Health inspection·January 6, 2026

F 0689 Level of Harm - Actual harm Residents Affected - Few V12 said it was not unusual, R1 was a fall risk and was always falling. V12 said she went into R1's room and saw R1 on the bathroom floor on her left side in the fetal position. V12 said R1 had a small puddle of blood under her head, her lips and hands were cyanotic, and she was dusky looking with agonal breathing. V12 said other staff came in and assisted to get R1 off the floor onto her bed. V12 said once in bed, R1's breathing and heartbeat were not detectable and R1 was pronounced dead by several nurses. On 1/6/26 at 1:28 PM, V14 RN said she had taken care of R1 frequently and R1 had been declining recently. V14 said R1 would be lethargic on days and then would have some good times. V14 said R1 was a fall risk and needed frequent monitoring. V14 said R1 would use the call light but was impulsive. V14 said R1 didn't like to be watched in the bathroom, but staff needed to stay close, in the room when R1 was in the bathroom because she didn't like to wait.On 1/6/26 at 2:07 PM, V10 RN said he was giving report when V4 came to the station and reported that R1 was on the floor. V10 said V5 put R1 in the bathroom and then left he room to check on another resident. V10 said R1's light was on and when V5 went back in, R1 was on the floor in the bathroom. V10 said he assisted the other nurses get R1 into bed and try to obtain vitals. V10 said R1 had a laceration to the left side of her scalp above her left ear. V10 said after multiple attempts, vitals were unable to be obtained, R1's pupils were dilated and fixed, and R1 was pronounced dead. V10 said R1 will not wait for help and will get up by herself if she must wait. On 1/6/26 at 4:25 PM, V16 Hospice RN said she saw R1 on 12/31/25 and noted R1 had increased physical weakness by a noticeable loss of strength when trying to sit up. V16 said R1's impulsivity was till noted during her visit. V16 said R1 was clinically sick and fragile.On 1/6/26 at 1:37 PM, V3 Assistant Director of Nursing said R1 was on hospice and slowly declining. V3 said R1 was a fall risk, and had had previous falls, due to her impulsiveness and getting up by herself. V3 said R1's fall intervention was to be monitored when in bathroom. When asked what that entailed, V3 replied frequent checks. V3 said R1 had previously had a habit of being in the bathroom for long periods of time ripping up toilet paper but had not been doing that recently. V3 said R1's fall interventions for the bathroom had not been updated since R1's recent decline and change in bathroom habit. V3 did not comment when asked how does staff do frequent checks if out in the hall or in another resident's room?On 1/7/26 at 1:18 PM, V17 Medical Director was called, and a message was left for a return call.R1's Client Coordination Notes Report from V16 Hospice Registered Nurse dated 12/31/25 shows No signs/symptoms of imminent death but patient very fragile and generally poor prognosis. Severe tiredness and lethargy. Worsening loss of strength, endurance, and stamina. Patient was arousable today but falls back asleep quickly, reviewed fall/safety precautions. Promote bedrest- Due to constraints of disease process and approaching end of life. Patient needs extensive care with all activities of daily living.R1's Progress notes dated 12/29/25 -12/30/25 document Resident lethargic.R1's Face sheet shows R1 has diagnoses of unspecified dementia, moderate, with other behavioral disturbance and history of falling.R1's Care Plan dated 12/3/25 shows R1 is at risk for falls due to unsteady gait and balance during turns and transitions. Will forget to use walker at times. Intervention dated 3/25/25: Staff to monitor resident while in bathroom and an intervention dated 12/6/18: Observe for gait unsteadiness. Proceed accordingly. The same Care Plan shows 12/2/25 Resident has had a decline in condition resulting in need for hospice care.2. On 1/6/26 at 1:31 PM, R3 was in bed. R3's bed had a bed alarm attached to the bed rail. The bed alarm indicator lights were not on or flashing on and off. V15 Certified Nursing Assistant came into R3's room and said R3 is napping and left the room. This surveyor asked V4 Certified Nursing Assistant Supervisor to check on R3's bed alarm. At 1:34 PM, V4 said the light is supposed to be flashing when the alarm is on. V4 checked R3's bed alarm and held up the cord which was on the floor under R3's bed. V4 said the alarm (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145652 If continuation sheet Page 2 of 3 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 01/06/2026 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 - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete is not even plugged in. V4 plugged the bed alarm in, and the bed alarm flashed red on and off indicating the alarm was on. R3's Care Plan dated 4/21/25 shows R3 is a risk for falls related to weakness and unsteady gait and balance. Fall risk assessment score of 16 indicates she is a risk for fall. 12/3/25 resident noted on the floor next to her bed. Intervention: Bed alarm.R3's Physician Orders dated 4/21/25 shows fall prevention/safety: Mobility Alarm: Bed. Special instructions: Ensure that alarm is in place and functioning properly every shift.The facility's Fall Risk Assessment and Prevention Program dated 12/2017 shows The purpose of this policy is to provide direction for nursing home staff to identify residents at risk for falls, to prevent falls whenever possible; and when unable to prevent falls, minimize the extent of the injury. The Care Plan will identify the resident as being at risk for falls. Interventions will be individualized and attempt to modify, or if possible, eliminate risk factors. There will be evidence of care plan review and update following each resident fall to demonstrate that risk factors and interventions remain appropriate for the resident. Event ID: Facility ID: 145652 If continuation sheet Page 3 of 3