Health inspection·March 23, 2023

F 0690 Level of Harm - Minimal harm or potential for actual harm skin condition. The same policy and procedure showed in-part under female resident, b. Wash perineal area, wiping from front to back. (1) Separate labia and wash area downward from front to back. (2) Continue to wash the perineum moving from inside outward to the thighs. Rinse perineum thoroughly in same direction, using fresh water and clean washcloth . e) Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. Residents Affected - Some 4. R119 has multiple diagnoses which includes type 2 diabetes mellitus, obstructive and reflux uropathy, retention of urine, hydronephrosis, hydroureter and cyst of kidney, based on the face sheet. R119's annual MDS dated [DATE], shows that the resident is severely impaired with cognition. The MDS showed that R119 required extensive assistance from the staff with most of her ADLs including toilet use (how resident manages her catheter). The same MDS showed that R119 had indwelling urinary catheter. On March 20, 2023, at 11:35 AM, R119 was sitting in her wheelchair inside her room with her daughter at the bedside. R119 had indwelling urethral catheter draining to moderated amount of yellow urine. R119's urinary catheter tubing had white sediments and her urinary catheter bag which was placed under her wheelchair was touching the floor. On March 22, 2023, at 8:40 AM, V2 (Director of Nursing) stated that the urinary catheter drainage bag should be contained inside a privacy bag. V2 added that the urinary catheter drainage bag should not touch the floor to prevent potential infection and to ensure no pathogens from the floor could contaminate the catheter drainage bag and catheter tubing. The facility's policy and procedure regarding urinary catheter care last reviewed by the facility on January 20, 2023, showed, It is the policy of [Nursing facility] to prevent catheter-associated urinary tract infections. The same policy and procedure under infection control showed in-part, 2. Maintain clean techniques when handling or manipulating the catheter, tubing, or drainage bag. b. Be sure that catheter tubing and drainage bag are kept off the floor. Based on observation, interview, and record review, the facility failed to provide incontinence care in a manner that would prevent potential urinary tract infection (UTI). The facility also failed to ensure that the indwelling catheter drainage bag was not touching the floor. This applies to 4 of 4 residents (R42, R101, R119, R134) reviewed for incontinence and urinary catheter care in the sample of 27 residents. The findings include: 1. On 3/21/23 at 3:41 PM, V13 and V14 (Both Certified Nursing Assistants/CNA) rendered incontinence care to R42 who was wet with urine and had a bowel movement. There was redness in the abdominal folds and excoriation to front and back of the peri-area, and groins. V13 wiped R42 from the abdominal folds down to mid perineum, then she proceeded to clean the back perineum. V13 did not separate the labial folds to clean the inner area and she did not wipe the groins. 2. On 3/21/23 at 4:19 PM, V13 and V14 provided peri-care to R134 who has an indwelling urinary catheter. R134 also had small bowel movement. V13 cleaned the tip and anterior part of R134's shaft, pubic area, groins, and back perineum. V13 changed her gloves without hand hygiene and proceeded to apply clean incontinence brief. However, V13 did not clean the posterior part of the penile shaft, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145892 If continuation sheet Page 2 of 10 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 145892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Hill Nursing Home of Will County 421 Doris Avenue Joliet, IL 60433 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 - Some scrotal area, and the catheter tube. V13 was about to close the brief and stated that she is finished with the care. State representative prompted staff to completely clean the frontal peri-area and the catheter tubing. On 3/22/23 at 12:51 PM, V2 (Director of Nursing/DON) stated that when providing incontinence care the staff must clean all the areas that has been soiled by urine and feces. This includes the whole peri-are and groins. If the resident is female, the staff must separate the labia and clean the inner folds. For the male, with catheter, the staff must clean the whole penile shaft including the tip, the scrotal area, and the catheter tube because it's going inside the shaft. This is to prevent infection from the contamination, so they must clean the whole area thoroughly. R42's and R134's most recent Minimum Data Set (MDS) shows that both residents require extensive assistance for toileting and hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145892 If continuation sheet Page 3 of 10 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 145892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Hill Nursing Home of Will County 421 Doris Avenue Joliet, IL 60433 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to flush a resident's gastrostomy tube when disconnecting an enteral feeding. This applies to 1 of 3 residents (R28) reviewed for tube feeding in the sample of 27. The findings include: R28's EMR (Electronic Medical Record) showed R28 was admitted to the facility on [DATE], with multiple diagnoses including hereditary ataxia, dysphagia, dementia, chronic kidney disease, and paralytic syndrome. R28's MDS (Minimum Data Set) dated December 29, 2023, showed R28 had severe cognitive impairment. R28's Order Summary Report dated March 22, 2023, showed an order for [Tube feeding], give 55 milliliters an hour via G-tube (gastrostomy tube) one time a day related to gastrostomy tube. Off at 12 noon. On March 21, 2023, at 3:39 PM, V15 (LPN/Licensed Practical Nurse) entered R28's room and said R28's tube feeding had been off since noon. V15 stated she was unsure why the tube feeding was still connected to R28's gastrostomy tube since it had not been running. V15 disconnected R28's tube feeding from R28's gastrostomy tube and left R28's room. V15 was not wearing gloves while disconnecting the tube feeding, and V15 did not flush R28's gastrostomy tube after disconnecting the tube feeding. On March 22, 2023, at 2:01 PM, V2 (DON/Director of Nursing) stated during gastrostomy care, the nurse should be wearing gloves. V2 continued to say the gastrostomy tube should be flushed with 15 to 30 milliliters of water. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145892 If continuation sheet Page 4 of 10 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 145892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Hill Nursing Home of Will County 421 Doris Avenue Joliet, IL 60433 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 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review the facility failed to ensure that narcotic medication administered to residents was recorded according to the facility's-controlled substances policy. Residents Affected - Few This applies to 2 of 2 residents (R294, R295) reviewed for medication storage in the sample of 27. The findings include: On March 22, 2023, at 10:20 AM, during review of the unit medication cart with V16 (Licensed Practical Nurse) the narcotics logbook was reviewed. When V16 was asked if she had administered any narcotics (controlled substances) on her shift that day, V16 reported she administered hydrocodone to R295 at 7:52 AM, and hydromorphone to R294 at 7:22 AM. The facility's Controlled Drug Receipt/Record/Disposition Form for these respective residents was reviewed, and it was noted that neither of these narcotic medications was recorded as administered to R294 and R295. When asked about this lack of documentation of the narcotic medications, V16 confirmed that she had not documented either dose when administered to the above-mentioned residents. V16 added that it was her usual practice to go back later in the shift and sign them (narcotics) out in the book. V6 (Assistant Director of Nursing for Risk Management) was available on the unit during this review and was asked about the facility's process of documentation of narcotics administration. V6 stated it was her expectation that the nurse sign on the paper sheet (in the Narcotic Logbook) when the medication is given, as well as the amount (of doses) remaining. V6 stated this is according to the facility's policy for narcotics administration. The facility's policy, Controlled Substances, dated January 20, 2023, documented: It is the policy of (the facility) to comply with federal and state requirements for storage and handling of controlled substance, and 10. While a CII controlled drug is in use, the nursing staff will maintain the following medication records: a. Record each dose at the time of administration b. Record date c. Record time d. Signature (includes minimum of first initial & last name and title) of nurse e. Document the number of doses remaining FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145892 If continuation sheet Page 5 of 10 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 145892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Hill Nursing Home of Will County 421 Doris Avenue Joliet, IL 60433 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 puree food was prepared to a smooth consistency for the dinner meal. Residents Affected - Some This applies to all the 11 residents (R5, R7, R12, R16, R19, R24, R55, R60, R92, R98, R119) who are receiving pureed diet in the facility in the sample of 27. The findings include: On 3/20/23 at 2:00 PM, V9 (Cook) pureed food for dinner time. V9 stated she's making pureed Philly Steaks for 12 servings. V9 placed 24 oz of beef, 3 cups of liquid (Meat Broth), 1 cup of thickener and 1 cup of shredded cheese in the blender. V9 pureed all these ingredients together. After pureeing the beef (Philly Steak), the state representative tasted it, the consistency was not smooth, it was grainy. State representative brought this to the attention of V9. She (V9) did not taste it and responded by saying that she will place the pureed beef in the oven which would soften it up more. V9 proceeded to put it in the container trays and covered it with plastic wrap and foil without tasting it. On 3/20/23 at 4:38 PM, V17 (Dietary Aid) was in the unit (1st Avenue) setting up the food for dinner at the steam table. The pureed beef remained very grainy. On 3/20/23 at 5:00 PM, V7 (Director of Food and Nutrition/Registered Dietitian) and V8 (Dietary Manager) tasted the pureed beef which was about to be sent to the unit. Both stated that the beef was not smooth and confirmed that it was grainy. On 3/21/23 11:05 AM, V7 stated that the pureed food is supposed to be smooth and creamy, pudding-like or baby-food like. Facility presented the list of their residents who receive pureed diet, there were 11 residents (R5, R7, R12, R16, R19, R24, R55, R60, R92, R98, R119). Facility's Policy/Procedure regarding Pureed (National Dysphagia Diet Level 1 Pureed) dated 2021 indicates: Distinguishing Features: The dysphagia pureed diet is the least advanced of the texture modified diets. It provides food that are pureed, homogenous and cohesive. The food should be semi-solid smooth consistency. No chewing or bolus formation is required. All foods must be pureed or be naturally pudding-like. Foods commonly avoided are those with coarse textures and difficult to puree to a pudding-like consistency. This diet is a transition to the dysphagia mechanically altered diet. Purpose: The dysphagia pureed diet is designed to optimized nutritional intake and facilitate swallowing for individuals with oral and/or pharyngeal dysphagia. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145892 If continuation sheet Page 6 of 10 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 145892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Hill Nursing Home of Will County 421 Doris Avenue Joliet, IL 60433 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 2. R101 has multiple diagnoses which includes generalized muscle weakness, stage 3 chronic kidney disease and history of MRSA (Methicillin Resistant Staphylococcus Aureus), based on the face sheet. Residents Affected - Few R101's admission MDS (minimum data set) dated January 5, 2023, shows that the resident is cognitively intact. The MDS showed that R101 required extensive assistance from the staff with most of her ADLs (activities of daily living) including toilet use and personal hygiene. The same MDS shows that R101 is always incontinent of bladder function. On March 21, 2023, at 1:07 AM, R101 was transferred to bed from the wheelchair. R101's wheelchair cushion was visibly wet when the resident was transferred. V3 (CNA/Certified Nursing Assistant) provided bladder incontinence care to R101 with the assistance of V4 (CNA). When V3 and V4 removed R101's disposable brief, the resident's brief was wet with urine. After wiping R101's front perineal area, V3 removed his gloves and without performing hand hygiene, V3 opened R101's bedside drawers looking for barrier/protectant cream, not finding the cream, V3 opened the resident's door to go out of the room to look for a barrier/protectant cream. When V3 returned to R101's room, that was the time that he went inside the resident's washroom to wash his hands. During this time, V4 was able to find the available barrier cream on top of R101's drawer. After V3 washed his hands, he put on a new pair of gloves and with the assistance of V4, V3 turned R101 on her right side, applied a new disposable brief under the resident, then V3 applied the barrier/protectant cream to R101's sacral/coccyx and buttocks without cleaning the mentioned back side of the resident. After applying the barrier cream, using the same gloves, V3 fastened the right side of the disposable brief while V4 fastened the left side, V3 assisted with putting on a new pair of pants to R101, assisted with repositioning R101 in bed and then used the bed remote to adjust R101's bed, while still using the same gloves that he used to apply the barrier cream. After R101's incontinence care the wound care team proceeded to provide treatments to R101's wounds and when it was completed, R101 was transferred back to her wheelchair by V3 and V12 (wound care Nurse). R101 used the same wheelchair cushion that was earlier observed to be wet with urine, without it being cleaned/disinfected. On March 22, 2023, at 8:45 AM, V2 (Director of Nursing) stated that after V3 provided incontinence care to R101's front perineal area and removed his gloves, V3 should perform hand hygiene such as handwashing or use of alcohol rub before opening the resident's drawers and touching the doorknob. According to V2, after V3 applied the barrier cream to R101's sacral/coccyx and buttock areas, V3 should remove his gloves, perform hygiene such as hand washing/use of alcohol rub and then put on a new pair of gloves, before touching/fastening the clean disposable brief, before putting on the clean pair of pants to R101, before repositioning R101 in bed and before touching any of the resident's equipment to prevent cross contamination, especially since V3 did not clean R101's sacral/coccyx and buttock areas before application of the barrier cream. During the same interview, V2 stated that to prevent cross contamination, the staff should have cleaned and disinfected R101's wheelchair cushion before putting the resident in the wheelchair because it was visibly wet with urine when the resident was transferred to bed. The facility's policy and procedure regarding handwashing last reviewed by the facility on January 20, 2023, showed, It is the policy of [Nursing facility] to ensure that the proper handwashing technique is used for the prevention and transmission of infectious diseases and is the cornerstone of all infection control practices. The same policy and procedure showed in-part under procedures, 6. Use an alcohol-based hand rub containing 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . h. Before moving from a contaminated body site (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145892 If continuation sheet Page 7 of 10 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 145892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Hill Nursing Home of Will County 421 Doris Avenue Joliet, IL 60433 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 - Few to a clean body site during resident care; . j. After contact with blood or bodily fluids; k. After handling used dressings, contaminated equipment, etc.; . m. After removing gloves. The facility's policy and procedure regarding infection control - gloves showed, It is the policy of [Nursing facility] for staff to use gloves for maintaining health and for monitoring infection control. The same policy and procedure under glove use and the need for hand hygiene showed in-part, When an indication for hand hygiene follows a contact that has required gloves, hand rubbing, or hand washing should occur after removing gloves. When an indication for hand hygiene applies while the health-care worker is wearing gloves, then gloves should be removed to perform hand rubbing or handwashing. Based on observation, interview, and record review, the facility failed to follow standard infection control practices with regards to changing of gloves and hand hygiene during provisions of care. This applies to 2 of 27 residents (R101, R134) reviewed for infection control in the sample of 27 residents. The findings include: 1. On 3/21/23 at 4:19 PM, V13 and V14 (both Certified Nursing Assistants/ CNAs) provided peri-care to R134 who had an indwelling urinary catheter. R134 also had small bowel movement. V13 cleaned the resident from front to back. V13 then changed her gloves and without performing hand hygiene V13 applied clean incontinence brief and repositioned R134. On /22/23 at 1:04 PM, V2 (Director of Nursing/DON) stated that when staff are providing incontinence care to residents the staff must perform hand hygiene before and after care. They should also remove gloves and do hand hygiene before they proceed to another task. This is to prevent cross contamination and spread of infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145892 If continuation sheet Page 8 of 10 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 145892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Hill Nursing Home of Will County 421 Doris Avenue Joliet, IL 60433 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 residents the pneumococcal vaccine. Residents Affected - Few This applies to 3 of 6 residents (R15, R8, and R81) reviewed for immunizations in the sample of 27. The findings include: The EMR (Electronic Medical Record) showed R15 was admitted to the facility on [DATE]. Facility documentation showed R15 received the PCV13 (13-valent pneumococcal conjugate vaccine) on November 21, 2018. On March 22, 2023, at 12:16 PM, V10 (IP/Infection Preventionist Nurse) stated [R15] has not been offered the PPSV23 (23-valent pneumococcal polysaccharide vaccine) because it has not been five years since his last pneumococcal vaccine. On March 22, 2023, at 1:33 PM, V2 (DON/Director of Nursing) stated the facility follows the CDC (Centers for Disease Control and Prevention) guidelines for the timing of pneumococcal vaccines. The facility does not have documentation to show R15 was offered or administered a second pneumococcal vaccine. 2. The EMR showed R8 was admitted to the facility on [DATE]. Facility documentation showed R8 had not received a pneumococcal vaccine. The facility does not have documentation to show R8 was offered a pneumococcal vaccine since 2021. On March 22, 2023, at 12:16 PM, V10 stated the facility offers the pneumococcal vaccine to residents yearly. 3. The EMR showed R81 was admitted to the facility on [DATE]. Facility documentation showed R81 received the PCV13 on October 31, 2016. On March 22, 2023, at 12:16 PM, V10 stated R81 had not been offered the PPSV23 vaccine prior to March 2023. The facility does not have documentation to show R81 was offered or administered a second pneumococcal vaccine prior to March 2023. The Pneumococcal Vaccine Timing for Adults on the cdc.gov website, dated April 1, 2022, showed CDC recommends pneumococcal vaccination for adults [AGE] years old and older. Adults 65 years or older with an immunocompromising condition, cerebrospinal fluid leak, or cochlear implant, CDC recommends one dose of PPSV23 at age [AGE] years or older. Administer a single dose of PPSV23 at least one year after PCV13 was received. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145892 If continuation sheet Page 9 of 10 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 145892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Hill Nursing Home of Will County 421 Doris Avenue Joliet, IL 60433 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The facility policy titled, PNEUMOCOCCAL VACCINATION - RESIDENT, dated January 20, 2023, showed, Policy: It is the policy of [the facility] to assure that residents are provided with the opportunity and encouraged to receive the pneumococcal vaccination and that the pneumococcal vaccine is given to all new unvaccinated residents with a physician order and resident consent. Procedure: . 10. For existing residents, who initially decline vaccination, the pneumococcal vaccination will be reoffered to residents on an annual basis . Event ID: Facility ID: 145892 If continuation sheet Page 10 of 10