Health inspection·July 18, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to assist a resident that was assessed to require assistance with ADLs (Activities of Daily Living). Residents Affected - Few This applies to 1 of 1 resident (R436) in the sample of 19. The findings include: R436's EMR (Electronic Medical Record) showed R436's most recent admission to the facility was on July 10, 2024. R436's diagnoses included generalized muscle weakness, Alzheimer's with late onset, dementia, polyneuropathy, and ESBL (Extended Spectrum Beta Lactamase) in his urine requiring him to be in contact isolation. R436's MDS (Minimum Data Set) dated July 16, 2024, showed R436 had severe cognitive impairment. R436 was recently discharged from this facility on February 2, 2024. His MDS was incomplete at the time of the survey due to recent admission. On July 15, 2024, at 11:02 AM, R436 was in bed asleep. He was unshaven and his nails were noted to be reaching out past the end of his fingers and were uneven and jagged. On July 16, 2024, at 11:45 AM, R436 was sitting up in his room, he said he would like to be shaved and have his fingernails cut. He was wearing facility sweatshirt and sweatpants. On July 16, 2024, at 11:55 AM, V11 (CNA/Certified Nurse Assistant) showed surveyor the shower book at the nurses' station and V11 said R436 should be showered today. V11 said residents in isolation are done at the end of the day and showers are disinfected once done to prevent the spreading of infection. On July 17, 2024, at 10:02 AM, R436 was sitting in his wheelchair wearing the same clothes as yesterday. There was a white substance down the front of his facility sweatshirt and a musty foul odor was noted. His hair was uncombed. R436 said he really wants a shave and wants to have his nails cut. On July 17, 2024, at 11:09 AM, V2 (DON/Director of Nursing) said residents should be offered hygiene care daily regardless of isolation status. Hygiene care would include oral care, shower if preferred or bed bath/wash up at sink, shaving, nail care, and clean clothes. Facility provided their policy titled, General Requirements for Nursing and Personal Care- Miller with revision date of February 2011. The policy showed .5. Personal care shall be provided on a 24-hour, seven day a week basis. This shall include but not be limited to the following a .daily personal attention including skin, nails, hair, and oral hygiene . b. each resident shall have at least one complete bath and hair wash weekly .c each resident shall have clean suitable clothing in order to be comfortable, sanitary, free of odors, and decent appearance . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145843 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 145843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miller Health Care Center 1601 Butterfield Trail Kankakee, IL 60901 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to manage a resident's pain during bathing and wound care. Residents Affected - Few This applies to 1 of 2 residents (R36) reviewed for pain management in the sample of 19. This failure resulted in R36 crying in pain during bed bath, wound treatment, and repositioning. Findings include: According to the face sheet R36 was admitted to facility on April 2, 2024, with multiple diagnoses including diabetes mellitus with neuropathic arthropathy, pressure ulcers, morbid obesity and end stage renal disease with dependence on renal dialysis. R36's MDS dated [DATE], shows resident has moderately impaired cognition, and is totally dependent on staff to complete most ADLs (Activities of Daily Living). On July 16, 2024, at 1:08 PM, V7 and V8 (Certified Nursing Assistants, CNAs) gave R36 a bed bath. R36 complained of pain, flinched, and grimaced throughout process. During perineal care R36 cried out multiple times during cleaning of abdominal folds. These areas were visibly reddened and tender. While cleaning R36's right foot, V8 noticed right toes were reddened and extremely tender, R36 flinched and cried as V8 attempted to clean between toes. An object was removed from between toes during process. R36 was not offered pain medications at any time during bathing process nor was the bathing process stopped. V8 was then prompted to stop manipulating R36's toes. On July 16, 2024, at 2:09 PM, V9 (wound care nurse) entered R36's room and started wound dressing preparation. V9 began the treatment process for multiple pressure ulcers. V8 notified V9 that R36 had issues with pain throughout bed bath and that there was a wound or injury to right foot. V9 continued with treatment. V9 applied dressings to pressure wounds, during which R36 continued to complain of pain during treatment and repositioning. V9 began to inspect R36's right foot, R36 complained and cried in pain during V9's initial examination. V9 then moved to obtain saline and gauze pads. V9 then stated she was going clean and examine R36's right foot and toes, at that point V9 was prompted to discontinue procedure until the assigned nurse was notified and R36 was assessed for pain and pain medication was administered. R36's Medication Administration Record (MAR) dated July 2024 shows the following physician's orders for pain medications: 1. Two tablets of acetaminophen 325 mg available every 6 hours and, 2. One tablet of Tramadol HCL 25 mg available every 12 hours for right leg pain. The most recently recorded administration of Tramadol was May 18, 2024 (prior to the incident mentioned above). On July 17, 2024, at 10:51 AM, V2 (Director of Nursing) stated that if staff becomes aware of resident being in pain, then staff should immediately notify the assigned nurse to have resident evaluated or have pain medication administered. Also, that if a procedure is causing resident pain, then that procedure should be paused until pain is relieved either by non-pharmacological methods or available pain medication because resident should not be in unnecessary pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145843 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 145843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miller Health Care Center 1601 Butterfield Trail Kankakee, IL 60901 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 0697 On July 17, 2024, at 12:59 PM, V21 (Nurse Practitioner) stated he was not aware of R36 having any pain during ADLs and wound treatment. Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Facility pain management policy dated July 2024 shows A. Each individual with pain, whether it be acute or chronic, has the right to obtain optimal pain relief . Event ID: Facility ID: 145843 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 145843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miller Health Care Center 1601 Butterfield Trail Kankakee, IL 60901 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 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 ensure carrots had smooth consistency for residents who required a pureed diet. Residents Affected - Some This applies to 4 of 4 residents (R16, R20, R38, and R47) reviewed for dietary needs in the sample of 19. The findings include: R16's EMR (Electronic Medical records) showed R16 had multiple diagnoses including vascular dementia, and dysphagia. R16's active order summary report showed an order dated November 16, 2023 for regular diet, pureed texture. R20's EMR showed R20 had multiple diagnoses including Alzheimer's disease, dementia, and traumatic brain injury. R20's active order summary report showed an order dated August 21, 2023 for regular diet, pureed texture. R38's EMR showed R38 had multiple diagnoses including Alzheimer's disease, dementia and feeding difficulties. R38's active order summary report showed an order dated March 22, 2024 for regular diet, pureed texture. R47's EMR showed R47 had multiple diagnoses including cerebral atherosclerosis and metabolic encephalopathy. R47's active order summary report showed an order dated March 22, 2024 for regular diet, pureed texture. On July 15, 2024 at 10:39 AM, V18 (Cook) was observed preparing pureed meals. V18 did not follow any recipes for pureed food. V18 blended a full #6 container (about 8 cups) of carrots and a half cup of thickener. After blending the carrots, V18 put it in a container for serving. The blended carrots looked chunky and not smooth. The blended carrots was tasted and it had hard chunks throughout. V18 took the temperature of the blended carrots, and it was not hot enough, so he placed it inside the steamer until it was time for it to be served. On July 15, 2024 at 11:31 AM, V18 took the container of blended carrots out of the steamer and placed it in the steam table for serving. V18 and V23 (Dietary Manager) were asked if the blended carrots were ready to be served and both V18 and V23 responded, yes. The blended carrots were again tasted. There were still hard chunks of carrots throughout, and the consistency was not smooth. V18 and V23 were asked to try the blended carrots and were asked, what they thought of the texture. V23 stated that the carrots needed to be cooked some more. V18 stated the carrots were chunky and that it needed to be blended some more. The facilities modified texture foods policy dated January 2024 showed that the foods requiring a modification to a puree texture will have a smooth texture. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145843 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 145843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miller Health Care Center 1601 Butterfield Trail Kankakee, IL 60901 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, interview, and record review, the facility failed to follow standard infection control practices related to hand hygiene and gloving during provisions of ADL (activities of daily living) care and wound care. In addition, the facility failed to ensure that a urinary catheter bag was not placed on the floor. Residents Affected - Some This applies 5 of the 19 residents (R26, R36, R39, R40, R53) reviewed for infection control in the sample of 19. The findings include: 1. R26 was on Enhance Barrier Precaution (EBP) due to gastrostomy tube according V11 and V17 (both Certified Nursing Assistants, CNA). On July 16, 2024, at 12:15 PM, V11 and V17 (Both CNA/Certified Nursing Assistants) provided grooming care to R26. After V11 completed the care, she removed her gloves and sanitized her hands, then she carried R26's soiled gown with her bare hands without a plastic linen bag and carried it through the hallway into the soiled linen room. 2. On July 16, 2024, at 2:19 PM, V17 and V20 (Both CNAs) assisted R40 to the toilet. After R40 used the toilet, V20 wiped R40's perineum. V20 removed her gloves and without hand hygiene, put the incontinence brief and pulled the pants back on to R40. Then V17 and V20 transferred R40 back to the wheelchair via the sit to stand mechanical lift without V20 performing hand hygiene. On July 17, 2024, at 11:48 AM, V2 (Director of Nursing) stated staff must wash their hands before and after care and perform hand hygiene and change gloves in between task. Soiled linen or items are to be placed in a plastic bag when bringing it from the resident's room to the soiled utility room, to prevent infection or spread of infection. 5. R53's EMR (Electronic Medical Record) showed R53 was admitted to the facility on [DATE]. R53's diagnoses included pressure ulcer stage 4 of sacral region, pressure ulcer stage 3 of other region, paraplegia, major depressive order, peripheral vascular disease, and diabetes type 2. R53's MDS dated [DATE], showed R53 had moderately impaired cognition. On July 17, 2024, at 9:29 AM, V10 (LPN/Licensed Practical Nurse) was preparing to provide wound care to R53. After supplies were gathered, hand sanitizer was used, gown and gloves were donned. V10 said R53's coccyx dressing had already been removed because he had just had a bowel movement. V10 picked up gauze she had soaked with normal saline and cleaned the wound in a circular motion. V10 removed gloves, used hand sanitizer, and put on new gloves. V10 picked up rolled gauze and wet it with a wound solution and packed the wound using a sterile cotton tipped applicator. V10 used her fingers to put zinc around the wound. V10 removed the glove from the hand that had the zinc on it and put on a new glove without using hand sanitizer. V10 covered the area with a bordered silicone super absorbent dressing. V10 moved to the left lower leg wounds. She removed her gloves, used hand sanitizer, and put on new gloves. V10 removed the soiled dressing from the left lower leg proximal wound and then the left lower distal leg wound. With the same gloves, V10 put some gauze over each wound and said she just puts it there because he usually bleeds. V10 picked up new gauze that was wet with normal saline and cleaned the proximal wound and then covered with a bordered silicone super absorbent dressing. With same gloves, V10 picked up another gauze wet with saline and cleaned the distal wound and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145843 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 145843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miller Health Care Center 1601 Butterfield Trail Kankakee, IL 60901 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 covered the wound with a bordered silicone super absorbent dressing. V10 removed her gloves, used hand sanitizer, and put on new gloves. R53 was repositioned to expose the right lower leg wound. V10 removed gloves, sanitized her hands, and put on new gloves. V10 then removed dressing from the wound and with the same gloves picked up gauzes soaked with normal saline and cleaned the entire wound. V10 removed gloves, sanitized her hands, and put on new gloves. V10 soaked gauze with wound solution and placed on wound, covered with bordered dressing. On July 17, 2024, 10:07 AM, V10 said she changes her gloves after she cleans the wound because the dressing, she removes is dirty and until she cleans the wound, the wound is also dirty and that is why she removed her gloves and used hand sanitizer after cleaning the wound and putting on new gloves to do the cleaning, treatment, and dressing. On July 17, 2024, at 10:15 AM, V2 (Director of Nursing) said before starting the procedure, the staff will hand hygiene and don gown and/or gloves. The old wound dressing should be removed, and then the gloves should be discarded, hand must be sanitized, and new pair of gloves must be donned. With the new gloves on, the treatment can be applied if ordered. If the nurse did not use a tool (cotton tipped applicator, tongue depressor) and instead used a gloved hand to apply the treatment, then the gloves get removed, hands must be sanitized, and new gloves should be donned before applying the outer dressing. Facility provided policy titled, Standard Precautions with revision date of May 2017 showed B. Handwashing. 1. Wash hands after touching blood, body fluids, secretions, excretions, and contaminated items, whether gloves are worn or not 3. Also wash hands between tasks and procedures on the same resident to prevent cross-contamination of different body sites .C. Gloves . 3. Change gloves between tasks and procedures on the same resident after contact with material that may contain a high concentration of microorganisms. 4. Removed gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident. Facility provided policy titled, Dressing- Clean Technique with revision date of February 2021 showed Procedure .I. remove soiled dressing J. Remove gloves, perform hand hygiene, apply new gloves L. Clean wound P. Remove gloves, perform hand hygiene, apply new gloves R. Apply prescribed topical agent to wound. S. Apply wound dressing. 3. R36 was admitted to facility on April 2, 2024, according to resident face sheet, with multiple diagnoses including diabetes mellitus with neuropathic arthropathy, pressure ulcers, morbid obesity, and end stage renal disease with dependence on renal dialysis. R36's MDS (Minimum Data Set) dated July 9, 2024, shows that resident has moderate cognitive impairment, and is totally dependent on staff to complete most ALDs (Activities of Daily Living). R36's care plan dated July 16, 2024, requires EBP (Enhanced Barrier Precautions) due to hemo dialysis access port and multiple pressure ulcers. An enhanced barrier precautions sign was posted on R36's door. On July 16, 2024, at 1:30 PM, V7 and V8 (CNAs) prepared R36 for bed bath by transferring R36 to bed using the mechanical lift. Both V7 and V8 were only wearing gloves. Then R36 was undressed, V7 and V8 were in the process to start giving R36 a bed bath, at this point V7 and V8 were prompted to put the gown on. Once bed bath was completed V9 (wound care nurse) was notified. On July 16, 2024, at 2:09 PM, V9 entered R36's room put on gloves and began preparing materials for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145843 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 145843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miller Health Care Center 1601 Butterfield Trail Kankakee, IL 60901 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 wound care. V9 performed hand hygiene and put on clean gloves and stated she was going to start the dressing change, at this point she was prompted to put on the gown. On July 17, 2024, at 10:51 AM, V2 (DON) stated that if staff are preparing to conduct any high contact resident care on a resident with EBP, gown and gloves are to be worn by all staff. V2 further stated the high contact resident care activities included dressing, bathing, transferring, device, and wound care. Facility EBP policy dated July 2024 shows . 2. EBPs employ targeted gown and glove use during high contact resident care activities .a. gloves and gown are applied prior to performing the high contact resident care activity .3. Examples of high contact resident care activities include .b. bathing and showering .c. transferring .g. device care and .h. wound care . 5. EBPs are indicated . for residents with wounds and/or indwelling medical devices. 4. R39's Face sheet shows diagnoses including neuromuscular dysfunction of bladder. R39's care plan dated March 24, 2024, shows R39 has indwelling supra pubic catheter. On July 16, 2024, at 12:55 PM, R39 was sitting in a chair in a reclined position, at 1:10 PM, V5 (CNA) unhooked the urinary collection bag and placed the bag on the floor during repositioning R39 for his meal. The urinary bag remained on the floor V6 (Nurse) was notified about the issue, then V5 with her bare hands (without wearing gloves) hung the urinary collection bag on the side of chair but it remained in contact with floor. On July 17, 2024, at 11:03 AM, V2 stated that no staff member should handle resident devices (catheters) without first putting on gloves, and that drainage bags should never be on the floor for any reason. Facilities Urinary Catheter Insertion and Removal policy dated July 2024 shows .L. To achieve free flow of urine .4. Collecting bags are always off the floor . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145843 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 145843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miller Health Care Center 1601 Butterfield Trail Kankakee, IL 60901 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 offer and administer the pneumonia vaccines to new and current residents residing in the facility. Residents Affected - Few This applies to 3 of 6 residents (R29, R53, R286) reviewed for immunizations in the sample of 19. The findings include: 1. R29's Electronic Medical record (EMR) showed R29 was admitted to the facility on [DATE]. The medical record failed to show R29 had received any pneumonia vaccines. The medical record failed to show that the facility had offered any type of pneumonia vaccine to the resident. 2. R53's EMR showed R53 was admitted to the facility on [DATE]. R53 received the pneumococcal conjugate 13-valent vaccine prior to his admission on [DATE]. R53 would have been eligible for the PPSV-23 (Pneumococcal polysaccharide vaccine) one year later. R53's medical record failed to show the facility offered the PPSV 23 vaccine to the resident. 3. R286's EMR showed R286 was admitted to the facility on [DATE]. There wasn't any documentation to show R286 had received any pneumonia vaccines. The medical record failed to show the facility had offered R286 any pneumonia vaccines. On July 17, 2024, at 2:26 PM, V12 (Vice President of Post-Acute Care) said she was unable to locate any pneumonia vaccine record for R29 and R286. On July 16, 2024, at 2:19 PM, V4 (Infection Prevention Nurse) said pneumonia vaccines should be offered to all new admission, and those that need the vaccine. The staff will document in the progress notes what vaccine was given, and it will also be documented under the immunization tab in the electronic medical record. Consents get scanned into the medical record and if the resident refuses, then there should be a progress note documenting the refusal and any education provided to the resident and/or their family members about the risks and benefits of receiving the vaccine. On July 17, 2024, at 10:53 AM, V3 (Assistant Director of Nursing) said she was not sure who is offering the vaccine to the residents, she said she believes it is to be offered on admission, and one staff member gets the consent, while someone else is responsible for looking up historical records. V3 was not sure what pneumonia vaccine was available to be given to the residents. On July 17, 2024, at 10:15 AM, V2 (Director of Nursing) said it is her understanding that all nurses are to offer the pneumonia vaccines to all new admission (Influenza offered during October to March). This is being discussed each morning in the morning meeting. If the resident has not had the vaccines, it is the expectation that the vaccines are offered. If it is offered, there should be a progress note showing it was offered, consented, or refused. If consented, it would be documented under the immunization tab. The facility policy titled, Pneumococcal Immunization, with revision date December 2019 showed, The purpose is to reduce the overall incident of pneumococcal by providing the pneumococcal vaccine to the residents [AGE] years of age and older and to others at high risk. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145843 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 145843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miller Health Care Center 1601 Butterfield Trail Kankakee, IL 60901 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 offer the Covid-19 vaccine to new and current residents residing in the facility. This applies to 2 of 6 residents (R286 and R437) reviewed for Covid-19 immunizations in the sample of 19. The findings include: 1. R286 was admitted to the facility on [DATE]. There wasn't any documentation to show R286 had been offered the Covid-19 vaccines. The medical record showed R286 had received one dose of the Covid-19 vaccine on September 20, 2021 and the medical record failed to show the facility had offered R286 the Covid vaccine on or after his admission to this facility. 2. R437 was admitted to the facility on [DATE]. The medical record showed she had not received any Covid-19 vaccines. The medical record failed to show that the facility offered the Covid-19 vaccine to R437. On July 17, 2024, at 2:26 PM, V12 (Vice President of Post-Acute Care) said she was unable to locate any other vaccine record for R286. On July 16, 2024, at 2:19 PM, V4 (Infection Prevention Nurse) said Covid-19 vaccines should be offered to all new admission, and those that need the vaccine. The staff should document in the progress notes of the resident what vaccine was given, and it should also be documented under the immunization tab in the electronic medical record. Consents get scanned into the medical record and if the resident refuses, then there should be a progress note documenting the refusal and any education provided to the resident and/or their family members about the risks and benefits of receiving the vaccine. On July 17, 2024, at 10:53 AM V3 (Assistant Director of Nursing) said she not sure who is offering the vaccine to the residents, she said she believes it is to be offered on admission, and one staff member gets the consent, while someone else is responsible for looking up historical records. V3 said the facility should offer the Covid-19 vaccine, but if the resident wants to have it, they will need to go to the local pharmacy because you have to order the vaccine in bulk, and it would be too costly. On July 17, 2024, at 10:15 AM, V2 (Director of Nursing) said it is her understanding that all nurses are to offer the Covid-19 vaccines to all new admission. This is being discussed each morning in the morning meeting. If the resident has not had the vaccines, it is the expectation that the vaccines are offered. If it is offered, there should be a progress note showing it was offered, consented, or refused. If consented, it would be documented under the immunization tab. Facility policy titled Covid Immunization with revision date of July 2024 showed the facility will encourage residents, staff, and families to remain up to date with Covid-19 vaccinations, including all eligible boosters. Nursing staff is responsible for the administration and assessment of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145843 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 145843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miller Health Care Center 1601 Butterfield Trail Kankakee, IL 60901 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 vaccine per the order of the physician, if not contraindicated or refused. Resident concerns will be obtained prior to the administration and then scanned into the resident's medical record. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145843 If continuation sheet Page 11 of 11