Health inspection·April 10, 2023

F 0602 bottle with dose of 0.25ml every four hours as needed. Level of Harm - Minimal harm or potential for actual harm R4's physician's orders, dated 3/9/23, documents R4 was prescribed Morphine Concentrate 100mg/5ml bottle with dose 0.5ml every four hours as needed. Residents Affected - Some R5's physician's order, dated 3/3/23, documents R5 was prescribed Morphine Concentrate 20mg/1ml bottle with dose of 0.25ml, 0.5ml, or 1.0ml every four hours as needed. R6's physician's orders, dated 10/24/22, document R6 was prescribed Morphine Concentrate 100mg/5ml bottle with dose of 0.25ml every two hours as needed. On 4/6/23 at 9:00a.m. and 10:20a.m.,V2 (Director of Nurses/DON) stated on 3/28/23 in the early morning after the change of shift, V8 (Licensed Practical Nurse/LPN) reported during the narcotics count, she noted R3's bottle of Morphine Concentrate was much lighter than it was supposed to be. V2 stated the facility drew up some of R3's Morphine into a syringe and noted the medication was almost clear, instead of the dark pink that it was supposed to be. V2 stated she suspected R3's Morphine Concentrate may have been diverted. V2 stated she and other supervisory staff inspected all the opened bottles of Morphine Concentrate in the facility. V2 stated those bottles were located on three of the four units and belonged to R1, R2, R3, R4, R5, R6. V2 stated all the opened bottles of Morphine for these six residents were lighter than they should have been, but R1, R2, and R3's were especially light. V2 stated V4 (Police Detective) instructed the facility to remove all the open bottles of Morphine belonging to R1, R2, R3, R4, R5, R6, and replace them with new bottles, which they opened. V2 stated the facility had narrowed the suspects down to one nurse, V13 (Registered Nurse/RN), who had worked on all three halls that week. V2 stated they suspected V13 right away because during staff interviews, V8 recounted during a previous shift change narcotic count, one of the Morphine Sulfate bottles was missing from the narcotic box. V2 stated V8 was counting the narcotics with V13, who was the night shift nurse. V2 stated when V8 noticed the bottle was missing, V13 pulled the bottle out of her pocket, and told V8 she had administered a dose of Morphine to a resident during the night, and had forgotten to replace the bottle in the narcotic drawer. V2 stated later, V8 looked through that resident's Medication Administration Record (MAR) and didn't see any documentation V13 had administered any Morphine to that resident. V2 stated on the morning of 3/31/23, V7 (RN), who was the oncoming day shift nurse, and V13 were counting the narcotics for the end of shift narcotic count. V2 stated when the Morphine bottles were placed on the medication cart, V7 noted R1's Morphine Concentrate was a much lighter color of pink. V2 stated V7 alerted V2 right away. V2 stated she examined the bottle, and noted R1's Morphine was a much lighter color. V2 stated she proceeded to call V4, who came to the facility to question V13, who had not left yet. V2 stated V13 confessed to taking R1's Morphine Sulfate and replacing the used doses with water. V2 stated V13 was arrested for misappropriation of residents' narcotic medications. V2 stated V13 was new to the facility as of 1/2023. V2 stated there is no way of knowing if V13 may have been diverting Morphine Sulfate since that time, as they only have visual proof of diluted Morphine from R1-R6's current bottles. V2 stated R1, R2, and R3's Morphine Concentrate bottles were highly diluted, with the color of the Morphine being clear when drawn up in a syringe. V2 stated R4, R5, and R6's Morphine Sulfate was only a little lighter. On 4/6/23 at 9:51a.m. and 10:20a.m., V4 stated the facility called him to report suspected diversion of Morphine Concentrate on 3/28/23 after a nurse noted a bottle of Morphine looked funny. V4 stated the medication in the bottle was light pink instead of darker pink like it is supposed to be. V4 stated the facility told him the Morphine was clear when they drew it up in a syringe, when it should have been pink. V4 stated the facility found several additional bottles, which were also not the right color. V4 stated there were initially six bottles which were a lighter color of pink than they (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145596 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 145596 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Snyder Village 1200 East Partridge Metamora, IL 61548 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some should have been. V4 stated he instructed the facility to gather all six bottles, and turn them over to him as evidence. V4 stated he then instructed the facility to replace the bottles with new, opened, and unused bottles. V4 stated the facility told him they had narrowed down the list of suspects to V13. V4 stated he told the facility to watch her closely to see if she diverts any Morphine Concentrate. V4 stated on Friday morning 3/31/23, after V13 had worked the night before, facility staff called him because they suspected V13 had diverted R1's Morphine Concentrate during her shift, because R1's new bottle was a lighter color of pink. V4 stated he went to the facility, and asked V13 to come to the police station for questioning, where she confessed to diverting R1's Morphine. V4 stated so far, the police crime lab has only tested R1's bottle of Morphine to see if it had been diluted. V4 stated V13 is being charged with felony misappropriation of narcotic medications, and has been referred to the States Attorney's office for prosecution. A facility Nurses' Schedule, dated 3/23/23 to 3/31/23, documents V13 worked the 12 hour evening/night shift on R1, R4, R5, R6's hall on 3/23/23 and 3/30/23; R2's hall on 3/26/23, and R3's hall on 3/27/23. On 4/6/23 at 11:00a.m., V6 (LPN) stated on 3/28/23 V14 (Wound Nurse/ Quality Assurance Nurse) and another supervisor nurse came to her and asked to check her narcotics drawer. V6 stated they took the bottle of Morphine Sulfate belonging to R2, and drew some up in a syringe to look at it. V6 stated once the medication was in the syringe, it looked clear instead of a dark pink like it normally is. V6 stated R2 only took his Morphine sporadically, and hadn't had any administered since before 3/24/23. V6 stated V14 and the other nurse took R1's opened bottle of Morphine Sulfate, and told V6 to replace it with a new, unused, but open bottle of Morphine Sulfate. On 4/6/23 at 11:17a.m., V7 (RN) stated on 3/28/23 V2 and V3 (Certified Nurse Aide Supervisor) asked her to line up all her bottles of Morphine Sulfate oral solution on the medication cart for comparison. V7 stated she had never compared the colors of the medication in the bottles like that before. V7 stated when she lined up the bottles, the medication could be seen through a clear vertical window in the side of the bottle, which is used to measure the number of doses left. V7 stated when all the bottles were next to each other, there was a difference in color for R1, R4, R5, and R6's opened bottles of Morphine then to a sealed, unused bottle of the same medication. V7 stated R4, R5, and R6 all used Morphine Sulfate oral solution on an as needed basis, but R1 is administered scheduled doses of Morphine four times daily, in addition to as needed doses. V7 stated that's when the facility decided someone was diverting residents' oral Morphine medication. V7 stated she knew the facility suspected V13 of diverting the Morphine. V7 stated during her day shift on 3/30/31, she was instructed by V2 to give her all opened bottles of Morphine, and to open new bottles right before the change of shift. V7 stated when V13 came in that evening, she made a comment that all the bottles were newly opened. V7 stated at that time, V13's nose was very runny and V13 broke out in a sweat during their nurse-to-nurse report, which makes V7 think V13 might have been exhibiting signs of drug withdrawal. V7 stated when she returned to work for the day shift the next morning on 3/31/23, V7 lined up all the bottles of Morphine Concentrate on the top of the medication cart. V7 stated R1's bottle was obviously a lighter color. V7 stated she did not mention this to V13, but instead alerted V2, who came to the floor to evaluate the bottle. V7 stated V13 was still at the facility attending an in-service. V7 stated V2 called the police, who took V13 to the police station for questioning. V7 stated later, V4 came back to the nurses' desk asking for all V13's belongings. On 4/6/23 at 12:30p.m. V8 (LPN) stated on 3/28/23 she came into work for the day shift. V8 stated the night shift nurse had already left, so she planned to count narcotics with another nurse from another unit. V8 stated while she waited for the other nurse, V8 lined up two bottles of Morphine (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145596 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 145596 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Snyder Village 1200 East Partridge Metamora, IL 61548 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Concentrate oral solution from her narcotic drawer on the top of the medication cart. V8 stated she noticed a marked difference in the color of the opened bottle of Morphine compared to an unopened bottle. V8 stated the Morphine is visible in the bottle through a clear window on the side of the bottle used for measuring the medication. V8 stated normally the Morphine is a dark pink in color. V8 stated she had two other nurses look at the bottle, and they agreed the medication was lighter than it should be. V8 stated V10 (Unit Coordinator) looked at the bottle, then drew up some of the Morphine into a syringe. V8 stated the Morphine in the syringe was completely clear instead of being pink. V8 stated V10 examined all the contents in the Morphine bottle, and all the medication was clear. V8 stated a medication discrepancy form was filled out and the discrepancy was reported to V1 (Administrator) and V2. V1 stated on 3/28/23 when V8 reported the color of R3's Morphine bottle didn't look right, that was the first time the facility became aware that someone might be diverting residents' Morphine. V1 stated R3's bottle of morphine was a lighter pink in the bottle, but when the nurses drew up the medication into a syringe, it looked clear when it should have been pink. V1 stated although V13 only admitted to diverting R1's Morphine when she was questioned by the police, through the course of the facility's investigation, they determined a total of six residents had opened bottles of Morphine, which appeared to have been diluted, and which V13 had access to those residents' medications when she worked that week. V1 stated R1, R2, and R3's Morphine was significantly lighter, but R4, R5, and R6's Morphine was a slightly lighter pink, which made them suspect all six residents' Morphine Sulfate was diverted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145596 If continuation sheet Page 4 of 4