Health inspection·February 9, 2023

F 0602 my son is in the building. Level of Harm - Minimal harm or potential for actual harm On 2/8/23 at 2:57 PM, V2 Assistant Administrator stated she did not report this incident to the local health department or the police. (No initial and final incident report available, requested all documents available for missing resident funds.) Residents Affected - Few The facility provided the following document following a request for missing money investigations. Nurse reported that [R54, room number withheld] was missing $40 from her wallet on 11/11/22 at 8:42 AM via email. Assistant Administrator started investigating concern. Room was searched by social services but missing money was not found. Front Desk confirmed that resident withdrew $50 on 11/4/22 out of the trust account. She stated she had (2) $20 and (2) $5. Resident stated that money was taken out to pay back her son. Called Son and he did not see the money on her person . The facility staff training dated 1/13/23 showed, I wanted to make you all aware that [the facility] has received 3 reports of missing money from residents from the 2nd floor . On 2/9/23 at 11:06 AM, V2 stated theft is abuse. V2 stated the facility was not able to determine what happened to R54's money. The facility's Resident Abuse and Neglect Policy revised 7/2019 showed Misappropriation of Resident's Property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of resident's belongings or money without the resident's consent. The policy shows the facility strictly prohibits misappropriation of resident property and all staff are trained on hire regarding this policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145652 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 145652 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley HI Nursing Home 2406 Hartland Road Woodstock, IL 60098 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 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 observation, interview and record review the facility failed to report to the local health department and local law enforcement the reasonable suspicion of resident theft. This applies to 3 of 3 residents (R54, R64, & R283) reviewed for abuse in the sample of 20. The finding include: 1. R54's Face Sheet showed she was admitted to the facility on [DATE] with diagnoses to include: reduced mobility, artificial hips, and a traumatic fracture. (No dementia or psychiatric diagnoses listed.) R54's 1/3/23 Minimum Data Set (MDS) showed she was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. On 2/7/23 at 11:28 AM, R54 was in her room and she was using a wheelchair to self-propel herself about her room. R54's room was clutter free and well decorated. R54, as well as all residents of the second floor, had her own free-standing closet with drawers. R54's free-standing closet was next to her bed and could not be mistaken for her roommate's closet. R54's roommate, (R64) was on the opposite side of her room and she had her own free standing closet. Between R54 and her roommate, was a curtain. On 2/07/23 at 11:28 AM, R54 stated .I had $40 dollars taken out of my wallet. I had two $20's and two $5's, they took the two 20's and left the [NAME]. R54 stated her son was going to take her shopping, so earlier that week she had withdrawn $50 from her account. R54 said, when her son arrived, she removed her purse from the closet, opened her wallet, and noticed the two $20 bills were gone. R54 said she had the money for about 5 days; however, she had not verified it was in her wallet since the day she had withdrawn it from her account. R54 said purchase any items or services from the time she withdrew the money to the time her son arrived. R54 stated she believed whoever took the two $20 bills left the $5 bills to make the theft less suspicious. On 2/9/23 at 12:38 PM, R54 repeated her story as stated above without discrepancies. R54 said, when she reported the money missing, she was not reporting she had lost the money, she was reporting the money was stolen. On 2/8/23 at 2:57 PM, V2 Assistant Administrator stated she did not report this incident to the local health department or the police. The facility staff training dated 1/13/23 showed, I wanted to make you all aware that [the facility] has received 3 reports of missing money from residents from the 2nd floor . On 2/9/23 at 11:06 AM, V2 stated theft is abuse. V2 stated the facility was not able to determine what happened to R54's money. V2 stated she only reports theft if the facility is able to substantiate the abuse. V2 stated she does not consider a resident reporting missing money as an allegation of abuse unless it is determined the money was stolen. V2 stated the facility is required to report allegations of abuse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145652 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 145652 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley HI Nursing Home 2406 Hartland Road Woodstock, IL 60098 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 On 2/9/23 at 11:57 AM, V1 Administrator stated he would report to the local health department if a resident was missing $100 but if they are only missing $10 or $15, I don't know. Our policy doesn't have a dollar amount to report to [the local health department.] V1 said, if a resident is confused he is not certain he would report missing money. The facility's Resident Abuse and Neglect Policy revised 7/2019 showed Misappropriation of Resident's Property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of resident's belongings or money without the resident's consent. The policy showed, Immediately or within 24 hours of receiving an allegation of abuse, neglect, or misappropriation of resident's property may have occurred, the administrator will send an initial report of the matter to the [local health department.] The policy showed, Certain incidents involving abuse, neglect, mistreatment, misappropriation of property .will also be reported to local law enforcement officials . 2. R64's Face sheet showed an admission date of 3/20/22 with diagnoses to include strokes and difficulty speaking. R64's 12/21/22 Minimum Data Set (MDS) showed moderate cognitive impairment with a brief interview for mental status score of 12 out 15. On 2/07/23 at 11:28 AM, R64 (R54's roommate) stated in addition to R54 missing $40 she was missing $10 as well. R64 said when R54 reported the missing $40 she checked her wallet. R54 said she had $14; a $10 bill and (4) $1 bills. R54 said someone took her $10 bill and left the (4) $1 bills. R64 said she had the money for 3-4 months and she was not certain the last time she verified she had the money. The facility's Missing Resident Items List 2023 showed on 11/11/22 R64 reported $10 was missing, her room was searched, and the money was not found. On 2/8/23 at 2:57 PM, V2 Assistant Administrator stated she did not report this incident to the local health department or the police. 3. R283's Face Sheet showed an admission date of 9/6/22 with diagnoses to include Parkinson's, stroke, and weakness. R283's 9/27/22 Minimum Data Set (MDS) showed she was cognitively intact with a brief interview for mental status score of 15 out of 15. On 2/08/23 at 12:59 PM, R283 stated approximately a month prior she had $20 taken from her coin purse, then a week later another $20 taken from the same purse, and then on Sunday 2/5/23 she had $10 taken. R283 said the facility searched for the money but it was never found. R283 stated she told V6 Registered Nurse about the missing money. V6 stated no one from administration spoke to her about the missing $10. The facility's Missing Resident Items List 2023 showed, on 1/1/23, the facility was aware that R283 had reported $40 was missing. The report did not show she was missing another $10. On 2/09/23 at 8:43 AM, V6 stated she was notified about the missing money. V6 stated she was unable to locate the money. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145652 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 145652 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley HI Nursing Home 2406 Hartland Road Woodstock, IL 60098 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 On 2/08/23 at 2:57 PM, V2 Assistant Administrator stated she did not report any of R283's missing money to the local health department or local law enforcement. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145652 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 145652 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley HI Nursing Home 2406 Hartland Road Woodstock, IL 60098 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to identify allegations of theft as being allegations of abuse and then failed to conduct a complete investigation of abuse. This applies to 3 of 3 residents (R54, R64, & R283) reviewed for abuse in the sample of 20. Residents Affected - Few The finding include: 1. R54's Face Sheet showed she was admitted to the facility on [DATE] with diagnoses to include: reduced mobility, artificial hips, and a traumatic fracture. (No dementia or psychiatric diagnoses listed.) R54's 1/3/23 Minimum Data Set (MDS) showed she was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. On 2/7/23 at 11:28 AM, R54 was in her room and she was using a wheelchair to self-propel herself about her room. R54's room was clutter free and well decorated. R54, as well as all residents of the second floor, had her own free-standing closet with drawers. R54's free-standing closet was next to her bed and could not be mistaken for her roommate's closet. R54's roommate was on the opposite side of her room and she had her own free standing closet. Between R54 and her roommate, is a curtain. On 2/07/23 at 11:28 AM, R54 stated .I had $40 dollars taken out of my wallet. I had two $20's and two $5's, they took the two 20's and left the [NAME]. R54 stated her son was going to take her shopping, so earlier that week she had withdrawn $50 from her account. R54 said when her son arrived she removed her purse from the closet, opened her wallet, and noticed the two $20 bills were gone. R54 said she had the money for about 5 days; however, she had not verified it was in her wallet since the day she had withdrawn it from her account. R54 said during the time from when she withdrew the money to her son arriving at the facility; she did not purchase any items from the facility and she did not have her hair done. R54 stated she believed whoever took the two $20 bills left the $5 bills to make the theft less suspicious. On 2/9/23 at 12:38 PM, R54 said, when she reported the money missing, she was not reporting she had lost the money, she was reporting the money was stolen. On 2/8/23 at 2:57 PM, all investigations for misappropriation of resident property were requested. On 2/9/32 at 8:15 AM, following the request for misappropriation documents, the facility provided a Missing Resident Items List 2023; and a stack of papers to include staff training for resident abuse, an email chain regarding missing money for R54, R64, & R283, and summaries of what the facility knew regarding the missing money for R54, R64, & R283. The papers provided did not include any resident interviews or staff witness statements. The papers included training signed by the facility's staff. The training was dated 1/13/23 On 2/09/23 at 11:06 AM, V2 Assistant Administrator stated when the staff signed the training they were asked if they knew about missing resident money. (Training was two months after R54's money was missing.) V2 stated any staff and resident interviews should be documented and collected into a single location for review. V2 stated she did not have any resident interviews regarding R54's missing money. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145652 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 145652 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley HI Nursing Home 2406 Hartland Road Woodstock, IL 60098 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 2/9/23 at 11:57 AM, V1 Administrator stated he would expect if a resident was missing money, an investigation would be conducted. V1 stated an investigation would include interviewing staff as well as residents in the surrounding area. V1 stated that would include residents a few doors up and down from the resident making the allegation. V1 stated interviewing residents is important to determine the possible extent of the abuse and to attempt to corroborate the resident's statements. (These interviews were not provided.) The facility's Resident Abuse and Neglect Policy revised 7/2019 showed Misappropriation of Resident's Property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of resident's belongings or money without the resident's consent. The policy did not state an investigation should be initiated, however, the policy referenced an investigation in regards to suspension of staff pending an investigation and notification of authorities of abuse following the results of an investigation. 2. R64's Face sheet showed an admission date of 3/20/22 with diagnoses to include strokes and difficulty speaking. R64's 12/21/22 Minimum Data Set (MDS) showed moderate cognitive impairment with a brief interview for mental status score of 12 out 15. On 2/07/23 at 11:28 AM, R64 (R54's roommate) stated in addition to R54 missing $40 she was missing $10 as well. R64 said when R54 reported the missing $40 she checked her wallet. R54 said she had $14; a $10 bill and (4) $1 bills. R54 said someone took her $10 bill and left the (4) $1 bills. R64 said she had the money for 3-4 months and she was not certain the last time she verified she had the money. The facility's Missing Resident Items List 2023 showed on 11/11/22 R64 reported $10 was missing, her room was searched, and the money was not found. On 2/9/32 at 8:15 AM, following the request for misappropriation documents, the facility provided a Missing Resident Items List 2023; and a stack of papers to include staff training for resident abuse, an email chain regarding missing money for R54, R64, & R283, and summaries of what the facility knew regarding the missing money for R54, R64, & R283. The papers provided did not include any resident interviews or staff witness statements. The papers included training signed by the facility's staff. The training was dated 1/13/23 On 2/09/23 at 11:06 AM, V2 Assistant Administrator stated when the staff signed the training they were asked if they knew about missing resident money. (Training was two months after R64's money was missing.) V2 stated any staff and resident interviews should be documented and collected into a single location for review. V2 stated she did not have any resident interviews regarding R64's missing money. 3. R283's Face Sheet showed an admission date of 9/6/22 with diagnoses to include Parkinson's, stroke, and weakness. R283's 9/27/22 Minimum Data Set (MDS) showed she was cognitively intact with a brief interview for mental status score of 15 out of 15. On 2/08/23 at 12:59 PM, R283 stated approximately a month prior she had $20 taken from her coin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145652 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 145652 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley HI Nursing Home 2406 Hartland Road Woodstock, IL 60098 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few purse, then a week later another $20 taken from the same purse, and then on Sunday 2/5/23 she had $10 taken. R283 said the facility searched for the money but it was never found. R283 stated she told V6 Registered Nurse about the missing money. V6 stated no one from administration spoke to her about the missing $10. The facility's Missing Resident Items List 2023 showed, on 1/1/23, the facility was aware that R283 had reported $40 was missing. The report did not show she was missing another $10. On 2/09/23 at 8:43 AM, V6 stated she was notified about the missing money. V6 stated she was unable to locate the money. V6 stated she did not report the missing money to her supervisor or administration. On 2/9/32 at 8:15 AM, following the request for misappropriation documents, the facility provided a Missing Resident Items List 2023; and a stack of papers to include staff training for resident abuse, an email chain regarding missing money for R54, R64, & R283, and summaries of what the facility knew regarding the missing money for R54, R64, & R283. The papers provided did not include any resident interviews or staff witness statements. The papers included training signed by the facility's staff. The training was dated 1/13/23 On 2/09/23 at 11:06 AM, V2 Assistant Administrator stated when the staff signed the training they were asked if they knew about missing resident money. (Training was two weeks after R283's money was missing.) V2 stated any staff and resident interviews should be documented and collected into a single location for review. V2 stated she did not have any resident interviews regarding R283's missing money. V2 said, I was not made aware of [R283] missing $10 and I would expect to be notified. I would expect to be notified so we could start an investigation to see if staff are taking the money. In general, the investigation is to determine that residents are safe and staff are following policy. possible extent of the abuse and to determine if the abuse happened. The investigation would be documented, collected, and reviewed by a singular person. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145652 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 145652 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley HI Nursing Home 2406 Hartland Road Woodstock, IL 60098 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 ensure catheter drainage bags and tubing were not laying on the floor or bed. The facility failed to ensure expired catheter supplies were removed from use for 4 of 4 residents ( R19, R65, R69 & R141) reviewed for catheters in the sample of 20. The findings include: 1. On [DATE] at 10:15 AM, V5 CNA (Certified Nursing Assistant) had R141 on the toilet in the bathroom to have a bowel movement. V5 washed, rinsed and dried R141's anal area and buttocks when R141 was done using the bathroom. V5 pulled up R141's incontinence brief and pants. V5 transferred R141 to her wheelchair. R141's indwelling urinary catheter bag was under her wheelchair without a cover in place. V5 wheeled R141 into her bedroom and placed a tray table in front of her. R141's catheter bag was folded over under her wheelchair and partially laying on the floor. R141 had catheter tubing laying on the floor. V5 stated the only catheter care she provides is emptying of the drainage bag. V5 stated she wipes the end of the drain on the catheter bag with alcohol after she empties the bag. On [DATE] at 10:15 AM, V4 RN (Registered Nurse) stated the catheter bag should be to dependent drainage and should be positioned below the level of the bladder. V4 stated the drainage bag should be inside of another bag. V4 stated the drainage bag and tubing should not touch the floor or be on the floor because of the chance for an infection; people with catheters are prone to infection. On [DATE] at 1:20 PM, V3 DON (Director of Nursing) stated when staff provide catheter care they should wipe the tubing down and away from the residents. V3 stated the same procedure should be used to dry the tubing. V3 stated this should be done three times per day, basically each shift and as needed if the tube becomes contaminated with stool etc. V3 stated the drainage bags should be in a bag and not touching the floor. The tubing should not touch the floor. This is important because of infection control. The Face Sheet printed on [DATE] for R141 showed diagnoses including hydronephrosis with renal and ureteral calculus obstruction, personal history of urinary tract infections, presence of urogenital implants, other fluid overload, congestive heart failure, syncope and collapse, orthostatic hypotension, weakness, type 2 diabetes mellitus, old myocardial infarction, anxiety and major depressive disorder. The Physician Orders for February 2023 for R141 showed, Urinary catheter: indwelling urinary catheter size 18 french, 30 ml; Urinary catheter for treatment of obstructive uropathy; Catheter care every shift days (7:30 AM - 3:30 PM), PM's (3:30 PM - 11:30 PM), nights (11:30 PM - 7:30 AM). R141's Care Plan showed it was last reviewed and revised on [DATE] and R141 was admitted with a long term indwelling urinary catheter. The diagnoses listed were acute kidney injury and urinary tract infection. The only intervention in place on R141's catheter care plan was to do catheter care every shift. The facility's Foley Catheter Care policy (3/16) showed catheter drainage bags are to be covered at all times using bag covers. The policy did not have any procedures for cleaning of the residents tubing or keeping the drainage bag and tubing off of the floor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145652 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 145652 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley HI Nursing Home 2406 Hartland Road Woodstock, IL 60098 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 2. R65's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include a history of urinary tract infection, quadriplegia, heart failure, and dysphagia. R65's facility assessment dated [DATE] showed he has no cognitive deficits and requires total assist from staff for all cares. R65's care plan initiated [DATE] showed, Urinary Incontinence, [R65] was admitted with a foley catheter for retention . Will remain free from urinary tract infection and injury related to foley . Foley care every shift . On [DATE] at 11:36 AM, V11 CNA and V12 CNA were providing catheter care for R65. R65 had a significant amount of sediment visible in the catheter tubing and a small amount of dark urine in the drainage bag. As V11 was providing care she took the catheter bag off the bed rail and set it up on the bed. Urine was visibly backflowing up the catheter tubing toward R65. On [DATE] at 12:18 PM, V9 RN (Registered Nurse) said, The catheter bag should not be on the bed, or above the level of the bladder, unless she (V11) forgot, because she did ok when she did catheter care with me. The reason to keep it below the level of the bladder is for the flow of the output and to prevent infection. The facility's policy with revision date of 3/2016 showed, Foley Catheter Care; Policy: It is the policy of the facility that catheter care will be provided to all residents with indwelling catheters at least every shift and as needed due to soiling with feces or when it is deemed necessary by the nurse The catheter and drainage bag should be kept as closed system with the drainage bag kept lower than the bladder to allow drainage by gravity . 3. On [DATE] at 10:44 AM, inside of the medication cart there was a urinary catheter insertion tray with an expiration date of 05-01-2022 and a urinary catheter with an expiration date of 04-2020. On [DATE] at 2:21 PM, there were expired supplies located in the supplies storage room on the first floor. The expired supplies were as follows: 1) Six urinary catheter insertion trays with an expiration date of [DATE], 2) Two 16 fr (French), 30 ml urinary catheters with an expiration date of [DATE], 3) Five 16 fr, 5-10 ml urinary catheters with an expiration date of [DATE], 4) Eleven 20 fr, 30 ml urinary catheters with an expiration date of [DATE], 5) Four 18 fr, 20 ml urinary catheters with an expiration date of [DATE], 6) One 16 fr, 5 ml urinary catheter with an expiration date of 10/2020, 7) Three 16 fr, 10 ml urinary catheters with an expiration date of [DATE], 8) Eleven 18 fr, 30 ml urinary catheters with no expiration date, 9) One 20 fr, 30 ml urinary catheter with no expiration date, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145652 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 145652 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley HI Nursing Home 2406 Hartland Road Woodstock, IL 60098 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 10) Four 16 fr, 30 ml urinary catheters with no expiration date, Level of Harm - Minimal harm or potential for actual harm 11) Twelve 12 fr, 30 ml urinary catheters with no expiration date. Residents Affected - Some On [DATE] at 2:40 PM, V4 RN (Registered Nurse) stated that the staff use supplies from the supplies storage room on the first floor for procedures. On [DATE] at 3:15 PM, V3 DON (Director of Nursing) stated that supply clerks remove the expired items and replace with newer supplies. V3 stated that the normal practice is for the supply clerk to replace items once, every week. On [DATE] at 1:17 PM, V8 RN (Infection Preventionist) stated that the expiration date on a sterile sealed product means the sterility and the integrity of the product is guaranteed until that date. V8 stated that if an expired item is used beyond that date for a resident, it could cause potential harm or infection. V8 stated that urinary catheter with expired date should not be used on residents as it places the resident at risk for UTI (Urinary Tract Infection). V8 stated that using an expired urinary catheter insertion tray on a resident would put that resident at risk for UTI. On [DATE] at 1:30 PM, V3 DON stated that the expiration date on a sterile sealed product guarantee the sterility of the product until that date and if used beyond that date, it could cause potential harm of infection. V3 stated that if urinary catheter with an expired date is used on a resident, it potentially places that resident at risk for UTI. V3 stated that if a urinary catheter insertion tray with an expired date is used on a resident, it potentially places that resident at risk for UTI. The facility matrix for providers which was provided on [DATE] showed R19, R65, R68 and R141 all had indwelling urinary catheters FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145652 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 145652 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley HI Nursing Home 2406 Hartland Road Woodstock, IL 60098 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow physician orders by administering insulin to a resident experiencing a low blood sugar level and failed to follow facility standing orders for treating low blood sugars for 1 of 1 resident (R35) reviewed for medications. Residents Affected - Few The findings include: R35's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include palliative care, acute respiratory disease, Type 2 diabetes mellitus with ketoacidosis without coma, anxiety disorder, atrial fibrillation, and history of malignant neoplasm of bronchus and lung. R35's facility assessment dated [DATE] showed he has severe cognitive impairment and requires extensive assist for most cares. R35's December 2022 eMAR (electronic Medication Administration Record) showed glucose levels as follows: 12/9/22 at 7:30 AM, 46 mg/dl; 12/9/22 at 4:30 PM, 50 mg/dl; 12/10/22 at 7:30 AM, 39 mg/dl; 11:30 AM, 61 mg/dl; 4:30 PM, 51 mg/dl; 9:00 PM, 49 mg/dl; 12/12/22 at 7:30 AM, 61 mg/dl; 9:00 PM, 64 mg/dl; 12/15/22 at 7:30 AM, 51 mg/dl; and 12/17/22 at 7:30 AM, 46 mg/dl. The same December 2022 eMAR showed, Levemir U-100 Insulin, Amount to administer: 10 units . hold if blood sugar is below 150 . The eMAR showed on 12/9/22 when R35's blood sugar was 75 mg/dl (outside of the parameters for receiving insulin) his insulin was still administered. There was no documentation of R35 receiving any form of glucose gel or glucose injection on R35's medication administration record. There was no evidence found in R35's complete medical record showing any glucose gel or glucose injection being given. R35's 12/9/22 nursing note entered at 9:07 AM showed, Call place to [Primary Care Physician] to update regarding resident blood sugars are between 40-57. Resident unable to arouse to take any medications, eat, or drink. Attempted to provide orange juice, resident unable to drink. Tongue hanging out side of mouth and drooling. [Primary Care Physician] advised to reach out to hospice for further orders. R35's 12/10/22 nursing note entered at 1:13 PM showed, Morning blood sugar was at 39 and resident is kind of semi awake, tried giving some liquid but won't even sip on the straw, tried multiple times with no avail. Hospice was updated and was told the hospice nurse will be here today. Also POA was updated and was here in 30 minutes. Lorazepam 0.25 was given around 10 AM due to respiratory grunting . R35's 12/14/22 nursing note entered at 9:01 AM showed, Went into residents room to do blood glucose check. Resident slouched over to side in bed, responsive to name, non verbal but did groan in response. Blood sugar at 7:30 AM was 46. Due to being responsive, gave glass of orange juice with sugar. Drank slowly and with no issue. Blood sugar at 7:45 was 58, recheck at 8:15 AM was 70 . On 2/09/23 at 12:18 PM, V9 RN (Registered Nurse) said, Whether or not a resident on hospice is treated for low blood sugars is dependent upon the doctor. It all depends on the doctor, they determine that. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145652 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 145652 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley HI Nursing Home 2406 Hartland Road Woodstock, IL 60098 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 2/09/23 at 1:02 PM, V3 DON (Director of Nursing) said there is no difference in the treatment of hypoglycemia for a resident on hospice services verses a resident not on hospice. V3 said hospice patients would receive treatment for low blood sugars. V3 said the facility does not have IM (Intramuscular) glucagon but they do have the glucose gel. V3 said they would not just let them go with a low blood sugar. V3 said the standing orders for the facility would be for the glucose gel and she would have expected them to use the glucagon gel. V3 said they should get the blood sugar up and then notify the doctor. V3 said they need to treat the patient because if they don't treat the patient they could go unresponsive and into a coma. The facility policy and procedure revised February 2014 showed, Treatment of Hypoglycemia, Preface: Typically hypoglycemia is defined as blood glucose levels that are less than 70 mg/dl (Some medical literature suggests 20-50 mg/dl as true hypoglycemia.) Serious or prolonged hypoglycemia can have devastating consequences such as: delirium, confusion, coma, or even death. Some patients may be extremely sensitive to glucose levels of 65, while others may function normally as low as 40 mg/dl. Therefore, stepwise treatment should be based on glucose levels and patient symptomatic presentation, in order to provide adequate treatment. Purpose: The purpose of this is the enable staff to quickly and adequately respond to episodes of hypoglycemia (low blood sugar). According to the position statement published by the American Diabetes Association: Nutrition Recommendations and Interventions for Diabetes, individuals with an episode of hypoglycemia should be treated with 15-20 G Glucose. Procedure: 1. If hypoglycemia occurs, and the patient remains conscious and able to swallow, a readily available source of glucose should be given, such as (but not limited to): 3-4 glucose tablets or glucose paste/gel . 2. If the resident is unconscious, NPO (nothing by mouth) and blood sugar is less than 50 mg/dl. Administer Glucagon 1 mg IM injection or Subcutaneous STAT (immediate) (located in pharmacy emergency box) and notify the physician by phone . 7. Nursing staff shall document interventions and results accordingly. The facility's policy and procedure revised May 2013 showed, Blood Glucose Monitoring and Physician Notification Policy The nurse shall perform a physical assessment of all residents to assist in determining the accuracy of a critical result of glucose measurement . Nurses will provide appropriate intervention when blood glucose level is below or above parameters ordered by physician. Nurse will notify physician regarding blood glucose level; below 70 and greater than 400; and intervention provided and outcome . Procedure: . The licensed nurse will notify the attending or on call physician whenever a resident blood sugar result falls below 70 or greater than 400. The licensed nurse will not hold insulin unless an order from the physician is obtained . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145652 If continuation sheet Page 13 of 13