Inspection·January 31, 2025

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The facility's policy titled, Bed Hold Policy last reviewed 1/21/25 states, Policy: It is the policy of Sunny Hill Nursing Home of Will County to inform residents and/or resident representatives in writing of the bed-hold and return policy prior to transfers and therapeutic leaves .Interpretation and Implementation: .3. Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail: .d. The details of the transfer (per the notice of the transfer) .3. R20's Face Sheet showed R20 was admitted to the facility on [DATE]. R20 had multiple diagnoses which included atherosclerotic heart disease, diabetes, dementia, hypertension, chronic kidney disease, and hemiplegia/hemiparesis. R20's MDS dated [DATE] showed R20 had severe cognitive impairment. R20's progress notes showed the following: 08/28/24 at 5:25 PM Doctor in to see residents and ordered to go to (Hospital) for blood in his urine. 08/28/24 at 6:17 PM Resident left with Ambulance, paperwork given and report. 08/29/24 2:42 AM Called emergency room and resident is admitted with dx (diagnosis) hematuria. 09/10/24 at 1:07 PM Resident came on stretcher by Ambulance from (Hospital). Wife updated on residents return. 09/12/24 6:10 PM Called attention per caregiver, resident observed CVC (CVC/Central Venous Catheter) line in resident's hand. No bleeding noted. Call to on call and ordered to send resident to ER (ER/Emergency Room) for CVC line replacement. 09/12/24 at 6:40 PM Ambulance here, took resident to (Hospital) ER. 09/13/24 at 12:56 AM 1230 AM resident came back from (Hospital) ER for s/p PICC (PICC/Peripheral Inserted Central Catheter) line placement transported by a stretcher with two paramedics. The electronic medical record showed no documentation of written notice of reason for transfer or discharge to the hospital given to the resident's representative. The facility was unable to provide written documentation given to the resident's representative. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145892 If continuation sheet Page 2 of 14 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 01/31/2025 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 0625 Level of Harm - Minimal harm or potential for actual harm Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on interview and record review, the facility failed to provide written bed hold policy to resident and/or their representative prior to the resident transfer to the hospital. Residents Affected - Few This applies to 1 resident (R103) reviewed for hospital transfers in a sample of 30. The findings include: R103's Face sheet shows an initial admission date of 8/27/2020. R103's Incident Note dated 10/11/24 at 13:15 shows R103 had an unwitnessed fall. R103's Health Status Note dated 10/11/24 at 14:25 shows R103 was transferred to the hospital. R103's Health Status Note dated 10/11/24 at 18:28 shows R103 was admitted to the hospital with hyponatremia. There is no documentation of bed hold notice being provided to resident or resident representative prior to transfer to the hospital. On 1/30/25 at 11:52 AM, V10 (Assistant Administrator) stated the facility did not send the bed hold notice to R103's family for her 10/11/24 hospital transfer. The facility's policy titled, Bed Hold Policy last reviewed 1/21/25 states, Policy: It is the policy of Sunny Hill Nursing Home of Will County to inform residents and/or resident representatives in writing of the bed-hold and return policy prior to transfers and therapeutic leaves .Interpretation and Implementation: .3. Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail: a. The rights and limitations of the resident regarding bed-holds; b. The reserve bed payment policy as indicated by the state plan (Medicaid residents); c. The facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond the state bed-hold period (Medicaid residents); and d. The details of the transfer (per the notice of the transfer) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145892 If continuation sheet Page 3 of 14 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 01/31/2025 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 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 observations, interviews, and record reviews, the facility failed to implement services to prevent further decline in range of motion and contractures for R59. This applies to 1 of 1 resident (R59) reviewed for restorative nursing in a sample of 30. The findings include: R59 is an [AGE] year-old female with severe cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. On 01/28/25 at 10:38 AM with V15 (Charge Nurse) R59 was noted with a right-hand contracture with no palm protector in place to prevent contraction. V15 stated that the palm protector should be on R59's right hand. V15 then added that she would put a towel roll in the hand and notify the therapist to get a palm protector. On 1/30/25 at 9:31 AM, V2 (Director of Nursing/DON) stated that the staff should have applied a palm protector to R59's right hand to prevent deterioration with her palm contraction. A review of the ADL self-care deficit care plan document interventions including: Apply palm protector to right hand if resident permits, may remove for hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145892 If continuation sheet Page 4 of 14 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 01/31/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow fall interventions for residents who were high risk for falls. This applies to 4 of 5 residents (R99, R51, R107, R24,) reviewed for accidents and supervision in a sample of 30. The findings include: 1. On January 28, 2025, at 11:56 AM, R99 had a falling star sign outside her room door. At 1:19 PM, R99 was in bed, and she had one thick fall mat on the ground on the right side of her bed. R99 did not have a call light on the left side of the bed. On January 29, 2025, at 3:12 PM, R99 was lying in bed and her adaptive call light was on the side table, out of reach. R99 only had one thick fall mat on the right side of the bed and nothing on the left side of the bed. R99's face sheet showed she was admitted to the facility with parkinson's disease, dementia, contracture on the left wrist and left hand, cognitive communication deficit, and adult failure to thrive. R99's MDS (Minimum Data Set) dated November 20, 2024, showed R99 had moderate cognitive impairment. R99's care plan showed she was high risk for falls related to Parkinson's, history of falls. February 26, 2023, found lying on the floor, no injury. R99's interventions included to Be sure my call light is within reach and encourage me to use it for assistance as needed. Floor mattress to the right side of the bed. I have a red star outside my bedroom door to alert staff to my high fall risk. 2. On January 28, 2025, at 10:31 AM, R51's room door did not have a falling star sign outside her room door, but her room had one fall mat folded and placed against the wall. On January 29, 2025, at 2:16 PM, R51 was lying in bed. R51 did not appear alert or oriented and was talking to herself. R51 had a fall mat on the right side of her bed. R51's bed was not pushed against the wall on either side. R51's face sheet showed she was admitted to the facility with diagnoses including alzheimer's disease, restlessness and agitation, dementia, anxiety disorder, and contractures of the right knee and left knee. R51's MDS dated [DATE], showed R51 had severe cognitive impairment. R51's care plan showed R51 was high risk for falls related to dementia, diabetes mellitus, hypertension, and history of falls. R51's interventions included I have the right side of my bed against the wall. 3. On January 29, 2025, at 11 AM, R107 was lying in bed. R107's fall mats were folded and placed against the wall. R107's bed was in a high position, and neither side of the bed was against the wall. R107's face sheet showed she was admitted to the facility with diagnoses including dementia and history of falling. R107's MDS dated [DATE], showed R107 had severe cognitive impairment. R107's care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145892 If continuation sheet Page 5 of 14 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 01/31/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm plan showed R107 was high risk for falls related to gait/balance problems, incontinence, psychoactive drug use, history of falls, dementia, history of self-transfers despite safety educations. R107 had falls on February 7, 2021, March 22, 2021, April 23, 2021, March 28, 2021, May 8, 2021, June 5, 2021. R107's interventions include I have a floor mat next to both sides of my bed when I am in bed. I have a red star outside my bedroom door to alert staff to my high fall risk. Residents Affected - Some 4. On January 28, 2025, at 10:23 AM, R24 had a falling star sign outside her room door. On January 29, 2025, at 2:13 PM, R24 was lying in bed, and she had one thick fall mat on the right side of the bed and no pad or mattress on the left side of the bed. R24's face sheet showed she was admitted to the facility with diagnoses including cognitive communication deficit, dementia, seizures, osteoarthritis, and personal history of traumatic brain injury. R24's MDS dated [DATE], showed R24 had severe cognitive impairment. R24's care plan showed I am high risk for falls related to deconditioning, gait/balance problems, incontinence, vision/hearing problems, seizure disorder. I have been falling and last fall was few weeks ago. I tend to roll from my bed onto mattress next to my bed. I am incontinent. R24's interventions included I have a mattress to the left side of my bed and a floor mat to the right side. I have a red star outside my bedroom to alert staff to my high fall risk. On January 29, 2025, at 2:52 PM, V16 (Restorative CNA/Certified Nurse Assistant) stated the residents in the wing were all high risk for falls and it was indicated with the red falling star. V16 sad R51 must have fallen out of bed on the right side so they placed the mat on the right side. V16 stated R51 was not alert or oriented and was not able to get out of bed. V16 stated she used the mechanical lift to put R51 back into bed and then put the one fall mat in place. V16 stated R24 was a high fall risk resident as well. V16 stated she had a fall mattress because she must have fallen out of bed at some point, so only had one fall mat. On January 30, 2025, at 12:41 PM, V2 (DON/Director of Nursing) stated the fall mats are used for residents who have had repeated falls or get out of bed. V2 stated the call lights should be placed within the residents' reach. On January 30, 2025, at 1:07 PM, V23 (Restorative Nurse) stated the residents with one fall mat in the room should have the other side of their bed against the wall. V23 stated if the care plan showed the residents' bed should be against the wall, they should be placed against the wall. V23 stated R99 used to be in a semiprivate room and her bed was against the wall and that was why she only had the one fall mat, but now that she was alone, she should have two fall mats or the bed against the wall. V23 stated R99 could use the adaptive call light and it should be placed within reach. V23 stated R24 should have two fall mats in place. The facility's Fall Prevention and Management policy revised on December 6, 2023, showed All staff is responsible to review and follow all individualized resident care plan approaches and interventions. The Red star serves to alert all staff, including clinical (medical, nursing, restorative, dietary, social service, clerical, environmental services, activities, laundry, and maintenance) to observe the resident closely and to intervene if the resident shows unsafe behaviors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145892 If continuation sheet Page 6 of 14 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 01/31/2025 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 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 observations, interviews, and record reviews, the facility failed to follow its catheter care policy by not having the catheter tube secured and not using warm water and soap to provide catheter care. The facility also failed to use new catheter bags and leg bags instead of reusing them and to have a resident in bed with a leg bag instead of a standard drainage bag to prevent backflow. This applies to 5 of 5 residents (R19, R59, R69, R126, and R132) reviewed for catheter care in a sample of 30. The findings include: 1.R19 is an [AGE] year-old female with cognition intact as per the Minimum Data Set (MDS) dated [DATE]. On 1/28/25 at 1:50 PM, R19 was observed with an indwelling catheter with urine leaks and staining on the incontinent brief. On 1/28/25 at 1:57 PM, V6 (Certified Nursing Assistant/CNA) provided incontinent care to R19 and V6 stated that the indwelling catheter shouldn't be leaking. On 01/29/25 at 9:50 AM, V3 (Assistant Director of Nursing/ADON) stated, The indwelling catheter for R19 was changed at 4:08 AM today (1/29/25). The order says to change the indwelling catheter and tubing as needed. The CNA should have reported the indwelling catheter leak to the nurses so they could promptly change the catheter. The general guidelines on the facility presented urinary catheter care policy (reviewed on 12/13/23) document: 1. Follow the aseptic insertion of the urinary catheter and maintain a closed drainage system 2. If the aseptic technique breaks, disconnection, or leakage occurs, replace the catheter and collecting system using the aseptic technique and sterile equipment, as ordered. On 1/28/25 at 2:00 PM, V6 provided indwelling catheter care by using cleaning wipes to wipe down the labia, catheter insertion site, and catheter. R19 verbalized, Oh. My vaginal area is itching and burning. On 1/30/25 at 9:31 AM, V2 (Director of Nursing / DON) stated that the staff should have used soap and warm water to provide indwelling catheter care per our policy. A review of the facility presented Urinary Catheter Care policy reviewed on 12/13/23 document: For a female resident: Use a washcloth with warm water and soap to cleanse the labia. 2. R59 is an [AGE] year-old female with severe cognitive impairment as per the MDS dated [DATE]. On 01/28/25 at 10:38 AM, V15 (Charge Nurse) checked on R59, with an indwelling urinary catheter whose tubing was not secured. On 01/30/25 at 09:31 AM, V2 stated, The indwelling catheter tubing should be secured with a stat lock or tape. If the tubing is not secured, it can cause tension at the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145892 If continuation sheet Page 7 of 14 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 01/31/2025 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 insertion site. Level of Harm - Minimal harm or potential for actual harm A review of the facility presented Urinary Catheter Care policy document: Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site.3. On January 28, 2025 at 10:32 AM, R126 was lying in bed and stated she had a urinary catheter leg bag on, and they switch her to the urinary catheter bag after dinner and then again at 8 AM. R126's bathroom had a plastic bag in it and there was a urinary catheter bag inside of it. On January 29, 2025 at 10:51 AM, R126 was lying in bed on the left side. R126 stated she had her leg bag on, and the staff changed it this morning. R126's bathroom had the plastic bag and the urinary catheter bag was inside of it. Residents Affected - Some R126's face sheet showed she was admitted to the facility with diagnoses including neuromuscular dysfunction of bladder, personal history of other diseases of the female genital tract, and personal history of urinary tract infections. R126's POS showed an order to Change foley catheter every 8th of the month. R126's care plan showed I have an indwelling catheter due to neurogenic bladder with potential for complications, with interventions including, Change catheter (monthly) and (As Needed). 4. On January 28, 2025 at 1:01 PM, R69 stated she had a catheter and was wearing the leg bag. R69's bathroom had a plastic bag with another leg bag in it. R69's face sheet showed she was admitted to the facility with diagnoses including neuromuscular dysfunction of bladder, need for assistance with personal care, dementia, retention of urine, and encounter for fitting and adjustment of urinary device. R69's POS (Physician Order Sheet) showed an order showing to Change foley catheter every 30 days and for system failure leakage. Foley catheter change [As Needed] based on clinical indications such as infection, obstruction or when closed system is compromised. R69's care plan showed she was admitted with indwelling catheter related to urinary retention, potential risk for CAUTI (Catheter Associated Urinary Tract Infection) with interventions which showed to Change foley catheter monthly. 5. On January 28, 2025 at 1:20 PM, R132 stated he had a catheter and was wearing the leg bag. R132 stated he wore the urinary catheter bag at night before he went to bed and wore the leg bag during the day. R132's bathroom had a plastic bag with a urinary leg bag and a urinary catheter bag inside of it. R132's face sheet showed he was admitted with diagnoses including urinary tract infection, chronic kidney disease, obstructive and reflux uropathy, encounter for fitting and adjustment of urinary device. R132's care plan showed I have an indwelling foley catheter, with interventions to change foley drainage tubing and drainage bag (As Needed). On January 28, 2025 at 1:50 PM, V17 (CNA/Certified Nurse Assistant) showed the surveyor R132's plastic bag with the unused urinary catheter bags. V17 stated they detach the catheter bag and place it inside the plastic bag. V17 stated the plastic bags are changed every day. V17 stated the staff rinse the inside of the bag out. V17 stated they were told to use the bags for three to seven days. V17 stated she did not know how often they were supposed to replace the bag. On January 28, 2025 at 3:19 PM, V18 (CNA) stated the residents with catheters are switched from the urinary bag to the leg bag every day. V18 stated they clean both ends of the tubing with alcohol pads and put it in the bathroom in the plastic bag until it was ready to be used again. V18 stated the catheter bags were good for seven days, but she looks at the bag and would throw it away when it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145892 If continuation sheet Page 8 of 14 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 01/31/2025 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 was stained or soiled. Level of Harm - Minimal harm or potential for actual harm On January 30, 2025 at 12:41 PM, V2 (DON/Director of Nursing) stated they do not throw the catheter bags away. V2 stated they cap the end of the tubing to keep it a clean, closed system. V2 stated she had not looked at the packaging but if the package shows the bags were sterile and single use, they should follow the manufacturer guidelines. V2 also stated the residents should not be lying in bed if they have a leg bag on because it could cause the urine to go back into the resident. Residents Affected - Some On January 30, 2025 at 1:07 PM, V23 (Restorative Nurse) stated the catheter bags should probably not be reused. The facility's Catheter Care, Urinary policy reviewed on December 13, 2023 showed If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment, as ordered. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. The facility's Urinary Catheter bags and leg bags showed symbols indicating the bags were sterile, do not re-sterilize, and should not be reused. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145892 If continuation sheet Page 9 of 14 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 01/31/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Based on observation and interview the facility failed to label, store, and dispose of medications to facilitate a safe administration to residents. This applies to 2 of 2 residents (R41 and R114) reviewed for safe medication storage in a sample of 30. Findings include: 1. R41 diagnosis includes type 2 diabetes mellitus with unspecified diabetic retinopathy. R41's current physician's orders includes insulin Glargine inject 10 units subcutaneously at bedtime hold if blood sugar is less than 60. On 01/30/25 at 10:51 AM, the 1st Avenue medication cart was reviewed with V27 LPN (Licensed Practical Nurse). A vial of insulin Glargine had an opened-on date of 11/21/24 and an expiration date of 12/19/24. V27 stated she labels insulin with the manufacture's expiration date. She did not label the vial but know it should be thrown out in 28 days after opening. 2. R114 diagnoses includes type 2 diabetes mellitus with diabetic nephropathy. R114's current physician orders include insulin Aspart inject as per sliding scale subcutaneously before meals. On 01/30/25 at 11:14 AM, the 4th Avenue medication cart was reviewed with V37 LPN (Licensed Practical Nurse). A vial of insulin Aspart was opened on 12/29/24. No use by date was written on the vial. V37 LPN stated the insulin was probably good for 31 days. V37 stated the insulin is still on the current orders for R114. On 01/30/25 at 01:54 PM, V2 DON (Director of Nursing) stated she did not know how long insulins are good for after they have been opened. It's not my job to give insulin. The nurses should make sure they aren't administering outdate medications. On 01/30/25 at 05:22 PM, V34 Pharmacist stated insulins are good for 28 days after opening. Insulins degrade and are not as effective after 28 days. The facility policy Insulin Administration dated December 22, 2023, states check the expiration date, if drawing from an opened multi dose vial. If opening a new vial record the expiration date and time on the vial. The facility provided policy Storage of Medications dated November 2020 states certain medications or package types require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency. The facility did not provide a policy that has specific directions as to when to discard Glargine and Aspart insulins after they have been opened. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145892 If continuation sheet Page 10 of 14 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 01/31/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to properly label/date/store food items, remove expired items, and wear hair restraints in the facility kitchen. Residents Affected - Many This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 1/28/25 documents the total census was 142 residents. On 1/28/25 at 10:20 AM, V12 (Dietician/Dietary Manager) said there are 2 NPO (Nothing by Mouth) resident; all other residents eat from the facility kitchen. On 1/28/25 starting at 9:31 AM, the facility kitchen was toured in the presence of V12 (Dietician/Dietary Manager). For the duration of the kitchen tour, V12's hair restraint was not covering her bangs; therefore, her hair was not properly restrained. During the kitchen tour the following was found: In walk-in cooler: 1. An opened bag of shredded carrots with manufacturer use by date of 1/12/25 and a staff handwritten date in marker of 1/13/25. V13 (Cook) said 1/13/25 is the date the bag of carrots was opened and served to the residents. Carrots were served to residents after the expiration date. 2. 31 4-ounce fat free milks with expiration date 1/26/25, expired. 3. An opened bag of celery with milky liquid in the bottom and best by date of 1/14/25. 4. A large bag of pre-diced/cut potatoes with a use by date of 1/5/25. Expired. 5. 2 large trays of what V13 (Cook) said were smoked breakfast sausage with no label or date. 6. 2 large trays of biscuits with no label or date. On 1/28/25 at 10:06 AM, V14 (Dietary Aide) was seen preparing food with her hair restraint not covering her bangs; therefore, her hair was not properly restrained. On 1/28/25 at 10:26 AM, V13 (Cook) was seen preparing food with her hair restraint not covering her bangs; therefore, her hair was not properly restrained. On 1/30/25 at 11:10 AM, V12 (Dietician/Dietary Manager) stated all foods in the kitchen should be labeled and dated for food safety; so, the kitchen staff know when products are delivered and when they expire because the staff do not want to serve expired food and put the residents at risk for food borne illness. V12 stated expired foods should be removed from food storage by the expiration date because if they are kept in food storage past their expiration date, they may be served to the residents and cause sickness. V12 stated if there was milky looking liquid in the bottom of the celery, it should have been thrown away. V12 stated all staff working in the facility kitchen need to wear a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145892 If continuation sheet Page 11 of 14 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 01/31/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many hair restraint that is covering all the hair on their head. V12 stated all staff member's bangs need to be restrained under the hair net. The facility's policy titled, Labeling and Dating Foods revised 2017 states, Policy: To decrease the risk of food borne illness and to provide the highest quality, foods are labeled with the date received, the date opened and the date by which the item should be discarded .Refrigerated Food . Refrigerated Potentially Hazardous Food (PHF) or Time/Temperature Controlled for Safety (TCS) foods are labeled with the date received and if not opened, are discarded by the manufacturer's expiration date. If opened, the cold food item is labeled with the date opened and the date by which to discard or use by . The facility's policy titled, Hair Restraints/Jewelry/Nail Polish last reviewed 1/14/25 states, Policy: It is the policy of Sunny Hill Nursing Home that FNS employees shall wear hair restraints . Procedure: Hairnets will be worn at all times in the kitchen . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145892 If continuation sheet Page 12 of 14 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 01/31/2025 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R19 is an [AGE] year-old female with cognition intact as per the Minimum Data Set (MDS) dated [DATE]. Residents Affected - Few On 1/28/25 at 1:57 PM, V6 (Certified Nursing Assistant/CNA) provided incontinent care to R19. On 1/28/25 at 2:00 PM, V6 removed gloves after incontinent care, wore a new set of gloves without sanitizing hands, and proceeded with indwelling catheter care. On 1/28/25 at 2:05 PM, V6 stated that she should have performed hand hygiene between incontinent care and indwelling catheter care. On 1/30/25 at 9:31 AM, V2 (Director of Nursing / DON) stated that the staff should have sanitized her hands in between incontinent care and catheter care. A review of the facility's Hand-Washing Policy (reviewed on 12/20/23) document: Perform hand hygiene before applying non-sterile gloves. Based on observation, interview, and record review, the facility failed to follow infection control practices. This applies to 3 of 5 residents (R52, R451, R19) reviewed for infection control in a sample of 30. The findings include: 1. On January 29, 2025, at 2:11 PM, V16 (Restorative CNA/Certified Nurse Assistant) was in R52's room without wearing a mask. V16 took R52 to the bathroom. At 2:46 PM, V16 re-entered R52's room without a mask on, and assisted R52 out of the bathroom. On January 29, 2025, at 2:52 PM, V16 stated the facility had residents with flu and norovirus but was not aware if they had COVID-19. V16 stated she should have been wearing a mask. R52 was admitted to the facility with diagnoses including anxiety disorder, insomnia, hypertension, long term use of antibiotics, and history of falling. 2. On January 30, 2025, at 9:25 AM, R131 was sitting in the dining room and R131 stated he had COVID-19 and he had to stay in his room. R131 stated the staff told him he needed to wear a mask in the hallways. On January 30, 2025, at 9:31 AM, V19 (RN/Registered Nurse) stated R131 was positive on January 17, 2025, and his isolation ended on January 27, 2025. V19 stated the isolation for positive residents was ten days. V19 stated the facility policy was to only put positive residents with positive residents. V19 stated they should not put a negative resident with a positive resident. On January 30, 2025, at 9:43 AM, V21 (CNA) stated R131 had COVID-19 and had a new roommate for one day. V21 stated R131's roommate went to the hospital for chest pain. On January 30, 2025, at 12:41 PM, V2 (DON/Director of Nursing) stated R451 was not in the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145892 If continuation sheet Page 13 of 14 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 01/31/2025 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 for even 24 hours. V2 stated R451 did not have COVID-19. V2 stated R451 should not be placed in a room with a resident with COVID-19. V2 stated in the process of trying to get R451 admitted to the facility, they did not realize R131 was positive for COVID-19. On January 30, 2025, at 12:52 PM, V22 (Admissions and Marketing Coordinator) stated it was not appropriate for R451 to be admitted to a room with a COVID-19 positive resident. V22 stated she forgot to mark on her sheet that R131 was positive, and it was the last remaining male bed available. V22 stated she notified the family, and the family were upset and had made a complaint. On January 30, 2025, at 11:13 AM, V8 (Infection Preventionist) stated masks were mandatory in the building because they were in an outbreak status. V8 also stated whoever did the screening for admission should have asked the resident and family if they would be ok with admitting to a room with a COVID-19 positive roommate and should have given them a choice and let them decide for themselves. On January 30, 2025, at 1:52 PM, V1 (Administrator) stated R451 was admitted on [DATE], at 7 PM and then went out by ambulance on January 25, 2025, at 7:18 PM. V1 stated she had questioned her staff why R451 was admitted to the same room as R131, who was COVID-19 positive. V1 stated they did not have another bed to move him to. R451 was admitted to the facility on [DATE]. R451 was admitted to the same room as R131. R451's progress notes dated January 24, 2025, at 10:19 PM showed the following: At 7:18 PM, [resident] was admitted to room [Number] via stretcher transferred by 2 EMTs [Emergency Medical Team]. He's alert to person, place, time, and situation, pleasant and cooperative. [Diagnoses] Acute exacerbation of diastolic heart failure (fluid overload), Lupus, [Status Post] abdominal surgery (exploratory per res) [with] 14 staples in place and dehiscent areas. Dressing changed as ordered. R131's progress notes were reviewed and showed a note on January 16, 2025, at 11:43 AM, which documented the following: Resident is on contact and droplet isolation due to exposure to roommate positive with covid. On January 16, 2025, at 6:01 PM, a progress note showed the following, A nonproductive cough was observed this evening and a rapid COVID-19 test done and resulted (+). R451's face sheet showed she was admitted with diagnoses including chronic embolism, anxiety disorder, hypertension, congestive heart failure, and gastro-esophageal reflux disease. A Concern Investigation Form was filled out on January 25, 2025, at 10:49 AM, which showed the following, R451 expressed concern about admitting to a COVID positive room. The facility's Masking Policy reviewed on January 8, 2025, showed It is the policy of this facility to don (put on) a mask in accordance with Standard and Transmission-based Precautions. Masks may also be required or recommended for source control to reduce the spread of certain respiratory infections. Staff, visitors, and family will wear a mask to protect the nose and mouth. Masks are to be worn when caring for residents in Droplet Precautions or when designated by the Infection Preventionist. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145892 If continuation sheet Page 14 of 14