Health inspection·March 20, 2024

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were served food at a safe temperature. This failure resulted in R273 spilling hot soup and receiving full thickness burns on his right forearm and abdomen. The facility failed to safely transfer residents with a mechanical lift. The facility failed to ensure medications were stored in a safe manner away from a cognitively impaired resident. The facility also failed to ensure residents at risk for choking were supervised during meal times and provided thickened liquids as prescribed. This applies to 6 of 18 residents (R17, R9, R51, R52, R53 & R273) reviewed for safety and supervision in the sample of 18. The failure to ensure safe food temperatures resulting in R273 sustaining a burn due to hot foods resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 6/5/23 when the facility failed to ensure residents were served soup at a safe temperature to prevent burns. V1 Administrator was notified of the Immediate Jeopardy on 3/19/24. This surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 3/20/24 however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training and staffing levels. The findings include: 1. On 3/19/24 at 11:46 AM, the soup on the second floor was measuring 181.7 degrees Fahrenheit (F). R52's facility event report dated 6/5/23 shows, Hot soup during lunch was spilled on resident's right hand and leg. R52's progress note dated 6/5/23 shows, During lunch time resident was served hot soup. Bowl slipped from universal worker's hand and was spilled on resident's right hand and lap . V4 Dietary Manager's statement for R52's event shows, he saw V5 Resident Aide (universal worker) trip and spill hot soup on R52. He heard R52 yell that she was burning and hot. On 3/20/24, V4 Dietary Manager confirmed his statement. On 3/20/24 at 9:01 AM, R52 stated, she remembered when soup was spilled on her. She didn't know what happened but that hot soup was spilled on her. It was very hot. I cried a lot because it hurt. She also stated, you have to let the soup sit and cool down because it is boiling hot before you can eat it. R52's Minimum Data Set, dated [DATE] shows, she is cognitively intact. On 3/19/24 at 1:05 PM, V4 Dietary Manager stated, they have not done anything different after R52 had hot soup spilled on her. The minimum temperature of the soup is kept at least 165 degrees F. R273's facility event report dated 11/6/23 shows, spilled hot soup during lunch on right arm. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145652 If continuation sheet Page 2 of 22 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 03/20/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few R273's progress notes dated 11/6/23 at 1:04 PM shows, Resident continues to refuse to get up from the bed to his wheelchair for meals. During lunch time he spilled hot soup on his right arm. Arm painful and red . The same progress notes at 11:48 PM shows, Received report about resident soup incident . Observed a blister on resident right side of the abdomen. R273's progress notes dated 11/7/23 at 2:35 PM shows, Observed fluid filled blister on the anterior of the right upper arm and open area approximate 7 cm (centimeter) x 5.5 cm partial thickness. Resident c/o (complain of) pain on the site . R273's wound doctor evaluation and management summary dated 11/13/23 shows, he has a full thickness burn wound of the right, upper, medial arm measuring 5.0 x 7.1 x 0.1 cm (length x width x depth). Additional wound detail: Area of partial, deep-partial and likely some full thickness thermal burn from where pt (patient) spilled coffee on himself. There is nothing documented about the burn on his abdomen. R273's wound doctor evaluation and management summary dated 11/20/23 shows, he has a full thickness burn wound of the right, upper, medial arm measuring 5.0 x 5.1 x 0.1 cm and a full thickness burn wound of the right, lower abdomen measuring 4.1 x 1.3 x 0.1 cm. On 3/20/24 at 10:49 AM, V6 Wound Care Nurse stated, R273 had between 2nd and 3rd degree burns on his forearm and abdomen. On 3/20/24 at 6:05 PM, V37 Advanced Practice Registered Nurse (APRN) stated, she was aware of R237 spilling hot soup on himself and obtaining full thickness burns to his right arm and abdomen. The expectation would be not to serve soup that is too hot for residents to eat. 185 degree F soup is too hot to serve to residents. On 3/19/24 at 1:19 PM, V4 stated, he did not have temperature logs for the soup. They are taking the temperatures of the soup but not logging them. The facility did not provide any food temperature logs for the soup. The facility's food temperatures policy dated 2017 shows, Policy: The temperatures of all food items will be taken and properly recorded prior to service of each meal. Procedure: 1. b. Hot food items may not fall below 135 degrees F after cooking, unless it is an item which is to be rapidly cooled to below 41 degrees F and reheated to at least 165 degrees F prior to serving. Caution should be taken to avoid serving food and liquids at temperatures that are too hot to avoid the risk of burns. The facility presented an abatement plan to remove the immediacy on 3/19/24. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a second revised abatement plan on 3/19/24. The survey team reviewed the abatement plan and was still unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a third abatement plan on 3/20/24. The survey team reviewed the abatement plan and was still unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a fourth abatement plan on 3/20/24 and the survey team accepted the abatement plan on 3/20/24. The Immediate Jeopardy that began on 6/5/23 was removed on 3/20/24 when the facility took the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145652 If continuation sheet Page 3 of 22 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 03/20/2024 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 0689 following actions to remove the immediacy. Level of Harm - Immediate jeopardy to resident health or safety 1. Facility Dietary Director updated the daily meal temp log to include soup temperatures; completed during survey and initiated with dinner 3/19/24. Residents Affected - Few 2. Facility dietary staff were immediately retrained on the procedure for taking meal temps at every meal, using the new log, and the appropriate ranges before the start of their next shift, this will be completed by the facility Dietary Director starting with staff currently on shift and will be completed by 3/30/24 3. Facility Administrator will review and update the facility policy for food temperatures, will send to the facility RD for approval by 3/22/24 a. Policy will be updated to reflect soup temperatures between 135 degrees to 150 degrees Fahrenheit to ensure soups are delivered to resident's at a safe temperature 4. Facility Dietary Director and Dietician will conduct a dietary department training on food safety, including proper food temperature monitoring and the updated policy after adoption; completed by 3/22/24 5. Facility Assistant Administrator will hold an emergency dietary QA meeting on 3/20/24 that will be attended by all dietary staff; the medical director was invited to attend either in person or via phone 6. Facility Administrator notified the Medical Director of the IJ on 3/19/24 and invited him to the emergency QA meeting 7. Facility Dietary Director will provide the Quality Assurance Committee with a monthly summary report identifying any food temps outside of policy range for 6 months or longer if determined necessary by the Committee 2. R273's facility event report dated 9/20/23 shows, Two CNA's (V38 & V39 Certified Nursing Assistants) had pt (patient) on the [mechanical lift] and bumped his head creating two skin tears on top of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145652 If continuation sheet Page 4 of 22 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 03/20/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few cranium . Measurement of Injury: 1.8 x 1.3 cm and 1x1 cm. Evaluation: On 9/20/23, resident was being transferred in [mechanical lift] and upon being lowered into chair, resident hit his head against pad on the lift and two skin tears were obtained . Nurse did immediate re-education with two CNAs on how to lower lift without bumping chair. On 3/20/24 at 9:15 AM, V39 CNA stated, V38 and her were transferring R273 from his bed to the wheelchair when he bumped his head on the mechanical lift. He hit his head on the cross bar of the mechanical lift. R273 had 2 open areas on the top of his head. The facility's transfer and positioning policy dated 5/2017 shows, 6. EZ lift (mechanical lift)- when someone is an EZ lift that means they cannot bear weight and are totally dependent for transfers . The most important thing to remember with the EZ lift is that the bars spin sideways and back and forth as well as around, so use extreme caution when moving the lift around the resident . 3. On 03/19/24 at 09:24 AM V27, R17's daughter, said she was not happy because her mom, R17, got hit with a (mechanical) lift. V27 said she was called and informed R17 had a mark under her eye from the incident on a Tuesday (1/8/24) and when she arrived to the facility on Saturday (1/13/24) to visit R17, R17 had a huge black eye. V27 said she worried R17's facial bone could be fractured and asked for an x-ray to be done. V27 said during this visit with R17 (on 1/13/24) R17 wanted to go back to bed. V27 said when the CNAs came in to transfer R17 to bed, they were not watching what they were doing and they hit R17 with the main bar of the lift again. On 3/18/24 at 2:22 PM, V21, CNA, said she along with another CNA were transferring R17 with the mechanical lift (on 1/8/24). V21 said the footrest of R17's wheelchair got caught on the leg of the mechanical lift, so when the lift was lowered, the wheelchair came down fast and R17 came forward and bumped her head on the lift. V21 said, That was my error. V21 said R17 did bruise up and have swelling, but she did not go to the hospital. On 3/20/24 at 10:41 AM, V22, CNA, said she was one of the CNAs assisting R17 to transfer from her wheelchair to her bed (on 1/13/24) with the full mechanical lift. V22 said they began moving the lift toward R17's wheelchair and did it slightly too quickly; we definitely could have done it a little slower and they bumped R17's head with the scale box on the lift. V22 said it was definitely user error on our part. On 3/20/24 at 11:20 AM, V30, CNA, said she was assisting to help transfer R17 from her wheelchair to bed with the full mechanical lift (on 1/13/24). V30 said they were getting R17 hooked up to the lift and were trying to maneuver it and I guess we were not careful enough and not watching and we bumped R17's head with the weight box on the lift. R17's Minimum Data Set (MDS) dated [DATE] shows she has severe cognitive impairment. R17's current Care Plan (edited 3/20/24) shows R17 sustained a bruise to her face below her left eye measuring 5 cm (centimeters) by 2 cm due to an incident with a full mechanical lift of 1/8/24. The same care plan shows R17 was bumped on her forehead with a mechanical lift machine when staff were giving care. The same care plan shows R17 requires extensive assistance with ADLs (activities of daily living) and two staff member for transfers with a mechanical lift. 4. On 3/19/2024 at 11:45AM, V17 Home Health Aide said she was transferring R48 with the assistance of V14 - Certified Nursing Assistant. V17 said the full mechanical lift started to tip and R48 bumped her head on the lift, no bleeding or bruising noted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145652 If continuation sheet Page 5 of 22 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 03/20/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On 3/19/2024 at 1:40PM, V14 said he was helping V17 with a full mechanical lift transfer and the lift started to tip and R48 bumped her head on the cross bar of the lift, no bleeding or bruising noted at that time. On 3/19/2024 at 12:27PM, V7 Licensed Practical Nurse (LPN)/ Rehab Coordinator said if the lift is used correctly, it should not tip over or start to tip over. R48's Care Plan, revised on 1/23/2024 states . At this time R48 needs max asst with adl's (activities of daily living). Transfers with total mechanical, w/c pushed by staff, and ambulation is not feasible at this time. 5. R9's Speech Therapy Evaluation and Plan of Treatment dated 3/15/24 states, Patient referred to SLP (speech language pathologist) due to new onset of signs/symptoms of dysphagia and risk for aspiration causing change in swallowing abilities related to dementia . Self Feeding = Patient requires assistance, to address in treatment plan . R9's Physician's Orders form (no date) shows R9's Dietary Order is general, honey thick, mechanical soft. R9's Dietary Order states, Needs 1:1 (one-to-one). Alternate solids/liquids. Small bites/drinks. No straws. Upright 90 degrees. Multiple swallows. On 3/19/24 at 8:37 AM, R9 was lying in bed with the head of the bed elevated approximately 45 degrees. On R9's bedside table, within R9's reach, was a breakfast tray with a half full bowl of cereal with thin 1% milk in it, a half full carton of thin 1% milk, and a half full cup of thin apple juice. Staff was not present. On 3/19/24 at 12:40 PM, the first floor kitchenette did not have any honey thickened milk but it did have honey thick juice and honey thick water. On 3/19/24 at 12:43 PM, V4 (Dietary Manager) showed this surveyor a full case of honey thick milk in the dry storage area in the main kitchen. V4 said even if staff run out of honey thick milk at the point of service, staff know to run to the kitchen and grab what is needed. V4 also said that there are thickening packets available in each kitchenette if staff need to thicken beverages at the point of service. On 3/19/24 at 11:44 AM, V4 said any resident ordered to receive honey thick liquids should never receive thin apple juice or thin 1% milk. If served thin liquids, their risk for aspiration, choking, or food in lungs can increase. V4 also said that a certified nursing assistant (CNA) should never leave that room if they require one-to-one assistance with meals. The tray should have been picked up and removed after finishing assisting R9 with feeding. There should be no food or drink in front of them and left with them if they are one-to-one and no staff are present. Facility Dining Room Seating, Swallow Protocol and Supervision Policy dated 2/2023 states, . Residents identified as 1:1 or close supervision cannot eat or drink in their rooms without a refusal of treatment. Swallow Precaution Status Definitions: 1:1- CPR certified CNA or nurse sitting at the table that only focuses on one resident. Staff member cannot leave the table while the resident is eating. No food or drinks set at the table until the designated staff member serves the resident's tray. 6. R59's Event Report dated 2/28/24 states, Resident is impulsive, forgetful, confused d/t (due to) UTI (urinary tract infection), just returned from hospital yesterday. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145652 If continuation sheet Page 6 of 22 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 03/20/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On 3/20/24 at 4:01 PM, V11 (LPN) said on 2/27/24 at approximately 9:15 AM, V11 prepared a small plastic pill cup (2 tablespoons in volume) with approximately one-half tablespoon of calmoseptine cream. After dispensing the cream into the pill cup, V11 went into R59's room and placed the cup down, waiting for R59 to return from breakfast. The pill cup with the cream in it was left unattended in R59's room. While waiting for R59 to return to the room, V11 was called to two different rooms back to back to send two residents out to the local hospital to receive emergency care. When V11 returned to R59's room, R59 was already taken for therapy. On 3/19/24 at 1:54 PM, V19 (Occupational Therapist) said on 2/27/24 at approximately 9:00 AM, V19 went to R59's room to get her ready for therapy. R59 was found in her wheelchair and V19 noticed something white on R59's lips and inside of R59's mouth. V19 asked R59 if she had taken her medicine and R59 could not recollect. V19 then called the unit secretary to let them know about the incident and the unit secretary informed the unit nurse. V18 (CNA) then came to the therapy room and returned R59 to R59's room. On 3/19/24 at 11:33 AM, V18 said on 2/27/24 at approximately 9:45 AM, V18 used a washcloth with warm water and a sponge to rinse out R59's mouth to remove the remaining cream. V18 said V59 had a pinkish white film coated on R59's teeth and all inside of R59's mouth. On 3/20/24 at 4:01 PM, V11 said after realizing that R59 had potentially ingested the cream that was left in R59's room, V11 went into R59's room and found the plastic pill cup of cream in R59's trash can. The cup looked as if a finger was used to scoop out the cream. V11 said R59 was recently placed on an antibiotic for a new diagnosis of a urinary tract infection. Due to the infection, V11 said that R59 was more confused and forgetful compared to R59's baseline. V11 called poison control with V15 (RN) and poison control said to monitor R59 for nausea, vomiting, and diarrhea. V11 said R59 did not experience any nausea, vomiting, or diarrhea throughout the rest of V11's shift. V11 said the cup with cream should not have been left in R59's room unattended. On 3/19/24 at 1:27 PM, V2 (Director of Nursing) said that ointments or treatments for confused residents shouldn't be left unattended. It is recommended that the task is completed while you are in there with the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145652 If continuation sheet Page 7 of 22 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 03/20/2024 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 - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review the facility failed to ensure a catheter drainage bag was maintained below the level of the bladder for 1 of 1 residents (R49) reviewed for catheters in the sample of 18. The findings include: On 3/18/24 at 1:54 PM, V23 and V24, CNAs (certified nursing assistants) were using a mechanical lift to transfer R49 from his wheelchair to his bed. V23 and V24 hung R49's catheter bag on the sling strap above R49 as they raised R49 with the lift. Once R49 was lying in bed, V23 told V24 to set R49's catheter drainage bag on his bed where it remained as they provided a bed bath. On 3/19/24 at 1:25 PM, V25, CNA, said the catheter drainage bag should be positioned lower than the bladder so urine does not go back up in the bladder. If urine backflows back into the bladder, the resident could get a urinary infection, chronic kidney disease, and neuromuscular bladder dysfunction. R49's Face Sheet printed 3/20/24 shows his diagnoses include, but are not limited to, quadriplegia, diabetes mellitus type 2, chronic kidney disease, and neuromuscular bladder dysfunction. The facility's Foley Catheter Care Policy (revised 3/2016) shows the urinary catheter drainage bag should be kept lower than the bladder. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145652 If continuation sheet Page 8 of 22 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 03/20/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility staff failed to ensure a resident took all medications during medication administration. This applies to 1 of 3 (R48) reviewed for medication administration in the sample of 18. The findings include: 1. On 3/19/2024 at 8:29AM, V16 License Practical Nurse (LPN) prepared the medications for R48's medication administration. V16 placed the pills into a medication cup and dissolved the Miralax into a cup of water. V16 went to administer the medications to R48 at 8:40AM. V16 watched the resident take her pills and left the cup of water with MiraLAX on the resident's breakfast table in the dining room. R48 did not drink the MiraLAX and water. V16 was observed talking to other residents on the opposite side of the dining room from R48 while the MiraLAX was still sitting next to R48. At 8:51AM the MiraLAX in water was [NAME] sitting on the table next to R48, untouched by the resident. On 3/19/2024 at 8:51AM, Surveyor asked V16 about the MiraLAX sitting on the table near R48. V16 then returned to R48's table and asked her if she was going to take her MiraLAX and R48 refused the medication. V16 said he normally leaves MiraLAX for R48 with her and comes back to check on her later. On 3/19/2024 at 1:27PM, V2 Director of Nursing (DON) said staff should stay with resident during medication administration. V2 said medications should not be left near the resident on the table because someone else could take them. The facility's Medication Pass Guidelines policy, dated 4/19, states . watch the resident swallow all medications. Do NOT leave any meds with the resident to take later. before going to the next resident, double-check that all medications have been administered for that pass time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145652 If continuation sheet Page 9 of 22 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 03/20/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview and record review the facility failed to ensure PRN (as needed) anti-anxiety (psychotropic) medications had a duration/end date. This applies to 2 of 5 (R53, R63) reviewed for unnecessary medications in the sample of 18. The findings include: On 3/19/2024, R53's Orders show resident has an active order since 7/18/2023 for lorazepam give 0.5mg/0.25mL PO (by mouth) Q (every) 2 hours PRN (as needed) for anxiety, agitation, or restlessness, with no stop date. On 3/19/2024, R63's Orders show resident has an active order since 2/27/2024 for lorazepam give 0.5mg tab PO Q 4 hours PRN for anxiety, with no stop date. On 3/20/2024 at 9:58AM, V2 Director of Nursing (DON) said PRN psychotropic and antipsychotic medications should have a 14 day stop date. The facility's Procedure for Psychotropic Medication Evaluation policy reviewed 3/2022 states . PRN medications psychotropic medications . will be limited to 14 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145652 If continuation sheet Page 10 of 22 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 03/20/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review the facility failed to ensure opened, multi-dose vials of medication, including inhalers and gels, were labeled with expiration dates. The facility failed to discard an expired medication. These failures apply to 5 of 5 residents (R23, R12, R41, R19, R31) reviewed for medication storage in the sample of 18. The findings include: 1. R23's March 2024 Prescription Order form showed R23 was prescribed an Albuterol Sulfate inhaler, 90 mcg (micrograms), inhale 2 puffs, twice a day. On 3/18/24 at 9:36 AM, a second floor medication cart was reviewed with V11 Licensed Practical Nurse (LPN). One opened, undated, albuterol inhaler, prescribed to R23, was found in the top drawer of the cart. V11 LPN stated, She (R23) gets that (inhaler) twice a day. It should be dated when opened so we know when it expires. I think inhalers are good for 90 days when opened. 2. R12's prescription order dated 10/26/21 showed R12 was prescribed Latanoprost 0.005% eye drops, one drop to each eye, once a day for her glaucoma. The order showed a bottle of the eye drops expired 42 days after being opened. R41's March 2024 Prescription Order form showed R41 was prescribed an Albuterol Sulfate inhaler, 90 mcg (micrograms), inhale 2 puffs, every 4 hours as needed. R19's March 2024 Prescription Order form showed R19 was prescribed an Albuterol Sulfate inhaler, 90 mcg (micrograms), inhale 2 puffs, every 4 hours as needed. R31's March 2024 Prescription Order form showed R31 was prescribed Oragel 3x Toothache/Gum Gel, to be applied twice a day. On 3/18/24 at 9:40 AM, a second floor medication cart was reviewed with V12 LPN. The following opened/not dated or expired medications were found: a. One opened, undated bottle of Latanoprost eye drops prescribed to R12. b. One opened, undated albutrol inhaler prescribed to R41. c. One opened albuterol inhaler, dated 10/1/23, prescribed to R19. d. One opened, undated tube of Oragel prescribed to R31. At 9:45 AM, V12 LPN stated she was unsure as to when inhalers expire once opened. On 3/19/24 at 10:17 AM, V2 Director of Nursing stated all medications need to be dated when opened so staff know when the medications expire. V2 stated, Most medications expire 28 days from the day they are opened. Inhalers expire 30 days from the day they are opened. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145652 If continuation sheet Page 11 of 22 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 03/20/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm The facility's Medication Pass Guidelines policy dated 4/2019 was reviewed and showed to check each medication's expiration date prior to administration. The policy showed no guidance in regards to dating medications once opened. The policy did not specify the expiration dates of oral gels or albuterol inhalers once opened. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145652 If continuation sheet Page 12 of 22 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 03/20/2024 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to serve pureed barbecue beef brisket at safe temperatures. This applies to 3 of 3 residents (R46, R28, R10) reviewed for pureed diets in the sample of 18. Residents Affected - Few The findings include: R46's lunch meal ticket for 3/18/24 shows that R46 received pureed barbecue beef brisket. R28's lunch meal ticket for 3/18/24 shows that R28 received pureed barbecue beef brisket. R10's lunch meal ticket for 3/18/24 shows that R10 received pureed barbecue beef brisket. On 3/18/24 at 11:59 AM, V20 (Cook) took food temperatures before plating lunch. The pureed barbecue beef brisket was at 130°F. This surveyor repeated the temperature to V20 and V20 confirmed the pureed barbecue beef brisket was at 130°F. V20 did not bring the pureed barbecue beef brisket back to the kitchen to be reheated prior to service. Facility provided temp log for the second floor kitchenette dated 3/17/24 shows the pureed entree was at 157°F; a different temperature than what was confirmed during service by V20. On 3/19/24 at 11:44 AM, V4 (Dietary Manager) said that foods should be greater than 135°F prior to service. If it is not at 135°F, staff should bring the food item back to the kitchen and quickly reheat the item to an internal temperature of 165°F. If the food item is not reheated and is below 135°F, the food could grow bacteria and increase the risks of food borne illness. Facility Food Temperatures policy from 2017 states, . 1. All hot food items must be cooked to the appropriate internal temperatures, held and served at a temperature of at least 135°F . b. Hot food items may not fall below 135°F after cooking, unless it is an item which is to be rapidly cooled to below 41°F and reheated to at least 165°F prior to serving. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145652 If continuation sheet Page 13 of 22 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 03/20/2024 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, and record review the facility failed to provide pureed barbecue beef brisket in a smooth, pudding-like consistency for residents requiring a pureed diet. This applies to 3 of 3 residents (R46, R28, R10) reviewed for pureed diets in the sample of 18. The findings include: R46's lunch meal ticket for 3/18/24 shows that R46 received pureed barbecue beef brisket. R28's lunch meal ticket for 3/18/24 shows that R28 received pureed barbecue beef brisket. R10's lunch meal ticket for 3/18/24 shows that R10 received pureed barbecue beef brisket. On 3/18/24 at 12:58 PM, facility provided test tray of pureed barbecue beef brisket, pureed squash, and pureed chicken noodle soup was evaluated. The pureed barbecue beef brisket was not smooth and required chewing. On 3/18/24 at 1:10 PM, V4 (Dietary Manager) said before testing the pureed barbecue beef brisket that he could already tell it was not a proper consistency. V4 said that it was stringy and not the proper consistency. The proper consistency for pureed food items is completely smooth, no chunks, and similar to a mashed potato consistency. If residents on a pureed diet receive food that is not at the correct consistency, those residents increase their risk of choking. Facility National Dysphagia Diet Level 1 Pureed policy (no date) states, The dysphagia pureed diet (also known as NDD Level 1) is the least advanced of the texture modified diets. It provides foods that are pureed, homogeneous, and cohesive. The foods should be a semi-solid smooth consistency. No chewing or bolus formation is required. All foods must be pureed or be naturally pudding-like. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145652 If continuation sheet Page 14 of 22 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 03/20/2024 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 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to evaluate a resident for Physical Therapy (PT) after receiving an order to start PT for 1 of 5 residents (R17) reviewed for rehab/therapy in the sample of 18. Residents Affected - Few The findings include: On 03/19/24 at 09:24 AM V27, R17's daughter, said the facility did not start therapy when the neurologist ordered it in October of 2023; they never started it until December 2023. On 3/19/24 at 11:33 AM, V7, Rehab Coordinator, said the physician can order therapy for a resident if they see a decline or would like an evaluation. V7 said when a resident comes back from their doctor's appointment, they send a packet with the resident and the nurse enters the orders and a copy of the order is given to her. V7 said all therapy will begin with an evaluation and therapy should start the evaluation within a week of it being ordered. V7 said delaying a therapy evaluation/treatment by two months could potentially contribute to a decline in the resident's function. R17's Neurologist's Progress Notes dated 10/4/23 shows he recommends dedicated physical therapy for lower extremity strengthening and balance with order provided on her facilities (sic) ordering sheet. R17's neurologist placed an order to Start therapy which is dated 10/4/23 at 2 PM and shows it was noted by staff on 10/5/23. R17's Order History dated 3/20/24 shows no order to evaluate and treat for PT until 12/15/23. R17's PT Evaluation & Plan of Treatment shows it was conducted on 12/23/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145652 If continuation sheet Page 15 of 22 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 03/20/2024 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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to ensure the facility's binding arbitration agreement was explained to a resident in a form and manner that the resident could understand for 2 of 3 residents (R274, R59) reviewed for binding arbitration agreements in the sample of 18. Residents Affected - Few The findings include: 1. R274's binding arbitration agreement dated 3/6/24 showed the agreement was signed by R274. On 3/19/24 at 12:26 PM, R274's binding arbitration agreement, dated 3/6/24, was reviewed by R274 and this surveyor. The agreement showed R274 initialed and/or signed each area of the binding arbitration agreement. When this surveyor handed the agreement to R274 for her to review, R274 stated, You will have to read this to me. I am legally blind. I can't read it. When this surveyor started to read the agreement to R274, R274 stated, No one read this part to me before! (V8 Concierge) just told me to sign it. If someone had read that to me, I would have never signed that. I thought I was signing my admission stuff. On 3/19/24 at 12:30 PM V8 Concierge stated she reviews the binding arbitration agreements with residents when they are admitted . V8 stated, I went over the agreement with (R274). I didn't know she was blind. I didn't read it all to her. She probably shouldn't have signed it. 2. R59's binding arbitration agreement dated 3/4/24 showed the agreement was signed by R59. On 3/19/24 at 12:33 PM, R59's signed binding arbitration agreement, dated 3/4/24, was reviewed with R59. R59 began reading the agreement. R59 stated, I didn't realize I was signing this. I didn't know what I was signing. I wouldn't have signed this. I thought this was part of the admission paperwork. On 3/20/24 at 10:41 AM, V1 Administrator stated the facility did not have a policy on binding arbitration agreements. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145652 If continuation sheet Page 16 of 22 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 03/20/2024 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to screen for and administer influenza (flu) and pneumococcal immunizations to residents for 2 of 5 residents (R64, R19) reviewed for influenza and pneumococcal immunizations in the sample of 18. Residents Affected - Few The findings include: 1. R64's Resident Face Sheet showed R64 was admitted to the facility on [DATE]. Influenza and Pneumococcal Vaccine Consent forms dated 11/6/23 for R64 showed R64's POA (power of attorney) gave consent for R64 to receive both vaccinations. R64's Preventative Health Care Record Form printed 3/19/24 showed R64 did not receive the influenza vaccination until 3/19/24. The form also showed R64 last received a pneumococcal vaccine (PPSV23) on 1/10/13 which showed R64 was eligible to receive an additional pneumococcal vaccine (PCV 20). R64's medication administration records dated 10/30/23-3/19/24 were reviewed and showed R64 had yet to receive a pneumococcal vaccination in the facility. 2. R19's Resident Face Sheet showed R19 was admitted to the facility on [DATE]. R19's vaccination records dated 3/3/20-3/19/24 showed R19 was screened for the need to receive a pneumococcal vaccine on 3/3/20. The records showed R19's POA refused the pneumococcal vaccine on 3/3/20 because he felt R19 was up-to-date on the vaccination at that time. The records showed R19 last received a pneumococcal vaccine (Prevnar 13) on 5/11/17 which showed R19 was currently eligible to receive an additional pneumococcal vaccine (PCV 20). The records showed no documentation that R19 had been re-screened for the vaccination, from 2022-3/18/24, while residing in the facility. On 3/19/24 at 9:00 AM, V9 Infection Preventionist stated residents are screened upon admission to receive the pneumococcal vaccine. V9 stated, If a new admission consents to the pneumococcal vaccine, we order the specific one they need, and administer it once it's delivered from pharmacy. We don't really have a process in place to annually check if our long term residents become eligible or need an additional pneumococcal vaccine. V9 stated, We offer the flu vaccination to our residents upon admission and then yearly between the months of October to March. V9 stated, We must have missed (R64). I don't know why he didn't get his vaccines after he consented in November (2023). (R19) should have been reassessed for her need for a pneumococcal booster. The facility's Pneumonia Vaccinations Policy dated 7/2023 showed, The vaccinations will be offered and administered to all qualifying residents. The Pneumococcal Vaccines will be re-offered annually to those who refuse. The facility's Influenza Vaccination Policy (undated) showed, Each resident or resident's legal representative be offered an influenza immunization annually unless medically contraindicated or resident has already been immunized during the time period of October 1 through March 31 or refused the vaccine. Upon admission, the Admissions Designee will ask resident or resident's legal representative if resident would like to receive the influenza vaccine annually . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145652 If continuation sheet Page 17 of 22 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 03/20/2024 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to screen for and offer the COVID-19 immunization to residents for 4 of 5 residents (R64, R38, R59, R65) reviewed for the COVID-19 immunization in the sample of 18. The findings include: 1. R64's Resident Face Sheet showed R64 was admitted to the facility on [DATE]. R64's Preventative Health Record form printed 3/19/24 showed no documentation of R64 receiving any doses of the COVID-19 vaccination. R64's admission records and progress notes dated 10/30/24-3/18/24 showed no documentation R64 was ever screened for or offered the COVID-19 vaccine while in the facility. A progress note for R64, dated 3/19/24 at 11:12 AM, showed, Left message for POA (power of attorney) regarding consent for COVID vaccine, awaiting return call. 2. R38's Resident Face Sheet showed R38 was admitted to the facility on [DATE]. R38's Preventative Health Record form printed 3/18/24 showed R38 last received a dose of the COVID-19 vaccination on 12/16/21. R38's admission records and progress notes dated 12/28/23-3/19/24 showed no documentation R38 was ever screened for and/or offered the COVID-19 vaccine while in the facility. A progress note for R38, dated 3/20/24, showed, Spoke with resident regarding eligibility for COVID vaccine. Discussed benefits of the vaccine. Resident gave consent for the vaccine. 3. R59's Resident Face Sheet showed R59 was admitted to the facility on [DATE]. R59's Preventative Health Record form printed 3/18/24 showed R59 last received a dose of the COVID vaccine on 3/25/21. R59's admission records and progress notes date 3/1/24-3/19/24 were reviewed and showed R59 was not screened for or offered a COVID-19 vaccine until 3/19/24 at 10:50 AM. 4. R65's Resident Face Sheet showed R65 was admitted to the facility on [DATE]. R65's admission records and progress notes dated 1/27/24-3/19/24 were reviewed and showed R65 was not screened for or offered a COVID-19 vaccine until 3/19/24 at 10:08 AM. On 3/19/24 at 9:00 AM, V9 Infection Preventionist (IP) stated residents are screened for the need to receive the COVID-19 vaccine/boosters upon admission to the facility. V9 stated, We screen them on admission. If they need the vaccine, we educate them on the vaccine, and get them signed up for the next COVID vaccine clinic. We don't have a consent form for the COVID vaccine. If a resident wants (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145652 If continuation sheet Page 18 of 22 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 03/20/2024 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 0887 Level of Harm - Minimal harm or potential for actual harm the vaccine, we document the education and the consent in a progress note. Nursing then notifies me if the resident wants the vaccine. On 3/19/24 at 9:30 AM, V9 IP stated she was unable to find any documentation that R64, R38, R59, or R65 had been screened for and offered the COVID-19 vaccine while in the facility. Residents Affected - Some The facility's COVID-19 Response Plan dated 6/2023 showed the facility will make the vaccine available to all employees and residents who wish to receive the vaccine and subsequent boosters . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145652 If continuation sheet Page 19 of 22 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 03/20/2024 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure resident care equipment was in safe working order. This applies to 2 of 18 residents (R24 & R37) reviewed for safe operating equipment in the sample of 18. Residents Affected - Few The findings include: 1. R37's facility event report dated January 11, 2024 shows, mechanical lift failure R37 already lying on bed. Evaluation Notes: On 1/11/24 an incident involving the mechanical lift occurred. After completion of a [mechanical lift] to bed was complete, the lift began to self lower on top of resident's right shoulder . [mechanical lift] was taken out of service for maintenance. R37's progress notes dated January 11, 2024 shows, At 8:30 p.m. while CNAs were transferring her (R37) into bed with easy lift, they had completed transfer, R37 was lying on bed the aides were unhooking sling from bars of lift there was a loud bang sound and lift lowered onto R37 with bar of lift pressing into her right shoulder . On March 19, 2024 at 9:32 AM, R37 stated, something was wrong with the mechanical lift. It just fell on her right shoulder. She did not have any injuries. On March 19, 2024 at 9:38 AM, V7 Rehabilitation Director stated, the motor malfunctioned on the mechanical lift. It made a clicking noise and then dropped down on R37. On March 19, 2024 at 9:51 AM, V28 Certified Nursing Assistant (CNA) stated, her and another CNA were transferring R37 back to bed. They had her over the bed when they heard a clicking noise and the mechanical lift just dropped on R37. She heard it was a motor malfunction. The facility's mechanical work order dated January 12, 2024 shows, The lift is taken out of service. Can not make lift fail per trouble. V3 Assistant Administrator is having manufacture come in to look over lift under warrantee . 1/18/2024- Lifts are being repaired by vender. R37's Minimum Data Set, dated [DATE] shows, she is cognitively intact. 2. R24's progress notes dated January 31, 2024 shows, CNA came and called the writer. Writer helping other resident next room. Resident was on the floor leaning back at the wheelchair. CNA and resident told the writer that while transferring from the toilet to the wheelchair the chair moved away. The chair was locked but the right lock was ineffective . R24's event details dated January 31, 2024 shows, On 1/31/24 R24 was guided to the floor when transferring from toilet to wheelchair. Brakes on wheelchair were locked but the right lock was not functioning properly causing the chair to move when transferring which resulted in fall. On 1/31/24 maintenance was notified via maintenance log to fix resident's brake. On March 20, 2024 at 8:31 AM, V40 CNA stated, she was transferring R24 from the toilet to her wheelchair. R24 went to sit in the chair but the chair turned and she had to guide R24 to the ground. The wheelchair was locked but the right lock was broken. R24 did not have any injuries. The facility's maintenance logs shows, 2/1/2024- please fix r (right) hand break of her wheelchair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145652 If continuation sheet Page 20 of 22 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 03/20/2024 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 0908 2/1/24- readjusted/tighten both brakes on wheel chair Level of Harm - Minimal harm or potential for actual harm The facility's management policy/procedure (not date) shows, Policy Statement: This policy establishes a Preventive Maintenance Program to ensure that all county equipment is inspected and tested on a monthly, quarterly, semi-annual or annual basis . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145652 If continuation sheet Page 21 of 22 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 03/20/2024 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 0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review the facility failed to provide mechanical lift training to facility staff using lifts for resident's requiring mechanical lifts for transfers. This applies to 1 of 1 (R48) reviewed for training requirements. Residents Affected - Few On 3/19/2024 at 11:45AM, V17 Home Health Aide said she had not received any training on the Hoyer lifts from the facility. V17 said she was transferring [R48] with the assistance of V14 - Certified Nursing Assistant. V17 said the Hoyer lift started to tip and [R48] bumped her head on the lift, no bleeding or bruising noted. On 3/19/2024 at 12:27PM, V7 Licensed Practical Nurse (LPN)/ Rehab Coordinator said she does not believe [V17] received Hoyer lift training. V7 said training is offered and those people working that day receive training. V7 said the facility is responsible for Hoyer lift training. On 3/19/2024 at 1:27PM, V2 Director of Nursing (DON) said staff using a Hoyer lift should be trained on the lift. R48's Care Plan, revised on 1/23/2024 states . At this time [R48] needs max asst with adl's. Transfers with total mechanical, w/c pushed by staff, and ambulation is not feasible at this time. The facility failed to provide in-service training on Hoyer lifts with [V17's] name on the list. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145652 If continuation sheet Page 22 of 22