Inspection·August 11, 2022

F 0686 R22's August 2022 TAR documents Right buttocks: Cleanse area with Skin integrity, pat dry and apply Exuderm change Q 3 days every night shift every 3 day(s) for open area -Start Date 07/28/2022. Level of Harm - Actual harm Residents Affected - Few R22's Ulcer/Wound documentation, dated 8/9/22, document, Date ulcer / wound was initially identified: 7/23/22. Right buttock 1.5 cm length, 1.6 cm width, 0.1 depth. Stage II. Peri wound Skin: Area has a 100% granulation tissue with macerated edges. Scant drainage. R22's pressure ulcer had increased in depth and was now classified as a Stage II pressure ulcer. R22's Ulcer/Wound documentation, dated 7/23/22, document, Date ulcer/ wound was initially identified: 7/23/22. Left ankle (outer) bruising 0.7 cm (centimeters) length, 0.7 cm width, 0 depth. Unstageable. There was no other Ulcer/Wound documentation in R22's medical record regarding R22's left outer ankle pressure ulcer/pressure injury. There were no treatments orders documented in R22's medical record for R22's left ankle pressure ulcer. R22's Ulcer/Wound documentation, dated 7/23/22, document, Date ulcer / wound was initially identified: 7/23/22. Right inner ankle (outer) pressure 0.5 cm (centimeters) length, 0.8 cm width, 0.1 depth. Suspected Deep Tissue Injury. Peri wound Skin: Deep purple tissue over bony prominence. There was no other wound/pressure documentation for R22's medical record regarding R22's right ankle pressure ulcer/pressure injury. There were no treatments orders documented for R22's right ankle in R22's medical record. R22's Ulcer/Wound documentation, dated 8/9/22, documents, Date ulcer / wound was initially identified: 7/23/22. Right heel: Pressure. 1.0 length, 0.9 width, 0.1 depth. Suspected Deep Tissue Injury. Peri wound: Area is purple in color skin intact. There was no other wound/pressure ulcer documentation in R22's medical record prior to 8/9/22 regarding R22's right heel pressure ulcer/pressure injuries. R22's July and August TARs document, Right heel: Clean heel with skin integrity, pat dry, apply skin prep and allow to air dry. Cover with Optifoam gentle. Change daily. Float heels on pillow when in bed every day shift for soft heel. -Start Date 07/25/2022 0600. R22's TAR does not document R22's treatment to her right heel was completed on 7/26/22 and 7/29/22. R22's Ulcer/Wound documentation, dated 8/9/22, documents, Date ulcer / wound was initially identified: 8/09/22. Coccyx. Pressure. 10 (cm) length. 8.5 (cm) width. 0.1 (cm) depth. Stage II. Peri wound: Area has small stage 2 pressure injuries with DTI (deep tissue injury) surrounding. New treatment in place. Scant drainage. R22's August 2022 TAR documents, Cleanse area on coccyx and apply exuderm to coccyx and change every three days and PRN. start date of 8/9/22. On 08/10/22 at 09:04 AM, V14, stated, that one week was really busy and that is why the measurements weren't done and that she did not realize that she had went over 2 weeks without measurements. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145721 If continuation sheet Page 2 of 11 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 145721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Health Care East 100 Marian Parkway Sherman, IL 62684 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 0686 Level of Harm - Actual harm Residents Affected - Few On 08/10/22 3:35 PM, V14, Licensed Practical Nurse/Wound Nurse changed R22's dressings to the left heel and right heel. V14 removed R22's left heel old dressing. R22's left outer heel has an area the approximate size of a quarter that is covered in a scab, then there is a line that runs down to the back of the heel with a small open slit in the heel. The area was cleansed, and sure prep was applied then covered with a foam dressing. R22's left outer upper ankle had a deep tissue injury the approximate size of a dime. The area appears to be from the immobilizer brace that R22 is wearing. No dressing/treatment was applied. R22's right outer heel pressure ulcer has pale pink skin over it. R22's coccyx wounds were unable to be observed related to R22's extreme pain. R22's Order Summary Report, print date of 8/10/22, documents, Cleanse area on coccyx and apply exuderm to coccyx and change every 3 days and PRN (as needed). as needed. Cleanse area on coccyx and apply exuderm to coccyx and change every three days and PRN. every night shift every 3 days. Left heel: Cleanse area with skin integrity, pat day, apply skin prep, cover with optifoam gentle. Change daily. Float heels on pillow when in bed. every day shift. Right heel: Clean heel with skin integrity, pat dry, apply skin prep and allow to air dry. Cover with Optifoam gentle. Change daily. Float heels on pillow when in bed every day shift for soft heel. On 8/11/22 at 11:19 AM, V2, Director of Nursing stated, I would have expected that the nurses would have caught (R22's) coccyx wound before it got as big as it did. 3. R6's admission Record, dated 8/10/22, documents that R6 was admitted [DATE] and has diagnoses of Major Depressive Disorder and Hypertension. R6's MDS, dated [DATE], documents R6 is severely cognitively impaired and requires extensive assistance of 1 staff member for dressing. R6's Health Status Note, dated 7/31/22, documents, Area on res (resident) left outer ankle has re-opened, area measures 1cm (centimeters) X 1cm. TX (treatment) was initiated as follows: Cleanse with wound cleanser, pat dry and sure prep peri wound. Apply Xeroform to wound bed and cover with dry drsg (dressing). R6's Ulcer/Wound documentation, dated 7/3/22, documents, L (left) outer heel blister 3.0 (cm) x 2.5 (cm) x 0.1 (cm). R6's Ulcer/Wound documentation, dated 8/2/22, documents, L lateral heel blister 2.7(cm) x 2.3 (cm) x < 0.1 (cm). Peri wound: Blistered opened up. Area is 75% macerated with some drainage and 25 % granulation tissue. R6 has no other wound documentation available for review regarding R6's pressure ulcers from 7/3/22 through 8/2/22. On 08/08/22 at 1:53 PM, V14 removed R6's shoe to change R6's pressure ulcer dressing on his left outer foot. There was no pressure ulcer dressing on R6's pressure ulcer. The wound bed is red and approximately the size of a dime. On 8/8/22 at 1:55 PM, V14 stated, He should have a had a dressing on it maybe it was his shower day. Based on observation, interview and record review, the facility failed to identify, monitor and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145721 If continuation sheet Page 3 of 11 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 145721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Health Care East 100 Marian Parkway Sherman, IL 62684 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 0686 Level of Harm - Actual harm provide treatments as ordered to prevent the worsening or formation of pressure ulcers for 3 of 4 residents (R41, R6 and R22) reviewed for pressure ulcers in the sample of 37. This failure resulted in R41's Stage III pressure ulcer worsening to an unstageable pressure ulcer. Residents Affected - Few Findings include: 1. R41's Current Face Sheet Documents R41 was readmitted on [DATE] with diagnoses of Peripheral Vascular Disease, and Chronic Kidney Disease. R41's Minimum Data Set (MDS) dated [DATE] documents R41 is cognitively intact and requires extensive assistance of one staff member for transfer, dressing, toileting and personal hygiene. R41's Care Plan dated 8/4/22 documents to provide wound care per treatment order. R41's Braden Pressure Ulcer assessment dated [DATE] documents R41 is a high risk for pressure ulcers. R41's Physician Order (PO), start date 7/29/22 documents Silver sulfadiazine cream 1% Apply to Left lateral foot topically every day shift for Pressure Injury. Cleanse wound with normal saline, apply cream to open area, apply dry gauze and cover with optifoam daily. R41's Physician Order (PO), start date 7/29/22, documents Apply Double Cream to left inner ankle for excoriation daily, every day shift. On 08/09/22 at 11:16 AM, V14 Licensed Practical Nurse, Wound Nurse, provided wound dressing changes to R41. R41's left heel and left outer ankle (lateral foot) old dressing was dated 8/7. R41's left lateral foot had a black scabbed area with a small amount of clear drainage on R41's old left lateral dressing noted. No measurement was taken. R41's right heel old dressing was dated 8/6. V14 verified the dates on R41's dressing. On 8/10/22 at 9:31 AM, V14, stated she wasn't able to get all the treatments done on Monday so R41 had left R41's wound dressings to be done by the staff nurses and they did not get done. V14 verified that R41 had an order for daily silver sulfadiazine and double cream and that R41 had old dressing dated 8/7/22 on left foot and a right heel dressing dated 8/6/22 that had not been changed daily. V14 states she notified day and night shift and they were supposed to do the treatments if she is not here, and they did not get to since date is from 8-6 and 8-7. V14 states resident gets silver and double cream daily but has not gotten as ordered. R41's Skin assessment dated [DATE] documents R41 has a left heel pressure ulcer 3 centimeters (cm) by (x) 2.8 cm, right heel pressure 5.7cm x 4.8 cm and a left outer ankle pressure ulcer 3.4 cm x 2 cm x 0.2 cm, stage 3 pressure ulcer. R41's Skin assessment dated [DATE] documents R41's left heel pressure ulcer is 2.1cm x 1.3 cm, Right heel pressure, 4.7cm x 4.5 cm x 0.1cm and left outer ankle (lateral foot) pressure ulcer 4.3 cmx 3.2 cm x .01 cm stage 3. R41's Treatment Administration Records document R41 received ordered daily treatment to left inner ankle and left lateral foot on 8/6 and 8/7/22, however observation on 8/9/22 of R41's intact wound dressing and interview with V14 verified treatment had not been completed since 8/6 and 8/7/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145721 If continuation sheet Page 4 of 11 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 145721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Health Care East 100 Marian Parkway Sherman, IL 62684 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 0686 Level of Harm - Actual harm Residents Affected - Few On 08/11/22 11:18 AM V2, Director of Nursing (DON) stated she expects staff to measure wounds weekly, expects staff to document accurately when treatments are done and expects wound treatment to be done per physician orders. 08/11/22 11:51 AM, V15, R41's Medical Doctor stated she was not aware R41 had not been getting the ordered topical medications of silver and double cream. R41 stated she expects the facility to follow the order. The Facility's Wound and Ulcer Policy and Procedure dated 1/10/2018 documents: It is the policy of this facility to provide nursing standards and for assessment, prevention, treatment, and protocols to manage residents at any level of risk for skin breakdown and for wound management. Protocols may include any or all of the following based upon the needs and condition of the resident. Additional measures may be added at the discretion of the facility. Weekly skin checks, changes in condition are promptly reported. When a resident is found to have a wound: document assessment of the wound, initiate treatment protocol, document wound/ulcer treatment on treatment administration record, Assessment of progress toward healing is completed at least weekly, if there is regression, the physician is notified of the condition change. treatment per physician orders until the wound and/or ulcer is healed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145721 If continuation sheet Page 5 of 11 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 145721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Health Care East 100 Marian Parkway Sherman, IL 62684 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to identify, monitor and implement interventions to address weight loss for 1 of 3 residents (R34) reviewed for weight loss in the sample of 37. This failure resulted in R34 having a significant weight loss of 47.3 pounds indicating a 28.3% weight loss in 6 months. Residents Affected - Few Findings include: R34's admission Record, print date of 8/10/22, documents that R34 was admitted on [DATE] and has diagnoses of Neuropathy, Gastro - Esophageal Reflux Disease without esophagitis. R34's Minimum Data Set, dated [DATE], documents that R34 is cognitively intact and requires supervision and one staff member physical assist for dining. R34's Weight Record documents the following dates, times and pounds weighed: 8/9/2022 10:01 119.5 Lbs. (pounds) 8/3/2022 14:02 119.0 Lbs. 8/3/2022 10:18 119.0 Lbs. 8/2/2022 12:26 119.0 Lbs. 8/2/2022 10:43 119.0 Lbs. 8/2/2022 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145721 If continuation sheet Page 6 of 11 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 145721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Health Care East 100 Marian Parkway Sherman, IL 62684 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 0692 08:49 Level of Harm - Actual harm 119.0 Lbs. Residents Affected - Few 7/27/2022 11:36 131.0 Lbs. 5/3/2022 17:55 161.6 Lbs. 4/19/2022 10:35 158.5 Lbs. 4/19/2022 09:49 158.5 Lbs. 4/1/2022 11:26 163.6 Lbs. 3/14/2022 15:50 155.0 Lbs. 3/1/2022 09:51 175.2 Lbs. 2/22/2022 16:26 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145721 If continuation sheet Page 7 of 11 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 145721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Health Care East 100 Marian Parkway Sherman, IL 62684 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 0692 168.0 Lbs. Level of Harm - Actual harm 2/21/2022 Residents Affected - Few 09:44 168.4 Lbs. 2/20/2022 10:57 168.0 Lbs. 2/19/2022 10:30 166.8 Lbs. 2/18/2022 12:19 166.8 Lbs. There was no documented weight in June 2022. This weight log documents R34 had a significant weight loss of 47.3 pounds indicating a 28.3% weight loss in 6 months. R34's Health Status Note, dated 6/3/22, documents, Another call out to (V16 Physician) office to request orders regarding res. c/o (complaint of) gastric reflux. Also requested a PRN (as needed) order for Zofran per res (resident). R34's Health Status Note, dated 6/15/22, documents, RD Note-Weight/Skin Review-HT:62 in (inches). Wt:145#'s. BMI=26.5 wnl (within normal limits). DBWR (desired body weight range) =104-148#'s. Wt. within DBWR. Per weight exception report resident had 10.3% decrease in weight times 1 month and 13.1% decrease in weight times 4 months. Noted resident currently on ABT for UTI. Diet Rx: Reg, Reg, thin liquids Appetite is ~51% at meals currently. Meds reviewed and noted tramadol and Amoxicillin added since last review that may decrease appetite and weight; and gabapentin added that may increase appetite and weight. Per 6/13-pressure wound report resident has pressure wounds on left heel, left big toe, and LLE rear times 2. Resident remains on Vit C, Zinc and MVI w/minerals that supports healing. See recommendation to add Liquid Protein 30ml's one time per day to meet her needs for weight maintenance and wound healing of multiple wounds. Monitor and refer to RD Prn. R34's Health Status Note, dated 7/13/22, documents, per 7/13 wound report resident has pressure wound on left heel and left big toe and DTI (Deep Tissue Injury) on right heel. Diet Rx (prescription): Reg (regular), Reg, thin liquid with Liquid Protein 30 ml one time per day. Appetite is ~26-50% of meals currently. Current wt. (weight): 157#'s. BMI (body mass index) =28.7H DBWR (desired body weight range) =104-148#'s. Wt. above DBWR but within UBWR for resident. Per weight exception report (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145721 If continuation sheet Page 8 of 11 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 145721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Health Care East 100 Marian Parkway Sherman, IL 62684 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 0692 Level of Harm - Actual harm Residents Affected - Few resident had 8.3% increase in weight times 1 month and 10.4% decrease in weight times 4 months. No new nutrition related med (medication) changes since last review. Resident remains on MVI (multivitamin) w (with)/minerals, Vit C (vitamin C) and Zinc that supports healing. No new labs to assess. No changes recommended at this time. Diet and wound supplement along with vitamins and minerals remains appropriate to support healing. Monitor and refer to RD Prn. (Registered Dietician) On 8/11/22 at 11:19 AM, V2, Director of Nurses (DON), stated that she just noticed (R34's) weight loss at the end of July. V2 also stated that the facility does weekly meeting to discuss weight loss and (R34) did not get noticed until the end of July. V2 also stated that R34 should have been weighed every month. V2 stated that R34 was moved from the rehabilitation wing to the room that she is in and maybe that caused some of the weight loss and also, she was put on Tramadol. V2 stated that R34 did have complaints of acid reflux and she has been seen and received medication for it. V2 stated that she did have an esophagram and she needs to see a specialist. On 8/11/22 at 1:19 PM, V16, Physician, stated, I am an outpatient internal medicine doctor. (R34) is usually brought to my office by someone. I last saw her on July 27, 2022 and she was concerned about her wounds and her pain. I was unaware. I can only treat what I am told. I was unaware of her weight loss. She is now malnourished. This will not help her wound healing. She needs to be on a calorie count, fortified foods and supplements. I am not sure if her weight loss is a medical problem or it's just because she does not feel good. She has pain from those wounds. We should try and get her pain under control and maybe that will help. R34's August 2022 Order Summary Report, documents, Weekly weights x 4 in the morning every Tue (Tuesday), Wed (Wednesday) for maintenance for four weeks. Start date 7/27/22. Regular diet, thin texture. Liquid Protein 30 ML (milliliters) in the morning for wound healing. The Facility's Weight Management Policy and Procedure with a revision date of 2/2016 documents, Each resident will be weighed at least once a month on a predetermined schedule. All residents will be monitored for significant weight changes to assure maintenance of acceptable parameters of body weight. Residents will be weighed using the same scale and in a consistent manner unless clinical condition warrants the use of a different scale or an altered manner. A change in scale or method will be noted if this occurs. A resident with a weight fluctuation of greater than five pounds (+ or -) will be re-weighed for accuracy. The new weight will be recorded in the medical record. Monthly weights will be obtained by the 10th of each calendar month and the Dietary Manager or designee will review the monthly weights by the 10th of the month. All scales will be calibrated at least monthly by the Facilities staff or their designee. At least monthly, resident weights will be compared to prior weights to identify any significant, severe or insidious weight changes. The Weight and Vitals Exception Report will be reviewed weekly by dietary staff to determine significant weight changes. Parameters of a significant weight change per OBRA (Omnibus Budget Reconciliation Act) guidelines will be used. Weight loss that occurs quicker than the OBRA guideline parameters will be addressed as they occur. (Example: If a 10% weight loss occurs in four months, the weight loss will be addressed at that time.) OBRA weight change parameters document significant change as 5% in 30 days or 10% change in 180 days. Any resident with a significant or insidious weight change will be referred to the dietitian for assessment of the residents' condition. They dietitian will implement any necessary clinical interventions or make recommendations regarding diet and supplementation to the physician. The physician will be notified of any significant weight change and be made aware of any recommendations made by the dietitian. The POA (power of attorney) for health care will be notified of significant weight changes. The interdisciplinary care plan team will assess the resident's overall condition to see if the weight change impacts more than one area of the resident's health status. A significant change (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145721 If continuation sheet Page 9 of 11 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 145721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Health Care East 100 Marian Parkway Sherman, IL 62684 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 0692 assessment will be completed if there is a consistent pattern of changes, with either two or more areas of improvement/decline. Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145721 If continuation sheet Page 10 of 11 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 145721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Health Care East 100 Marian Parkway Sherman, IL 62684 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food was stored in a manner which prevents potential contamination. This has the potential to affect all 84 residents living in the facility. Residents Affected - Many Findings include: On 8/9/2022 at 8:55 AM in the first standing refrigerator there was a tray of assorted beverages covered with foil. There was a sticker with handwritten dates on the tray, but there was no way to distinguish the contents of each individual beverage. On 8/9/2022 at 9:05 AM in the walk in refrigerator there was a cart covered with plastic that contained ten trays of food. The covering did not reach the bottom of the cart, and the bottom four trays were completely exposed to air. These four trays included approximately 8 individual cups of cottage cheese, 40 individual cups of melon, and 20 slices of chocolate cake on individual dishes. On 8/9/22 at 9:07 AM, V5, Dietary Manager, stated, I would expect all items to be covered, labeled, and dated. Yes, of course. On 8/9/2022 at 9:10 AM in the walk in freezer there was a clear plastic bag of steak fries that had been opened but was not dated or labeled. There was a plastic bag with six (approximately 8 ounce) pieces of an unknown meat that was previously opened but had not been labeled or dated. V5, Dietary Manager, stated, These are pork cutlets. The Facility's Food Labeling and Dating policy dated 2/2022 documents, Labeling and dating food is important to assure foods are used in a timely manner. Proper food labeling includes: name of product, date stored, and in some cases the time of the day. The food must be labeled and dated if it is removed from its original container. The Resident Census and Condition of Residents Form, (CMS 672), dated 8/8/2022 documents the facility has 84 residents residing in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145721 If continuation sheet Page 11 of 11