Health inspection·October 24, 2023

F 0600 to Anger and Aggression in Dementia. Level of Harm - Actual harm 2. Care plans were updated with new resident centered behavior interventions. Residents Affected - Few 3. The Interdisciplinary team reviewed residents whom displayed aggressive behaviors daily during their morning Quality Assurance meetings and implemented additional interventions based on the root cause or trigger of the behavior. 4. V1 Administrator is taking responsibility for implementing and communicating interventions and ensuring they are being followed. 5. Residents who are currently on a behavior management program or are having increased behaviors have been reviewed during weekly Psychotropic/Behavior Quality Assurance meetings with the Quality Assurance Team to ensure that current behavior interventions are effective and if non-effective new interventions were developed and implemented based on the root cause of the behavior. 6. V1 Administrator has been responsible to ensure that any new interventions will be communicated to the staff and IDT will monitor to ensure interventions are being followed. 7. The facility's Quality Assurance Committee has monitored compliance through the daily and weekly internal Quality Assurance process. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146039 If continuation sheet Page 2 of 23 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 146039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastview Healthcare & Senior Living 100 Eastview Place Sullivan, IL 61951 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to obtain a new PASARR (Pre-admission screening and resident review) screening when a change in behaviors occurred for one (R46) of four residents reviewed for PASARR on the sample list of 29. Findings include: R46's PASARR screening dated 7/19/23 documents R46 has a diagnosis of Dementia and that R46 has no mental health conditions and is not receiving antidepressants, mood stabilizers, antipsychotics, or other mental health medications prescribed currently or in the last six months for mental health. This form documents a level two is not required. This form documents, There is no evidence of a PASARR condition of an intellectual/developmental disability or a serious behavioral health condition. If changes occur or new information refutes these findings, a new screen must be submitted. R46's Electronic Health Record (EHR) documents R46 was admitted to the facility on [DATE]. R46's EHR documents a physician order dated 10/20/23 for Haloperidol Lactate (antipsychotic) Injection Solution 5 milligrams per milliliter (mg/ml); Inject 1 mg intramuscularly every 6 hours as needed for Aggression. This record documents an order dated 9/12/23 for Seroquel (antipsychotic) 50 MG (Quetiapine Fumarate); Give 1 tablet by mouth at bedtime related to Insomnia. This record also includes an order dated 8/22/23 for Trazodone Hydrochloride 150 MG; Give 1 tablet by mouth at bedtime related to Insomnia and an order dated 8/22/23 for Depakote 500 mg for Dementia with Behavioral Disturbance. R46's Behavior Tracking dated 10/10/23 through 10/23/23 documents behaviors of grabbing others, frustration and anger towards others, agitation, delusions, hitting others, physically aggressive towards others, entering others' room and personal space, refusing cares, wandering, anxious, restlessness, grabbing others, rummaging, hoarding, insomnia, and cursing at others. On 10/23/23 at 1:45 PM, V1 stated R46 did not have behaviors when he first admitted but then started having behaviors a couple days later on 7/29/23 when R46 was involved in a resident to resident incident. V1 stated the behaviors continued until they sent him out today to be admitted to an inpatient psychiatric facility. On 10/24/23 at 11:35 AM, V13 sister facility Administrator stated a new PASARR should be completed when a resident is displaying new behaviors or increased behaviors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146039 If continuation sheet Page 3 of 23 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 146039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastview Healthcare & Senior Living 100 Eastview Place Sullivan, IL 61951 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) level II screening was completed for one (R1) of four residents reviewed for PASARR level II screenings, from a total sample list of 29. Residents Affected - Few Findings Include: R1's level I PASARR dated 8/24/04, documents that a level II PASARR is required due to R1's history of depression with electric shock therapy treatments and inpatient psychiatric hospitalizations. R1's undated diagnosis sheet documents diagnoses of Schizophrenia, Anxiety and Major Depression. R1's October 2023 physician order sheet documents the following psychotropic medications: Risperidone .25 milligrams (mg), to be given six of seven days for schizophrenia, Sertraline 50 mg daily to be given for major depression, Lorazepam .25 mg to be given twice daily for anxiety and Buspar 10 mg to be given twice daily for anxiety. On 10/23/23 at 1:45 PM, V1 Administrator stated, We can't find the Level II PASARR for (R1) and they are saying it wasn't done. She should have had it done. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146039 If continuation sheet Page 4 of 23 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 146039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastview Healthcare & Senior Living 100 Eastview Place Sullivan, IL 61951 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 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview and record review the facility failed to develop a comprehensive care plan for contractures for one of 15 residents (R35) reviewed for care plans on the sample list of 29. Residents Affected - Few Findings include: R35's Occupational Therapy Plan of Care report dated 12/9/21 documents treatment diagnoses including Right Elbow Contracture, Left Elbow Contracture, Right Wrist Contracture, Left Wrist Contracture, Right Hand Contracture and Left Hand Contracture. This report documents a goal of R35 using a resting hand splint for contracture prevention. R35's electronic care plan initiated 6/15/23 does not document any contracture diagnoses nor does it document any contracture as a concern or interventions to prevent decline. On 10/22/23 at 9:08 AM, R35 was in R35's room in R35's wheelchair leaning over the lap cushion. R35's hands were clinched closed and no cushions were in R35's hands but there was one of the cushions on top of the dresser. On 10/22/23 at 12:02 PM, V20 R35's family stated R35's hands are so contracted that V20 is not sure if they can even clean them. V20 stated that sometimes R35's hands even smell. V20 stated that R35 has hand contracture cushions that R35 is supposed to be wearing but V20 hasn't seen R35 have them in R35's hands in at least a couple of weeks. On 10/24/23 at 2:17 PM, V19 Corporate Minimum Data Set/Care Plan Coordinator confirmed R35's contractures were not documented on R35's care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146039 If continuation sheet Page 5 of 23 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 146039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastview Healthcare & Senior Living 100 Eastview Place Sullivan, IL 61951 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 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to provide discharge planning to one (R47) of one residents reviewed for discharge planning from a total sample list of 29 residents. Residents Affected - Few Findings include: The facility provided undated transfer and discharge policy documents that the facility and the physician are required to document regarding discharge in the resident's clinical record. R47's undated census sheet documents that R47 discharged from the facility on 10/13/23. R47's medical record does not contain an order for discharge, discharge goals, a discharge plan or R47's needs at the time of discharge. On 10/24/23 at 1:34PM, V1 Administrator said that she thought she recalled R47 wanting to go home but that she could not find any documentation related to the discharge. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146039 If continuation sheet Page 6 of 23 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 146039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastview Healthcare & Senior Living 100 Eastview Place Sullivan, IL 61951 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 0661 Level of Harm - Minimal harm or potential for actual harm Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Based on interview and record review the facility failed to develop a discharge summary for one (R47) of one residents reviewed for discharge planning from a total sample list of 29 residents. Residents Affected - Few Findings include: The facility provided undated transfer and discharge policy and procedure documents that the facility and the physician are required to document regarding discharge in the resident's clinical record. R47's undated census sheet documents that R47 discharged from the facility on 10/13/23. R47's medical record does not contain a physician's order for discharge, a discharge summary, a reconciliation of medications or plans for outpatient services. R47's discharge summary from physical therapy services dated 10/12/23 documents that R47 had not performed car transfers and is to have outpatient therapy services. On 10/24/23 at 1:34PM, V1 Administrator stated that she thought that R47 was supposed to have outpatient therapy and that there should be discharge information documented in the medical record, but that she was unable to locate any information except the physical therapy discharge notes. On 10/24/23 at 3:33PM, V18 Family Member stated, The facility didn't help me arrange any therapy for us before he was discharged and he really needs therapy. I am going to talk to his doctor about getting therapy outpatient. They didn't tell us about his medication and didn't send us home with any medicine. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146039 If continuation sheet Page 7 of 23 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 146039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastview Healthcare & Senior Living 100 Eastview Place Sullivan, IL 61951 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to address and implement interventions for a decline in the ability to communicate for one (R23) of 16 residents reviewed for communication on the sample list of 29. Residents Affected - Few Findings include: On 10/23/23 at 10:35 AM, R23 was sitting in the lobby of the facility. R23 could not hear when he was spoken very loudly to. R23 yelled I don't have my hearing aides and I can't hear nothing. I never got them back. I need them. On 10/23/23 at 10:35 AM, V9 Certified Nurse's Assistant stated R23 would be interviewable however the hospital lost his hearing aides a couple months ago. V9 stated R23's glasses are also missing. V9 stated R23 can't communicate with them. On 10/23/23 at 3:33 PM, V12 Transport stated R23 has an internal implant and a processor and when he went to the hospital in July the hearing aide/processor went missing. R23's Health Status Note dated 7/8/2023 at 4:59 AM documents, (R23) agitated this shift due to not having hearing aide. On 10/23/23 at 11:30 AM, V11 Certified Nurse's Assistant stated it's been two or three months since R23 has had his hearing device. V11 stated R23 will get frustrated because of not being able to hear. V11 stated this contributes to R23's behaviors. V11 stated before his hearing device went missing R23 was able to communicate with them. V11 stated no one has told the staff how to communicate with R23 and he does not have a communication board or anything like that. R23's care plan dated 6/07/23 documents R23 has sensorineural hearing loss. This care plan included an update dated 10/23/23 that documents R23 returned from the hospital in July without R23's hearing device. This care plan does not include new communication interventions for R23 after his hearing device was lost. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146039 If continuation sheet Page 8 of 23 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 146039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastview Healthcare & Senior Living 100 Eastview Place Sullivan, IL 61951 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 observation, interview and record review the facility failed to provide adaptive equipment to prevent further reduction in Range of Motion for one of one resident (R35) reviewed for Range of Motion in the sample list of 29. Findings include: R35's Occupational Therapy Plan of Care dated 12/28/21 documents diagnoses of Right Elbow Contracture, Left Elbow Contracture, Right Wrist Contracture, Left Wrist Contracture, Right Hand Contracture and Left Hand Contracture. R35's Minimum Data Set (MDS) dated [DATE] documents no impairment in range of motion. R35's MDS dated [DATE] documents no impairment in range of motion. On 10/22/23 at 12:02 PM, V20 R35's family stated that R35's hands are contracted and R35 is supposed to have a hand contracture cushion in both hands but V20 has not seen them in R35's hands for at least a couple of weeks. On 10/22/23 at 9:08 AM, R35 was in R35's room in R35's wheelchair leaning over the lap cushion. R35's hands were clinched closed and no cushions were in R35's hands but there was one of the cushions on top of the dresser. On 10/22/23 at 12:07 PM and on 10/23/23 at 9:21 AM R35's hands were closed tight and R35's elbows were bent at least 90 degrees and R35 was sitting in the wheelchair with a lap cushion across her lap. On 10/24/23 at 10:47 AM, V13 Sister Facility Administrator stated the hand cushions are to keep R35 from digging into R35's palm. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146039 If continuation sheet Page 9 of 23 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 146039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastview Healthcare & Senior Living 100 Eastview Place Sullivan, IL 61951 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review, the facility failed to elevate the head of bed during enteral feeding and failed to completely transcribe a dietician's enteral feed orders. This failure affects one resident (R13) of one reviewed for enteral feeding in the sample list of 29. Findings include: 1. R13's medical diagnosis list (10/23/2023) documents R13's diagnoses include: Gastro-Esophageal Reflux Disease, Hemiplegia (paralysis of one side of the body), Hemiparesis (weakness on one side of the body), Stroke, Asthma, Chronic Obstructive Pulmonary Disease, Epilepsy (seizure disorder), and Muscle Weakness. R13's comprehensive assessment (7/12/2023) documents R13 requires extensive assistance or is totally dependent on staff to complete all activities of daily living. R13's Physician Orders (10/23/2023) document R13 receives nutrition via enteral feed. R13's Care Plan (10/23/2023) documents R13's head of bed needs to be elevated to 45 degrees during and thirty minutes after receiving enteral feed. On 10/22/2023 at 10:07 AM, R13 was in bed receiving enteral feed solution via a pump and R13's head of bed was level and not elevated. On 10/22/2023 at 1:15 PM, R13 was in bed receiving enteral feed and R13's head of bed remained level. On 10/23/2023 at 2:27 PM, R13 was in bed receiving enteral feed and R13's head of bed remained level. 2. R13's Physician Orders (10/23/2023) documents R13 receives enteral feed (Diabetic Source AC 1.2) at a rate of 65 milliliters per hour. The order does not document a total volume, total duration, or total calorie amount R13 is to receive per day. V6's (Consulting Dietician) progress notes (9/8/2023 and 10/23/2023) document R13 is to receive enteral feel for 23 hours per day. On 10/23/2023 at 3:50 PM, V7 (Dietary Manager) reported V6's (Consulting Dietician) progress notes (9/8/2023) document R13 should receive enteral feed at a rate of 65 milliliters per hour for 23 hours per day. V7 reported R13's head of bed should be elevated at least 30 degrees at all times R13 is receiving enteral feed and facility staff should be aware of the need to elevate R13's head of bed to prevent aspiration. On 10/24/23 at 9:50 AM, V15 (Licensed Practical Nurse) reported R13 receives enteral feed continuously and R13's head of bed should be elevated anytime R13 is receiving enteral feed. The facility Enteral Feedings policy (February 2008) documents a resident receiving enteral feeding will be maintained with the head of bed elevated 30-45 degrees during and for at least 30 minutes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146039 If continuation sheet Page 10 of 23 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 146039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastview Healthcare & Senior Living 100 Eastview Place Sullivan, IL 61951 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 after each feeding. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146039 If continuation sheet Page 11 of 23 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 146039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastview Healthcare & Senior Living 100 Eastview Place Sullivan, IL 61951 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to provide oxygen therapy as ordered for one (R1) of one residents reviewed for oxygen therapy on the sample list of 29. Residents Affected - Few Findings include: The facility provided oxygen therapy policy dated 3/2019 documents that oxygen is administered to promote adequate oxygenation and to provide relief of symptoms of respiratory distress. If humidification is indicated, date the prefilled bottles when changed. R1's physician order sheet dated 3/15/23 documents an order for oxygen at three liters per nasal cannula with tubing and humidification changes weekly and as needed. On 10/22/23 at 10:15 AM, R1's concentrator is running at 4 liters per nasal cannula and the humidification bottle is dated 10/12/23. On 10/23/23 at 9:18 AM, R1's concentrator is running at 3 liters per nasal cannula, R1 is lying in bed and R1's water bottle is dry and dated 10/12/23. On 10/24/23 at 1:20 PM, R1 was wearing a nasal cannula in her bedroom with oxygen running at 3 liters per nasal cannula and the water bottle continues to be dry with the date of 10/12/23. On 10/24/23 at 1:25 PM, V15 Licensed Practical Nurse stated, There should be water in the bottle. It keeps the residents from drying out. I will change the tubing and the water. It is supposed to be changed weekly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146039 If continuation sheet Page 12 of 23 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 146039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastview Healthcare & Senior Living 100 Eastview Place Sullivan, IL 61951 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on observation, interview, and record review the facility failed to employ a full time Director of Nursing and staff a Registered Nurse for eight consecutive hours a day. This failure has the potential to affect all 44 residents residing in the facility. Findings include: The facility's Long Term Care Application for Medicaid and Medicare form dated 10/23/23 and signed by V1 Administrator documents there are 44 residents residing in the facility. On 10/22/23, 10/23/23, and 10/24/23 from 8:30 AM to 4:00 PM there was not a Director of Nursing working in the facility. The facility's nursing schedules dated September 2023 and October 2023 do not document that a Registered Nurse worked for 8 consecutive hours on 9/26/23, 9/29/23, 10/1/23, 10/2/23, 10/10/23, 10/15/23, 10/16/23, 10/20/23, 10/23/23, or 10/24/23. On 10/24/23 at 9:15 AM, V1 Administrator stated there has not been a full time Director of Nursing since 9/15/23. V1 confirmed there was not a Registered Nurse working for 8 consecutive hours per day on 9/26/23, 9/29/23, 10/1/23, 10/2/23, 10/10/23, 10/15/23, 10/16/23, 10/20/23, 10/23/23, and 10/24/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146039 If continuation sheet Page 13 of 23 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 146039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastview Healthcare & Senior Living 100 Eastview Place Sullivan, IL 61951 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 0756 Level of Harm - Minimal harm or potential for actual harm Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interview and record review the facility failed to address a pharmacy recommendation for one (R46) of five residents reviewed for unnecessary medications on the sample list of 29. Residents Affected - Few Findings include: The facility's Pharmacy Consultation Summary report dated 9/20/23 documents a recommendation for R46 for, Valproic Acid (Divalproex Sodium) containing product; monitor SDC (Serum Depakote Concentration). On 10/24/23 at 10:47 AM, V13 sister facility Administrator stated R46's pharmacy recommendation to draw a Depakote level was not addressed by the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146039 If continuation sheet Page 14 of 23 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 146039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastview Healthcare & Senior Living 100 Eastview Place Sullivan, IL 61951 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete Psychotropic medication assessments and care plan targeted behaviors and interventions for five of five residents (R35, R9, R24, R46, R13) reviewed for Unnecessary medications in the sample list of 29. Findings include: 1.) R35's Order Summary Report dated 10/23/23 documents diagnoses including Unspecified Dementia, Unspecified Severity with Agitation, Alzheimer's Disease, Bipolar Disorder, Anxiety Disorder, Metabolic Encephalopathy, Epilepsy and Major Depressive Disorder. This Order Summary Report documents orders for Haloperidol (antipsychotic) 1 mg (milligram) tablet two times a day related to Bipolar Disorder, Seroquel Tablet (antipsychotic) 25 mg give 6.25 mg at bedtime related to Bipolar Disorder and Anxiety Disorder, and Trazodone (antidepressant) 100 mg one tablet in the evening related to Major Depressive Disorder. R35's electronic medical record did not contain any psychotropic medication assessments and R35's paper chart did not contain any psychotropic medication assessments after September 2022. R35's Behavior Monitoring and Interventions Report dated 10/24/23 documents R35 has Physical Behaviors Directed at Others, Verbal Behaviors Directed at Others, Socially Inappropriate Behaviors and Other Behaviors Not Directed at Others in September and October of 2023. On 10/24/23 at 9:37 AM, V13 Sister facility Administrator confirmed they had no psychotropic medication assessments for R35 for the last 12 months. 2.) R9's Order Summary Report dated 10/24/23 documents diagnoses including Anxiety Disorder, Unspecified Dementia with Other Behavioral Disturbance, Insomnia and Depression. This Order Report documents orders for Bupropion SR (Sustained Release) (antidepressant) 100 mg every 12 hours related to Depression, Duloxetine HCL (Hydrochloride) (antidepressant) Delayed Release Sprinkle 20 mg give two capsules two times a day related to Depression, Mirtazapine (antidepressant) 15 mg one tablet at bedtime related to Depression and Risperidone (antipsychotic) 0.25 mg give half a tablet every other day related to Anxiety Disorder. R9's electronic medical record did not contain any psychotropic medication assessments and R9's paper chart did not contain any current psychotropic medication assessments. R9's Behavior Monitoring and Interventions Report dated 10/24/23 documents R9 has Physical Behaviors Directed at Others, Verbal Behaviors Directed at Others and Other Behaviors Not Directed at Others in September and October of 2023. On 10/24/23 at 9:37 AM, V13 confirmed there were no current psychotropic medication assessments for R9. 3.) R24's Order Summary Report dated 10/24/23 documents diagnoses including Unspecified Dementia Without Behaviors and Major Depressive Disorder. This Order Summary documents orders for Buspirone HCL (antianxiety) 7.5 mg two times a day for Anxiety, Sertraline HCL (antidepressant) 25 mg once a day related to Major Depressive Disorder and Trazodone HCL (antidepressant) 150 mg give half a tablet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146039 If continuation sheet Page 15 of 23 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 146039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastview Healthcare & Senior Living 100 Eastview Place Sullivan, IL 61951 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 0758 every evening for Agitation and Insomnia. Level of Harm - Minimal harm or potential for actual harm R24's Behavior Monitoring and Interventions Report dated 10/24/23 documents R24 has Socially Inappropriate Behaviors, Verbal Behaviors Directed at Others and Other Behaviors Not Directed at Others in September and October of 2023. Residents Affected - Some On 10/24/23 at 9:37 AM, V13 confirmed there were no current psychotropic medication assessments for R24. 4.) R46's Electronic Health Record (EHR) documents R46 was admitted to the facility on [DATE]. R46's EHR documents a physician order dated 10/20/23 for Haloperidol Lactate (antipsychotic) Injection Solution 5 milligrams per milliliter (mg/ml); Inject 1 mg intramuscularly every 6 hours as needed for Aggression. This record documents an order dated 9/12/23 for Seroquel (antipsychotic) 50 MG (Quetiapine Fumarate); Give 1 tablet by mouth at bedtime related to Insomnia. This record also includes an order dated 8/22/23 for Trazodone Hydrochloride 150 MG; Give 1 tablet by mouth at bedtime related to Insomnia and and order dated 8/22/23 for Depakote 500 mg for Dementia with Behavioral Disturbance. R46's EHR does not include assessment for the use of R46's Psychotropic medications (Haloperidol Lactate, Seroquel, Trazodone and Depakote). On 10/24/23 at 9:00 AM, V13 Sister Facility Administrator stated R46 was not assessed for the use of psychotropic medications. 5. R13's medical diagnosis list (10/23/2023) documents R13's primary diagnosis is Unspecified Dementia: unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. R13's Physician Orders (10/23/2023) document the following anti-psychotic medication orders: Risperidone (anti-psychotic medication), give a 0.25 milligram tablet orally one time daily and Quetiapine (anti-psychotic medication), give a 100 milligram tablet orally one time daily. On 10/24/2023 at 9:00AM, R13's electronic medical record (undated) did not document any psychotropic medication assessment for R13's anti-psychotic medication use. On 10/24/2023 at 9:36 AM, V13 (sister facility Administrator) reported the facility does not have any psychotropic medication assessments for R13's psychotropic medication use. The facility Psychotropic Medication Policy (11/28/2017) documents psychotropic medications will only be used for residents with approved psychiatric diagnoses and documented evidence of maladaptive behavior considered harmful to themselves or others, destructive to property, or if emotional problems exist which cause the resident frightful distress. On 10/24/2023 at 11:30 AM, V15 (Licensed Practical Nurse) denied R13 has indicators of persistent psychotic distress or persistent behaviors endangering R13 or other people. R13's electronic medical record (undated) does not document any specific targeted behaviors or indicators of persistent psychotic distress necessitating the use of antipsychotic medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146039 If continuation sheet Page 16 of 23 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 146039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastview Healthcare & Senior Living 100 Eastview Place Sullivan, IL 61951 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 0758 R13's Care Plan (10/23/2023) does not document any specific targeted behaviors, expressions of psychotic distress, or non-pharmacological interventions in lieu of anti-psychotic medication use for R13. 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: 146039 If continuation sheet Page 17 of 23 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 146039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastview Healthcare & Senior Living 100 Eastview Place Sullivan, IL 61951 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services and failed to employ a person-in-charge (PIC) with the required Food Protection Manager Certification. These failures have the potential to affect all 44 residents in the facility. Findings include: On 10/23/2023 at 10:46 AM, V7 (Dietary Manager) was actively supervising dietary operations in the facility kitchen. V7 reported being the full-time manager of the facility food service (PIC) and reported not being a clinically qualified Certified Dietary Manager or having equivalent training. V7 also denied being a certified Food Protection Manager, as required, and denied any other dietary staff were certified Food Protection Managers. V7 denied: -being a dietician; -being a certified dietary manager; -having an associate's or higher degree in food service management or in hospitality; -having 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting; -being a graduate of a dietetic and nutrition school or program authorized by the Accreditation Council for Education in Nutrition and Dietetics, the Academy of Nutrition and Dietetics, or the American Board of Nutrition; -being a graduate, prior to July 1, 1990, of a Department (Illinois Department of Public Health) approved course that provided 90 or more hours of classroom instruction in food service supervision and having experience as a supervisor in a health care institution which included consultation from a dietician; -or having completed an Association of Nutrition & Foodservice Professionals approved Certified Dietary Manager or Certified Food Protection Professional course. The Food and Drug Administration Food Code (2022) documents a dietary service Person in Charge (PIC) shall be a Certified Food Protection Manager. On 10/23/2023 at 11:30AM, V6 (facility consulting Dietician) reported V7 is not a Certified Dietary Manager and does not have the equivalent training and also reported being unaware V7 was not a Certified Food Protection Manager. The Facility Assessment (2023) documents a full-time clinically qualified nutrition professional is needed to provide competent support and care for the facility's resident population every day and during emergencies. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146039 If continuation sheet Page 18 of 23 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 146039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastview Healthcare & Senior Living 100 Eastview Place Sullivan, IL 61951 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 0801 The facility Long-Term Care Facility Application for Medicare and Medicaid (10/23/2023) documents 44 residents reside in the facility. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146039 If continuation sheet Page 19 of 23 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 146039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastview Healthcare & Senior Living 100 Eastview Place Sullivan, IL 61951 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** Based on observation, interview and record review the facility failed to prevent potential cross contamination by failing to perform hand hygiene and change gloves during incontinence care and failing to maintain clean linens for two of two residents (R31, R35) reviewed for incontinence care in the sample list of 29. Residents Affected - Few Findings include: The facility's Perineal Cleansing policy with a reviewed date of December 2017 documents, Policy: To eliminate odor; to prevent irritation or infection and to enhance resident's self-esteem. Note: The basic infection control concept for peri-care (perineal-care) is to wash from the cleanest to the dirtiest area and remember to change or remove gloves and wash hands when going form working with contaminated items to clean items. 1.) R31's Order Summary Report dated 10/24/23 documents diagnoses including Acute Kidney Failure with Tubular Necrosis and Urinary Tract Infection. R31's Minimum Data Set (MDS) dated [DATE] documents R31 is cognitively intact, requires extensive assistance of one person for toileting and is always incontinent of bowel and bladder. On 10/23/23 at 1:52 PM, R31 was lying in bed in R31's room. V8 and V9 Certified Nursing Assistants (CNA) prepared supplies to perform incontinence care for R31. V8 and V9 washed their hands and donned gloves. V8 and V9 then uncovered R31, opened R31's incontinence brief and began to wash R31's perineal area. After washing the front of R31, without performing hand hygiene or changing gloves, they assisted R31 to roll to R31's side, removed the saturated incontinence brief, folded the wet bed pad underneath R31 and washed R31's buttocks and anal area. Without performing hand hygiene or changing gloves, V8 and V9 assisted R31 to roll back and placed a clean brief and bed pad underneath R31. After getting the incontinence brief fastened V8 removed V8's gloves and without performing hand hygiene, V8 touched R31's blouse and stated that it was also wet so V8 and V9 changed R31's blouse. There was a visible brown substance on the bedsheet between R31's knees. V8 stated that R31 had diarrhea earlier and confirmed it was stool on the sheet and stated V8 did not get R31's sheet changed. Without changing R31' sheet, V8 and V9 covered R31 back up with the top sheet and blanket. V9 removed V9's gloves and then they both washed their hands. 2.) R35's Order Summary Report dated 10/23/23 documents diagnoses including Dementia, Alzheimer's Disease, Anxiety, Metabolic Encephalopathy and Muscle Weakness. R35's MDS dated [DATE] documents R35 is severely cognitively impaired, requires extensive assistance of two persons for toileting and is always incontinent of bladder and occasionally incontinent of bowel. On 10/23/23 at 1:10 PM, V9 and V10 CNAs assisted R35 into bed and washed their hands and donned gloves. They opened the incontinence brief and washed the front perineal area and R35 became combative. With the same gloves on, they assisted R35 to roll to R35's side, R35 was not combative on R35's side. V9 washed R35's back side, hips and anal area. They stated that R35 is ordered to lay without a brief on. With the same gloves on, they repositioned the bed pad underneath R35 and covered R35 up with the top sheet and bed spread. V9 then removed V9's gloves and washed V9's hands. V10 lowered the bed and laid the mat on the floor next to the bed then removed V10's gloves and washed V10's hands. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146039 If continuation sheet Page 20 of 23 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 146039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastview Healthcare & Senior Living 100 Eastview Place Sullivan, IL 61951 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 On 10/24/23 at 2:17 PM, V13 Sister Facility Administrator stated that staff should change their gloves anytime they go from a dirty area to a clean area. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146039 If continuation sheet Page 21 of 23 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 146039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastview Healthcare & Senior Living 100 Eastview Place Sullivan, IL 61951 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to provide education for and offer Pneumococcal vaccines for two of five residents (R23, R24) reviewed for vaccinations on the sample list of 29. Residents Affected - Few Findings Include: 1.) R23's Care Plan with a revised date of 9/6/23 documents diagnoses including Neurocognitive Disorder with Lewy Bodies, Dementia, Parkinson's Disease, Generalized Epilepsy, Morbid Obesity and Cochlear Implant Status. There is no documentation in R23's medical record of Pneumococcal vaccination history or that the facility provided education regarding the Pneumococcal vaccine, offered the vaccine, or that the vaccine was given or declined. 2.) R24's Order Summary Report dated 10/24/23 documents diagnoses including Dementia, Disorder of Thyroid, Cardiomegaly and Chronic Kidney Disease. There is no documentation in R24's medical record of Pneumococcal vaccination history or that the facility provided education regarding the Pneumococcal vaccine, offered the vaccine, or that the vaccine was given or declined. On 10/24/23 at 1:18 PM, V13 Sister Facility Administrator confirmed there are a lot of residents that need their Pneumococcal vaccine and V13 stated that V13 just ordered 40 doses of the Pneumococcal vaccine. On 10/24/23 at 2:35 PM, V13 confirmed they do not have any consents signed yet for the Pneumococcal vaccine. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146039 If continuation sheet Page 22 of 23 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 146039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastview Healthcare & Senior Living 100 Eastview Place Sullivan, IL 61951 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 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. Based on observation, interview, and record review, the facility failed to maintain resident bed side rails in a safe condition. This failure affects two residents (R4, R40) of two reviewed for bed side rails in the sample list of 29. Findings include: R4's medical diagnosis list (10/24/2023) documents R4's diagnoses include: Hemiplegia (paralysis of one side of the body), Hemiparesis (weakness on one side of the body), Stroke, Epilepsy (seizure disorder), and Reduced Mobility. R4's comprehensive assessment (9/6/2023) documents R4 has impaired range of motion in upper and lower extremities and has severely impaired cognition. R4's Physician Orders (10/24/2023) document R4 receives the medication Levetiracetam to prevent seizures. R4's Care Plan (10/24/2023) documents R4 utilizes half-length bed side rails for mobility and staff should observe for injury or entrapment related to the side rail use and to reposition as needed to avoid injury. R40's medical diagnosis list (10/24/2023) documents R40's diagnoses include: Dementia and Muscle Weakness. R40's Physician Orders (10/24/2023) document R40 receives the medication Divalproex to prevent convulsions. On 10/24/2023 at 1:26 PM, R4's left and right bed side rails were both in the upward position. Both side rails had a seven inch gap between the top of the rail and the headboard and also had a seven and a half inch spacing between the vertical supports of the rail. R40, the roommate of R4, was sleeping in the adjacent bed which also had the exact same bed side rails as R4, including excessively wide spacing between the vertical supports and an excessive gap between the top of the side rail and R40's headboard. R40's left bed side rail was in the upward position as R40 slept. On 10/24/2023 at 1:44 PM, V13 (sister facility Administrator) observed the above bed side rails and reported yeah, that's (the side rail gap between the center supports of the side rail) too wide (for safety). The Food and Drug Administration Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment (3/10/2006) documents to reduce the risk of entrapment, injury, and death, the maximum safe spacing in a bed side rail system should not exceed 4 3/4. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146039 If continuation sheet Page 23 of 23