Inspection·October 25, 2023

F 0624 Level of Harm - Minimal harm or potential for actual harm I had everything set up for her. She already had Help at Home visits on Mondays through Fridays set up, so we were keeping that going. I also had Home Health set up and the nurse was going to be there within 48 hours. We could not keep her here. She would have received a bill and she said she could not pay that bill. What were we supposed to do? I understand that she would have been home by herself for the weekend, and that is not right, but there was nothing we could do. Residents Affected - Few On 10/24/23 at 12:10 PM, R3 stated When I was discharged from the facility before, I thought they had Home Health set up for me. I already had most of the equipment I need at home from my husband, who died a few years ago, but what I really need was someone to come to my home and help me. I would have been afraid to go home without someone coming to help me. On 10/24/23 at 12:25 PM, V9, Licensed Social Worker (LSW) at (local hospital), stated I was familiar with (R3's) situation at home because I spoke with her at the hospital prior to her being discharged . (R3) had no family to assist her and was very concerned about her cat at home. I got ahold of (V11, pet sitter) who owns the (Animal Rescue Center), and she was willing to care for her cat until she made it back home. (R3) was discharged to (Facility) for rehab and when they discharged her, (V11) was the one who picked her up from the facility and took her home. (V11) called me back and stated that (R3) could hardly transfer herself from chair to chair or walk across the house to get needed items, like food and drinks. Home Health was set up, but from I understood, it was not going to happen for a couple of days after she was home. When she got home, there was a large bag of medications and (R3) said she wasn't sure which ones to take or when. This is what the concern was, she was going to be by herself for a couple of days and no one was able to help her. On 10/24/23 at 1:40 PM, V2, Director of Nursing (DON), stated (R3) had the right to go home and not stay here. She fell at home but that was more than 48 hours after discharge, so the Home Health nurses should have been doing something with her. I understand that she was sent home with no one to care for her for 48 hours, but she wanted to go home. The nurses went over the medications with (R3), and she had discharge instructions about her medications to take with her, and most of them she was already on at home, so probably understood when to take them. On 10/24/23 at 2:10 PM, R3 stated I don't have any friends or family anymore. My sister is really all I have, and she is in her 70's and lives in Florida. I did not feel safe going home from here, but I didn't have any other options. I figured therapy would not be doing anything with me over the weekend, anyway, so why not just go home. It was scary, so I just did the least amount of activity to stay safe. (V11) came and got me and took me home and got me settled inside, then she left. When I got home, I had all the medications in a bag and was confused what was what. I already had some pills in little plastic containers that I knew what they were, so I just took them until the nurse came in and figured it out. The nurse didn't show up until Monday. I live in a mobile home and get around the best I can by using a walker and holding onto furniture. I fell twice after I got home and both times, I had to use my emergency button and call 911. They showed up and took me to the ER (Emergency Room). This next time I get discharged , I'm going to go live with my husband's family, they are getting me a room set up to live with them. On 10/24/23 at 2:41 PM, V11, R3's pet sitter/ride home, stated I work for the (Animal Rescue Center), and we have an agreement with (local hospital) for when patients are hospitalized and have no one to watch their pets, we go take care of their pets for them. (V9, Social Worker) called me and asked me to take care of (R3's) cat and that is how I got involved. I was in contact with (R3) about her cat, while she was in the facility, so when she was getting ready to be discharged , she called me and said the facility was going to charge her $150 to take her home and she couldn't afford that, so (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146160 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 146160 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springfield Suites Rehab and Nursing 3089 Old Jacksonville Road Springfield, IL 62704 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 0624 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few I went and got her. When we got to her home, it was disheveled and very difficult to walk around her house. When we got her in her house, she was so weak she could hardly do anything. I could not leave her like that, but I could not stay with her all night either. The facility called in prescriptions for her medications, so my friend went and picked them up and paid for them, then stopped and picked up some food and brought it back for her. I ended up calling (R3's) niece and explained what was going on to her and I believe she did come see (R3) at some time and ended up texting me and told me that (R3) needs twenty-four-hour care and should not be living by herself. On 10/24/23 at 4:00 PM, V1, Administrator, stated I would expect Social Service to plan and arrange a safe discharge for all residents, including appropriate home care and DME (Durable Medical Equipment) as resident requires. R3's Social Services Note, dated 9/19/23 at 2:00 PM, documents Social Service Discharge Planning: Insurance set the guest a discharge date for September 22nd. Writer made the guest aware and let her know that she does have the option to appeal it. She said she does not want to appeal it and signed the NOMNC (Notice of Medicare Non-Coverage). Writer asked if she wanted home health therapy, and she said yes. Writer let her know she will set up Advanced home health. Writer asked if she needed caregivers, and she said yes. Writer let her know she will send her referral to Senior Services. She said thank you. Writer asked if she needed any equipment, and she said no. Writer let her know that family would have to pick her up. She said she does not have anyone in town. Writer let her know she will call a local Transport Company transport and see if they could take her home. She said OKAY. R3's Social Service Note, dated 9/19/23 at 2:16 PM, documents Social Service Discharge Planning: writer sent the guest's referral to (Home Health Agent) with (Home Health Company #1 Name) home health. Writer faxed the guest's referral to agency to assist with Senior Services for caregivers. R3's Social Service Note, dated 9/19/23 at 3:05 PM, documents Social Service Discharge Planning: Advanced home health is unable to accept. Writer emailed the guests referral to (Home Health Agent) with (Home Health Company #2 Name) home health. R3's Social Service Note, dated 9/21/23 at 1:16 PM, documents Social Service Discharge Planning: the guest let therapy know she now needs a walker. Writer submitted for a 2 wheeled walker through (Medical Equipment Company) online portal. R3's Physical Therapy (PT) Note, dated 9/21/23, documents Response to Session Interventions: Good, some goals met, recommend home health and 24/7 care and to continue at home at WC level and ambulate with assistance only. R3's Physical Therapy Discharge Note, dated 9/21/23, documents Discharge Recommendations: Recommend senior services, home health to follow, 24/7 care and a two wheeled walker. R3's Social Service Note, dated 9/22/23 at 12:56 PM, documents Social Service Discharge Summary: (R3) discharged to home with help from a friend. AXO (alert and oriented). Follow up with PCP (primary care physician). Follow up with (Home Health Company #1) home health and help at home. Patient unable to pay for DME at this time will use her four wheeled walker at home. Belongings were sent home with the guest. R3's Social Service Note, dated 9/22/23 at 3:33 PM, documents Social Service Discharge Planning: writer called Dr. office and let them know that the guest discharged today, and the NP (Nurse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146160 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 146160 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springfield Suites Rehab and Nursing 3089 Old Jacksonville Road Springfield, IL 62704 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 0624 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Practitioner) would like a follow up in a week. Writer asked if she would call the patient with the appointment. She said she will give the message to the nurse. R3's Hospital Record, dated 10/14/23, documents [AGE] year-old female presenting after a fall. Patient was here yesterday with same complaint. She had x-ray hips and CT (cat scan) of the pelvis yesterday which were unremarkable. She also had a UA (urinalysis) that showed findings of UTI, but this was not treated since patient was reportedly asymptomatic. Since then, culture has grown >100,000 E coli. She had another fall today; says she is not eaten since yesterday morning because she has not been able to get up at home. Yesterday she refused ECF (extended care facility) placement. Today she is saying she still has bilateral hip pain, but it has not changed since yesterday. She has some complaints of rib pain and right arm pain which she says have been going on for some time. R3's Hospital Record/OT (Occupational Therapy) Note, dated 10/15/23, documents Safety concerns: home access, lives alone, Patient is unsafe to live independently at home at this time. Will require (at a minimum) 24 hour assist at home. OT recommends ECF (extended care facility) stay following discharge. Problem list: impaired activity tolerance, impaired balance, impaired safety awareness, difficulty with bed mobility, difficulty with transfers, difficulty with activities of daily living, difficulty with instrumental activities of daily living, Frequent falls. R3's Nurse's Note, dated 10/19/23, documented The guest is a [AGE] year-old female admitted on [DATE]th following repeated falls. R3's Care Plan, dated 10/20/23, documents R3 has an ADL (Activities of Daily Living) deficit. Interventions: transfer/mobility per therapy recommendations, provide set up for meals as needed, assist with hygiene as needed, encourage oral care BID (twice daily) as needed, assist to bedpan/toilet upon request, provide physical assistance for dressing as needed. The facility's Discharge Planning Policy, dated 11/28/16, documents To ensure appropriate discharge planning and communication of necessary information to a continuing care provider if indicated. The facility's Addendum to the Transfer/Discharge Policy, dated 11/28/16, documents The facility will provide and document sufficient preparation and orientation to residents to ensure a safe and orderly transfer or discharge from the facility. The orientation will be provided in a form and manner that the resident understands. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146160 If continuation sheet Page 4 of 4