precautions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146068 If continuation sheet Page 23 of 24 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 146068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Acres Nursing Home 19130 Sunny Acres Road Petersburg, IL 62675 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 3. R39's Physician Order Sheet, dated 3/5/25, documents R39 has an indwelling catheter. Level of Harm - Minimal harm or potential for actual harm On 03/04/2025 at 12:44 PM, V16 (CNA/Certified Nursing Assistant) entered R39's room without sanitizing her hands or donning a gown. V16 provided incontinence care to R39 without wearing a gown. Residents Affected - Some On 03/04/2025 at 1:00 PM, V16/CNA stated she did not know R39 was in Enhanced Barrier Precautions. V16 verified she did not sanitize her hands prior to applying gloves or wear a gown during cares. On 3/3/25 at 10:00 AM V1/Administrator provided a list of residents who were in Enhanced Barrier Precautions which included R6 and R39. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146068 If continuation sheet Page 24 of 24