Health inspection·December 11, 2025

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (hydrochloride) oral tablet/25 mg three times daily, Lithium Carbonate (mood stabilizer medication) oral tablet/150 mg at bedtime, and Depakote Sprinkles (anticonvulsant/mood stabilizer medication) delayed release oral tablet/125 mg four times daily.R2's POC (Point of Care) Transfer Chair/bed-to-chair status documentation dated 11/11/2025-12/10/2025 documents, R2 required substantial/maximal assistance from 11/11-11/17. This same sheet documents from 11/18-11/30 R2 began requiring full assistance with transfers and from 11/30-12/10, R2 was dependent with all transfers. R2's Progress note dated 11/9/2025 at 1:24 PM documents, Resident rude and condescending to writer at both med passes this shift. Resident attempting to throw herself out of her wheelchair after lunch in order to get put to bed sooner. Resident now resting in bed.R2's Progress note dated 11/9/2025 at 2:08 PM documents, Resident continues to yell out, curse out staff, and yell that she is calling the police and for people to get out of her house, even though nobody is in her room. PRN Olanzapine administered at this time. Resident continues to curse at writer. Resident's sitter arrived at facility at this time.R2's Progress note dated 11/9/2025 at 2:35 PM documents, PRN (as needed) Administration of Olanzapine 5 mg (milligrams) IM (intramuscular) was: Effective. Resident eventually stopped yelling and cursing at staff.R2's Progress note dated 11/11/2025 at 3:58 PM documents, Screaming you f---ing b.h several times. Trying to get out of bed.R2's Progress note dated 11/11/2025 at 7:10 PM documents, PRN Administration of Olanzapine 5 mg (milligrams) IM (intramuscular) was: Effective.R2's Progress note dated 11/12/2025 at 3:03 AM documents, Resident yelling, being disruptive and attempting to hit staff while staff provides care.R2's Progress note dated 11/12/2025 at 3:41 AM documents, PRN Administration of Olanzapine 5 mg (milligrams) IM (intramuscular) was: Effective.R2's Progress note dated 11/14/2025 at 3:40 PM documents, Hollering out at every person walking by room telling them to Get the F*** out of here. Non-pharm interventions: Staff attempted to approach and redirect, resident screamed for them to get the f*** out. Staff left room but was outside room to monitor her safety while resident continued to yell within room at no one in particular. She hollered for V13 (R2's Family Member) to get the f*** in here and take me out. Where the f*** are you V13, I know you are here. Staff attempted to redirect her and to reassure her that V13 is not here and that we could get her up and take her out of her room to confirm that she is not there. Resident refused and continued to holler out.R2's Progress note dated 11/14/2025 at 3:57 PM documents, PRN Administration of Olanzapine 5 mg (milligrams) IM (intramuscular) was: Effective.R2's Progress note dated 11/18/2025 at 5:26 PM documents, Cursing at others in the dining room, cursing at writer and calling staff the C word. Mocking writer when talking to other residents.R2's Progress note dated 11/18/2025 at 7:24 PM documents, PRN Administration of Olanzapine 5 mg (milligrams) IM (intramuscular) was: Effective.On 12/9/2025 at 10:30 AM, V6 (Certified Nurse Assistant) stated R2's behaviors are typically yelling, and screaming when she is upset and is typically in the afternoons after 2 PM. V6 also stated R2 is not physically abusive towards residents, R2 has seemed very drowsy these last few weeks and went from being a two person assist for transfers to a mechanical lift. V6 stated R2 can be redirected most of the time and stated she feels that R2 has the most verbal outbursts when she is bored or when she can hear people talking in the hallways. V6 stated R2 is not a danger to herself or other residents. On 12/9/2025 at 10:45 AM, V7 (Registered Nurse) stated R2's behaviors are typically screaming and yelling curse words towards staff members when it is time for cares. V7 stated R2 can be physical towards staff but only during cares when she is in a frustrated and confused state of mind. V7 stated R2 is not a harm to herself or other residents. V7 stated R2 is typically very pleasant and fun to talk to, and is easily redirected at times, but it depends on how you approach R2. On 12/9/2025 at 2:00 PM, R2 was in her room, in her bed laying, dressed and on her back. R2 appeared lethargic with her eyes hardly open. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146042 If continuation sheet Page 2 of 8 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 146042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE H & J Vonderlieth Lvg Ctr, The 1120 North Topper Drive Mount Pulaski, IL 62548 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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete R2 stated she looks and feels tired all the time. R2 stated I want to live at home. On 12/9/2025 at 2:00 PM, V8 (Certified Nurse Assistant) stated R2 recently had a Urinary Tract Infection and V8 felt that R2 had more outburst than usual. V8 also stated sometimes R2 can be redirected by going to a different area, or by the fish or the birds. V8 stated R2 typically will be screaming and cussing and calling names towards staff, and that R2 typically does not yell at residents. V8 confirmed R2 is not a danger to herself or to other residents. On 12/10/2025 at 9:30 AM, V13 (R2's Family Member) stated she has been called by facility staff that R2 yells out for her, then R2 will become frustrated and starts cussing and screaming towards staff. V13 stated when she came to visit R2 on 11/25/2025 that R2 was very lethargic and was slouching over in her wheelchair and could not sit up or stay awake. V13 stated she is worried about all R2's psychotropic medications and feels that R2 does not need all of them.On 12/10/2025 at 10:50 AM, R2 was in her room, in her bed, dressed and laying on her back. R2 appeared lethargic and had her eyes closed. R2 would hardly open her eyes. R2 stated I do not want to be here. R2 stated she has no trouble with the staff here but does not want to live here. R2 stated she has felt weaker lately and cannot get up. On 12/10/2025 at 10:45 AM, V14 (Certified Nurse Assistant) stated R2 typically blurts out, cusses, screams, and that is how R2 shows her frustration. V14 stated R2 is not usually physical towards staff. V14 states most of R2's behaviors start after 2PM. V14 stated R2 has recently went from being a two person assist to a mechanical lift. V14 stated R2 is not a harm to herself or other residents. On 12/10/2025 at 11:24 AM, V2 (Director of Nursing) confirmed R2 does not have a diagnosis to warrant her antipsychotic medications. V2 stated R2 is not at risk for hurting other residents and she is on duplicate antipsychotic medication therapy. On 12/10/2025 at 1:41 PM, V18 (Physician) confirmed R2's Depakote, Olanzapine, Rexulti, Valium, and Lithium could be contributing to her lethargic appearance and decline in ability to transfer. V18 also confirmed that R2 receiving multiple Olanzapine injections on an as needed bases are too frequent, and her psychotropic medications should be reviewed.On 12/11/2025 at 11:24 AM V17 (V18's Certified Medical Assistant) stated V18 is aware of R2's psychotropic medications and he believes her behaviors are related to R2's dementia. Event ID: Facility ID: 146042 If continuation sheet Page 3 of 8 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 146042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE H & J Vonderlieth Lvg Ctr, The 1120 North Topper Drive Mount Pulaski, IL 62548 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interview, the facility failed to give medications as ordered by the physician for three of 15 residents (R22, R23 and R44) reviewed for medication pass in the sample of 45. This failure resulted in three errors out of twenty-six opportunities totaling an 11.5% medication error rate.Findings include:The facility's Medication Administration policy, dated 1/11/2010, documents Objective: To provide accuracy during medication pass to assure quality care for residents. Policy: It is the policy of this facility to accurately administer medication following physician's orders. Crush only medications that can be crushed, or physician has given orders to crush.The facility's Insulin Administration policy, dated 10/2009, documents Objective: Proper administration of insulin to promote control of blood glucose levels. This policy also documents Be sure there are no air bubbles in syringe.The facility's employee training guide (undated), provided by V2 (Director of Nursing), documents (for insulin pen administration) Remove protective tab from the pen needle and screw pen needle onto insulin pen. Turn the dosage knob to two units. With the needle end up, tap the insulin pen so any air bubbles collect at the tip. Push the injection button completely. Insulin should come out of the needle. If insulin is not released, repeat the priming process up to four more times until insulin appears. If insulin still does not appear, set pen aside and inform pharmacy; use a new pen. This same training guide documents Priming the pen every time a new needle is attached is vital to insulin pen administration. This ensures the pen is functioning properly and that the desired dose is administered with every injection.1. R22's Order Summary Report, dated 12/11/25, documents a Physician Order to receive Tylenol ES (Extra Strength) 500 milligrams (mg) three times a day for Pain Management.On 12/8/2025 at 11:45 AM V5 (Licensed Practical Nurse) prepared to administer R22 two tablets of Tylenol ES 500 mg (for a total of 1000 mg). At this time V5 confirmed R22's order and stated that she would've given a double dose.2. R23's Order Summary Report, dated 12/11/25, documents a Physician Order to receive Insulin Lispro (1 unit dial) 100 units/milliliter solution (rapid) pen-injector. Inject six units subcutaneously (SQ) in the afternoon related to Type Two Diabetes Mellitus with Hyperglycemia.On 12/8/25 at 1:00 PM, V9 (Registered Nurse) dialed R23's (rapid) insulin pen-injector to six units, applied a SQ needle and then, without first ensuring all air was expelled from the attached needle, injected R23 with insulin in her abdomen. On 12/8/25 at 1:05 PM, V9 stated she isn't sure if she was supposed to prime the needle and stated, It makes sense so that you don't have air in the needle. On 12/8/25 at 1:10 PM, V9 stated I verified with (V16 Licensed Practical Nurse/Minimum Data Set coordinator) and the needle should be primed with about a unit on the (rapid) insulin pen injections, or until we can see the liquid come out of the top of the needle.3. R44's Order Summary Report, dated 12/11/25, documents R44 has an order to receive Omeprazole Oral Capsule Delayed Release. Give 20 milligrams by mouth one time a day, 30 minutes before lunch related to Gastro-Esophageal Reflux Disease without Esophagitis.On 12/8/25 at 11:51 AM, V9 (Registered Nurse) took R44's Omeprazole capsule, sprinkled it into a medication cup and crushed the contents along with two other prescribed medications (Potassium Chloride and Loratadine). V9 then mixed the crushed medications with chocolate pudding and approached R44 who was sitting at a table in the dining room. At this time R44 had begun eating and had a plate in front of her with partially eaten fried chicken, potatoes and mixed vegetables. R44 finished chewing a bite of food, took a drink and then consumed the prepared pudding with medications (including Omeprazole) from V9.On 12/11/25 at 11:20 AM, V2 (Director of Nursing) stated R44 has had recent orders changed and she should be getting her Omeprazole 30 minutes before she eats lunch, not at the same time as her noon medications and not when she is eating food. V2 confirmed those instructions on R44's orders were implemented on 12/6/25.On 12/11/25 at 12:07 PM, V2 stated she Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146042 If continuation sheet Page 4 of 8 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 146042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE H & J Vonderlieth Lvg Ctr, The 1120 North Topper Drive Mount Pulaski, IL 62548 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 0759 Level of Harm - Minimal harm or potential for actual harm spoke with the facility's pharmacy, who confirmed that R44 should be taking the prescribed Omeprazole on an empty stomach, away from other medications and that the capsule contents should not be crushed or administered with pudding. V2 stated I was told it can be sprinkled onto applesauce or yogurt but not pudding and the contents should not be crushed. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146042 If continuation sheet Page 5 of 8 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 146042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE H & J Vonderlieth Lvg Ctr, The 1120 North Topper Drive Mount Pulaski, IL 62548 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure injectable medications for two residents (R1 and R38) were labeled and dated when opened, and failed to ensure a multidose tuberculin vial was discarded after the expiration date when opened. These failures have the potential to affect all 55 residents residing in the facility.Findings include: The Storage of Medication Policy dated [DATE] documents Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Expiration Dating G. All expired medication will be removed from the active supply and destroyed in the facility, regardless of the amount remaining. The medication will be destroyed in the usual manner. The Insulin Storage Chart printed [DATE] documents Generic Name: Insulin Glargine, Stability: Room Temp for 28 days, Insulin Lispro Vial, Cartridge, Pen: 28 days Pump Reservoir: 6 (six) days. Vaccines - Tuberculin PPD (Purified Protein Derivative), Expiration Notes Refrigerate, discard 30 days after opening. The Tuberculin Multi-Dose Vial Label documents Discard opened product after 30 days.The facility's CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Application for Medicare and Medicaid Form 671 dated [DATE] and signed by V1 (Administrator) documents 55 residents currently reside within the facility. R1's Order Summary Report, dated [DATE], documents R1 has a Physician order to receive Insulin Lispro100 unit/ml (milliliter) inject as per sliding scale subcutaneously before meals related to Type Two Diabetes Mellitus.R38's Order Summary Report, dated [DATE], documents R38 has a Physician order to receive Lantus 100 unit/ml inject 30 units subcutaneously at bedtime related to Type 2 Diabetes Mellitus with Hyperglycemia.On [DATE] at 11:09 AM V5 (Licensed Practical Nurse) was standing at the medication cart. V5 opened the top left drawer of the medication cart where resident's opened insulin injector-pens were stored. In this drawer R1's Insulin Lispro 100unit/ml multi-dose pen was opened (3/4 full) and undated and R38's Lantus 100 unit/ml multi-dose pen was opened (1/2 full) and undated. V5 verified at this time R1 and R38's injector pens were not labeled with an open date and were only good for 28 days after opening and at room temperature. V5 stated all opened multi-dose insulin pen injectors should be labeled with an open date after opening.On [DATE] at 11:17 AM V5 opened the refrigerator located in the north medication room. Two vials of Aplisol (Tuberculin) 5TU (Tuberculin Units) 0.1 ml were in the medication room refrigerator. Both (Tuberculin) vials were opened, 1/4 full, and was labeled with an open date of [DATE]. V5 verified the (Tuberculin) vials were opened and dated with an open date of [DATE] and stated, The (Tuberculin) is used for all residents residing in the facility. (Tuberculin) should be discarded after 30 days of opening. Both (Tuberculin) vials are expired. Event ID: Facility ID: 146042 If continuation sheet Page 6 of 8 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 146042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE H & J Vonderlieth Lvg Ctr, The 1120 North Topper Drive Mount Pulaski, IL 62548 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 Based on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP) for residents with open wounds and surgical wounds for six of six residents (R2, R8, R9, R18, R26, and R31) reviewed for EBP in the sample of 45. Findings include: The Enhanced Barrier Precaution Protocol dated 4/8/24 documents Enhanced Barrier Precautions (EBP) expands the use of Personal Protective Equipment (PPE) beyond situations in which exposer to blood and body fluids is anticipated, refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of Multi-Drug-Resistant Organisms (MDROs) to staff hands and clothing. If Enhanced Barrier Precautions are required, a sign should be placed outside the resident's room to assist in educating staff, residents, and visitors on appropriate personal protection. When required, Enhanced Barrier Precautions apply to everyone caring for the resident. Personal Protective Equipment PPE (e.g. (example), gloves and gowns) should be used during high-contact resident care activities. Examples of high-contact resident care activities requiring gown and glove use include Dressing, Bathing/showering, Transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, and or/wound care: any skin opening requiring a dressing. Enhanced Barrier Precautions May Be Indicated for Residents with Any of The Following: Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage (e.g., (adhesive covering) or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers.The CDC (Centers for Disease Control) and Prevention Enhanced Barrier Precautions sign, provided by the facility, documents Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing Briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, and/or Wound Care: any skin opening requiring a dressing.The facility's Weekly Pressure Wound Report dated 12/8/25 documents that R8 has a stage two pressure wound to her coccyx that requires a dressing. The facility's Non-Pressure Wound Report dated 12/8/25 documents that R2, R9, and R26 have Moisture Associated Skin Damage/MASD, R18 has three surgical wounds, and R31 has Vascular wounds. All these wounds require a dressing. On 12/10/25 at 10:50 AM, V10 (Infection Preventionist) stated that there are five residents in EBP. They all have an indwelling catheter. There are residents in the facility that have wounds but none of these residents are in EBP. Residents that have wounds do not require EBP unless the wounds are infected or not healing. On 12/10/25 at 11:25 AM, V11 (Certified Nursing Assistant/CNA) and V12 (CNA) provided incontinent care for R8 and did not wear a gown. R8 has a stage two pressure wound to her coccyx. V11 stated that EBP was not required while caring for R8. On 12/10/25 at 11:30 AM, V9 (Registered Nurse) provided pressure ulcer treatment to R8's coccyx and did not wear a gown. V9 stated that EBP is not required for R8's pressure ulcer because it is not a stage three or four, not infected, and is not nonhealing. On 12/10/25 at 11:40 AM, a tour of the building was done. During this tour R2, R8, R9, R18, R26, and R31's doors did not have signs indicating they were in Enhanced Barrier Precautions. On 12/10/25 at 11:50 PM V2 (Director of Nursing/DON) stated that R2, R8, R9, R26, and R31 have open wounds that are getting a dressing. R18 has surgical wounds. None of these residents are in EBP and EBP is not required for any of these residents. EBP is only required for wounds that are infected or non-healing. On 12/10/25 at 12:42 PM, V2 (DON) stated that she was not aware that EBP was required for any skin opening that required a dressing. V2 also stated after reading the policy and the sign that is to be posted on the door that EBP should be worn when providing care for Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146042 If continuation sheet Page 7 of 8 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 146042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE H & J Vonderlieth Lvg Ctr, The 1120 North Topper Drive Mount Pulaski, IL 62548 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 residents with wounds. 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: 146042 If continuation sheet Page 8 of 8