Health inspection·August 28, 2025

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete helped me didn't feel comfortable. There is an aide (V12, Certified Nursing Assistant) who comes in at 5:00 AM because that is when I like my showers, but I don't know if there's not enough help or what, because she is by herself and so I only have gotten bed baths for several weeks.R2's Shower Sheets, dated 7/31/25-8/25/25, document R2 has been given only bed baths and no showers for over three weeks.On 8/27/25 at 12:25 PM, V12 (Certified Nursing Assistant) stated When staff have transferred and assisted (R2) they have been getting hurt. It really does take two people. If I don't have help, then (R2) only gets a bed bath. We have a bariatric shower chair, but our commodes are plastic, and I am not sure they would be safe. (R2) gets scheduled showers on Monday and Friday and she will tell me (if she wants a shower). If there are no other staff to help, (R2) gets a bed bath. (R2) toilets on the bedpan. I don't think we have a bariatric commode to use for her. (R2) could get up to toilet if we had the right equipment. Her wheelchair and the commodes do not fit her and so her recliner is the only place for her to go right now.On 8/27/25 at 12:45 PM, V13 (Certified Occupational Therapy Assistant) stated (R2) has had a recent weight gain. Staff brought to our attention that the shower chair and (R2's) wheelchair are too small now. The largest commode they have here is a size 28 inch and (R2) would probably need larger than that. V13 confirmed that the facility's shower chair is suitable for R2, but her wheelchair and the available commodes are too small to use. On 8/27/25 at 1:10 PM, V1 (Administrator in Training), stated (R2) is adamant that they (showers) occur first thing in the morning. It is a busy time of day for staff, so we have an aide that comes in early. I am not sure why there wouldn't be enough staff to at least get her transferred to the shower chair though. That seems doable for staff to get completed. We have been searching for a commode since we don't have one the appropriate size for (R2). Her wheelchair does not fit her either. We realize these are accommodations that need met to care for (R2) properly. Event ID: Facility ID: 146068 If continuation sheet Page 2 of 4 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 08/28/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, Interview and Record Review, the facility failed to ensure resident rooms were kept free from leaking water condensation, water damaged ceilings and dark fuzzy discoloration on the walls and ceilings for 15 of 16 residents (R1, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16) reviewed for environment in the sample of 16.Findings include:The facility's Resident Rights policy, dated 11/2018, documents As an individual living in long term care facility, you retain the same rights as every citizen of Illinois and of the United States. The following regulations provide clarity on specific rights granted to residents living in long-term care facilities: Your facility must be safe, clean, comfortable, and homelike.The facility's Mold policy, dated 6/14/17, documents Molds are microscopic organisms found everywhere in the environment, indoors and outdoors. Most molds are harmless, but some can cause infections, allergy symptoms and produce toxins. Inhalation is the exposure of most concern to cleanup workers. It is our policy to remediate immediately upon notification of mold. How to recognize mold: Sight, usually appear as gray or black and can be fuzzy. This policy also documents Always notify your facilities manager upon finding mold or mildew. Identify moisture problems and remove excess moisture with a wet-dry vacuum and dry out the building as quickly as possible.The facility's Fall Assessment and management Policy, dated 6/2024, documents It is the policy of this facility to assess each resident's fall risk on admission, quarterly, and with each fall. This will help facilitate 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. This policy also documents Interventions will be based on the fall risk assessment and the circumstances surrounding the risk for injury or actual injury or fall. Some examples may be, Falls related to environmental hazards.On 8/27/25 at 10:10 AM, R4's room was observed. R4's ceiling near the room's entry way had a strip of black speckled fuzzy substance on the white ceiling that was scattered amongst an approximate two foot by three-inch area, horizontal to the doorway. The ceiling over R4's bed was lowered, and the corners, wallpapered walls and ceiling contained several speckled gray areas.R1's current care plan, dated 8/26/25, documents R1 has diagnoses including but not limited to Lack of Coordination, Unsteadiness on Feet and Abnormalities of Gait and Mobility. This care plan documents (R1) is at risk for falls related to weakness, hypertension, use of devices such as walker for ambulation, use of psychotropic medications. Fall on 6/10/25 and 8/26/25. Interventions, ensure that (R1) is wearing appropriate footwear with non-slip soles or non-skid socks when ambulating or mobilizing in wheelchair. Night light on in room/bathroom to illuminate area and decrease trip/fall hazards.On 8/27/25 at 10:50 AM, R1 was sitting in a recliner chair in her room. R1's ceiling in front of her recliner contained a large square shaped air vent. The ceiling around the vent was stained tan and bubbled in multiple areas. The ceiling also contained a large metal tract for a privacy curtain and some areas along the tract also were surrounded by tan stained marks. At this time, R1 stated When the air conditioning runs a lot, it will drip water on the floor. I usually put some paper towel over the water when it happens. At this same time on the opposite side of R1's room, near R8's recliner chair, the ceiling contained a smoke detector. This smoke alarm had a ring surrounding it approximately two to three centimeters in width of speckled gray and dark gray scattered spots, along with tan stained areas surrounding. R1 stated facility staff and maintenance are aware of the damages. On 8/27/25 at 10:55 AM, R3's room was observed with a ceiling air conditioning vent which was surrounded by multiple areas of tan stains and bubbled paint. R3's smoke alarm was pulled down approximately eight inches from the ceiling (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146068 If continuation sheet Page 3 of 4 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 08/28/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete and hanging by covered electrical wires. Surrounding the smoke alarm were areas of tan stains on the ceiling.On 8/27/25 at 11:00 AM, V11 (Certified Nursing Assistant) confirmed the ceiling damage in R1, R3 and R8's rooms. V11 stated There is water that drips when it is hot, and the AC (air conditioner) runs frequently. The smoke detector in (R3's room) has been pulled down because they had condensation behind the detector, so they had to pull it out to dry. All the rooms on this side (Rose Lane) drip when it's hot. They all have damage on the ceiling.On 8/27/25 at 11:05 AM, V2 (Director of Nursing) toured the facility's [NAME] Lane hallway and rooms. V2 confirmed that every room in the [NAME] Lane hallway has tan stains surrounding the air vents on the ceilings. V2 stated (V4, Maintenance Supervisor) is trying to reach out to corporate and get a solution for the air conditioner drip problem. It's been an issue for close to a month. When it is hot, the vents will drip onto the floor. The rooms on [NAME] Lane are the ones affected. V2 confirmed the dark gray speckled areas around the smoke detector in R1 and R8's room and the dark black speckled area on R4's ceiling. V2 stated the damage appears to be from water or moisture in the ceiling. On 8/27/25 at 11:20 AM, V4 (Maintenance Supervisor) Confirmed there he has had work orders for the water dripping in [NAME] Lane rooms. V4 stated I believe the room for the work order was room [ROOM NUMBER] or 9 (R14 or R15 and R16's rooms). We had fans blowing constantly in the ceiling. That pulls warm air from the outside and it meets the cool air which causes the moisture. R4 confirmed R17's room has a large black speckled area on the ceiling and over R4's bed there are gray scattered areas on the wallpaper and ceiling. V4 stated There is a vent directly above (R4's) bed and the moisture could be coming from the vents blowing through to the other side of the building. V4 stated he was made aware of the moisture problem, and he has been in contact with (V14, Corporate [NAME] President of Maintenance) for about a month regarding the moisture around air vents, but nothing has been finalized yet to correct the ongoing issue. The facility's (undated) Room Roster provided by V1 (Administrator in Training) on 8/26/25, documents R1, R3 and R5-R16 all reside in the facility's [NAME] Lane hallway. Event ID: Facility ID: 146068 If continuation sheet Page 4 of 4