Inspection·December 14, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some diagnoses of Right humerus fracture, Hypertension (HTN), Atherosclerotic heart disease (ASHD), Atrial fibrillation, Cardiac pacemaker, Sick sinus syndrome, Osteoarthritis, Falls, Hyperlipidemia, Myocardial infarction, Urinary tract infections (UTI), and Left tibia fracture. R157's Care Plan, dated 12/8/23, documents R157 is at risk for falls related to weakness, impaired mobility, balance, and age. Interventions: Therapy as ordered for mobility, keep personal items, and frequently used items within reach, fall risk assessment on admit and per protocol, encourage to call for assistance as needed, assist to toilet upon request. It continues R157 will improve ability in ADL's (Activities of Daily Living). Interventions: Transfer/mobility per therapy recommendations-see mobility Kardex sheet in closet, see therapy plan of treatment for therapy specific goals, PT (Physical Therapy)/OT (Occupational Therapy) for strengthening/endurance, follow PT/OT/ST (Speech Therapy) recommendations, assist to bedpan/toilet upon request and per mobility Kardex instructions. R157's MDS, dated [DATE], documents R157 is cognitively intact and the rest of the MDS is not completed. R157's Mobility Kardex, taped to her closet door, dated 12/8/23, documents Transfers to wheelchair/bed: GB (gait belt) X1, Quad Cane. Transfers to toilet: GBX1, grab bars. Ambulation: With therapy only. On 12/11/23 at 11:05 AM, R157 stated she fell at home and broke her right arm. R157 has her right arm in a sling, and extensive bruising to her right face and forehead. R157 stated that therapy is working with her because she is so weak. On 12/12/23 at 9:58 AM, R157 was sitting in her wheelchair and requesting to use the restroom. V13, CNA, entered to assist to assist R157 to the restroom. V13 pushed R157 to the toilet, and with no gait belt around R157, V13 held onto R157 around her armpit area as R157 stood up. V13 pulled R157's pants down and R157 was lowered to toilet to void. V13 did not instruct the resident to use the grab bars by the toilet. On 12/14/23 at 10:45 AM, V1, Administrator, stated On the Mobility Kardex for each resident, the GBX1 or GBX2 refers to the use of a Gait Belt. On (R157's), someone hand wrote in Grab Bars to use in the restroom as well. 3. R1's Face Sheet, undated, documents R1 was originally admitted to the facility on [DATE] and has diagnoses of Traumatic subdural hemorrhage, Hypertension, Major depressive disorder, UTI's, Falls, Overactive bladder, Hypothyroidism, and Peripheral vascular disease. R1's admission Fall Assessment, dated 4/7/23, documents R1 as a High Fall Risk. R1's Care Plan, dated 11/24/23, documents R1 is at risk for falls related to weakness, impaired mobility, balance, age, and history of falls: 8/3/23 and 10/10/23. Interventions: 10/11/23: Non-skid to wheelchair, fall risk assessment on admit and per protocol, therapy as ordered for mobility, keep personal items, and frequently used items within reach, encourage to call for assistance as needed, assist to toilet upon request. It continues (11/30/23) R1 has ADL (Activities of Daily Living) deficit. Guest admitted s/p fall with small subdural hematoma and UTI (Urinary Tract Infection). R1 is alert with confusion noted. R1 is a two assist with pivot transfer to wheelchair. R1 has some resistance due to fear of falling. May use assist of two and (full body mechanical lift) for transfers. Requires assistance with tray due to impairment and weak grasps. Incontinent of Bowel and Bladder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146160 If continuation sheet Page 2 of 15 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 12/14/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interventions: transfer/mobility per therapy recommendations-see mobility Kardex sheet in closet, see therapy plan of treatment for therapy specific goals, assist to bedpan/toilet upon request and per mobility Kardex instructions, follow PT (Physical Therapy)/OT (Occupational Therapy)/ST (Speech Therapy) recommendations, PT/OT for strengthening/endurance. R1's MDS, dated [DATE], documents R1 has a moderate cognitive impairment and requires extensive assistance from one to two staff members for all ADLs. R1's MDS documents R1 is always incontinent of bladder and frequently incontinent of bowel. The facility's Fall Log, dated from 7/11/23 through 12/11/23, documents R1 has had a fall on 8/3/23 and 10/10/23. R1's Progress Note, dated 8/3/23 at 4:56 AM, documents at 7:50 PM on 8/2/2023, writer was called by CNA (Certified Nursing Assistant) that guest was lowered to the floor by her to avoid her from falling. Guest was seen sitting on the floor in front of her bed in her room. Since guest was sitting on the floor, it is considered a fall with no injury. No injury or pain was sustained by guest. Guest is alert and oriented. CNA stated she was moving guest into bed from her wheelchair and as she was trying to resist the movement into bed, she then lowers her to the floor to prevent her from falling. Doctor notified about fall. Resident's son called and informed of resident's fall. The on-call nurse notified. VS (vital signs) 97.3 (temperature), 80 (pulse), 20 (respirations), 132/67 (blood pressure), 96 (oxygen saturation level). R1's Care Plan, does not have a fall intervention after this fall dated 8/3/23. R1's Progress Note, dated 10/10/23 at 6:46 PM, documents Aide came to nursing desk and stated (R1) fell at 6:20 PM. Aide stated that she was transferring guest to bed from wheelchair and as she was scooting guest forward in wheelchair the pad in the chair started to slide out. Aide stated that she lowered guest to the floor. Writer went to room with aide, guest was sitting up against the wall. Shoes were on guest. Guest stated that she was in no pain. Guest was able to perform ROM (Range of Motion) without pain, guest skin intact no redness noted. Aide gathered vital signs as follows . BP- 167/83, P-95, T- 97.3, O2- 93 room air, Resp- 20. Writer and aide helped guest to chair and then to the side of the bed to transfer into bed. Guest tolerated transfer well. Writer assessed buttocks and back once into bed, no redness, skin intact. Writer then asked again guest pain level if any and guest stated she was in no pain still. Writer notified guest son via telephone. Writer notified Doctor NNO (no new orders). Fall event put in as well. R1's Care Plan Update, dated 10/11/23, has a new fall intervention of Non-skid to wheelchair. There are no other Fall Assessments documented in R1's Medical Record, other than the initial admission Fall Assessment on 4/7/23. 4. R167's Face Sheet, undated, documents R167 was admitted to the facility on [DATE] and has diagnoses of Metabolic encephalopathy, Traumatic subdural hemorrhage, Major depressive disorder, UTI, Right fibula fracture, HTN, Generalized anxiety disorder, and Sepsis. R167's Care Plan, dated 12/11/23, documents R167 is at risk for falls related to weakness, impaired mobility, balance, and age. Intervention: reminder signs, 12/8/23: bed alarm to remind to call for assistance, fall risk assessment on admit and per protocol, therapy as ordered for mobility, keep personal items, and frequently used items within reach, encourage to call for assistance as needed, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146160 If continuation sheet Page 3 of 15 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 12/14/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some assist to toilet upon request. It continues R167 will improve ability in ADLs: Interventions: Transfer/mobility per therapy recommendations-see mobility Kardex sheet in closet, see therapy plan of treatment for therapy specific goals, assist to bedpan/toilet upon request and per mobility Kardex instructions, PT/OT/ST recommendations, PT/OT for strengthening/endurance. R167's MDS, dated [DATE], documents R167 is cognitively intact and the rest of R167's MDS was not completed. The facility's Fall Log, dated 7/1/23 through 12/11/23, documents that R167 had a fall on 12/8/23. R167's Fall Risk Assessment, dated 12/5/23, documents R167 is a High Risk for falls. R167 has not had another Fall Risk Assessment completed after his fall on 12/8/23. R167's Progress Note, dated 12/8/23 at 7:29 AM, documents Guest admitted to facility with UTI/sepsis and subdural hemorrhage. Guest is alert and able to make his needs be known. Takes medications whole without any difficulties. Midline in place and patent. Currently on IV ABT/UTI-sepsis. No adverse reactions from antibiotics. Guest is afebrile. LS (lung sounds) CTA (clear to auscultate), no cough or SOB noted at this time. Respirations even and unlabored. Guest is incontinent of bowel and bladder, peri-care performed q2hr and PRN. Abdomen is soft and nontender. BSx4. VS WNL. Denies any pain or discomfort at this time. Currently resting in bed. R167's Progress Note, dated 12/8/23 at 6:37 PM, documents CNA, (proper name), reported that guest had gotten himself out of bed and into his wheelchair. she went to get assistance to get him in bed and get a bed alarm. when she went back into room guest had gotten himself out of the wheelchair and on the floor. writer and two CNAs got the guest back into his bed. Doctor was contacted and made aware of the situation. Emergency contact was contacted and made aware of the situation. Nurse manager was made aware of the situation. Physical assessment: writer did not observe any open wounds on guest. Vitals: T-97.3F, BP-143/89, HR-76,02-94%, Pain-guest did state that he was in some pain. On 12/11/23 at 12:43 PM, R167 was seen sitting in his recliner, stated he's here for rehab, and has a sign on wall Please use call light to call for assistance. R167 stated he has fallen here at the facility. 5. R154's Face Sheet, undated, documents R154 was admitted to the facility on [DATE] and has diagnoses of Pneumonia, Acute respiratory failure, Thoracic aortic ectasia, Atrial Fibrillation, HTN, Acute cystitis, CKD, Obstructive and reflux uropathy, Hyperlipidemia, Hypothyroidism, and Cardiac Arrest. R154's Care Plan, dated 11/13/23, documents R154 is at risk for falls related to weakness, impaired mobility, balance, and age. Interventions: Fall risk assessment on admit and per protocol, therapy as ordered for mobility, keep personal items, and frequently used items within reach, encourage to call for assistance as needed, assist to toilet upon request. It continues R154 has an ADL deficit. Interventions: Transfer/mobility per therapy recommendations-see mobility Kardex sheet in closet, see therapy plan of treatment for therapy specific goals, assist to bedpan/toilet upon request and per mobility Kardex instructions. follow PT/OT recommendations, PT/OT for strengthening/endurance. R154's MDS, dated R154 has a moderate cognitive impairment and requires partial/moderate assistance from staff for toileting, sit to stand assistance, and chair/bed-to-chair transfers. R154's MDS documents R154 has a urinary catheter in place and is always continent of bowel. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146160 If continuation sheet Page 4 of 15 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 12/14/2023 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 0689 R154's Fall Assessment, dated 11/13/23, documents R154 is a High Fall Risk. Level of Harm - Minimal harm or potential for actual harm On 12/12/23 at 9:52 AM, R154 requested to get into his wheelchair. V13, CNA, and V14, CNA, entered the room to provide assistance to R154. R154 had sat himself up to the side of his bed, and with no gait belt placed around R154, both CNAs grabbed under R154's armpit with one hand and onto R154's top of his pants with the other hand and assisted R154 to stand. R154 was weak and unable to stand on first attempt, so he sat back down onto the bed. R154 stood up again and pivoted to his locked wheelchair and then sat down. Residents Affected - Some On 12/14/23 at 1:08 PM, V25, CNA, stated We use the Kardex taped to the resident's closet to see what requirements they have for transfers, especially if they are a new admission. On 12/14/23 at 1:10 PM, V1, Administrator, stated I would expect all staff to use the resident's Kardex to see what that resident's needs are for transfers and assistance. The Facility's Fall Policy, undated, documents To identify interventions related to the guest's specific risks and causes to try to prevent the guest from falling and to try to minimize complications from falling. Procedure: 1. The IDT will identify appropriate interventions to reduce the risk of falls. 4. The licensed nurse is responsible for completing a Fall Risk Assessment following a fall as well as identifying and implementing relevant intervention(s) to try to minimize serious consequences of falling. 7. If falling occurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146160 If continuation sheet Page 5 of 15 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 12/14/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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** Based on observation, interview and record review the facility failed to provide complete incontinent care for 4 of 4 (R1, R7, R160, R253,) residents reviewed for incontinence care in a sample of 34. Findings include: 1. R7's Care Plan, date 8/17/23, documents Problem: ADL (Activities of Daily Living) deficit with potential for improvement. R7's Care Plan documents R7 is occasionally incontinent of bowel and bladder and requires assist with ADLs (activities of daily living). R7's Minimum Data Set (MDS), dated [DATE], documents that R7 is cognitively intact, dependent for toileting and occasionally incontinent. On 12/12/23 at 10:05 PM V16, Certified Nurse's Assistant (CNA), and V15, CNA, assisted R7 with toileting. V16 and V15 assisted R7 into the standing position revealing incontinent brief hanging between R7's leg. V15 then removed the soiled incontinent brief. V15 and V16 assisted R7 onto the toilet. R7 then voided urine and feces. Using a wet washcloth with soap and water and handed it to R7 and R7 washed her face. V16 then using a wet a washcloth, wiped down each side of R7's peri area. V15 and V16 then assisted R7 into a standing position. V16 then cleansed R7's anal area. V15 and V16 then pulled up R7's incontinent brief and pants and assisted her into the wheelchair. V16 did not cleanse R7's labia, inner thighs, or buttocks. V16 did not cleanse all skin surfaces exposed to urine and feces. On 12/14/23 at 11:23 AM V2, Director of Nursing, stated that she would have expected the staff to perform incontinent care even if the resident voids on the toilet. On 12/14/2023 at 1:03 PM V24, Registered Nurse (RN), stated that she would expect the staff to cleanse all areas of incontinence. V24 stated that this would include anywhere the urine or stool could be. 2. R253's Care Plan does not address R253's incontinence. R253's admission Nursing Assessment, dated 12/1/2023, documents that R253 is alert, oriented to person, place and time. The assessment continues to document that R253 has a range of motion functional limitation that effects R253's bathing and mobility. It also documents that R253 is always incontinent. On 12/11/2023 at 10:58 AM V7, CNA, provide incontinent care to R253. R253 was incontinent of urine. V7 using a washcloth and soap cleansed R253's peri area. V7 then turned R253 onto her right side and cleansed R253's left buttock and partial right buttock. V7 then placed a clean incontinent brief under R253. V7 then turned R253 to her left side and pulled the incontinent brief under R253. V7 then assisted R253 onto her back and pulled the incontinent brief between R253's legs and fastened the brief. V7 stated at that time she was finished with incontinent care. V7 pulled bed linen over R253 and left the room. V7 did not cleanse R253's inner thighs, inner labia, and entire right buttock. V7 did not cleanse all skin surfaces exposed to urine. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146160 If continuation sheet Page 6 of 15 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 12/14/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. R160's Face Sheet, undated, documents R160 was originally admitted to the facility on [DATE] and has diagnosis of Osteomyelitis, Acquired absence of left toe, Anemia, Hypertension (HTN), Atrial Flutter, Asthma, Anxiety disorder, Hypothyroidism, Insomnia, and Macular degeneration. R160's Care Plan, dated 12/7/23, documents R160 has an ADL deficit, incontinent of bowel and bladder. Interventions: Assist to bedpan/toilet upon request and per mobility Kardex instructions, assist with hygiene as needed, transfer/mobility per therapy recommendations-see mobility Kardex sheet in closet. It continues R160 is at risk for falls related to weakness, impaired mobility, balance, age, and recent amputation of left second toe. Interventions: Equip resident with device that monitors rising bed alarm, give resident verbal reminders not to ambulate/transfer without assistance, fall risk assessment on admit and per protocol, therapy as ordered for mobility, keep personal items and frequently used items within reach, encourage to call for assistance as needed, assist to toilet upon request, fall risk. R160's MDS, dated [DATE], documents R160 has a moderate cognitive impairment and requires dependence on staff for toileting. R160 is frequently incontinent of urine and occasionally incontinent of bowel. On 12/12/23 at 10:08, AM, R160, V13, CNA, and V14, CNA, entered to provide peri-care to R160. V14 wet some disposable wipes, with no cleanser, and placed them on the cold windowsill, used one to wipe once down each of R160's groin and then using same wipe, once down the middle of her vagina. R160 rolled to the right side, and her wet brief was removed. V14 using the same soiled gloves, wiped three times to R160's anal area, which had feces, and then a new incontinence brief was placed under R160, with no drying done. V14 used the same soiled gloves again to apply barrier cream to R160's buttocks and anal area, and then fastened the incontinence brief and covered R160 up with her sheet. 4. R1's Face Sheet, undated, documents was originally admitted to the facility on [DATE] and has diagnoses of Traumatic subdural hemorrhage, Hypertension, Major depressive disorder, UTI's (urinary tract infection), Falls, Overactive bladder, Hypothyroidism, and Peripheral vascular disease. R1's Care Plan, dated 11/24/23, documents R1 is at risk for falls related to weakness, impaired mobility, balance, age, and history of falls: 8/3/23 and 10/10/23. Interventions: Non-skid to wheelchair, fall risk assessment on admit and per protocol, therapy as ordered for mobility, keep personal items and frequently used items within reach, encourage to call for assistance as needed, assist to toilet upon request. It continues (11/30/23) R1 has ADL deficit. Guest admitted s/p fall with small subdural hematoma and UTI. R1 is alert with confusion noted. R1 is a two assist with pivot transfer to wheelchair. R1 has some resistance due to fear of falling. May use assist of two and (full body mechanical lift) for transfers. Requires assistance with tray due to impairment and weak grasps. Incontinent of Bowel and Bladder. Interventions: transfer/mobility per therapy recommendations-see mobility Kardex sheet in closet, see therapy plan of treatment for therapy specific goals, assist to bedpan/toilet upon request and per mobility Kardex instructions, follow PT (physical therapy)/OT (occupational therapy)/ST (speech therapy) recommendations, PT/OT for strengthening/endurance, R1's MDS, dated [DATE], documents R1 has a moderate cognitive impairment and requires extensive assistance from one to two staff members for all ADLs. R1 is always incontinent of bladder and frequently incontinent of bowel. On 12/12/23 at 10:35 AM, R1 was lying in bed, V14, CNA had just put a clean sweater on R1 and requested V13, CNA, assistance to put R1's pants on. Both CNAs were attempting to put R1's pants on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146160 If continuation sheet Page 7 of 15 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 12/14/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some without checking to see if R1 was incontinent. When asked if R1 was wet or soiled, V14 checked R1's incontinence brief and stated, yes, she is wet. V13 gathered incontinence supplies and brought over a handful of wet disposable wipes, and an incontinence brief, and placed them on a dirty bedside table. V14 tucked R1's soiled brief between R1's legs, and then used a wet wipe, with no cleanser on it, and wiped once down each of R1's groin and then once down the middle of R1's vagina. R1 rolled to her right side and V13 wiped R1's anal area three times, which was showing feces on the wipes. R1's buttocks was not wiped/cleaned at any point, and R1 was not dried at all. Both CNAs used the same soiled gloves throughout the procedure and to put a new incontinence brief on R1, fastened the brief, and then put R1's pants on. The Facility's Incontinent/Perineal Care Policy, undated, documents It is the policy of the facility to provide incontinent/perineal care for the guests as indicated by the guest's condition and ability to provide self-care. Perineal care will cleanse the perineum and prevent infections and odors. Incontinent care will include all skin surfaces exposed to urine and/or feces. Procedure: Moisten the washcloth with warm water and apply No Rinse Cleanser. Cleanse all skin areas that have been exposed to urine and/or feces. Repeat cleansing, if necessary, using each cloth only once. Pat dry. Remove and discard soiled gloves after completing perineal care and prior to touching anything clean (sheets, blankets, etc.). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146160 If continuation sheet Page 8 of 15 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 12/14/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On [DATE] at 9:47 AM the F Hall medication cart was inspected. The cart had the following: R255's Glargine insulin pen with no opened date on the label. V8, LPN, verified that the Glargine was open and in use. On [DATE] at 12:46 PM V2 stated that she expects the nurses to put an open date on the insulin pen once opened. V2 stated that this is because the insulin has a shorter expiration once open. 3. R14's Refresh Classic (PF) (polyvinyl alcohol-povidone(pf)) eye drops were opened. There was opened date on the label. 4. R16's Timolol Maleate drops; 0.5 %; amt (amount): 1gtt (drop) OU BID (place the drops in both eyes, but separately); ophthalmic (eye). No open date. 5. On [DATE] at 10:09 AM R48's Anti-fungal powder was on R48's over bed table in R48's reach. R48's Physician Order Sheet (POS) documents Anti-fungal powder under bilateral breasts and abdominal fold. Special Instructions: Gently cleanse area, pat dry, apply powder. The physician orders do not document keep at bedside. R48 does not have an order to keep medications at bedside. 6. On [DATE] at 10:13 AM a bottle of ipratropium bromide nasal spray was on R31's bedside table in R31's reach. R31's POS, documents ipratropium bromide spray, non-aerosol; 42 mcg (micrograms) (0.06 %); amt (amount): 2 sprays; nasal. The order does not document keep at bedside. R31 does not have an order to keep medications at bedside or self-administer medication. 7. On [DATE] at 9:20 AM R17 was sitting in the recliner with a Diltiazem ER 180 mg (milligrams) pill, and a Zoloft 100 mg pill in a clear cup in R17's reach. R17's POS documents [DATE] sertraline tablet; 100 mg; amt: 1 tab; oral Once a Day and Diltiazem HCl capsule, extended release 24 hr. (hour); 180 mg; amt: 1 cap; oral Once a Day. The orders do not document to keep at bedside or self-administer. R17 does not have an order to keep medications at bedside. On [DATE] at 11:19 AM V24, Registered Nurse (RN), stated that when opening the insulin and the eye drops that they are multi dose bottles and pens. V24 stated that they put an open date on the pens and eye drops because these medications have a different expiration date once open. V24 stated that the open date is what informs them of the date the medication is expired. V24 stated that when administering medication, they are to stay with resident until the medication is taken. V24 stated that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146160 If continuation sheet Page 9 of 15 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 12/14/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many the medications are not to left with the resident. V24 stated that no medications are left at bedside unless there is an order. On [DATE] at approximately 1:30 PM V19, LPN, stated that the eye drops are to be dated with an open date. V19 stated that this was because the expiration for the eye drops changes and is less than the manufacture. The facility's Storage of Medication poly, not dated, documents Purpose: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Procedure: Drugs and Biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. 2. Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. The facility's Medication Administration policy, not dated, documents Administration of Oral Medications: 4. Administer the medications with at least 4 oz (ounce) of water. 5. Observe the guest swallow the medication. Only leave it at bedside if there is a physician's order for self-administration for the medications. Based on observations and interview the facility failed to date multi use vials of medications when accessed, failed to date an open insulin pen, failed to date eye drops and left medications unattended at bedside. This failure has the potential to affect all 64 residents in the facility. Findings include: 1.On [DATE] at 10:45AM the medication storage refrigerator located on B hall contained a vial of Afluria quadrivalent (influenza immunization) that was opened and not dated. On [DATE] at 10:47AM, V9, Licensed Practical Nurse, LPN states the vial of influenza immunization should be dated with the date of when it was opened. [DATE] 12:46 PM V2, Director of Nursing, stated that any resident who has orders for and is not allergic to the flu vaccine could have received the non-dated influenza immunization and that she expects the staff to date open vials, eye drops and to not leave meds unattended at the bedside. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146160 If continuation sheet Page 10 of 15 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 12/14/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations and interview, the facility failed to remove expired food from the shelves and for resident use. This has the potential to affect all 64 residents in this facility. Residents Affected - Many Findings include: On 12/11/23 at 9:15 AM, the facility's kitchen was toured with V5, Dietary Manager, and the following was found: In the dry storage room, there was one gallon of Teriyaki Sauce, open and used, with an expiration date of 11/12/23, with no open date written on the bottle. There was another gallon of Teriyaki Sauce that was unopened with an expiration date of 11/12/23. Two one-gallon containers of 1000 Island Dressing was seen unopened with an expiration date of 12/26/22. V5 stated that any leftover in a pan is only good for three days and then must be pitched. The refrigerator was toured with V5, and the following items were seen: Five-pound container of Cottage Cheese, with an open date of 11/28/23 and an expiration date of 11/23/23. There was another five-pound container of Cottage Cheese, unopened, with an expiration date of 11/23/23. There were another two five-pound containers of Cottage Cheese with expiration dates of 12/7/23. There was a pan of mixed vegetables covered with plastic wrap and dated 12/8/23, a pan of Turkey Salad that was dated 12/6/23, a pan of Vegetable Soup covered with plastic wrap with a date of 12/5/23, and a five-pound container of Dry Grated Parmesan Cheese with an expiration date of 8/29/23. On 12/13/23 at 8:45 AM, V5 stated When a new delivery truck arrives, we rotate stock and should be checking expirations at that time and frequently afterwards. Any leftover covered in pans in the refrigerator is only good for three days. I would expect the staff to check for expirations and throw away anything expired. On 12/13/23 at 8:55 AM, V17, Dietary Aide, stated I'm usually the one who unloads the truck. I will pull out the old stuff, date the new stuff, and put on the shelves, then put the old stuff in front of it and make sure we use it first. The leftovers put in the fridge is only good for three days. On 12/13/23 at 3:30 PM, V1, Administrator, stated I was told that (V5) and his staff were watching the expirations of food items and taking care of them. On 12/14/23 at 9:10 AM, V22, Dietary Aide, stated We use whatever is left over for various reasons. Sometimes the cook will use the leftovers for another plate, for example, if there is leftover chili, the cook will add it to noodles to make chili mac. Sometimes a resident will request something that we had yesterday, and if there is any left, we will give them some. I believe the cook is the one supposed to be watching for the expirations. On 12/14/23 at 9:20 AM, V23, Cook, stated The cooks are the ones who usually keep track of the expiration dates and will throw things out if expired. I always say use it or lose it after three days. There are occasions when an expired item will slip past us and not get noticed, but not too often. If I recall, we have to save some of the food items in case we have a food borne illness and the food can be examined. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146160 If continuation sheet Page 11 of 15 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 12/14/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 12/14/23 at 9:48 AM, V5 stated Any leftovers, should be in a covered pan with the date the item was cooked written on top. When we go into the refrigerator and see a date of three days ago, we are supposed to dispose of that item. The policy says that leftover foods will be covered, labeled and dated with the date the product was prepared and use by date (discard date). The Facility's Food Storage Policy, dated 12/10/22, documents 1. All foods stored in the refrigerator or freezer are covered, labeled, and dated (use by date). 7. Refrigerated foods are labeled, dated, and monitored so they are used by their use by date. The Facility's Sanitation and Food Safety: Leftovers Policy, dated 5/31/21, documents Leftovers shall be cooled and stored in a safe and sanitary manner to maintain food safety and quality. 2. Leftover foods will be properly covered, labeled, and dated with date product was prepared and use by date (discard date). The Resident Census and Conditions of Residents, CMS 671, dated 12/11/23, documents that the facility has 64 residents living in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146160 If continuation sheet Page 12 of 15 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 12/14/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 12/11/2023 at 10:16 AM R3's Nebulizer Therapy tubing was attached to the machine. The tubing was lying on top of R3's bedside table with multiple items. The tubing was uncovered. The tubing was not in a plastic bag. Residents Affected - Some On 12/12/23 at 9:25 AM R3's Nebulizer Therapy tubing was attached to machine. The tubing was lying on top of bedside table with multiple items. The tubing was uncovered. On 12/14/2023 AM R3's nebulizer Therapy tubing was in a plastic bag on top of bedside table. On 12/11/2023 at 10:1 AM R3 stated that she uses the machine and has not seen anyone wash it with soap and water. R7 stated that the tubing is usually sits like this all the time. On 12/14/2023 at 11:19 AM V24, Registered Nurse, RN, stated that the nebulizer tubing is to be washed and placed in a plastic bag. V24 stated that this help prevent germs from getting on the tubing that could be inhaled in the lungs. On 12/14/2023 at 12:14 PM V2, Director of Nursing, stated that she would expect her staff to follow policy and procedure and cleanse the parts with soapy water and store in plastic bag. 4. On 12/11/2023 at 1:40 PM R7's Nebulizer Therapy tubing was attached to the machine. The tubing was lying on top of R7's bedside table with multiple items. The tubing was uncovered. The tubing was not in a plastic bag. On 12/12/23 at 10:05 AM R7's Nebulizer Therapy tubing was attached to machine. The tubing was lying on top of bedside table with multiple items. The tubing was uncovered. On 12/11/2023 at 1:40 PM R7 stated that she uses the machine and has not seen anyone wash it with soap and water. R7 stated that she does not remember them being covered. R7 stated that the tubing is usually in the same place. R7's Minimum Data Set, dated [DATE], documents that R7 is cognitively intact. The facility's policy Nebulizer Therapy, not dated, documents Procedure: 15. Rinse all parts of the nebulizer under warm water after each treatment. 16. Wash all parts of the nebulizer in warm soapy water daily. 17. Rinse well and shake excess water from equipment. 18. Store in a plastic bag. The facility's Hand Hygiene, not dated, documents The facility considers hand hygiene the primary means to prevent the spread of infection. Procedure: 8. The use of gloves does not replace hand hygiene. Based on interview, observation, and record review, the facility failed to provide hand hygiene/glove changes during incontinent care and cleanse and store respirator equipment to prevent the spread of infection for 4 of 6 residents (R1, R3, R7, R160) reviewed for infection control in a sample of 34. The findings include: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146160 If continuation sheet Page 13 of 15 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 12/14/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1. R160's Face Sheet, undated, documents R160 was originally admitted to the facility on [DATE] and has diagnosis of Osteomyelitis, Acquired absence of left toe, Anemia, Hypertension (HTN), Atrial Flutter, Asthma, Anxiety disorder, Hypothyroidism, Insomnia, and Macular degeneration. R160's Care Plan, dated 12/7/23, documents R160 has an ADL (Activities of Daily Living) deficit, incontinent of bowel and bladder. Interventions: Assist to bedpan/toilet upon request and per mobility Kardex instructions and to assist with hygiene as needed. R160's Minimum Data Set (MDS), dated [DATE], documents R160 has a moderate cognitive impairment and requires dependence on staff for toileting. R160 MDS documents R160 is frequently incontinent of urine and occasionally incontinent of bowel. On 12/12/23 at 10:08, AM, R160, V13, Certified Nursing Assistant (CNA), and V14, CNA, entered to provide peri-care to R160. V14 wet some disposable wipes, with no cleanser, and placed them on the cold windowsill, used one to wipe once down each of R160's groin and then using same wipe, once down the middle of her vagina. R160 rolled to the right side, and her wet brief was removed. V14 using the same soiled gloves, wiped three times to R160's anal area, which had feces, and then a new incontinence brief was placed under R160, with no drying done. V14 used the same soiled gloves again to apply barrier cream to R160's buttocks and anal area, and then fastened the incontinence brief and covered R160 up with her sheet. 2. R1's Face Sheet, undated, documents R1 was originally admitted to the facility on [DATE] and has diagnoses of Traumatic subdural hemorrhage, Hypertension, Major depressive disorder, Urinary Tract Infections (UTI's), Falls, Overactive bladder, Hypothyroidism, and Peripheral vascular disease. R1's Care Plan, dated 11/24/23, documents R1 is at risk for falls related to weakness, impaired mobility, balance, age, and history of falls: 8/3/23 and 10/10/23. Interventions: Non-skid to wheelchair, fall risk assessment on admit and per protocol, therapy as ordered for mobility, keep personal items, and frequently used items within reach, encourage to call for assistance as needed, assist to toilet upon request. It continues (11/30/23) R1 has ADL deficit. Guest admitted s/p fall with small subdural hematoma and UTI. R1 is alert with confusion noted. R1 is a two assist with pivot transfer to wheelchair. R1 has some resistance due to fear of falling. May use assist of two and (full body mechanical lift) for transfers. Requires assistance with tray due to impairment and weak grasps. Incontinent of Bowel and Bladder. Interventions: transfer/mobility per therapy recommendations-see mobility Kardex sheet in closet, see therapy plan of treatment for therapy specific goals, assist to bedpan/toilet upon request and per mobility Kardex instructions, follow PT/OT/ST recommendations, PT/OT for strengthening/endurance, R1's MDS, dated [DATE], documents R1 has a moderate cognitive impairment and is always incontinent of bladder and frequently incontinent of bowel. The rest of R1's MDS has not been completed. R1's MDS, dated [DATE], documents R1 has a moderate cognitive impairment and requires extensive assistance from one to two staff members for all ADLs. R1 is always incontinent of bladder and frequently incontinent of bowel. On 12/12/23 at 10:35 AM, R1 was lying in bed. V14 had just put a clean sweater on R1 and requested V13 assistance to put R1's pants on. Both CNAs were attempting to put R1's pants on without checking to see if R1 was incontinent. When asked if R1 was wet or soiled, V14 checked R1's incontinence brief and stated, yes, she is wet. V13 gathered incontinence supplies and brought over a handful of wet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146160 If continuation sheet Page 14 of 15 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 12/14/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete disposable wipes, and an incontinence brief, and placed them on a dirty bedside table. V14 tucked R1's soiled brief between R1's legs, and then used a wet wipe, with no cleanser on it, and wiped once down each of R1's groin and then once down the middle of R1's vagina. R1 rolled to her right side and V13 wiped R1's anal area three times, which was showing feces on the wipes. R1's buttocks was not wiped/cleaned at any point, and R1 was not dried at all. Both CNAs used the same soiled gloves throughout the procedure and to put a new incontinence brief on R1, fastened the brief, and then put R1's pants on. Event ID: Facility ID: 146160 If continuation sheet Page 15 of 15