Inspection·March 25, 2025

F 0697 R3's Progress Notes dated 12/25/2024 - 1/22/2025 documents Hydrocodone-Acetaminophen Oral Tablet 5/325 MG. Give 1 tablet by mouth two times a day for pain, Unavailable. Level of Harm - Actual harm R3's Pain level assessment dated [DATE] at 8:00 PM documents pain level 5. Residents Affected - Few R3's Pain level assessment dated [DATE] at 8:00 PM documents pain level 3. R3's Progress Notes dated 12/26/2024 at 11:40 AM documents Made call out to Physician's office to request updated script for Norco refill, message left. R3's Progress Notes dated 12/27/2024 at 9:12 AM Call out to Physician's office for Norco script. R3's Progress Notes dated 12/30/2024 at 2:41 PM documents Made another call out to Physician's office in regard to Norco refill, have left several messages and no returned call and script has not been filled. Reception stated, will put back urgent. R3's Progress Notes dated 12/31/2024 at 11:38 AM documents: Made another call out to Physician's office regarding Norco script update for refill. Message states office is closed for holiday until Thursday 1/2. Writer requested on call physician to return call. R3's Progress Notes dated 12/31/2024: Made another call out to Physician's office due to script still not received at pharmacy. Verified place, fax, and phone number. Physician did not have the correct phone number or fax but did have correct pharmacy and location. Numbers updated and will send updated script today. R3's Progress Note dated 2/19/2025 at 10:48 AM, documents Made call out to Medical Doctor's office to request updated Norco script for refill. R3's Progress Notes dated 2/19/2025-2/20/2025 documents Hydrocodone-Acetaminophen Oral Tablet 5/325 MG. Give 1 tablet by mouth two times a day for pain, Unavailable. R3's pain level assessment dated [DATE] at 8:00 PM documents pain level 1. R3's pain level assessment dated [DATE] at 8:00 AM documents pain level 5. R3's Progress Note dated 2/20/2025 at 1:18 PM, documents Medical Doctor's office confirmed Norco Rx(script) sent this AM. Writer confirming with pharmacy at this time. On 3/21/2025 at 9:35 AM R3 stated the facility has ran out of her prescription for Hydrocodone-Acetaminophen in the months of December and February. R3 stated in December she had to go without her pain medication for almost 10 days. R3 stated during the time she had to go without her pain medication, she was in pain. R3 stated she has taken the pain medication for many years and without it, it is hard to function due to being in pain. R3 stated while not getting her pain medication for so long, she experienced increased pain. On 3/21/2025 at 2:07 PM V3, Nurse Manager, stated R3 did go a while without her prescription pain medication back in December and recently for about 2 days in February. V3 stated R3's primary care provider is the doctor who prescribes R3's Hydrocodone. V3 stated the facility reached out to R3's primary care provider before R3's script for Hydrocodone ran out in December and then the primary care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146160 If continuation sheet Page 2 of 5 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 03/25/2025 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 0697 Level of Harm - Actual harm Residents Affected - Few provider's office closed for the holidays. V3 stated the facility reached out to the on-call physician to see if they would fill R3's script for Hydrocodone and the on-call doctor would not fill it. V3 stated since the on-call doctor would not write the script for R3's medication, R3 had to go without her pain meds. V3 stated R3 did not receive her Hydrocodone on 2/19/20 or 2/20/25 due to the facility waiting for a new prescription from the MD (doctor). On 3/25/2025 at 11:46 AM V8, R3's Primary Care Doctor's Licensed Practical Nurse (LPN), stated R3's Primary Care Doctor is a [NAME] when it comes to a facility following his prescriptions the way it is written. V8 stated R3's Primary Care Doctor expects the facility to give a resident their medications as ordered and written. V8 stated with R3's medical diagnoses, if R3 went without her pain medication as prescribed it puts R3 at risk for increased and unnecessary pain. 2.) R2's Face Sheet documents admission date of 3/3/25 with medical diagnoses of Chronic Pain Syndrome, Disorders of Muscle, and Hypertension. R2's Minimum Data Set, MDS, dated [DATE], documents R2 has no cognitive impairments. MDS documents R2 requires supervision or touching assistance with transfer and bed mobility. R2's Care Plan dated 3/3/25, documents R2 has an alteration due to pain related to chronic pain syndrome. Interventions include Encourage PT/ OT participation, administer medication & treatments ordered by MD and monitor for side effects and effectiveness to current medication regimens. R2's Physician Order dated 3/11/25, documents Hydrocodone-Acetaminophen (Norco) Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen) *Controlled Drug* Give 1 tablet by mouth every 8 hours as needed for moderate pain (5-7 on pain scale) and Give 2 tablets by mouth every 8 hours as needed for severe pain (7-10 on pain scale). R2's Medication Administration Records, MAR, dated 3/3/25-3/31/25 documents Hydrocodone Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 8 hours as needed for moderate pain (5-7 on pain scale) **DO NOT GIVE WITH DIAZEPAM** -Start Date 03/11/2025 1345 and Hydrocodone-Acetaminophen Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen) Give 2 tablet by mouth every 8 hours as needed for severe pain (7-10 on pain scale) **DO NOT GIVE WITH DIAZEPAM** -Start Date 03/11/2025 1345. There was no documentation that medication was administered on 3/18/25 AM and PM dose. R2's Progress Note dated 3/18/25 at 8:46 AM documents Writer contacted pharmacy due to Norco refill did not come with delivery. Pharmacy stated, MD needs contacted due to oral route missing on script that was sent. Writer contacted the MD and Nurse Practitioner and requested script be corrected. R2's Progress Note dated 3/18/25 8:46 AM documents Nurse Practitioner stated, script corrected and updated and sent to pharmacy. R2's Progress Note dated 3/19/25 at 12:40 AM documents Guest very upset with facility; writer continues to wait on pharmacy for Norco. R2's Progress Note dated 3/19/25 at 1:08 AM documents Guest pain medication did not arrive with pharmacy delivery. R2's Progress Note dated 3/19/25 at 8:50 AM documents Writer contacted pharmacy related to Norco script did not come with delivery again after script was corrected by MD and staff is unable to pull (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146160 If continuation sheet Page 3 of 5 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 03/25/2025 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 0697 Level of Harm - Actual harm Residents Affected - Few medication from medication machine due to facility does not carry the Norco 10/325 mg dose needed. Pharmacy stated, script was corrected by Nurse Practitioner and received yesterday, medication will come with delivery today. R2's Progress Note dated 3/19/25 at 9:53 AM documents Writer contacted Nurse Practitioner and made aware of situation, requested temporary script for Norco 5/325 mg prn because it is available to staff in the medication machine. Nurse Practitioner gave new order, okay for Norco 5/235 mg 2 tablets every 8 hours as needed for 24 hours until Norco 10/325 mg script arrives. Facility nurse made aware, and medication given to guest as ordered. R2's daytime pain level assessment dated [DATE] documents pain level 5. R2's nighttime pain level assessment dated [DATE] documents pain level 3. R2's daytime pain level assessment dated [DATE] documents pain level 5. On 3/21/2025 at 8:24 AM, R2 stated she recently did not receive her prescribed pain medication Hydrocodone-Acetaminophen for almost 2 days. R2 stated the facility informed her they did not have her pain medication. R2 stated she has taken the prescribed pain medication for years due to multiple medical issues and without the pain medication she is pain and cannot complete her therapy as ordered. R2 stated during the time she did not receive her pain medication she was experiencing increased pain. On 3/21/2025 at 9:23 AM, V5, Licensed Practical Nurse, stated she has heard the facility has ran out of R2's prescribed pain medication recently. On 3/21/2025 at 2:07 PM V3, Nurse Manager, stated the facility did recently run out of R2's prescription for Hydrocodone-Acetaminophen and R2 had to go about a day and a half without her medication. V3 stated the facility reached out to the MD for a new script and when he sent the script to the pharmacy, he did not write the route on the script, therefore the pharmacy would not fill R2's medication. V3 stated she was able to reach out to the Nurse Practitioner and the Nurse Practitioner sent a new script to the pharmacy. V3 stated once the pharmacy received the script, staff were able to pull it from their in-house medication machine. On 3/21/2025 V3, Nurse Manager, stated if the facility's on call doctor will not write for a prescription when a resident's primary care doctor is the ordering physician, the resident will have to go without that medication until the resident's primary care doctor sends the facility a prescription. V2, Director of Nursing, stated the facility's medication machine does contain Hydrocodone that the staff can pull a resident's needed mediation from once a script is received by the pharmacy, until their package of medication arrives. On 3/25/25 at 12:30 PM, V9, Facility Medical Doctor, stated it is expected that the facility gives residents their prescriptions as written and ordered. V9, Facility Medical Doctor, stated if a resident goes without receiving their pain medication, the resident can experience unnecessary pain and an increase in pain. The facility's Administering Medication Policy and Procedure revised 10/15/2023, documents Purpose: To ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations. Procedure: Medications shall be administered according to physician's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146160 If continuation sheet Page 4 of 5 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 03/25/2025 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 0697 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete written/verbal orders upon verification of the right medication, dose, route, time and positive verification of the resident's identity when no contraindications are identified, and the medication is labeled according to accepted standards. Should a drug be withheld, refused, or given other than at the scheduled time, the individual administering the mediation shall chart in the Electronic Medical Record (eMAR) and sign off for that particular drug and document a rationale. Should a medication be withheld or refused, the physician will be notified when three (3) consecutive doses or a pattern of frequent withholding or refusal is noted. Documentation identifying the explanation of withholding or reason for refusal will be documented in the medical record. The facility's Pain Management and Assessment Policy and Procedure revised 11/22/2021, documents Policy: to provide a broad spectrum of treatments for pain management as they apply specifically to older people and with specifically to older people with specific recommendations to aid in decision making about pain management. To develop clinical practice guidelines for the management of acute or chronic pain. Event ID: Facility ID: 146160 If continuation sheet Page 5 of 5