Inspection·August 13, 2024

F 0761 Level of Harm - Minimal harm or potential for actual harm 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. 6. Both the high and low blood glucose machine control liquids had expiration dates of 3/4/24. Residents Affected - Some On 8/6/24 at 12:20 PM, V7 stated that the control liquids are not her responsibility to check and see if they are in date. On 8/6/24 at 12:45 PM, the Zone 3 Hall cart was observed with V8, Registered Nurse. Both the high and low blood glucose machine control liquids had expiration dates of 3/4/24. On 8/6/24 at 12:50 PM, V2, Infection Preventionist, Licensed Practical Nurse, stated, It's night shifts responsibility to check the control liquids. The facility provided listof Diabetics, undated, documents that R2, R11, R14, R15, R21, R22, R23, R33, R41,R43, R51, R66, and R179 are the residents residing on Zone 2 and 3 that are Diabetics. The policy Blood Glucose Testing and Monitoring, dated 2/2016, fails to document how the blood glucose monitor quality control measures. Based on observation, interview and record review, the facility failed to ensure medications were securely stored, failed to ensure opened medications were labeled with open dates, and the facility was using expired blood glucose control liquids for 16 of 24 residents (R2, R11, R13, R14, R15, R21, R22, R23, R33, R41, R43, R51, R54, R57, R66, R179) reviewed for medication storage in the sample of 55. Findings include: On 8/6/2024 at 11:35 AM, a medication cart was observed with V7, Licensed Practical Nurse (LPN). At this time: 1. There was an open bottle of Timolol eye drops with R13's name on it. At this time V7 stated she couldn't tell the surveyor the date the bottle was opened, because she did not open it, but V7 knows everything is supposed to be dated when it is opened. R13's Physician's Orders dated 10/21/2020 documents, Timolol Maleate Solution 0.25 %- Instill 1 drop in both eyes in the morning for Glaucoma. 2. There was an open bottle of Durezol with R14's name on the label. There was no date to indicate when the bottle was opened. This information was also confirmed by V7. R14's Physician's Orders dated 5/9/2024 documents that R14 is prescribed Durezol Ophthalmic Emulsion 0.05 % (Difluprednate)-Instill 1 drop in right eye six times a day for inflammation. 3. In the bottom of the drawer, there was an open tube of Systane (eye lubricant) that was unlabeled. At this time, V7 stated she knows the tube belongs to V54 because she is the only resident on it. V7 then said, Look her box is here. There was another opened tube of Systane enclosed in the box. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145721 If continuation sheet Page 2 of 8 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 08/13/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R54's Physician's Orders dated 2/6/2024 documents, Systane Nighttime Ophthalmic (eye) Ointment- Instill 1 drop in both eyes every 1 hours as needed for dryness. 4. On 8/8/2024 at 12:53 PM, the Facility's medication storage room was observed with V7. At this time, there was an opened bottle of Pantoprazole Oral Suspension labeled with R57's name on it and an expiration date of 6/8/2024. At this time, V7 stated, That should have been thrown away a long time ago. R57's Physician's Orders dated 5/30/2024 documents, Pantoprazole Sodium Oral Suspension 4 MG/ML (milligram per milliliter) give 1 ML via G-tube (Feeding tube) in the morning. 5. On 8/8/2024 at 12:50 PM, There was a cart located behind the Nurses Station that was noted to be unlocked. This observation was confirmed with V7. At this time V7 stated the medication cart was V8's (Registered Nurse) but V8 had left off the floor (left the area). At this time V7 unlocked the medication storage room and entered with this surveyor. V7 didn't not lock the medication cart (which can be done by pushing a button/lock). On 8/8/2024 at approximately 12:55 PM, after inspecting the medication room (approximately 5 minutes). V7 and this surveyor came out of the medication storage room and V7 stated, Oh there's (V8). At this time V8 was asked if the medication cart was V8's and why was it unlocked. V8 stated I guess because I forgot to lock it. On 8/12/2024 at 11:40 AM, V2, Director of Nursing, stated she expects all medication bottles including eye drops, to be dated when opened and labeled with the resident's name. V2 continued to state expired medications should be disposed of and the medication cart should be locked when unattended. The Facility's Policy Storage of Medication, undated, documents, Al discontinued/expired medications are to be removed from the active storage/medication use area. The policy does not address the labeling and dating of medications nor ensuring medications within the medication carts are secured by locking the cart while unattended. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145721 If continuation sheet Page 3 of 8 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 08/13/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to implement infection control practices, failed to wear Personal Protective Equipment (PPE), failed to disinfect multi-use equipment, failed to test residents with COVID-19 symptoms, and failed to ensure residents and staff were tested on COVID-19 days to prevent the spread of COVID-19 infection for 8 of 24 residents (R6, R13, R24, R30, R38, R43, R45, R178) reviewed for infection control in the sample of 55. Residents Affected - Some Findings include: 1. On 8/5/2024 at 11:28AM V23, Licensed Practical Nurse (LPN) donned a gown, placed a surgical mask over a N95 mask, donned gloves, but did not sanitize their hands prior to donning gloves. V23 removed a blood glucose glucometer from a drawer of medication cart and entered R43's room and obtained an accu check. R43 then exited the room with the blood glucose machine and laid it on top of a dispatch wipe on the medication cart. At 11:46AM V23, LPN stated they need to give report to a nurse relieving her. V23 takes the glucometer in dispatch wipe and rubs it few times and places it in drawer of medication cart. R43's physician order (PO) dated 8/5/2024 documents contact/droplet isolation x 10 days. R43's progress notes dated 8/4/2024 documents R43 is positive for COVID 19. The facility infection prevention and control policy and procedure dated revised July 26, 2021, documents the facility uses the CDC guidelines for instruction regarding infection prevention and control practices. The facility Covid -19 testing and response plan dated revised 8/29/2023 documents dedicated medical equipment should be used when caring for a resident with suspected or confirmed SARS-Cov-2 infection. Reusable equipment must be cleaned and disinfected between residents. On 8/12/2024 at 12:25PM, V2, Director of Nursing (DON) stated the facility does not dedicate blood glucose machines to COVID-19 positive residents. V2 stated the facility uses dispatch disinfecting wipes and items are to be cleansed for 3 minutes. On 8/8/24 at 11:47 AM, V2, Infection Preventionist, stated, On 7/6/24 when we had 2 cases on the rehabilitation unit (VTR). It was R4 and R42. At that time, we tested residents and staff just on that hall. The staff began to wear N95 masks and full PPE when caring for a resident with COVID, no dining room activities, and the rehabilitation unit has dedicated staff, so they weren't going to other halls. We were testing on Tuesdays and Thursdays. I did have a week off during the outbreak and staff nurses were supposed to test all residents and document in the computer system that they were tested and the results. I have realized that this didn't exactly happen. On 7/29/24 (R24's son) took her (R24) to the hospital and she did test positive for COVID. On 8/4/24, I received a phone call telling me we had a couple of employees test positive. We had some that tested before their shift andwere positive, so they did not work. One was an agency nurse and she tested positive at the end of her shift. At that point, we started testing all residents and all staff members facility wide. The zone 2 and 3 residents are eating their meals in their rooms and staying in their rooms. We continued testing on Tuesday and Thursday. All agency and our staff are supposed to test before every shift. They go to a floor nurse and get tested. The staff write their name, and the nurse will fill-in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145721 If continuation sheet Page 4 of 8 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 08/13/2024 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 result. Any resident that has any type of COVID symptom, cold symptom, or allergy symptom should be tested then and not wait until the next test date. Staff should be wearing a N95 mask, gown, gloves, and face shield / goggles. If multi- use equipment is used on a COVID positive resident it should be disinfected before it is used again. We have been in-touch with the Health Department and letting them know of our outbreak status. Residents Affected - Some 2. R24's admission Record, print date of 8/12/24, documents that R24 was admitted on [DATE] with diagnoses of Congestive Heart failure and Hypertension. R24's Health Status Note, dated 7/16/2024 at 06:48, documents, Res. (resident) tested for COVID and negative. R24's Electronic Medical Record (EMR) fails to document COVID testing being completed between 7/17/24 and 7/29/24. R24's Health Status Note, dated 7/27/2024 at 14:36, documents, Call out to (V19, Physician) to inform him that res. is c/o (complaint of) nasal drainage dripping down the back of her throat which is causing her throat to be irritated and cough. Also, c/o watery eyes and allergy symptoms. Requesting orders for Flonase and Zyrtec daily. (V19) to return call. R24's Health Status Note, dated 7/27/2024 at 14:46, documents, Received call back from (V19) - new orders received for Flonase nasal spray, 1 spray in each nostril daily & Zyrtec 10 mg (milligram) daily for allergies. R24's Health Status Note, dated 7/29/2024 at 11:03, documents, Son, came to desk and stated that he was going to take patient to (local hospital) himself at this time. Face sheet and medicine orders copied and given to son. Patient was sitting in wheelchair alert to surroundings, talking with her daughter who was standing beside her. R24's Health Status Note, 7/29/2024 15:44, documents, Resident admitted to hospital Covid positive. R24's Clinical Admission, dated 8/2/24 5:41 PM, documents, admission Details: Arrived by: Arrived by Other: Facility transport. R24's Hospital History and Physical, dated 7/29/24, documents, Impression: Pyelonephritis vs COVID - 19. Patient tested positive in the ED (Emergency Department) Currently saturating 96 % O2 (oxygen on room air, Patient is asymptomatic, negative, CXR (chest x-ray) shows no evidence for acute pneumonia viral panel negative. 3. On 8/6/24 at 1:05 PM, V20, Agency Certified Nurse's Aide, (CNA), was questioned when she was tested for COVID last, V20 stated, Last week. V20 was questioned if she was tested at the facility or at another facility, V20 stated, I tested myself at home. 4. The facility COVID Outbreak Line List of Residents documents that R30 tested positive on 8/6/24, R45 tested positive on 8/13/24, R38 test positive on 8/6/24, R178 tested positive on 8/4/24, and R6 tested positive on 8/6/24. On 8/6/24 all of these residents except R45 (who was negative at the time) had signage on the door indicating staff must wear a N95 mask, gown, gloves, and eye protection and an isolation cart outside of their doorway. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145721 If continuation sheet Page 5 of 8 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 08/13/2024 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 On 8/6/24 at 12:46 PM, V20 CNA was observed passing lunch meal trays on the Skilled 3 hall. V20 was wearing a N95 mask. V20 entered R30's room with her meal tray. V20 did not perform hand hygiene before entering the room. V20 only wore a N95 mask. V20 moved items around the bedside table to make room for the meal tray and set up R30's meal tray. V20 exited the room, went to the lunch tray cart, touched multiple trays looking for R45's meal tray. V20 found the tray and entered R45's room and delivered and set up R45's meal tray. V20 exited the room, went to the lunch tray cart, touched multiple trays looking for R38's meal tray. V20 found the tray, put gloves on and entered R38's room, delivered and set up R38's meal tray. V20 exited the room, removed her gloves, went to the lunch tray cart, touched multiple trays looking for R178's meal tray. V20 entered V20's room, set up R178's meal tray for R178, exited the room, and performed hand hygiene. V20 went to the lunch tray cart and found R6's lunch tray. V20 did not perform hand hygiene before entering the room. V20 moved items around the bedside table to make room for the meal tray and set up R6's meal tray. V20 exited the room and performed hand hygiene. During this meal tray pass, V20 did not wear eye protection or a gown. There were multiple observations of V20 not wearing gloves or performing hand hygiene when entering COVID positive rooms. 5. On 8/8/24 at 11:40 AM at V24, LPN, prepared to administer 650 mg of Acetaminophen to R13. R13's door has signage that documents staff must wear a N95 mask, gown, gloves, and eye protection. R13 has an isolation cart outside of her doorway. V24 entered the room with a N95 mask on only. R13 requested stronger pain medication, V24 exited the room, preformed hand hygiene, obtained a Tramadol pill from the medication cart, and entered R13's room again to provide medication with only a N95 mask on. V24 left the room and performed hand hygiene. The facility COVID Outbreak Line List of Residents documents that R13 tested positive on 8/4/24. 6. On 8/6/24 at 12:18 PM, V7, Licensed Practical Nurse entered R43's room. R43's door has contact isolation signage on the door. R43 enters the room in full PPE and sets the blood glucose monitor on top of R43's bed side table. R43 obtains a blood sample and goes to the doorway. V7 leans out of the door and places the blood glucose monitor on top of the isolation cart outside of the doorway. V7 removes her face mask, gloves, gown, sanitizes her hands, and gets a Dispatch disinfecting wipe and lightly wipes down the blood glucose machine and sets it on a paper towel on top of the medication cart. V7 fails to disinfect the isolation cart. The facility COVID Outbreak Line List of Residents documents that R43 tested positive on 8/4/24. The policy COVID- 19 Testing and Response Plan, dated 8/29/23, documents, Healthcare workers must use proper PPE when exposed to a resident with suspected or confirmed COVID- 19 or other sources of SARS-CO-2. If a resident is suspected or confirmed to have COVID-19 or other respiratory illnesses, at a minimum, HCP (health care provider) must wear an N95 respirator, eye protection, gown, and gloves. If a facility is experiencing an outbreak of COVID-19 or other respiratory illness, at a minimum, HCP must wear a well fitted mask while on the unit or floor experiencing an outbreak. COVID-19 testing is required for any of the following: Symptomatic residents or HCP, even those with mild symptoms of COVID-19, should receive a viral test for SARS-CoV-2 infection as soon as possible. It continues, Outbreak Testing. When using the broad based approach, a facility should continue to test every 3 - 7 days until there are no more positive cases identified for 14 days. It continues, Environmental Infection Control. Dedicated medical equipment should be used when caring for a resident with suspected or confirmed SARS-CoV-2 infection. Reusable equipment must be cleaned and disinfected between residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145721 If continuation sheet Page 6 of 8 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 08/13/2024 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 The policy Blood Glucose Testing and Monitoring, dated 2/2016, documents, Clean blood glucose meter with Dispatch product if meter is shared between residents. The policy Disinfecting Products, dated 1/1/23, documents, Dispatch Wipes - 3 minute contact time. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145721 If continuation sheet Page 7 of 8 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 08/13/2024 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 provide education or documentation of refusal for the COVID-19 vaccine for 3 of 5 residents (R44, R51, R231) reviewed for immunizations in the sample of 55. Findings include: On 8/5/24 at 2:30 PM, V2, Infection Preventionist Licensed Practical Nurse stated that the facility does not have education material or declination refusals for the COVID-19 immunization. V2 stated that R44, R51, and R231 are the only residents in the building that have not been vaccinated for COVID-19 . The COVID 19 Vaccination Policy for Residents, dated 2/1/22, documents, Procedure: 1. Education is provided for all residents and / or responsible party on the COVID-19 vaccination. This policy fails to document how acceptance or refusal of the vaccine will be documented. 1. R51's admission Record, print date of 8/12/24, documents that R51 was admitted on [DATE]. R51's Electronic Medical Record (EMR) fails to document that R51 was educated and offered the COVID-19 vaccine. 2. R44's admission Record, print date of 8/12/24, documents that R44 was admitted on [DATE]. R44's EMR fails to document that R44 was educated and offered the COVID-19 vaccine. 3. R231's admission Record, print date of 8/12/24, documents that R231 was admitted on [DATE]. R231's EMR fails to document that R231 was educated and offered the COVID-19 vaccine. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145721 If continuation sheet Page 8 of 8