Sullivan Healthcare & Senior Living

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

showed dark grime underneath the ends of her nails. On 11/24/25 at 3:00 PM Resident R12 was sitting in the resident lounge with other residents with the same mustache and chin hair showing. Resident R12's fingernails showed dark grime under the same nails as previous observation.On 11/24/25 at 2:55 PM V13 Certified Nurse Aide (CNA) confirmed Resident R11 and Resident R12 had facial hair and grime underneath their fingernails. V13 stated residents should be shaved everyday if needed. V13 CNA stated she does not think Resident R11 nor Resident R12 would like to have long chin hairs. On 11/24/25 at 11:45 AM V24 Certified Nurse Aide (CNA) confirmed Resident R10 likes to be clean shaven, in clean clothes and have his hair combed down. V24 CNA stated she was going to do that but haven't gotten around to it yet. On 11/25/25 at 11:45 AM V3 Director of Nurses (DON) stated all residents should be groomed per their preference. V3 DON stated she was aware the resident's personal hygiene was an issue with getting staff to ensure residents are clean and well groomed. V3 DON stated she has seen several female residents that need shaved, several residents that are in need of nail care and also some that need their hair brushed. V3 DON stated she is working on in servicing staff on Activities of Daily Living (ADL). The facility policy titled Dignity revised February 2021 documents each resident should be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life and feelings of self-worth and self-esteem. Staff are expected to treat cognitively impaired residents with dignity and sensitivity.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sullivan Healthcare & Senior Living

11 Hawthorne Lane Sullivan, IL 61951

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 0600 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

aware this incident happened and fully expected to be cited for this resident-to-resident abuse that happened. V1 Administrator stated V1 wishes it didn't happen, but it did. The facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021 documents residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

This same policy documents staff are to protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including other residents.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sullivan Healthcare & Senior Living

11 Hawthorne Lane Sullivan, IL 61951

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review the facility failed to report a resident's allegation of staff to resident abuse for one of five residents (Resident R1) reviewed for Abuse in a sample list of 17 residents.Findings include:Resident R1's Minimum Data Set (MDS) dated [DATE REDACTED] documents Resident R1 as cognitively intact.Resident R1's Care Plan initiated 1/9/2025 documents staff are to allow resident time and opportunity to express feelings, anger or frustration. Provide empathy and validation of feelings. Allow resident time and opportunity to express self and verbalize frustrations. Approach in a calm, non-threatening manner.Resident R1's Nurse Progress Note dated 10/13/25 at 9:53 AM documents Resident R1 has been cursing and throwing objects at staff. (Resident R1) was asked to wait

a couple of minutes until staff finished with another resident that staff was caring for. This same note documents when staff entered Resident R1's room to care for Resident R1, he started making accusations that they (staff) are abusing him. This same note documents Resident R1 was administered pain medication and Resident R1 started yelling and cursing at staff. This same note documents V28 LPN explained to Resident R1, If (Resident R1) keeps treating staff like this anymore, (V28) LPN will send (Resident R1) to the hospital for behaviors. Then (Resident R1) wants to take a gun and kill all of night shift.Resident R1's Initial Report to the State Agency dated 11/23/25 documents Resident R1 alleged abuse from staff

on 10/13/25. On 11/25/25 at 10:30 AM V2 Administer in Training (AIT) stated she was aware Resident R1 had alleged the staff abused him on 10/13/25. V2 AIT stated she did speak with Resident R1 on 10/13/25 and he denied

the allegation. V2 AIT stated she did not speak with any other cognitively intact residents or staff. V2 AIT stated she did not report Resident R1's abuse allegation to the State Agency. V2 AIT stated anytime a resident alleges abuse it should be investigated and reported to the State Agency. On 11/25/25 at 1:20 PM V1 Administrator stated V2 Administrator in Training (AIT) should have reported this incident to the State Agency. V1 stated anytime a resident makes an allegation of abuse the facility abuse policy must be followed and that includes doing a full investigation and reporting the finding to the State Agency. The facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021 documents staff are to identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Staff are to investigate and report any allegations within timeframes required by federal requirements.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sullivan Healthcare & Senior Living

11 Hawthorne Lane Sullivan, IL 61951

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

FORM CMS-2567 (02/99) Previous Versions Obsolete

Licensed Practical Nurse (LPN) was standing at the nurses station facing the resident lounge where Resident R9, Resident R10 and Resident R13 were sitting. V10 LPN stated Resident R9, Resident R10 and Resident R13 are all cognitively impaired, not able to determine or let staff know if they need to use the restroom and all are incontinent of bladder and bowel. On 11/25/25 at 2:40 PM V3 Director of Nurses (DON) stated all dependent residents should be provided incontinence care at least every two hours. V3 stated these same residents should be repositioned and well groomed. V3 stated staff should not assume they know the bladder and bowels habits of any resident as that can change day to day. V3 DON stated allowing residents to sit in the same position in a soiled incontinence brief could cause pressure ulcers and Urinary Tract Infections (UTI) among other clinical issues in addition to a negative psychosocial impact. D3 DON confirmed Resident R9, Resident R10 and Resident R13 were all sitting

in the resident lounge for four hours without any attention from staff. V3 DON stated she is not certain if there is a direct policy for this, but the expectation is to provide the standard of care which is to provide incontinence care at least every two hours.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sullivan Healthcare & Senior Living

11 Hawthorne Lane Sullivan, IL 61951

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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Based on observation, interview and record review the facility failed to employ a Certified Dietary Manager (CDM). This failure has the potential to affect all 71 residents residing in the facility.Findings include:The Daily Midnight Census dated 11/23/25 documents 71 residents reside in the facility.The facility was unable to provide any documentation of employment of a CDM and/or Dietary Manager. Throughout the survey timeframe on 11/23/25-11/25/25 at various times on first and second shifts there was no CDM or Dietary Manager in the facility. On 11/23/25 at 9:00 AM, V9 [NAME] was providing verbal guidance to dietary staff.

V9 [NAME] stated the facility does not have a CDM or Dietary Manager.On 11/24/25 at 12:15 PM V1 Administrator was serving resident meals from the kitchen. V1 Administrator stated she was helping due to

a CDM was not onsite. On 11/25/25 at 3:25 PM V6 Regional Certified Dietary Manager (CDM) stated she splits her time in facilities with this facility and one other facility. V6 stated she had not been onsite at this facility for at least ten days. V6 stated prior to that time, she would have been onsite once a week on average. V6 stated she is not the interim Dietary Manager. V6 stated the facility has not had a Dietary Manager for six months or so.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sullivan Healthcare & Senior Living

11 Hawthorne Lane Sullivan, IL 61951

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

FORM CMS-2567 (02/99) Previous Versions Obsolete

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 maintain kitchen sanitation, failed to obtain temperatures of cold stored foods and foods prepared for meal service. These failures have the potential to affect all 71 residents.Findings include:The facility Daily Midnight Census dated 11/23/25 documents 71 residents reside in the facility.The facility was unable to provide any temperature logs for meal service.The facility temperature logs dated, November 2025, document temperatures obtained on 11/8 and 11/10-14/25 for the facility walk in cooler, reach in vegetable freezer, third door reach in cooler and

the reach in meat freezer. There were no other temperatures documented on the logs. On 11/23/25 at 12:15 PM V9 [NAME] did not obtain temperatures of country fried steak, mashed potatoes/gravy, mixed vegetables, spaghetti or green beans prior to meal service on 11/23/25. On 11/23/25 at 12:20 PM The facility reach in cooler, reach in vegetable freezer and reach in meat freezer had an unknown pink sticky liquid spilled on the bottom shelf along with dozens of pieces of food debris. On 11/24/25 at 12:35 PM V1 Administrator obtained food temperatures on a test tray of sliced pork, mashed potatoes and gravy, green beans and cornbread. The temperature of the sliced pork was 108 degrees Fahrenheit (F), mashed potatoes with gravy was 120 degrees F and the green beans were 86 degrees F. On 11/23/25 at 12:30 PM V9 [NAME] stated the kitchen is a mess because there are not enough staff. V9 [NAME] stated the staff that work in the kitchen do their best but can't keep up. V9 [NAME] stated the temperature logs posted on

the coolers and freezers are not completed as they should be. V9 [NAME] stated the hot food service temperature logs have not been completed since she started a year ago. V9 [NAME] stated she is the main cook for all three meals served five to six days per week for the past year and has never checked food temperatures for food service. On 11/24/52 at 12:45 PM V1 Administrator confirmed the test tray of foods were not warm enough to be palatable. V1 Administrator stated she has her food handler's certificate and knows what the temperatures should be and these are not up to temp.On 11/25/25 at 3:25 PM V6 Regional Certified Dietary Manager (CDM) stated the facility should be checking the temperatures of all the coolers, freezers, dishwashing cycles and food service temperatures. V6 CDM stated not checking those temperatures could cause a food borne illness.

Event ID:

Facility ID:

If continuation sheet