Health inspection·August 18, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm The Facility's Resident Council Meeting Minutes dated 10/21/22 document, Residents state that they are having slow response to answering call lights. The Facility's Resident Council Meeting Minutes dated 11/21/22 document, Lack of availability to respond to call lights, getting meals timely, environment cleaned, etc. Residents Affected - Some On 8/18/23 at 9:32 AM, V3 (Assistant Director of Nursing/ADON) stated she expects staff to answer call lights as promptly as possible. The Facility's Call Light Policy, undated, documents, The facility will have all call lights in working order. These call lights will be accessible to the residents and will be answered promptly by staff. All nursing personnel must be aware of call lights at all times. Answer ALL call lights promptly whether or not you are assigned to the resident. Answer all call lights in a prompt, calm, courteous manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145601 If continuation sheet Page 2 of 13 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 145601 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviston Countryside Manor 450 West 1st Street Aviston, IL 62216 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide distilled water and cleaning for Continuous Positive Airway Pressure (CPAP) machines for 2 of 2 residents (R2, R25) reviewed for respiratory therapy in the sample of 37. Residents Affected - Few Findings include: R2's Physician Order Sheet (POS) dated 3/8/23 documents CPAP home setting with 2 liters of oxygen bled into CPAP apply at HS (Bedtime) remove upon rising. R2's Care plan dated 6/22/23 and revised on 8/2/23 documents resident (R2) will have an effective respiratory rate and depth and rhythm. R2's Care Plan intervention is assessing signs of ineffective breathing. The CPAP Care Plan does not document the cleaning of the CPAP machine or the changing of the filters. R2's July and August 2023 Medication Administration Record (MAR) documents CPAP at home setting with 2L 02 bled into CPAP twice a day apply at HS and remove upon rising. This MAR did not document cleaning of the CPAP machine. On 8/17/23 at 9:50 AM, V3 (Assistant Director of Nursing/ADON) stated the CPAP was not found on the treatment sheet, but it is found on the MAR. On 8/17/23 at 11:00 AM, R2's (Company name) CPAP machine was on his nightstand. The CPAP machine was on and running. V12 (Certified Nursing Assistant/CNA) turned it off when it was brought to her attention. The (CPAP Company's) Website dated 2021 documents R2's CPAP machine had been recalled due a defective foam. 08/17/23 10:21 AM, V15 (Registered Nurse/RN) and V11 LPN (Licensed Practical Nurse) both stated they think the night should be cleaning R2's CPAP machine. They both noted it comes up on the MAR to put the water in and place it. V15 (RN) also stated, The family comes in to clean the machines. Although we shouldn't rely on them. On 08/17/23 12:04 PM, V16 (R2's Power of Attorney/POA) stated, I've been bringing in the water (distilled) because they (the facility) want 6 dollars a gallon. I've been cleaning his machine. On 08/18/23 at 2:00 PM, V3 (ADON) stated, I called the family about the recall, and they stated the company sent out a new machine, but they didn't like it and instead sent the old machine to the facility. The family will bring out the new machine. V3 (ADON) stated, I talked with the family and let them know that we will now supply water and clean the machine. The (CPAP Company) User Manual dated 2018, which states, Rinse the blue pollen filter at least every two weeks and replace with a new one every six months. The disposable light blue filter should be replaced after 30 months. The tubing and mask adapter should be washed with warm water and liquid dish soap before the first use and daily. 2. R25's POS dated 4/24/23 documents CPAP at HS (hour of sleep) at home setting, apply at HS, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145601 If continuation sheet Page 3 of 13 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 145601 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviston Countryside Manor 450 West 1st Street Aviston, IL 62216 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 0695 remove upon rising bleed 2L 02 into CPAP. Level of Harm - Minimal harm or potential for actual harm R25's Progress Note dated 1/18/23 documents Family in office at this time upset that resident does not have distilled water for her CPAP. Aggressive with V20 (CNA) telling her that she will not leave until V20 (CNA) brings distilled water to her. CNA told family member we do not have distilled water for CPAP, and she requested to speak with myself (V21-ADON). Discussed with family that if we are to supply distilled water, we will have to order from (Supply Company), and it is $18 for 6 gallons to be billed to family. Stated understanding and took my card and said she would discuss with family and let me know if they want us to supply the distilled water. Will follow up with family. Residents Affected - Few On 8/17/23 at 10:00 AM, V17 (R25's POA) stated, We bring in the distilled water, because the facility wants to charge us 6 dollars a gallon for the water. I bring in a vinegar solution to clean the machine, but I doubt they are cleaning the machine. R25's CPAP Care Plan dated 12/16/22 and revised 7/26/23 documents goal the resident will state feeling rested her (R25) intervention or approach is assure CPAP is applied and in working order. (This CPAP Care Plan does not document cleaning of the CPAP or changing of the filters.) The undated (R25's CPAP Company) Clinical Guide documents empty the humidifier tub and wipe it thoroughly with a clean disposable cloth. Allow it to dry out of direct sunlight. refill the humidifier tub with distilled water daily. Weekly wash the components using one of the following options: wash the humidifier tub, air tubing, and outlet connector with warm water using a household dishwashing liquid. The air tubing should not be washed in temperatures higher than 149 Fahrenheit or wash the humidifier and outlet connector in a solution of 1 part vinegar and 9 parts water wash the air tubing in warm water using a household dishwashing liquid. the air tubing should not be washed in temperatures higher than 149 Fahrenheit. rinse each component thoroughly in water and allow to dry out of direct sunlight and heat. wipe the exterior of the device with a dry cloth. The air filter is not washable or reusable. The facility policy entitled CPAP Support dated July 2014 documents To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen. To improve arterial oxygenation in residents with respiratory insufficiency, obstructive to sleep apnea or restrictive/obstructive lung disease. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145601 If continuation sheet Page 4 of 13 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 145601 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviston Countryside Manor 450 West 1st Street Aviston, IL 62216 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of 4 of 4 residents (R9, R29, R30, and R52) reviewed for staffing in the sample of 37. Findings include: On 8/16/23 at 12:38 PM, during the Group Resident Council Meeting, R9, R29, R30, and R52 all stated nurse aid staffing has become a problem. They stated it often takes more than an hour to get help, especially around bedtime. R9's Minimum Data Set (MDS) dated [DATE] documented R9 was cognitively intact. R29's MDS dated [DATE] documented R29 was moderately cognitively impaired. R30's MDS dated [DATE] documented R30 was cognitively intact. R52's MDS dated [DATE] documented R52 was moderately cognitively impaired. On 8/17/23 at 12:21 PM, V10 (Certified Nurse Aide/CNA) stated she was assigned to C Hall but was helping out with a resident on A Hall. She stated sometimes residents have to wait a while for help due to CNA staffing. On 8/17/23 at 12:24 PM, V11 (Licensed Practical Nurse/LPN) stated each hallway could use an extra CNA to help out with things like showers and call lights. On 8/17/23 at 12:26 PM, V12 (CNA) stated, I'm a little preoccupied right now. I've got somebody in bed trying to get them on the bed pan, and I'm helping with a transfer, and somebody else needs to get in the shower. On 8/27/23 at 12:28 PM, V4 (CNA) stated weekend staffing is atrocious. She stated CNAs get residents up and ready, take them to the dining room, help serve and feed them, then clean them up and put them in bed or take them to activities or whatever they want to do. V4 stated the hallways have four or five showers to be given each morning on top of everything else. She stated, I've had residents crying, because it takes so long for us to help them, and it's not fair for them to wait 45 minutes to use the bathroom or whatever it is they need to do. V13 (CNA) agreed that the facility needs more CNAs. On 8/16/23 at 1:57 PM, V9 (CNA Scheduler) stated typically there is one CNA on A Hall and two CNAs on B and C Halls, but sometimes there is no CNA on A Hall so the nurses on B and C Halls have to take A Hall and split it. On 8/17/23 at 9:44 AM, V1 (Administrator) stated the facility meets minimum staffing requirements, but the residents want more staff, and that has been ongoing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145601 If continuation sheet Page 5 of 13 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 145601 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviston Countryside Manor 450 West 1st Street Aviston, IL 62216 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 0725 Level of Harm - Minimal harm or potential for actual harm The Facility's Resident Council Meeting Minutes dated 8/24/22 documents, Residents stating takes 40 plus minutes to have call light answered to use toilet. (More than 2 residents reported this.) The Facility's Resident Council Meeting Minutes dated 10/21/22 document, Residents state that they are having slow response to answering call lights. Residents Affected - Some The Facility's Resident Council Meeting Minutes dated 11/21/22 document, Residents feel that staffing shortages are affecting quality of care. Lack of availability to respond to call lights, getting meals timely, environment cleaned, etc. On 8/18/23 at 9:32 AM, V3 (Assistant Director of Nursing/ADON) stated she expects staff to answer call lights as promptly as possible. The Facility's Staffing Policy revised 7/2019 documents, Our facility provides adequate staffing to meet needed care and services for our resident population. Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services. Certified Nursing Assistants are available on each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145601 If continuation sheet Page 6 of 13 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 145601 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviston Countryside Manor 450 West 1st Street Aviston, IL 62216 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 observation, interview, and record review, the facility failed to store food in a manner that prevents foodborne illness. This has the potential to affect all 63 residents living in the Facility. Residents Affected - Many Findings include: On 8/15/23 at 8:07 AM, in the walk-in refrigerator, there was a pitcher containing brown liquid labeled tea and 8/1/23. There was a cart with one tray of individual cups of fruit and three trays with individual cups of dessert. Each tray was covered with another tray, and none were labeled or dated. There was a bag of crumbled sausage that was previously opened and tied up in a knot but was not labeled or dated. There were three bags of shredded cheese that were previously opened and resealed but were not dated. On 8/15/23 at 8:09 AM, in the standing freezer, there was a plastic bag containing yellow, crescent shaped items that was previously opened and resealed, but was not dated or labeled. There was a plastic bag of meat patties with no date or label. V8 (Cook) stated the items in the bags were omelets and hamburgers. On 8/15/23 at 8:11 AM, there were boxes stacked directly on the floor in the storeroom. The first stack was comprised of two boxes of chips. The second stack included pizza sauce, spaghetti sauce, baked beans, cranberry juice, and apple juice. V8 (Cook) stated the boxes just came last night. In the storeroom, there were also four clear bins with oats, thickener, sugar, and flour that were labeled but were not dated. On 8/15/23 at 8:14 AM, in the standing freezer in the storeroom, there were four bags of breaded meat strips that were not labeled or dated. There was a plastic bag of chocolate chip cookie dough inside a cardboard box. The bag was previously opened, but not resealed. The contents were open to air, and package was not dated upon opening. There was an opened plastic bag of buns that was not resealed, labeled, or dated. There was a plastic bag of cinnamon rolls, a bag of breadsticks, and a bag of egg rolls that were all opened and tied up but were not labeled or dated. On 8/15/23 at 8:21 AM, on the tray line there were four clear tubs of dry cereal that were labeled but not dated. On 8/15/23 at 9:23 AM, the refrigerator in the dining room contained four slices of pizza inside a plastic bag with no label or date. On 8/15/23 at 9:24 AM, the entire ice scoop, including handle, was inside the cooler on the beverage cart in the dining room. On 8/18/23 at 8:37 AM, V3 (Assistant Director of Nursing/ADON) stated she expects food service staff to follow their policies and label and date all items. The Facility's Food and Supply Storage Policy revised January 2012 documents, Food and supply storage areas shall be maintained in a clean, safe, and sanitary manner. Food and supplies will be stored six (6) inches above the floor on clean racks or shelves and at least eighteen (18) inched from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145601 If continuation sheet Page 7 of 13 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 145601 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviston Countryside Manor 450 West 1st Street Aviston, IL 62216 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 sprinkler heads. All foods will be covered, labeled, and dated. Level of Harm - Minimal harm or potential for actual harm The Facility's Resident Census and Conditions of Residents Form (CMS 672) dated 8/15/23 documents there are 63 residents living in the Facility. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145601 If continuation sheet Page 8 of 13 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 145601 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviston Countryside Manor 450 West 1st Street Aviston, IL 62216 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R5's Face Sheet undated documents diagnosis as Enterocolitis due to Clostridium difficile, recurrent. Residents Affected - Some R5's Minimum Data Set (MDS) dated [DATE] documents R5 is cognitively intact is occasionally of bladder, frequently incontinent of bowel, is not on a bowel or bladder training program. R5's MDS documents antibiotics are documented as a medication that R5 received in past 6 days. R5's Physician Order Report undated documents orders Dificid (fidaxomicin) tablet 200 milligram (mg), 1 tab twice a day for 11 days. Start date 5/27/23 and End date 6/7/23. Cephalexin 500 milligram (mg) capsule 1 tab four times a day. Start date 5/27/23 and End date 6/3/23; Vancomycin 125 mg tablet every 6 hours (four times a day) for 14 days. Start date 6/22/23 and End date 7/6/23; Vancomycin 125 mg tablet, twice a day for 7 days. Start date 7/7/23 and End date 7/14/23; Vancomycin 125 mg tablet, once a day for 7 days. Start date 7/15/23 and End date 7/22/23 and Vancomycin 125 mg tablet, 1 tablet every other day for 28 days. Start date 7/23/23 and End date 8/16/23. R5's electronic Medication Administration Record (eMAR) dated 01/01/23-01/31/23 documents R5 received 8 out of 8 doses of 500mg of Levofloxacin with a Start date 1/10/23 and End date 1/17/23. R5's (eMAR) dated 03/01/23-03/31/23 documents R5 received 18 out of 18 doses of 500 mg of Cephalexin three times a day with a Start date 03/26/23 and End date 04/01/23. R5's (eMAR) dated 04/01/23-04/30/23 documents R5 received 3 out of 3 doses of 875-125 mg of Amoxicillin-pot Clavulanate with a Start date 04/14/23 and End date 04/15/23. R5's (eMAR) dated 04/01/23-04/30/23 documents R5 received 18 out of 18 doses of 875-125 mg of Amoxicillin-pot Clavulanate with a Start date 04/15/23 and End date 04/23/23. R5's (eMAR) dated 04/01/23-04/30/23 documents R5 received 3 out of 3 doses of 500 mg Cephalexin with a Start date 03/36/23 and End date 04/01/23. R5's (eMAR) dated 05/01/23-05/31/23 documents R5 received 4 out of 4 doses of 500 mg Cephalexin with a Start date 05/21/23 and End date 05/22/23. R5's (eMAR) dated 05/01/23-05/31/23 documents R5 received 18 out of 18 doses of 500 mg Cephalexin with a Start date 05/27/23 and End date 06/03/23. R5's (eMAR) dated 05/01/23-05/31/23 documents R5 received 4 out of 4 doses of 200 mg Dificid (fidaxomicin) with a Start date 05/27/23 and End date 06/07/23. R5's (eMAR) dated 05/01/23-05/31/23 documents R5 received 1 out of 1 dose of 1-gram Ertapenem injection (administer 1,000 mg-3.57 mL) with a Start date 05/27/23 and End date 05/28/23. R5's (eMAR) dated 05/01/23-05/31/23 documents R5 received 3 out of 3 doses of 1-gram Ertapenem injection (administer 1,000 mg-3.57 mL) daily for 4 days with a Start date 05/28/23 and End date 05/30/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145601 If continuation sheet Page 9 of 13 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 145601 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviston Countryside Manor 450 West 1st Street Aviston, IL 62216 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 0881 Level of Harm - Minimal harm or potential for actual harm R5's (eMAR) dated 05/01/23-05/31/23 documents R5 received 3 out of 3 doses of 100 mg Macrobid (Nitrofurantoin) twice a day with a Start date 05/23/23 and End date 05/27/23 (DC date). R5's (eMAR) dated 07/01/23-07/31/23 documents R5 received 16 out of 16 doses of 125 mg Vancomycin for seven days with a Start date 07/07/23 and End date 07/14/23. Residents Affected - Some R5's (eMAR) dated 07/01/23-07/31/23 documents R5 received 13 out of 14 doses of 125 mg Vancomycin capsule for 7 days with a Start date 07/15/23 and End date 07/22/23. R5's (eMAR) dated 07/01/23-07/31/23 documents R5 received 12 out of 12 doses of 125 mg Vancomycin capsule four times a day with a Start date 06/22/23 and End date 07/06/23. R5's Urinalysis collected 6/21/23 documented the presence Toxigenic C. difficile DNA detected (Positive). R5's Urinalysis dated 7/25/23 did not document the presence of any organisms and collection of another sample was requested due to possible contamination. R5's Urinalysis dated 7/28/23 did not document the presence of any organisms. On 8/18/23 at 12:35 PM, V3 (Assistant Director of Nursing/Infection Control Preventionist-ADON/ICPC) stated the doctor has begun a taper of the antibiotics. Efforts have been made to encourage providers to adhere to the Antibiotic Stewardship Program. R5 is currently not experiencing any loose stools but remain on isolation. 3. R16's Face Sheet undated documents a pertinent diagnosis as a personal history of Urinary Tract Infections. R16's MDS dated [DATE] documents R16 has moderate cognitive impairment is frequently incontinent of bowel and bladder, is not on a bowel or bladder training program. Antibiotics are not documented as a medication that R16 received in past 7 days. R16's Physician Order Report dated 06/01/2022-08/18/2023 documents orders for antibiotics: sulfamethoxazole-trimethoprim 400-80 mg, 1 tablet once a day on Monday, Wednesday and Friday (order on hold from 4/24/23 to 5/02/2023) Start date: 06/09/2022- End date: Open Ended; Vibramycin (doxycycline hyclate) 100 mg capsule, 1 tablet, twice a day for 3 days, Start date: 07/11/2022- End date 07/14/2022; Vibramycin (doxycycline hyclate) 100 mg capsule, 1 tablet, twice a day. Start date: 12/13/2022- End date 12/20/2022; Azithromycin 500 mg, 1 tablet once a day. Start date: 4/18/2023-End date: 4/20/2023; Bactrim DS (sulfamethoxazole-trimethoprim) 800-160 mg, 1 tablet twice a day x 7 days, Start date: 4/24/2023- End date- 5/01/23. R16's eMAR dated 01/01/2023-01/31/2023 documents R16 received 13 out of 13 doses of sulfamethoxazole-trimethoprim. R16's eMAR dated 02/01/2023-02/28/2023 documents R16 received 12 out of 12 doses of sulfamethoxazole-trimethoprim. R16's eMAR dated 03/01/2023-03/31/2023 documents R16 received 14 out of 14 doses of sulfamethoxazole-trimethoprim. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145601 If continuation sheet Page 10 of 13 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 145601 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviston Countryside Manor 450 West 1st Street Aviston, IL 62216 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 0881 Level of Harm - Minimal harm or potential for actual harm R16's eMAR dated 04/01/2023-04/30/2023 documents R16 received 9 out of 9 doses of sulfamethoxazole-trimethoprim (order on HOLD from 4/24/23-5/2/23). R16's eMAR dated 05/01/2023-05/31/2023 documents R16 received 13 out of 13 doses of sulfamethoxazole-trimethoprim. Residents Affected - Some R16's eMAR dated 06/01/2023-06/30/2023 documents R16 received 13 out of 13 doses of sulfamethoxazole-trimethoprim. R16's eMAR dated 07/01/23-07/31/2023 documents R16 received 13 out of 13 doses of sulfamethoxazole-trimethoprim. R16's eMAR dated 08/01/23-08/18/2023 documents R16 received 8 out of 8 doses of sulfamethoxazole-trimethoprim. R16 urinalysis specimen collected 4/21/23 was positive for the organism proteus mirabilis and was resistive to the drug sulfamethoxazole-trimethoprim. R16's Nurse's Progress Notes dated 07/28/2023 04:58 PM documents discuss long-term use of Bactrim DS antibiotic with Nurse Practitioner (NP). Resident takes medication for personal history of UTI and at this time the NP wants to keep this drug regimen related to it has decreased hospitalizations and has improved quality of life and patient is therapeutic at this time. On 8/18/23 at 10:30 AM, R16 stated she was on long-term antibiotics because of her getting a lot of urinary tract infections (UTIs). 4. R35's Face sheet undated documents pertinent diagnosis as history of Urinary Tract Infections (UTIs), and Neuromuscular Dysfunction of Bladder, Unspecified. R35's MDS dated 7/1423 documents R35 is cognitively intact, has an indwelling catheter, urinary incontinence was not rated but R35 is frequently incontinent of bowel, is not on a bowel or bladder training program. R35's MDS documents antibiotics are documented as a medication that R16 received in past 7 days. R35's Physician Order Summary dated 07/01/2022-08/18/2023 documents physician orders for Amoxicillin-Potassium Clavulanate 875-125 mg, 1 tablet twice a day Start date: 1/20/23- End date 1/20/23 (DC date); Amoxicillin-Potassium Clavulanate 875-125 mg 1 tab twice a day, start date: 1/21/23- End date: 1/28/23; Sulfamethoxazole-trimethoprim 800-160 mg, 1 tab twice a day, Start date 6/26/23-7/8/23. UA with C&S if indicated, once 6/6/23-6/6/23; UA with C&S if indicated, once 6/14/23. R35's eMAR dated 01/01/2023-01/31/2023 documents R35 received 1 out 1 dose of Amoxicillin-Potassium Clavulanate 875-125 mg. Start Date:1/20/23- End Date: 1/21/23 (DC Date) R35's eMAR dated 01/01/2023-01/31/2023 documents R35 received 15 out 16 doses of Amoxicillin-Potassium Clavulanate 875-125 mg. Start Date:1/21/23- End Date: 1/28/23. R35's eMAR dated 06/01/2023-06/30/2023 documents R35 received 10 out of 10 doses of Bactrim DS (sulfamethoxazole-trimethoprim) 800-160 mg. Start Date: 06/26/23- End Date: 07/06/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145601 If continuation sheet Page 11 of 13 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 145601 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviston Countryside Manor 450 West 1st Street Aviston, IL 62216 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 0881 Level of Harm - Minimal harm or potential for actual harm R35's eMAR dated 07/01/2023-07/31/2023 documents R35 received 12 out of 12 doses of Bactrim DS (sulfamethoxazole-trimethoprim) 800-160 mg. Start Date: 06/26/23- End Date: 07/06/23. R35's eMAR dated 08/01/2023-08/18/2023 documents R35 received 17 out of 18 doses Bactrim DS (sulfamethoxazole-trimethoprim) 800-160 mg. Start Date: 07/08/23- End Date: Open Ended Residents Affected - Some R35's urinalysis specimen collected 6/21/23 was positive for 2 organisms ((1) Escherichia Coli and (2) Proteus Mirabilis. Bactrim DS (sulfamethoxazole-trimethoprim) was sensitive to both organisms. R35's Nurse Progress notes dated 7/7/23 documents R35 will be started on Bactrim DS long-term daily related to re-current urinary tract infections. On 8/18/23 at 12:35 PM, V3 stated R35 is on hospice and hospice has stopped all lab work and testing. 5. R217's Face Sheet undated documents pertinent diagnosis as Obstructive and Reflux Uropathy and history of Urinary Tract Infections. R217's Minimum Data Set (MDS) dated [DATE] documents Cognitive Skills for Daily Decision Making is moderately impaired. R17 has an indwelling catheter and is frequently incontinent of bowel. R217 is not on a bowel or bladder toileting program. Antibiotics are documented as a medication that R217 received in past 6 days. R217's Physician Order Summary dated 06/01/2023-06/30/2023 documents orders for Macrobid (nitrofurantoin monohydrate-macrocrystalline) 100 mg capsule once a day. Start date: 6/24/2023- Open Ended. R217's eMAR dated June 2023 documents 7 out of 7 doses of Macrobid 100 mg. Start date: 6/24/23 -open ended. R217's eMAR dated July 2023 documents 1 out of 1 dose of Macrobid 100 mg. Start date: 6/24/23-open ended. On 8/18/23 at 12:39 PM, V3 stated R217 was placed for respite stay. V3 stated R217 was unable to talk and walk and required total care. V3 stated R217 arrived on antibiotics for frequent Urinary Tract Infections (UTIs) and was under Hospice care. The Facility's Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes revised October 2017 documents, Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. As part of the facility Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the Infection Preventionist, or designee. The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. Therapy may require further review and possible changes if: (1) The organism is not susceptible to the antibiotic chosen; (2) The organism is susceptible to narrower spectrum antibiotic; (3) Therapy was ordered for prolonged surgical prophylaxis; or (4) Therapy was started awaiting culture, but culture results and clinical findings do not indicate continued need for antibiotics. All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145601 If continuation sheet Page 12 of 13 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 145601 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviston Countryside Manor 450 West 1st Street Aviston, IL 62216 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some gathered will include a. Resident name and medical record number; b. Unit and room number; c. Date symptoms appeared; d. Name of antibiotic (see approved surveillance list); e. Start date of antibiotic; f. Pathogen identified (see approved surveillance list); g. Site of infection; h. Date of culture; i. Stop date; j. Total days of therapy; k. Outcome; and l. Adverse events. Based on interview and record review, the facility failed to establish an infection prevention and control program that reduces the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use in 5 of 5 residents (R5, R16, R35, R50, and R217) reviewed for antibiotic stewardship in the sample of 37. Findings include: 1. The Facility's Infection Tracker documents R50's 6/29/23 onset infection type as Prophylaxis. R50's Order History documents order for Trimethoprim tablet; 100 mg (milligrams); Take one tablet by mouth at bedtime for long term abx (antibiotics) for tx (treatment) of frequent UTI (Urinary Tract Infection) with start date of 4/1/22 and end date of 8/15/23. R50's Medication Administrator Record (MAR) for the months of May 2023 through August 2023 document R50 received 106 doses of Trimethoprim. R50's Progress Note dated 7/28/23 at 2:44 PM documents, This nurse informed NP (Nurse Practitioner) of resident long-term use of antibiotic for history of UTI (Urinary Tract Infection). At this time, NP wants to continue and let hospice address. Waiting callback from hospice. R50's Progress Note dated 8/11/23 at 3:01 PM documents, This nurse called hospice in regarding long-term antibiotic use. awaiting callback. On 8/17/23 at 8:40 AM, V3 (Assistant Director of Nursing/ADON and Infection Control Preventionist/ICP) stated R50 was on Trimethoprim prior to admission, and the Facility does not have a culture. On 8/18/23 at 8:37 AM, V3 stated she expects the Facility to obtain a culture for any residents receiving antibiotics to treat urinary infections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145601 If continuation sheet Page 13 of 13