Inspection·April 8, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of the needs were being met, it just took longer to meet them. V6 stated the average time it takes to answer a call light is fifteen minutes. On 4/7/25 at 1:45 PM, V5 (Licensed Practical Nurse/LPN) stated they have one nurse and four CNA's working today. When asked if that was enough staff to meet the needs of the residents timely, V5 stated, Sometimes. V5 stated when she got to work this morning, R2 was on the commode and was yelling out, Hey, for assistance which is what he does. V5 stated the day shift CNA's assisted R2 off the commode. V5 stated R2 didn't tell her how long he had been waiting for assistance. On 4/27/25 at 9:22 PM, V10 (LPN/Licensed Practical Nurse) stated she works night shift, and they don't always have enough staff to meet the needs of the residents timely. V10 stated it probably takes longer to answer them during the morning routine. V10 stated she worked night shift beginning on 4/6/25 at 6:00 PM and ending on 4/7/25 at 6:00 AM. When asked if there were call lights that took longer to answer the morning of 4/7/25, V10 stated there was a bathroom call light (R2) going off, and it may have taken longer to answer it. V10 stated it took maybe 15-20 minutes. On 4/7/25 at 9:30 PM, V11 (CNA) stated they are not able to meet the needs of the residents timely. V11 stated when you don't have enough staff, nothing gets done on time. When asked if she was aware of it taking 45 minutes to assist a resident off the commode, V11 stated, (R2). When asked why it took so long, V11 stated they don't have enough staff to get to it timely. On 4/8/25 at 1:03 PM, when asked if she was aware of a resident sitting on a commode waiting for assistance for a long period of time, V17 (CNA) stated, Sometimes it takes longer to get to the them. V17 stated if they have enough staff, they answer the call lights almost immediately. 2. R3's admission Record, with a print date of 4/8/25, documents R3 was admitted to the facility on [DATE], with diagnoses that include atrial fibrillation, heart failure, heart disease, disc degeneration, major depressive disorder, and restless leg syndrome. R3's MDS, dated [DATE], documents a BIMS score of 15, indicating R3 is cognitively intact. This same MDS documents R3 requires supervision or touching assistance for toilet hygiene. R3's current Care Plan documents a Focus area of ADL Function Rehab: resident is usually able to perform ADL's independently or with supervision. Date Initiated: 07/25/2024 This Focus area includes the intervention of, Encourage the resident to use bell to call for assistance .Date Initiated: 07/28/2024. R2's current Care Plan includes the Focus area of, Urinary Incontinence: the resident has MIXED bladder incontinence r/t impaired mobility. Date Initiated: 7/28/2024. This focus area includes the following interventions, Incontinent: Check every 2 house and as required for incontinence . Date Initiated: 07/28/2024. On 4/7/25 at 11:30 AM, R3 stated she hardly ever pushes her call light; she just goes and gets staff to assist her when needed. R3 stated when she does push it they answer it timely. On 4/7/25 at 1:00 PM, V4 (Ombudsman) stated she attends Resident Council Meetings at the facility, and the residents voice concerns at every meeting that call lights aren't being answered timely. V4 stated R2 and R3 reported to her it is worse on evening shift and night shift. V4 stated R2 reported to her it takes up to 45 minutes to get assistance off the commode. V4 stated R3 reported she will go searching for help at times because she can't get anyone to answer the call light. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145903 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 145903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2025 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 0550 Level of Harm - Minimal harm or potential for actual harm On 4/7/25 at 2:07 PM, V7 (CNA) stated they don't have enough staff to meet the needs of the residents timely. When asked what care is delayed, V7 stated, resident care, toileting, and showers. V7 stated, I leave (at the end of her shift) feeling bad (due to delayed care). On 4/7/25 at 2:36 PM, V8 (CNA) stated they don't have enough staff to answer call lights timely. Residents Affected - Few On 4/7/25 at 2:56 PM, when asked if call lights were answered timely, V9 (CNA) stated it depended on staffing. V9 stated if they only have two CNA's on unit 2, and one goes to lunch, then it takes longer to answer the call lights. On 4/7/25 at 9:40 PM, V12 (CNA) stated they aren't able to answer call lights timely when they only have one CNA on each unit. On 4/8/25 at 12:23 PM, V15 (CNA) stated they didn't have enough staff to answer call lights timely. On 4/8/25 at 1:35 PM, V1 (Administrator) stated two CNA's in the facility were enough to meet the needs of the residents on night shift when everyone was in bed. When asked if the residents were safe with just one CNA on each unit, V1 stated, To a certain extent I would say yes, but I would like more. On 4/8/25 at 1:53 PM, V2 (Acting Director of Nurses/MDS Coordinator) stated she would want more staff when asked if one nurse and two CNA's were enough staff to meet the needs of the residents timely. The facility Resident Council Minutes documents the following 1/30/25- Old Business .both shifts call lights a problem. 3/4/25 for [DATE] .Old Business: Any unresolved issues from last month: Call lights still an issue. The facility Answering the Call Light policy dated 9/2022 documents, .The purpose of this procedure is to ensure timely responses to the resident's requests and needs Steps in the Procedure: 1. Answer the resident call system immediately FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145903 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 145903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2025 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain sufficient staff to meet the needs of the residents timely. This has the potential to affect all 37 residents currently residing at the facility. Findings Include: The facility Resident Matrix provided to this surveyor on 4/7/25 document 37 residents currently reside at the facility. 1. R2's admission Record with a print date of 4/8/25 documents R2's admitted to the facility on [DATE] with diagnoses that include acute and chronic respiratory failure, heart failure, sleep apnea, diabetes, morbid obesity, and chronic obstructive pulmonary disease. R2's MDS (Minimum Data Set), dated 1/3/25, documents R2 has a BIMS (Brief Interview for Mental Status) score of 15, which indicates R2 is cognitively intact. This same MDS documents R2 requires substantial/maximal assistance for toileting. R2's current Care Plan documents a Focus Area of, ADL's (activities of daily living) Self care deficit-needs supervision and/or assist to complete quality care and/or poorly motivated to complete ADL's R/T (related to): reduced mobility and Obesity. Date Initiated: 01/23/2024. This Focus area includes the intervention of, Assist Resident to transfer into wheelchair/Geri-chair/Broda chair and assist to position for comfort .Date Initiated 07/14/2024 .Assist with ADL's as necessary with staff assist of 1 .Date Initiated: 01/23/2024 . On 4/7/25 at 1:29 PM, R2 stated call lights aren't answered timely. R2 stated evenings and overnights are the worst. R2 stated this morning, he put on his call light on and it was 45 minutes before it was answered. R2 stated he put his call light on around 5:30 AM, and it didn't get answered until day shift arrived. R2 stated V6 (Certified Nursing Assistant/CNA) answered the call light and helped him get off the toilet. R2 stated he gets left on the toilet frequently. R2 stated they had cut CNA hours back on his unit. On 4/7/25 at 1:58 PM, V6 (CNA) stated she answers call lights as quickly as she can, but if she is in a room providing care, it may take a little longer. V6 stated this morning (4/7/25), R2's call light was going off when she arrived to the facility around 6:00 AM. V6 stated there were a few lights going off and she started answering them immediately. V6 stated she answered R2's bathroom light first, since she knew that was an instant need. V6 stated R2 said he had been waiting for assistance for awhile. When asked if it was typical to have call lights needing answered as soon as she got to the facility and for residents to say they had been waiting awhile, V6 stated the night shift staff were in a room providing care to another resident when she arrived, and it was a little different, so they must have had a rough night. V6 stated she felt like they were short staffed. V6 stated all of the needs were being met, it just took longer to meet them. V6 stated the average time it takes to answer a call light is fifteen minutes. On 4/7/25 at 1:45 PM, V5 (Licensed Practical Nurse/LPN) stated they have one nurse and four CNA's working today. When asked if that was enough staff to meet the needs of the residents timely, V5 stated, Sometimes. With our census being what it is, now it is better. V5 stated they had some residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145903 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 145903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2025 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many pass away, and some were discharged home. V5 stated they have one resident in the hospital who has a lot of behaviors, and he should be discharged back to the facility any day now. V5 stated being the only nurse in the facility, she doesn't feel like she can get to the other side of the facility (to the locked dementia unit) if there is an emergency. V5 stated when she got to work this morning, R2 was on the commode and was yelling out, Hey, for assistance, which is what he does. V5 stated the day shift CNA's assisted R2 off the commode. V5 stated R2 didn't tell her how long he had been waiting for assistance. On 4/27/25 at 9:22 PM, V10 (LPN/Licensed Practical Nurse) stated she works night shift, and they don't always have enough staff to meet the needs of the residents timely. V10 stated they are supposed to have three CNA's and one nurse, but a lot of times they only have two CNA's, which is one CNA per unit and one nurse. V10 stated there are a few people who require assist of two for incontinence care. V10 stated if they have enough staff, they get residents up in the morning, but when they don't, they just get them dressed and leave them in bed. When asked if call lights are answered timely, V10 stated it probably takes longer to answer them during the morning routine. V10 stated she worked night shift beginning on 4/6/25 at 6:00 PM and ending on 4/7/25 at 6:00 AM. When asked if there were call lights that took longer to answer the morning of 4/7/25, V10 stated there was a bathroom call light (R2) going off, and it may have taken longer to answer it. V10 stated it took maybe 15-20 minutes. On 4/7/25 at 9:30 PM, V11 (CNA) stated they are not able to meet the needs of the residents timely. V11 stated when you don't have enough staff nothing gets done on time. When asked if she was aware of it taking 45 minutes to assist a resident off the commode, V11 stated R2. When asked why it took so long, V11 stated they don't have enough staff to get to it timely. V11 stated they are supposed to have two CNA's on unit two, and one on unit one, but sometimes is is just one CNA for the whole building. V11 stated they have residents who require assist of two for incontinence care. When asked how they provide incontinence care to those residents if they only have one CNA, V11 stated, The nurse sits on one unit while the CNA does the bed checks for the other unit, and will come help for the residents who require assist of two, and then goes back to the other unit to check on those residents. V11 stated she wasn't working, but she heard there was only one CNA working on night shift on 3/29/25, and she worked alone about a week before that. V11 stated it happens quite often. On 4/8/25 at 1:03 PM, when asked if she was aware of a resident sitting on a commode waiting for assistance for a long period of time, V17 (CNA) stated, Sometimes it takes longer to get to the them. V17 stated if they have enough staff, they answer the call lights almost immediately. 2. R3's admission Record, with a print date of 4/8/25, documents R3 was admitted to the facility on [DATE], with diagnoses that include atrial fibrillation, heart failure, heart disease, disc degeneration, major depressive disorder, and restless leg syndrome. R3's MDS, dated [DATE], documents a BIMS score of 15, indicating R3 is cognitively intact. This same MDS documents R3 requires supervision or touching assistance for toilet hygiene. R3's current Care Plan documents a Focus area of ADL Function Rehab: resident is usually able to perform ADL's independently or with supervision. Date Initiated: 07/25/2024 This Focus area includes the intervention of, Encourage the resident to use bell to call for assistance .Date Initiated: 07/28/2024. R2's current Care Plan includes the Focus area of, Urinary Incontinence: the resident has MIXED bladder incontinence r/t impaired mobility. Date Initiated: 7/28/2024. This focus area includes the following interventions, Incontinent: Check every 2 house and as required for incontinence . Date (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145903 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 145903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2025 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 0725 Initiated: 07/28/2024. Level of Harm - Minimal harm or potential for actual harm On 4/7/25 at 11:30 AM, R3 stated she hardly ever pushes her call light; she just goes and gets staff to assist her when needed. R3 stated when she does push it, they answer it timely. Residents Affected - Many On 4/7/25 at 1:00 PM, V4 (Ombudsman) stated she attends Resident Council Meetings at the facility, and the residents voice concerns at every meeting that call lights aren't being answered timely. V4 stated R2 and R3 reported to her it is worse on evening shift and night shift. V4 stated R2 reported to her it takes up to 45 minutes to get assistance off the commode. V4 stated R3 reported she will go searching for help at times because she can't get anyone to answer the call light. On 4/7/25 at 2:07 PM, V7 (CNA) stated they don't have enough staff to meet the needs of the residents timely. V7 stated they changed some staff to as needed to lower the staffing numbers, and they have had to gradually bring more people back to the floor to assist with resident care. V7 stated they usually have staff call in, and sometimes only have two CNA's for unit two, and that isn't enough. When asked what care is delayed, V7 stated, resident care, toileting, weights, vital signs, and showers. V7 stated, I leave (at the end of her shift) feeling bad (due to delayed care). On 4/7/25 at 2:36 PM, V8 (CNA) stated they don't have enough staff to meet the needs of the residents timely. V8 stated call lights don't get answered timely when they are short staffed. V8 stated she usually works unit one (locked dementia unit), and they have eight residents with one CNA and a nurse that is shared with the other unit. On 4/7/25 at 2:56 PM, when asked if call lights were answered timely, V9 (CNA) stated it depends on staffing. V9 stated if there are only two CNA's working on side two, and one goes to lunch it gets rough. On 4/7/25 at 9:40 PM, V12 (CNA) stated they aren't able to answer call lights timely when they only have one CNA on each unit. On 4/8/25 at 12:23 PM, V15 (CNA) stated they didn't have enough staff to answer call lights timely. On 4/8/25 at 11:56 AM, V6 (CNA) stated she worked on 4/6/25, but had to leave around 9:30 AM for a family emergency. V6 stated she was working with two agency nurses, V15 and V16 (CNA's). On 4/8/25 at 12:23 PM, V15 (CNA) stated she worked on 4/6/25 with one CNA on each side of the facility. V15 stated no one came in to assist them. V15 stated she was working on unit one, and she felt bad for the CNA working (V16) working on the other unit. V15 stated they started their shift at 6 AM with three CNA's and two nurses. V15 stated V6 (CNA) had to leave early for a family emergency, and one of the nurses left at 2:00 PM. V15 stated it is unusual for them to have two nurses, they usually have one nurse and three CNA's. V15 stated they normally have one CNA on unit one and two on unit two. V15 stated if the CNA working unit one gives a resident a shower, the other residents are not being monitored. V15 stated the residents on that unit are all on 15 minute checks, and there are several who are fall risks. V15 stated one nurse and two CNA's are not enough to meet the needs of the residents. When asked what needs aren't met timely when they are short staffed, V15 stated, call lights, incontinence care, showers, all the important stuff. V15 stated they notified administration they were short staffed on 4/6/25, and V1 (Administrator) sent out a group message asking people to come in. V15 stated no one came in. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145903 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 145903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2025 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 4/8/25 at 12:51 PM, V16 (CNA) stated she worked on 4/6/25. V16 stated V15 was the CNA on unit one with an unknown agency nurse. V16 stated she and V6 were the CNA's on unit two, and V6 had to leave for a family emergency around 9:30 AM. V16 stated she was the only CNA on unit two until 6:00 PM. V16 stated they had two nurses working on 4/6/25, but one of them left at 2:00 PM. V16 stated that is not enough staff to meet the needs of the residents timely. When asked what needs weren't met, V16 stated, I mean, all of them. V16 stated she had worked night shift in the past as the only CNA, but not recently. V16 stated she knows night shift often only has one CNA. When asked if one CNA was enough to meet the needs of the residents timely on night shift, V16 stated, No. V16 stated V1 (Administrator) and the on call nurse V2 (Acting Director of Nurses/MDS Coordinator) were aware of them being short staffed on 4/6/25, and neither one came in to assist. On 4/8/25 at 1:53 PM, V2 (Acting Director of Nurses/MDS Coordinator) stated she was not aware of only one CNA working on any shift. V2 stated if for some reason staff call in and/or don't show up, one of the administration staff will come in. V2 stated, I am not going to leave them hanging. When asked if she was aware they were short staffed on 4/6/25, V2 stated she was out of town. When asked if one nurse and two CNA's were enough staff to meet the needs of the residents, V2 stated she would want more. On 4/8/25 at 1:35 PM, V1 (Administrator) stated two CNA's in the facility were enough to meet the needs of the residents on night shift when everyone was in bed. When asked about staffing on 4/6/25, V1 stated they didn't notify her there was an issue until later that day. V1 stated she put out two messages; one for a 10 AM to 6 PM shift and one for a 2 PM to 6 PM shift, and no one wanted to work. When asked if her offering a shift at 10 AM meant she knew at 10 AM they were short staffed, V1 stated it was probably a little before that. When asked if any administration came in to assist the staff in meeting the needs of the residents, V1 stated she didn't because she was out of town, and none of the other administration staff would answer the phones/messages. When asked if the residents would be safe with just one CNA on each unit, V1 stated, To a certain extent I would say yes, but I would like more. The facility undated Nurse Staffing policy documents, Policy: it is the policy of (name of an organization) to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental and psychosocial well being of each resident. Nurse staffing shall be based upon resident evaluation by the Administrator and Director of Nursing as specified by the (name of surveying agency). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145903 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 145903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2025 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were provided with a bedtime snack. This has the potential to affect all 37 residents who currently reside at the facility. Findings Include: The facility Resident Matrix provided to this surveyor on 4/7/25 documents 37 residents currently reside at the facility. On 4/7/25 at 1:00 PM, V4 (Ombudsman) stated she frequently attends the Resident Council Meetings at the facility. V4 stated R3 and R4 reported to her they were not getting snacks served at the facility unless the State Survey Agency was in the facility. On 4/7/25 at 11:30 AM, R3 and R4 stated they are served bedtime snacks. R3 and R4 stated they get them on the tray with their evening meal. On 4/7/25 at 1:29 PM, R2 stated he recently had an issue getting snacks, but after he complained he started getting them again. R2's admission Record, with a print date of 4/8/25, documents R2's admitted to the facility on [DATE],3 with diagnoses that include acute and chronic respiratory failure, heart failure, sleep apnea, diabetes, morbid obesity, and chronic obstructive pulmonary disease. R2's MDS (Minimum Data Set) dated 1/3/25 documents R2 has a BIMS (Brief Interview for Mental Status) score of 15, which indicates R2 is cognitively intact. R3's admission Record, with a print date of 4/8/25, documents R3 was admitted to the facility on [DATE] with diagnoses that include atrial fibrillation, heart failure, heart disease, disc degeneration, major depressive disorder, and restless leg syndrome. R3's MDS dated [DATE] documents a BIMS score of 15, indicating R3 is cognitively intact. R4's admission Record, with a print date of 4/8/25, documents R4 was admitted to the facility on [DATE] with diagnoses that include atrial fibrillation, chronic obstructive pulmonary disease, and diabetes. R4's MDS, dated [DATE], documents a BIMS score of 13, indicating R4 is cognitively intact. On 4/7/25 at 1:45 PM, V5 (LPN/Licensed Practical Nurse) stated residents used to be offered snacks, but they have been told it is no longer in the budget. V5 stated they get one snack at 8:00 PM that is served to them on their supper tray. V5 stated most of the residents eat it with supper, and then they don't have anything to eat at bedtime. V5 stated the kitchen is locked, so the staff will buy snacks for the residents to have. On 4/7/25 at 2:07 PM, V7 (CNA/Certified Nurse Aide) stated they used to get snacks at 10 AM and 2 PM, but they don't anymore. V7 stated the staff are buying snacks and bringing them in for the residents. V7 stated supper is served at 4:30 PM, and they don't get anything else to eat until the next morning when breakfast is served. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145903 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 145903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2025 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 0809 On 4/7/25 at 2:36 PM, V8 (CNA) stated the kitchen never has snacks for the residents. Level of Harm - Minimal harm or potential for actual harm On 4/7/25 at 9:22 PM, V10 (LPN/Licensed Practical Nurse) stated the facility is cutting back on snacks, so they pass them out with the supper trays. V10 stated they don't leave any snacks out for the staff to offer residents if they get hungry later. V10 stated they don't have access to the kitchen, and if there is a resident who is diabetic with a low blood sugar, she doesn't have much to choose from to offer them to eat. V10 stated she has the applesauce and pudding she uses to pass medications with that she can offer them. Residents Affected - Many On 4/7/25 at 9:30 PM, V11 (CNA) stated the residents are served their 8:00 PM snack at 4:30 PM with their supper meal. V11 stated a lot of them eat it when it is served, and then they are hungry at bedtime. V11 stated they have a lot of residents who are diabetic and the kitchen is locked up. V11 stated they used to leave one door open for the night shift staff to access it if they needed to, but now it is locked, and they don't leave food out for the residents anymore. On 4/7/25 at 9:40 PM, V12 (CNA) stated snacks are passed to the residents on their supper tray. V12 stated they eat them with their supper meal, and then they go till breakfast the next morning with no snack. V12 stated the kitchen no longer leaves snacks out for them, and they lock the kitchen up. On 4/8/25 at 12:23 PM, V15 (CNA) stated they were told the company who purchased the facility cut the budget for the kitchen, so they are only allowed to have an 8:00 PM snack now. V15 stated if someone asks for a snack between meals she doesn't have anything to offer them. When asked if she was aware of snacks in the kitchenette/linen closet, V15 stated they only bring snacks for 8:00 PM, for each resident and it is served with their supper trays. V15 stated they don't put snacks in the kitchenette/linen closet for the residents. V15 stated there is one individual juice cup in the refrigerator on unit one that has been there for awhile, but other than that, she only has water and coffee to offer the residents. On 4/8/25 at 12:51 PM, V16 (CNA) stated residents get their bedtime snack with their supper and eat them with supper. V16 stated then they don't have anything for the rest of the night. V16 stated she usually works on side 2, and they don't have anything in the kitchenette to serve the residents. On 4/8/25 at 1:03 PM, V17 (CNA) stated they have multiple residents who ask for snacks, and they don't have anything to give them. V17 stated they used to stock the kitchenette/linen closet, but they don't do that anymore. V17 stated they were told it was a budget thing. On 4/8/25 at 10:33 AM, V14 (Dietary Manager) stated meals are served at 7:30 AM, 11:30 AM, and 4:30 PM. V14 stated they serve a house snack for 8:00 PM. When asked what a house snack was, V14 stated it is a snack served to everyone. V14 stated it is served to them on their supper trays or passed from room to room. V14 stated if they pass them from room to room, they are passed around 5:00 PM. V14 stated they pass them with supper or right around supper because some of the residents like to eat it at supper time. When asked if it is really an 8:00 PM snack if they are served it and eat it with supper, V14 stated, No. V14 stated they also keep snacks at both nurses station (kitchenette/linen closet), so if they get hungry at night they have options. V14 sated they have lunch meat, cheese, peanut butter, juice, koolaid, and water. When asked if the food options would be in the kitchenette/linen closet now, V14 stated yes it was in there at all times. V14 stated it gets refreshed three times daily. This surveyor walked with V14 to the linen closet on side one where the snacks were kept. There was a bottle of jelly in the refrigerator, along with one individual juice cup. There was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145903 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 145903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2025 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many thickener for drinks on the counter along with condiments and a few pudding cups. There was a can of peanut butter on top of the refrigerator and box of oatmeal on the counter. When asked where the bread was to make peanut butter and jelly sandwiches, V14 stated there was none. At 10:45 AM, this surveyor walked with V14 to the kitchenette located on side two. There were many bottles of water, soda, and juice noted in the refrigerator, as well as take out containers, and containers of food. None of these items were labeled, and V14 stated they were either staff food and drinks, or residents who had asked for them to be refrigerated. There was a can of peanut butter on top of the refrigerator; no pudding cups, no juice, a gallon jug of water in the refrigerator. V14 confirmed there was no bread and no jelly in this kitchenette. When asked about the individual packets of oatmeal on top of the refrigerator, V14 stated the residents get tired of the plain oatmeal, so staff will purchase the flavored oatmeal and bring it to the facility for the residents to have variety. V14 stated the nurses also have keys to the kitchen should they need anything after the kitchen staff have left for the day. V5 (LPN) was working as the nurse for side one and side two. With this surveyor and V14 observing, V5 attempted the keys on the nurses key ring and was not able to open the kitchen door. When asked if she had any concerns brought to her related to residents not getting snacks, V14 stated she had, but it was from CNA staff who she was concerned had been taking food from the kitchen for their personal use. This surveyor reviewed with V14 the observation of the kitchenette and linen closet where snacks are to be stored for resident use, and V14 stated she knew it looked bad, but the kitchen staff were probably just restocking them. V14 stated they used to pass snacks from a cart at 8:00 PM, but the residents were complaining the CNA staff didn't pass them out, so they started putting them on their dinner trays but some do eat them with their supper. On 4/8/25 at 11:00 AM, V1 (Administrator) stated the residents are supposed to be served snacks and the facility staff are supposed to restock the kitchenette/linen closet with snacks for the residents. The facility Evening Snack Policy, dated 10/15, documents, It is the policy of (name of an organization) to offer each resident an evening snack and document whether the resident accepted or declined the evening snack. Procedure: 1. An evening (H.S.) snack is incorporated into the daily menu. 2. Bulk snacks will be provided by the Food Service Department according to the number and types of diet being served. The snacks should be compatible with the resident's diet order and preference. 3. Appropriate snacks may include: assorted cookies, crackers, cakes, brownies, half sandwiches, fruit, ice cream, sherbet, and pudding. 4. Dietary staff will deliver H.S. snacks to the nursing units. 5. All residents will be offered an H.S. snack. 6. Acceptance of and/or declining of the H. S. snack is recorded by the CNA. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145903 If continuation sheet Page 10 of 10