Inspection·December 5, 2024

F 0584 time someone cleaned her window sill. Level of Harm - Minimal harm or potential for actual harm 5. On 12/05/24 at 12:40PM, observed R12's bathroom which is adjoined to R3's room. Observed a sign on R12's bathroom door that states, Do not enter this area it's closed at this time Observed the bathroom with the 13 missing tiles from the floor and some water noted to floor. Window sill in R12's room had dirt and debris on it. Residents Affected - Some On 12/05/24 at 12:40PM, R12, who was alert to person, place, and time, stated he hasn't been able to use his bathroom for over 6 months. R12 said he knows the bathroom is missing tiles, and the toilet doesn't work. R12 said they told him they couldn't get the part to fix the bathroom. R12 said it was a hassle to have to go down the hall to use the bathroom. R12 stated sometimes the restroom down the hall gets busy, and you have to wait. R12 said they come in his room and clean it often, but doesn't think they clean his windows. On 12/05/24 at 12:30PM, V3 (Certified Nurse Assistant/CNA) stated R3's and R12's bathroom hasn't been working for several months. V3 said they did have a maintenance man who was working on the toilet, but he was having to use his own money to fix things, and then he quit, so the toilet didn't get fixed. V3 said the tiles around the toilet in that bathroom are all up, and R3 and R12 have to use the shower room bathroom when they have to use the restroom. On 12/05/24 at 12:32PM, V4 (CNA) stated R3's and R12's bathroom hasn't worked in over several months. V4 said the maintenance man that quit a week ago was working on some of the toilets, but quit, and didn't finish repairing them. V4 said the maintenance man was using his own money to repair some of the things at the facility. On 12/05/24 at 12:35PM, V5 (CNA) said R3's and R12's bathroom hasn't worked for several months. V5 said R3 and R12 use the shower room bathroom when they have to use the restroom. V5 said the maintenance man was working on the toilets and some of the repairs at the facility, but was having to use his own money because he didn't have a budget. V5 said the maintenance man quit about a week ago. On 12/05/24 at 1:00PM, V6 (Housekeeping) said she was the only housekeeper working today. V6 said they are supposed to have 2 housekeepers working every day. V6 said they didn't have no housekeeper yesterday and the laundry worker was trying to clean rooms and keep up with laundry. V6 said she usually cleans the window sills when she can, but she only works 2 days a week most of the time, and she has had to work by herself a lot, and she is just trying to get done what she can. On 12/05/24 at 1:30PM, V2 (Maintenance/Therapy Assistant) stated he has been helping do the maintenance for over 2 years at the facility. V2 said he was aware R3's and R12's bathroom wasn't working. V2 said he wasn't aware of any work order to repair the bathroom. V2 wasn't aware of any other bathrooms needing repair. V2 said he thought the last maintenance man that worked at the facility looked at R3's and R12's toilet, and it needed a metal flange or something, and he needed to replace it. V2 said he usually will pay for the parts and then get reimbursed for his expenses. V2 said he didn't know if there was anything being done to fix the toilet in R3's and R12's room or not. V2 was not aware R1's toilet was leaking in the front of the toilet, and the toilet was crooked and the wall was missing tiles. V2 said he also was not aware R2's toilet was not secure to the floor and moved. V2 said he was going to go look at all of those toilets and see what he could do to fix them. V2 said he usually does a quick round in the morning to see what needs to be fixed. V2 said usually QA (Quality Assurance) will do round in the morning and midday of the resident's rooms, and let him know what needs fixed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145903 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 145903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vandalia Healthcare & Senior Living 1500 West St Louis Avenue Vandalia, IL 62471 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 12/05/24 at 2:20PM, V1 (Director of Nursing/DON) said she didn't know R3's and R12's bathroom was out of order. V1 said since she started at the facility, which was in August, she has always observed R3 and R12 using the shower room on the hall to go to the restroom. V1 was aware of R1's toilet leaking and being cracked along with the tiles missing. V1 said they tried to get R1 to move to a different room until they got his bathroom fixed, but he refused to move. V1 said she didn't know R2's toilet was not secure to the floor. V1 said she knows they do have several toilets ordered in bulk to fix several of the toilets at the facility. V1 was not sure which toilets were being replaced. V1 said she will make sure all the toilets are checked in the facility and make sure they all get fixed. A undated policy titled Physical Plant and Environmental Policy and Guidelines documents under the policy statement It is of the utmost importance to provide a safe, hospitable, clean, and organized facility and ground to ensure an environment that is conducive to providing the best care, comfort and home-like surrounding for residents. The policy statement also states The building and grounds must be maintained in the best presentable state and must be done so through routine maintenance and upkeep, housekeeping, and ensuring compliance with current federal, state, local and NFPA (National Fire Protection Association) codes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145903 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 145903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vandalia Healthcare & Senior Living 1500 West St Louis Avenue Vandalia, IL 62471 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 interview, observation, and record review, the facility failed to maintain safe water temperatures for 14 of 14 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13 and R14) reviewed for water temperatures in a sample of 14. Findings include: On 12/5/24 at 8:54 AM, a digital metal stemmed thermometer used for taking temperatures for this survey was checked for accuracy using the ice-point method, and was accurate within +/_ 2 degrees Fahrenheit. 1. On 12/5/2024 at 9:12 AM, the hot water temperature taken with a calibrated digital metal stemmed thermometer was taken at the handsink of the shared bathroom of R1 and R10, and registered 120.2 degrees Fahrenheit. On 12/5/24 at 9:12 AM, R1 who was alert to person, place, and time, stated the maintenance man told him a week ago the bathroom water temp was 118. R1 then stated the water is hot, but that it has never burned him. 2. On 12/5/2024 at 9:16 AM, the hot water temperature taken with a calibrated digital metal stemmed thermometer was taken at the handsink of the shared bathroom of R3, R11, and R12, and registered 117.5 degrees Fahrenheit. This bathroom did have a sign on the door that stated, Do not enter this area it's closed at this time. The door was not locked and could be entered. On 12/5/24 at 9:16 AM, R3 who was alert to person, place, and time, stated he hasn't been able to use the bathroom for a while he said that sign has been on the door for several months. He said he has to go down the hall to use the restroom. He said it is a hassle to have to go down the hall and wait at times. 3. On 12/5/2024 at 9:20 AM, the hot water temperature taken with a calibrated digital metal stemmed thermometer was taken at the handsink of bathroom of R13, and registered 117.6 degrees Fahrenheit. On 12/5/24 at 9:20 AM, R13 who was alert to person, place, and time, stated he uses the bathroom all of the time and stated the water was not too hot. R13 stated they did have some flooding on Monday, and they have to fix the water lines. 4. On 12/5/2024 at 9:21 AM, the hot water temperature taken with a calibrated digital metal stemmed thermometer was taken at the handsink of the bathroom of R2, and registered 117.8 degrees Fahrenheit. 5. On 12/5/2024 at 9:23AM, the hot water temperature taken with a calibrated digital metal stemmed thermometer was taken at the handsink of room [ROOM NUMBER], which was empty, and registered 119.6 degrees Fahrenheit. 6. On 12/5/2024 at 9:30 AM, the hot water temperature taken with a calibrated digital metal stemmed thermometer was taken at the handsink of the bathroom of R14, and registered 119.8 degrees (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145903 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 145903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vandalia Healthcare & Senior Living 1500 West St Louis Avenue Vandalia, IL 62471 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 Fahrenheit. Level of Harm - Minimal harm or potential for actual harm 7. On 12/5/2024 at 9:35 AM, the hot water temperature taken with a calibrated digital metal stemmed thermometer was taken at the handsink of the Shower Room of the E Hall, and registered 116.6 degrees Fahrenheit. At that time, the shower head in the shower was not working. Residents Affected - Some 8. On 12/5/2024 at 9:38 AM, the hot water temperature taken with a calibrated digital metal stemmed thermometer was taken at the handsink of room [ROOM NUMBER], which was empty, and registered 116 degrees Fahrenheit. 9. On 12/5/2024 at 9:50 AM, the hot water temperature taken with a calibrated digital metal stemmed thermometer was taken at the handsink of the Shower Room on D Hall, and registered 122.5 degrees Fahrenheit. On 12/5/24 at 9:50 AM, V1 (Director of Nursing/DON) came into the Shower Room on D Hall to observe the water temperature taken at the handsink. As the temperature was being taken, V1 was asked what the temperature should be, and she said she thought not above when 110. As V1 was answering the question, the thermometer reading at the handsink was at 122.5 degrees Fahrenheit. V1 then stated they did have a maintenance man up until a week ago. She said he used to check the temps and keep logs. V1 stated V2(Maintenance Assistance/Therapy Assistant) the therapist has been trying to fill in as a maintenance man, and they have had the corporate maintenance man coming down when they had the pipes bust last week. V1 stated they really haven't had any complaints from residents other than R1, who said that the water was too hot and he got burned. V1 stated at that time, they investigated it, and every resident said the water temp was fine, including R1, and nothing more was ever said about the water being too hot. V1 stated she did do interviews and they did do testing of the water temps. Facility Incident Investigation Form, dated 11/8/24, documents R1 was asked the question, Have you had any issues with water temperature in this facility? R1's answer was, Yes, too hot. Never got burned by water. On 12/5/25 at 1:30 PM, V2 (Maintenance Assistance/Therapy Assistant) stated the last maintenance man left about a week ago, and he is the assistant. V2 stated he is the one that last took the water temperatures last week and this week, and documented on the log, and had found no issues with the temperatures. V2 stated he takes the water temperatures in 4 places to include both shower rooms and a room farthest away from the hot water heater. V2 said he uses a dial thermometer to take the temperatures, and he last calibrated back in November when one of the residents had complained of the water being too hot. V2 stated when he checked there were no issues. V2 stated the temperature range he is looking is to not go over 112, but likes to hit 110. V2 stated he would adjust the mixing valve if there was a problem. V2 stated no one had complained recently of the water being too hot. V2 stated the facility has 2 units, 1 unit has two hot water heaters, and so does the other. A list provided by V1 (DON), dated 12/5/24, of cognitively impaired and ambulatory residents included R1, R2, R3, R5, R6, R7, R8, and R9. On 12/05/24 at 2:30 PM, V1 (DON) stated one of the wandering cognitively impaired residents could have went into any of the shower rooms or bathrooms and turned on the sinks. V1 said they did have a plumber currently working on the hot water heater. V1 said they found a hole in the pipe leading to the hot water heater. V1 said they think the hole was causing the water heater to keep running and making the water too hot. V1 said the water heater was set at 110 degrees Fahrenheit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145903 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 145903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vandalia Healthcare & Senior Living 1500 West St Louis Avenue Vandalia, IL 62471 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 An undated Water Temperature Control Policy documents, It is the policy of (Name of Corporate) Health Care to maintain water temperature available to residents between 100 and 110 degrees Fahrenheit . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145903 If continuation sheet Page 6 of 6