Inspection·August 17, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician of changes in a resident's weight for one resident of 4 residents (R31) reviewed for physician notification in a sample of 22. Findings Include: R31's Face Sheet documents R31 is an [AGE] year-old female resident with an admittance date of 10/10/17. R31's Face Sheet documents diagnosis including: Cerebrovascular disease, Chronic obstructive pulmonary disease, Type 2 diabetes mellitus with diabetic neuropathy, Edema, Arthropathy, Essential hypertension, Dysphagia, Acute upper respiratory infection, Iron Deficiency anemia, and Barrett's esophagus without dysplasia. R31's Physician Order Sheet documents an order for Metformin tablet 1000 mg (milligrams) twice a day with a start date of 04/04/2021 and a discontinued date of 04/26/23. R31's Physician Order Sheet documents an order for Torsemide tablet 10 mg, for a diagnosis of fluid retention, one time per day with a start date of 12/29/2021 and a discontinued date of 04/26/23. R31's Physician Order Sheet documents an order for Torsemide tablet 20 mg, for a diagnosis of fluid retention, one time per day with a start date of 12/29/2021 and a discontinued date of 04/26/23. R31's progress notes document on 04/27/23 at 11:08 AM, V8 (Medical Director) was at the facility doing rounds on 04/26/23, V8 discontinued R31's order for Metformin, Torsemide and Colace and initiated daily weights for 5 days to monitor fluid retention, no swelling noted at this time. The facility document dated 04/27/23 - 08/16/23 titled, Vitals Report documents: on 04/27/23 at 6:59 PM R31's weight was 113.8 pounds and on 04/28/23 at 1:48 PM 116.6 pounds. On 05/01/23 at 1:37 PM R31 had a weight of 115.6 pounds. On 05/08/23 at 9:36 AM R31 had a weight of 120.4 pounds. On 08/16/23 at 1:12 PM, V2 (Director of Nursing/DON) stated the order from V8 (Medical Director) was to monitor R31's weight for 5 days. V2 stated he would have no expectation to monitor any longer than what V8 ordered. When V2 was asked if V8 was notified of the weight gain R31 had between 4/27 and 4/28 V2 stated, no. V2 said the order stated to only monitor. When V2 was asked if V8 was notified of the 7 pound weight gain in the week of 5/1 to 5/8 V2 stated they (the facility) did not notify the doctor because that would be outside the parameters V8 specified. On 08/17/23 at 1:45 PM, V8 (Medical Director) stated, he discontinued R31's metformin and Torsemide because she was dehydrated and was not eating well. He was wanting her to gain some weight. He ask for them to monitor her weight for 5 days for fluid retention, but did not set any parameters because R31 was a smaller lady. V8 would not state whether he would expect them to notify him or not of the 2.8-pound weight gain the next day or the 7 pound weight gain 11 days later. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145880 If continuation sheet Page 2 of 6 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 145880 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillview Senior Living & Rehab 512 North 11th Street Vienna, IL 62995 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure restorative programs were implemented for 1 of 8 (R25) residents reviewed for restorative care in the sample of 22. Findings Include: R25's Face Sheet with a print date of 8/17/23 documents R25 was admitted to the facility on [DATE] with diagnoses that include Stage 3 pressure ulcer left hip, spondylosis, osteoarthrosis of spine, dementia, mood disturbance, and cognitive communication deficit. R25's Minimum Data Set (MDS) dated [DATE] documents R25 has a severe cognitive impairment. This same MDS documents under Section G, R25 is totally dependent on staff for bed mobility, transfers, locomotion, dressing, toilet use, and personal hygiene. R25's Care Plan dated 6/28/23 documents a problem area with a start date of 4/8/23, Category: ADL's (activities of daily living) Functional Status/Rehabilitation Potential Res (resident) needs PROM (passive range of motion) Restorative Program r/t (related to) at risk for developing an impairment in functional joint ability R/T recent decline in ADL's self-performance abilities, weakness, Decreased Mobility, Cognitive Communication Deficit, Dementia, Contracture BUE/BLE (bilateral upper extremity/bilateral lower extremity). The interventions with approach dates of 4/8/23, documented for this same problem area include, .Assist to move through tol (tolerated) range, supporting joints above et (and) below all major joints BID (twice daily) x (times) 7 days per week Evaluate and tx (treat) discomfort as needed . Gradually decrease assistance as tol to encourage progress to AAROM (active assisted range of motion) .Refer res (R25) to therapy as needed Report any declines in ROM abilities Reposition res (R25) for comfort at end of session . R25's Physician Order Report dated 8/1/23 to 8/17/23, documents the following physician order with a start date of 4/8/23, PROM (passive range of motion) to all major joints BID (twice daily) 7 days/wk (week) as tolerated . R25's Point of Care Restorative Nursing Category Report dated 8/17/23 documents no restorative programs were documented as administered for the following dates, 7/11-7/15, 7/17- 7/24, 7/26, 7/28- 7/30, 8/2-8/16/23. The report documents passive range of motion was provided for five minutes on 7/16, 7/25, 7/27, and 8/1/23 and for 15 minutes on 7/31/23. On 8/16/23 at 4:23 PM, R25 was observed while V5 (Licensed Practical Nurse/LPN) was administering treatments to the pressure ulcer located on R25's left hip. During this observation, R25 did not independently move his lower extremities. R25's legs were contracted at the knees with approximately a few inches of movement. V2 (Director of Nurses) who was present for this observation stated, R25 had the contractures when he was admitted to the facility. On 08/17/23 at 9:43 AM, V11 (Certified Nursing Assistant/CNA) was observed assisting R25 with passive range of motion. V2 (DON) was present during this observation. V11 was assisting R25 with upper extremity passive range of motion when V2 asked this surveyor if there was anything specific I was wanting to see. This surveyor explained I needed to see the restorative programs but also needed to see the restorative programs for R25's lower extremities. V2 stated R25 has been that way since he was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145880 If continuation sheet Page 3 of 6 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 145880 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillview Senior Living & Rehab 512 North 11th Street Vienna, IL 62995 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few admitted to the facility and R25 grimaces when they do lower extremity restoratives so they don't really do them. This surveyor asked V11 (CNA) if she did any restoratives with R25's lower extremities during activities of daily living. V11 stated she did with R25's upper extremities but R25 didn't really move his lower extremities. When asked how she assisted R25 with putting his pants on, V11 stated she was able to get R25's legs apart far enough to slide his pants on. Throughout this observation, R25 was lying in bed with his legs partially drawn up, with the left leg on top of the right leg. This is the same position R25 was observed in during the observation on 8/16/23 at 4:23 PM. The facility Restorative Nursing Programs policy dated 2021 documents, Policy: It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level 2. Nursing personnel are trained on basic, or maintenance nursing care that does not requires the use of a qualified therapist or licensed nurse oversight. This training may include but is not limited to: a. Maintaining proper positioning and body alignment. b. Encouraging and assisting residents, as needed, in turning and position changes. c. Encouraging residents to remain active and assisting with any exercises according to the plan of care .f. Assisting residents with range of motion exercises, performing passive range of motion for residents who lack active range of motion ability .4. All residents will receive maintenance nursing services as described above, as needed, by certified nursing assistants. 5. The Restorative Nurse and restorative aides receive additional training on restorative nursing program activities upon hire and as needed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145880 If continuation sheet Page 4 of 6 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 145880 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillview Senior Living & Rehab 512 North 11th Street Vienna, IL 62995 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and observation the facility failed to ensure staff provided urinary catheter care and performed hand hygiene per current standards of practice for 2 of 3 (R23 and R28) residents reviewed for catheter care in the sample of 22. Findings Include: 1. R23's Face Sheet with a print date of 08/17/23 documents R23 was admitted to the facility on [DATE] with diagnoses that include orchiectomy, congestive heart failure, acute kidney failure, benign prostatic hyperplasia (BPH), urinary retention, obstructive and reflux uropathy, and history of urinary tract infection. R23's MDS (Minimum Data Set) dated 6/9/23 documents a BIMS (Brief Interview for Mental Status) score of 09, which indicates R23 has a moderate cognitive deficit. R23's current Care Plan dated 4/18/23 documents a problem area with a start date of 12/10/2019 of, Category: Indwelling Catheter, (R23) requires an indwelling urinary catheter R/T (related to) DX (diagnosis) of Urinary Retention, Neurogenic Bladder, Bladder Spasms, Obstructive Uropathy, et (and) BPH. The interventions (Approaches) documented for this problem area include; provide catheter care every shift and as needed, report urinary tract infection signs/symptoms, administer medications as ordered, store collection bag inside protective dignity pouch, and use a catheter strap. On 08/16/23 at 2:52 PM, V10 (CNA/Certified Nursing Assistant) was observed providing catheter care to R23, with V2 (Director of Nurses/DON) present for the observation. V10 donned gloves and used a no rinse wipe to clean R23's groin area. V10 used a clean wipe to wipe around the tip of R25's penis near the catheter insertion site. V10 did not pull R25's foreskin back and clean under/around the foreskin. V10 used a clean wipe to wipe down the catheter tube from the insertion site. V10 wiped up and down the catheter tubing three to four times, wiping to and from the insertion site. V10 doffed her gloves and donned clean gloves and used a dry washcloth to dry the areas. V10 doffed her gloves and donned clean gloves and covered V10 up with a clean sheet. V10 did not hand sanitize between glove changes. At 2:58 PM on this same date, V10 stated she normally would use hand sanitizer between glove changes but she was nervous and forgot. On 08/16/23 at 2:59 PM, when asked if he observed V10 cleaning the catheter tube to and from the insertion site, V2 (DON) stated, Well, you are supposed to go from the insertion site down, but she cleaned the tube so that is all I have to say. 2. R28's Resident Face Sheet with a print date of 8/17/23 documents R28 was admitted to the facility on [DATE] with diagnoses that include Parkinson's disease, heart disease, diabetes, chronic kidney disease, benign prostatic hyperplasia, and obstructive and reflux uropathy. R28's MDS dated [DATE] documents a BIMS (Brief Interview of Mental Status) score of 07, which indicates R28 has a severe cognitive deficit. R28's Care Plan dated 6/27/23 documents a Problem area with a start date of 6/8/23 of, Res (R28) admitted from hospital with an indwelling urinary catheter R/T (related to) Hospice Care, decline in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145880 If continuation sheet Page 5 of 6 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 145880 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillview Senior Living & Rehab 512 North 11th Street Vienna, IL 62995 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 0690 Level of Harm - Minimal harm or potential for actual harm health condition et (and) ADL's (activities of daily living) self-performance, weakness, decreased mobility. This problem area documents interventions that include avoid lying (R28) on top of tubing, avoid obstructions in the drainage, change catheter bag every week and as needed, change catheter every month and as needed, position bag below the level of the bladder, report signs/symptoms of UTI (urinary tract infection), and provide catheter care every shift and as needed. Residents Affected - Few On 08/16/23 at 3:50 PM, V7 (CNA) was observed providing catheter care to R28 with V2 (DON) present. V7 used no rinse wipes to clean down both sides of R28's groin then used a clean wipe to wipe around the foreskin that was covering the head of the penis, without pulling the foreskin back to clean the head of the penis. V7 then used a clean wipe to wipe down the catheter tubing. When asked if that was the way she would normally clean the penis, V7 didn't respond. When asked if she should have pulled the foreskin back and cleaned the head of the penis, V7 stated she should have done that. V7 then pulled the foreskin back and cleaned the head of the penis with a clean wipe. The facility Hand Hygiene policy dated 2022 documents, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility Additional Considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves The facility Catheter Care policy dated 2021 documents, Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Policy explanation: 1. Catheter care will be performed every shift and as needed by nursing personnel Male: 14. Gently grasp penis, draw foreskin back if applicable. 15. Using circular motion, cleanse the meatus with a clean cloth moistened with water and perineal cleaner (soap)/non-rinse cleansing cloth. 16. With a new cloth, starting at the urinary meatus moving down, cleanse the shaft of the penis. 17. With a new cloth, starting at the urinary meatus moving outward, wipe the catheter making sure to hold the catheter in place so as not to pull on the catheter. 18. Dry area with towel FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145880 If continuation sheet Page 6 of 6