Inspection·May 25, 2023

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many can be used on any resident who has an order. V2 continued to state that she would expect suppositories to be in a zip lock bag and dated. On [DATE] at 11:35 AM, V2 stated that they do not have a stock medication policy. Drug Insert for Lantus, dated 06/2022, documented, Do not use Lantus after the expiration date stamped on the label or 28 days after you first use it. The facility's Pharmaceutical Service Policy and Procedure Manual, undated, documented, Drug Packaging and Labeling Specifications, It continues, III. ALL medication for each specific resident shall be labeled with the following information, It continues, C. Resident's name, room and bed number. It continues, G. Expiration date of drug. The Resident Census and Conditions of Residents, CMS-672, dated [DATE], documents that the facility has 86 residents living in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145721 If continuation sheet Page 2 of 7 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 05/25/2023 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 05/23/2023 at 10:23 AM, R25 stated that at night a big pan of snacks are brought out and put behind the nurses station but it is not brought to their rooms or offered that way. The snacks are usually cookies, cakes or graham crackers. R25's Minimum Data Set (MDS), dated [DATE], documented that her cognition was intact. 3. On 05/23/2023 at 10:23 AM, R36 stated that pan of snacks are brought out at night and put behind the nurses station but it is not brought to their rooms or offered that way. The snacks are usually cookies, cakes or graham crackers. R36's MDS, dated [DATE], documented that his cognition was intact. 4. R34 stated that she is not offered a snack at night and that sometimes her blood sugars the next morning are affected like they are low. R34's MDS, dated [DATE], documented that her cognition was intact. 5. R42 stated that it is around 16 hours between supper and the next day's breakfast. She continued to state that breakfast lunch and supper are all too close together. R42's MDS, dated [DATE], documented that her cognition was intact. The Resident Census and Conditions of Residents, CMS-672, dated 5/22/23, documents that the facility has 86 residents living in the facility. Based on interview, observation and record review, the facility failed to provide a substantial snack at nighttime. The failure has the potential to affect all 86 residents living in the facility. Findings include: 1. On 05/23/23 at 8:37 AM, the breakfast service began in the main dining room. On 5/23/23 at 9:00 AM, V3, Dietary Manager, stated that the mealtimes are 8:00 AM, 12:00 PM and 5:00 PM. (This leaves a 15-hour time frame between meals overnight without a substantial snack). On 5/23/23 at 3:45 PM, V12, Certified Nurse Aide (CNA), stated that dinner is served at 5:00 PM. V12 stated that the CNAs have a snack box with a variety of snacks in it and they go to each room and ask them what type of snack they want. V12 stated they have a variety of cookies and cakes. On 5/24/23 at 8:30 AM, V13, Licensed Practical Nurse (LPN), stated, There is a snack box that has a snack in it. The snacks vary like cheese crackers, cakes, pies and graham crackers. The staff take the snacks and go and offer the regular residents a snack. The VTR (facility Total Rehab) patients are just asked if they would like a snack. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145721 If continuation sheet Page 3 of 7 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 05/25/2023 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete On 5/24/23 at 2:45 PM, V3 stated that he did not realize that staff were not taking snacks out to the residents. V3 stated that the snacks are crackers, cookies and things like that. V3 was questioned if he thought that was a substantial snack and he agreed that it was not. The facility provided Dining Room Mealtimes, undated, documents, Breakfast 7:00 AM - 9:00 AM. Lunch 12:00 PM - 1:00 PM. Supper 5:00 PM - 6:00 PM. The facility failed to follow these mealtimes. Event ID: Facility ID: 145721 If continuation sheet Page 4 of 7 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 05/25/2023 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 Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on interview, observation and record review, the facility failed to store and serve food to prevent food borne illness, maintain kitchen storage in a sanitary fashion and assist a resident with dining with gloves on. This failure has the potential to affect all 86 residents living in the facility. Findings include: 1. On 05/22/23 at 8:30 AM, the kitchen was entered. The refrigerator in the kitchen had 1 container of cheese that had a use by date of 5/14/23, 1 container of macaroni salad that had a use by date of 5/18/23 and 1 container of three bean salad that had an use by date of 5/21/23. The walk-in refrigerator had a single premade salad on a shelf that was not covered. A large stainless steel rectangle storage container with multiple pounds of cooked ground beef that was dated cooked 5/22/23 was on a shelf that had items on the rack above. The lid to the container was open so 50% of the ground beef was not covered. The dry storage room had a large cardboard box of Styrofoam storage containers sitting on the floor. 2. On 05/23/23 at 12:10 PM, the noon meal was served from the steam table in the kitchen. One of the substitute meals was a hamburger or a sloppy joe. V8, Cook, would take a bun out of the bun bag with her gloved hand that she has been using during the service touching all the ladles, plates and trays. The main meal was Lasagna and a bread stick. V9, Dietary Aide, placed the bread stick onto the plate with a gloved hand that she has used throughout the service. V8 removed her gloves, went and got 2 new scoops, got a pair of gloves, put a glove on the right hand and with the ungloved left hand rubbed her eyebrow / forehead area then put a glove on that hand. The bottom of the portable rack that holds the plate covers was covered with debris and dry spillage. The bottom of the rack that holds the food trays is covered with food debris and brown debris. 3. On 5/23/23 at 12:40 PM, V7, Certified Nurse Aide (CNA), was assisting R18 with his hamburger. V7 was not wearing gloves. V7 picked up R18's hamburger and tore off a section of the bottom hamburger bun. V7 then flipped the burger over into the palm of her hand and patted the top of the burger to secure hamburger top bun then handed the hamburger back to R18. On 05/23/23 at 3:07 PM, V3, Dietary Manager, stated that nothing should be stored on the floor of the dry storage room, no out of date food should be in the refrigerator, if gloves are changed hands should be washed, single serve items should be placed on the tray with a utensil and staff should not be touching residents' food without gloves on. The Food Labeling and Dating, dated 02/22, documents, 4. Once refrigerated or frozen items are properly labeled, they need to be used or disposed of according to the Refrigerator and Freezer Storage Chart. It continues, Use by date is the last date recommended for the use of the product while at peak quality. The policy Hand Washing and Glove Use, dated 02/22, When should hands be washed? Before putting on new, single use gloves and between glove changes. The Resident Census and Conditions of Residents, CMS-672, dated 5/22/23, documents that the facility has 86 residents living in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145721 If continuation sheet Page 5 of 7 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 05/25/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 4. On 5/24/2023 at 11:15AM, a sign posted on the wall outside R72's room documents contact and droplet isolation; gloves and gowns should be worn, N95 mask is required. At this time, V17, CNA, entered R72's room with surgical mask and gloves. V17 then exited room, donned a gown, then reentered R72's room. V17 then exited R72's room again, donned N95 mask and reentered 72's room. Residents Affected - Some On 5/24/2023 at 2:15PM, V6, Infection Preventionist, stated that she would expect staff to follow contact and droplet isolation policy. The facility's policy contact and droplet precautions protocol dated, revised July 26, 2021, documents personal protective equipment documents a gown should be applied before room entry. N95 respirator is required. Based on interview, observation and record review, the facility failed to wash hands when needed, change gloves when soiled and wear the proper personal protective equipment to prevent cross contamination for 4 of 18 residents (R3, R72, R47, R69) reviewed for infection control in the sample of 32. Findings include: 1. On 5/23/23 at 10:00 AM, V5, Certified Nurse Aide (CNA), and V7, CNA, entered R3's room to perform incontinent care. R3's incontinent brief was soiled with urine and feces. V7 failed to change her gloves when they became soiled during the care. When care was completed, V7 assisted R3 with rolling over touching R3's bare skin with the same gloves used for incontinent care, applied a new incontinent brief and covered R3 up. On 5/24/23 at 2:21 PM, V6, Infection Preventionist, stated that staff should change gloves when soiled and one pair of gloves should not be used for the process of incontinent care and then putting a new brief or clothing on. 2. On 05/24/2023 at 09:15 AM, V15, CNA, took R45 into the bathroom, donned gloves without benefit of hand hygiene, placed gait belt on R45 and assisted her to the toilet. V15 removed R45's soiled incontinent brief, placed it in the trash. V15 turned on the water, with the same gloves, placed the clean washcloths in the sink. V15 got a clean incontinent brief, added powder to it and placed in R45's pants. Once the washcloths were wetted, she applied shampoo and body wash to the washcloths. V15 changed gloves, without benefit of hand hygiene, and cleansed R45's perineal area. V15 continued to wear the same soiled gloves to towel dry all areas she cleansed. V15 pulled up R45's pants and assisted her back to her wheelchair still wearing the same soiled gloves. V15 then doffed her gloves and performed hand hygiene. The facility's policy, Hand Hygiene Protocol dated 07/26/2021, documented, During routine resident care. Use an Alcohol Based Hand Sanitizer. It continues, Before moving from work on a soiled body site to a clean body site on the same resident. It continues, Immediately after glove removal. 3. On 5/22/23, R69's door has sign posted stating Enhanced Barrier Precautions (EBP). EBP sign on R69's room door states. provider and staff must wear gloves and gown for wound care: any skin opening requiring a dressing change. On 05/24/23 at 10:20 AM, V14, Registered Nurse (RN)/ Assistant Director of Nursing, and V16, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145721 If continuation sheet Page 6 of 7 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 05/25/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Licensed Practical Nurse (LPN), performed dressing change for R69. V14 and V16 entered R69's room with gloves, surgical mask but were not wearing gowns. V16 performed dressing change with V14's assistance with neither wearing a gown. On 5/24/2023 at 10:47AM, V14 stated they should have worn gowns in the room when they did the dressing change for R69. On 5/24/2023 at 10:35AM, V16 stated she just started on Monday, but reading that sign she should have worn a gown in the room while performing the dressing change for R69. On 5/24/2023 at 2:15PM, V6, Infection Preventionist, stated she expects staff to wear gowns when doing dressing changes on R69 due to R69 being on EBP's for an open wound. The Facility's Enhanced Barrier Precautions Protocol dated July 26, 2021, states that Enhanced barrier precautions may be considered for wound, PPE (Personal Protective Equipment) (gloves and gowns) should be used during high contact resident care activities. examples of high contact resident activities requiring gown and gloves use include wound care: any skin opening requiring a dressing change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145721 If continuation sheet Page 7 of 7