Inspection·June 13, 2025

F 0692 On 6/12/25 at 8:40am, V9 was observed to have her glass of milk poured over her fruit loops. Level of Harm - Minimal harm or potential for actual harm On 6/13/25 at 8:28am, V2 (DON/Director of Nurses) said it was her expectation that R9's milk not be poured on her cereal because you wouldn't really know how much she drank and that the supplements be given as they should. V12 also said it is her expectation that residents be given the supplements as ordered. Residents Affected - Few On 6/12/25 at 2:00pm, V12 (Dietary Aide) said they get orders for supplements from the dietary manager but they currently do not have one. V12 said that V2 tells them of new orders. V12 said that supercereal and milk is given at breakfast, pudding and ice cream is usually at lunch. V12 said it was probably okay to pour the milk over the cereal and that they currently have no one on whole milk. On 6/13/25 at 8:35am, V13 (CNA/Certified Nurse Assistant) said that before today, she always poured R9's milk on her cereal and R9 didn't drink the milk left in the bowl. On 6/13/25 at 9:45am, V14 (RD/Registered Dietician) said that R9 had a significant weight loss of 10.8% over 3 months. V14 said she would expect that R9 get her fortified pudding at lunch. V13 also said technically by the order she did get the whole milk at breakfast. V13 then said she would have staff give her 2- 4 oz (ounce) cups of milk, 1 for the cereal and 1 to drink. Facility document labeled Food and Nutrition Services (revised October 2017) notes that meals and/or nutritional supplements will be provided within 45 minutes of either resident request or scheduled meal time, and in accordance with the Resident's medication requirements. 2. R144's admission record documents she was admitted to the facility on [DATE]. The same admission Record lists some of R144's diagnoses as ventricular tachycardia, long term use of anticoagulants, Type 2 Diabetes Mellitus without complications, malignant neoplasm of unspecified site of left female breast. R144's Physician's Order Summary document on 5/30/25 an order for 1800 ml (milliliter) Fluid Restriction-Dietary 360 ml per meal, Nursing 630 ml a day. R144's diet card documents an 1800 ml/24hr Fld (Fluid) Restriction for each meal. R144's care plan document initiated 6/2/25 that R144 is at risk for fluid imbalance/weight fluctuations R/T CHF(Congestive Heart Failure) , 1800ml/24hr Fld Restriction, recent hospitalization after fall at home, Weakness, Decreased Mobility, Decline in ADLs Self Performance Abilities, Previous R) Rotator Cuff Injury. Some of the interventions listed are, Diet as ordered per physician's order, 1800ml/24hf Fld Restriction. (Date Initiated: 06/02/2025), Encourage oral intake (Date Initiated: 06/02/2025), Establish food preference. An undated cup list provided by the facility documents: juice cup: 4oz/120cc, water cup: 8oz/240cc, coffee cup: 8oz/240cc, milk cup: 12oz/360cc, sweet tea cup: 12oz/360cc, unsweet tea cup: 12oz/360cc. On 6/12/25 at 12:15pm, R144 was observed to have a glass of tea, small glass of water, cup of milk with only about 1/4 left in cup. According to the cup list provided R144 was given 960cc of liquids. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145880 If continuation sheet Page 2 of 5 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 06/13/2025 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 0692 Level of Harm - Minimal harm or potential for actual harm On 6/12/25 at 12:15pm, R144 who was alert to person, place and time said she just does not drink the extra fluids they give her. On 6/13/25 at 8:10am, R144 was observed to have cup of coffee, glass of milk and small cup of juice. According to the cup list provided R144 was given 720 cc of liquids. Residents Affected - Few On 6/12/25 at 1:30pm, V3 (Cook) said she didn't know anything about the fluid restrictions and does not know if anyone is on one. On 6/13/25 at 8:28am, V2 (DON) said that R144 is on a fluid restriction and she told dietary the amount R144 gets with meals. V2 said her expectation would be that residents get there fluid restrictions as ordered. V2 also said she does random checks to make sure residents are getting them. On 6/13/25 at 9:45am, V14 (RD) said the order in the chart does not specify the amount for dietary. After informing V14 that the order was in there yesterday, she said that she got the order changed last night and she is going to calculate the amount for dietary and nursing. V14 also said she is going to speak with R144 to get her preferences and set up the restriction on that. V14 said she also will inservice the dietary staff on fluid restrictions. Document labeled Encouraging and Restricting Fluids (Revised October 2010) document the The purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. This may include encouraging or restricting fluid. The same document also notes Follow specific instructions concerning fluid intake or restrictions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145880 If continuation sheet Page 3 of 5 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 06/13/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to dispose of vials of multi dose medications after open date had expired for greater than 30 days. This has the potential to affect all 39 residents living in the facility. Findings include: R21's admission Record documents admission date of [DATE], and includes diagnoses of Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Hypo magnesium, Left Hip Prosthesis, and Thiamine Deficiency. R21's MDS (Minimum Data Set) dated for [DATE] documents a BIMS (Brief Interview for Mental Status) score of 15 indicating R21 is cognitively intact. R21's Care plan documents R21 has Diabetes Mellitus with goal of R21 will have no complications related to diabetes through review date (no date documented). Interventions include monitoring hyperglycemia, hypoglycemia and educate regarding medications and importance of compliance. R21's Physician current order sheet contains orders for Trulicity 0.75mg/0.5ml subcutaneous every Friday for Diabetes Mellitus, Novolin Flex Pen for sliding scale accu checks for Diabetes Mellitus, and Lantus 15 units twice a day for Diabetes Mellitus. On [DATE] at 12:30PM, V2 DON (Director of Nursing) and V6 LPN (Licensed Practical Nurse) were present for the inspection of the medication room. During the inspection of medications in the refrigerator, there was a vial of Lantus Insulin with R21's listed on it with an open date of [DATE]. The open date was validated by V2 and V6. Also, at that time there was a vial of Tubersol, Facility Stock with open date of [DATE]. On [DATE] at 1:15PM, V2 was asked how long they use a refrigerated vial of medication after the marked open date, V2 stated no longer that 30 days. V2 stated she expects staff to discard the medication after the 30 days and not use the medication. V2 stated the Tubersol is used for all new staff, all new admissions, if physician orders one or a resident has symptoms, and those are 2 step TB (Tuberculosis) screens. On [DATE] at 3:40PM, V10 RN (Registered Nurse) stated when a new vial (multidose) is opened the date of which it was opened must be put on the bottle. The medication is only safe to use for either 28 or 30 days, according to medications. V10 stated then the bottle must be discarded to avoid being used and medication must be replaced if needed. V10 stated she would not use a medication that had been opened for more than the days allowed. On [DATE] at 3:45PM, V6 LPN (Licensed Practical Nurse) stated she marks the vials with a sharpie with the date when she opens the bottles. V6 stated the reason for dating the bottles is to let everyone know when the bottle was opened and not to use after either 28 or 30 days. On [DATE] at 8:10AM, V11 LPN stated when she opens a new multidose vial of medication she always dates the bottle. The reason she dates the bottle is because some medications are only good for 28-30 days after the vial has been opened. V11 stated they have a list to go by on the safe length of use of the medication after the bottle has been opened. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145880 If continuation sheet Page 4 of 5 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 06/13/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On [DATE] at 8: 15AM, V5 RN (Registered Nurse) stated all multidose vials are dated with the date the bottle was opened. V5 stated the purpose of dating the bottles is because the medication in the vials is only good for 30 days (most meds) to be used. V5 stated after the allotted time the vial should be discarded and replaced with a new vial if it is necessary. Document titled Insulin Expiration Date, was provided by V2, which is kept in the medication room as a reference for the medication nurses. The document reads Lantus Vial & Solostar Pen, 28-day expiration date after opening or removing from refrigerator, whichever comes first. On the Tubersol package insert under Storage documents A vial of TUBERSOL which has been entered and in use for 30 days should be discarded. The Department of Health and Human Services Center for Medicare and Medicaid Services form CMS-20089, dated 2/2017, documents multi-dose vials which have ben opened or accessed (e.g. needle-punctured) should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. Policy titled Storage of Medications #4 stated The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Revision date of [DATE]. Long Term Care Facility application for Medicare and Medicaid (CMS-671) signed and dated [DATE] documents a total of 39 residents residing in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145880 If continuation sheet Page 5 of 5