Inspection·March 15, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on interview and record review, the facility failed to revise a care plan to include target behaviors for the use of an antipsychotic medication for one of three residents (R1) reviewed for antipsychotics in the sample of 27. Findings include: The facility's Psychotropic Medication policy, dated 2/14, documents, Psychopharmacologic drug usage must be addressed in the Care Plan and reassessed at least every 90 days. Documentation of behaviors and conditions requiring the use of these medications must be done on a routine basis including resident response to the medication. R1's Physician's orders, dated 2/14-3/14/23, document that R1 has orders to receive Seroquel (antipsychotic) 12.5 mg (milligrams) by mouth twice a day on Monday, Tuesday, Friday and Saturday and Seroquel 12.5 mg by mouth daily at bedtime on Sunday, Wednesday, and Thursday for the diagnosis of Persistent Mood Disorder. R1's Psychotropic care plan, dated 12/28/22, documents, I receive Sertraline and Seroquel daily for my diagnosis of MDD (Major Depressive Disorder) and psychosis and alprazolam daily for anxiety. The care plan has no documentation of R1's target behaviors to warrant the use of R1's Seroquel. R1's Psychoactive Medication Evaluation, dated 3/14/23, documents, Diagnosis: Major Neurocognitive disorder, mixed etiology with behavior disturbance. Behavior warranting use of medication: Hallucinations, delusions, extensive confabulation of words, paranoia. On 03/14/23 at 10:54 AM, V6 (Care Plan Coordinator) confirmed that R1's care plan does not include R1's target behaviors for the use of R1's Seroquel. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145404 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 145404 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Farmington Village Nrsg 701 South Main Street Farmington, IL 61531 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review the facility failed to keep a urinary catheter bag off the floor for three of three residents (R5, R45, R63) reviewed for urinary catheters in the sample of 27. Residents Affected - Few Findings include: The facility's Urinary Catheter Care policy dated 09/2005 documents, The purpose of this procedure is to prevent infection of the resident's urinary tract. General Guidelines: 11. Be sure the catheter tubing and drainage bag are kept off the floor. 1. R5's admission Electronic Diagnoses dated 2-15-23 documents R5 has the diagnosis of Quadriplegia. R5's Care Plan dated 2-20-23 documents, Problem: I have a foley (indwelling urinary catheter) and a history of urinary tract infections. On 03/12/23 from 07:04 AM through 9:30 AM R5 was lying in bed. R5's indwelling urinary catheter bag was lying flat on the floor beside the right side of the bed and was not inside a privacy bag. R5 stated, I do not know why the staff put the bag on the floor. 2. R45's Physician's Order Sheets, dated 3/10/2023, documents, Indwelling catheter 16 French with a 30 cc (Centimeter) for a diagnosis of neurogenic bladder. R45's Care Plan, dated 1/10/2023, documents, Indwelling Catheter 16 French with 30 CC for a neuromuscular disease of the bladder and urinary retention. On 3/12/23 at 08:52 AM R45 was lying in bed waiting to get up for breakfast. R45 had an indwelling catheter that was hanging from the side rail on the right side of bed. R45's catheter bag was laying on the ground and was not covered with a privacy bag. R45 states, The catheter lays on the floor quite often. On 3/12/2023 at 9:10 AM, V7/CNA (Certified Nursing Assistant) stated, I was trying to get R45 up for breakfast. I didn't think it would be a problem to leave the catheter bag on the floor. 3. On 3/12/23 at 10:19 AM R63 was sitting in his room in his wheelchair. R63 had an indwelling catheter that was hanging from the side of the wheelchair with the urinary bag laying on the ground. R63's Physician Order Sheets, dated 1/24/2023, documents, Specialized catheter 20 French with a 30 cc (centimeter) bulb. R63's Problem List, dated 7/22/22, documents, R63 has the following diagnosis of Urinary Retention, Calculus on Ureter, Neurogenic Bladder, and a Neuromuscular Dysfunction of the Bladder. On 3/15/2023 at 8:15 AM V2/Director of Nurses, stated, The catheter bag does not belong on the floor. They should all be kept off the floor and in a privacy bag. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145404 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 145404 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Farmington Village Nrsg 701 South Main Street Farmington, IL 61531 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to prepare and hold food at a safe temperature. This has the potential to affect all 75 residents residing in the facility. Residents Affected - Many Findings include: The facility's Hot Food Service Temperature policy, dated 5/8/18, documents, Food will be held in the steam table at 135 degrees F (Fahrenheit) or above during tray assembly. Food temperatures of food being held in the steam table will be recorded. On 03/12/23 at 07:05 AM, V9 (Cook) had the breakfast food prepared and stored in the steam table. Holding temperatures were checked by V9. The scrambled eggs were at 120 degrees F (Fahrenheit), sausage 130 degrees F, bacon 110 degrees F, mechanical sausage 115 degrees F, pureed sausage 130 degrees F, and sausage gravy 130 degrees F. V9 stated the temperatures should be at least 135 degrees F. The facility's CMS (Centers for Medicare and Medicaid Services) Resident Census and Conditions of Residents Form 672, dated 3/12/23 and signed by V2 (Director of Nursing), documents that 75 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145404 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 145404 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Farmington Village Nrsg 701 South Main Street Farmington, IL 61531 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor and record the levels of sanitizing solution of the facility dishwasher and three compartment sinks, the temperatures of food while in the steam table, the temperatures of the refrigerators and freezers, and failed to document the food cooling process and perform safe thawing of potentially hazardous food. These failures had the potential to affect all 75 residents residing in the facility. Findings include: The facility's CMS (Centers for Medicare and Medicaid Services) Resident Census and Conditions of Residents Form 672, dated 3/12/23 and signed by V2 (Director of Nursing), documents that 75 residents reside in the facility. The facility's Storage Temperatures policy, no date, documents, Temperatures of food storage areas are monitored, and action is taken to maintain temperatures within ranges recommended by licensing and surveying agencies. Frozen storage: Must keep frozen foods frozen solid. Refrigerate Storage: 41 degrees F (Fahrenheit) or below. Each mechanically refrigerated unit storing potentially hazardous food shall be provided with a numerically scale indicating thermometer, accurate to +/-3 degrees F, located to measure the air temperature in the warmest part of the facility and located to be easily readable. The facility's Storage of Frozen Foods policy, no date, documents, Freezers will be equipped with an internal thermometer and monitored. Temperatures will be documented. The facility's Storage of Refrigerated Foods policy, no date, documents, Refrigerated foods are stored at 41 degrees or below. Refrigerators will be equipped with an internal thermometer and monitored. Temperature will be checked and documented. The facility's Cold Food Storage, Preparation, and Meal Service policy, dated 5/18/18, documents, Food will be prepared by methods that conserve nutritive value, flavor, and appearance. Food will be prepared and served in a safe manner to prevent food borne illness. A food temperature log will be kept for each and each food item. The facility's Two Stage Cool Down Process policy, no date, documents, Potentially hazardous foods will be cooled properly to prevent food borne illness. Foods will be cooled to proper temperatures. A two-stage cooling process will be followed: Stage I: Cool foods from 135 degrees F (Fahrenheit) to 70 degrees F within two hours. Stage II: Cool foods from 70 degrees F to 41 degrees F within four hours (total of six hours). Foods will be cooled in pans less than 4 (inches) deep (preferably 2 deep). Cut large items such as roasts into quarters. Food will be covered loosely to allow heat to escape. Foods will be labeled, dated, and show time prepared. The time and temperature of food cooling will be documented at two- and four-hour intervals. Food that has not been cooled to 70 degrees F, or below, within the first two hours, will be reheated one time only and the cooling process using a different process will be utilized or the product will be discarded. The facility's Thawing Hazardous Food policy, no date, documents, Potentially hazardous food will be thawed in a safe and sanitary manner. Potentially hazardous foods will be thawed: 1. In (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145404 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 145404 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Farmington Village Nrsg 701 South Main Street Farmington, IL 61531 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many refrigerated units in a way that the temperature of the food does not exceed 41 degrees F (Fahrenheit) (Recommended Method) or 2. Under potable running water at a temperature of 70 degrees F or below with sufficient water velocity (pressure) to agitate and float off loose food particles into overflow or 3. As part of conventional cooking process or 4. In a microwave oven only when the food will be immediately transferred to conventional cooking facilities as part of a continuous cooking process or when the entire cooking process take place in the microwave. The facility's Dishwashing Procedure, no date, documents, Fill the dish machine with water. Turn on the heater. Check chemicals to determine an adequate supply. If not, replace. Check wash and rinse temperature on the dish machine. Check the temperature gauge. Record temperatures. If temperatures are too low, report this to the food service supervisor. Test strips are available through the food service supervisor. Before dishes are washed, the sanitation temperature or level of chemical sanitizer in the dish machine should be tested with the correct test strip. The procedure also documents, For chemical sanitizing machines: Dip the appropriate chemical sanitizer test strip in the water on the drain board nearest to the opening at the clean end of the dish machine. Dip for one second only. The test strip should return the appropriate color to indicate 50 ppm (parts per million) for chlorine. The facility's Pots & Pans Sanitization (three compartment sink) Log, dated 3/23 and provided by V9 (Cook) on 03/12/23 at 06:45 a.m., has no documentation of the sanitizer levels being checked 3/4 & 3/5 for breakfast and lunch and 3/6-3/11/23 for all three meals. The facility's Dish Machine Log-Low Temperature dated 3/23 and provided by V8 (Dietary Manager) on 3/14/23 at 1:40 p.m., documents, Instructions: Record wash temperature and sanitizer PPM (Parts Per Million), and provide initials, three times per day. Notify supervisor immediately if sanitizer PPM is not within acceptable range of 50-100 (PPM). The log also has no documentation of this being completed on 3/2 breakfast & lunch, 3/3 on all three meals, 3/6 on breakfast & lunch, 3/9 at supper, and 3/10 at supper. On 03/12/23 at 06:32 AM, a cooler (milk cooler) that contained milk and egg mixture had no thermometer located inside of it. On 03/12/23 at 06:36 AM, a cooler (tray [NAME] cooler) that contained an assortment of drinks and condiments had a broken thermometer inside of it. On 03/12/23 at 06:39 AM, a walk-in freezer that contained meat and vegetables had a broken thermometer inside of it. On 03/12/23 at 06:45 a.m. V9 (cook) provided two binders and stated that the binders were where the staff documented food temperatures, three compartment sink sanitizer, and cooler temperatures. V9 confirmed the missing documentation in the binders and stated, The cooks are responsible for checking refrigerator and freezer temperatures and food temperatures, but we get busy and forget. The facility's Temperature Log-Milk Cooler dated 3/23 dated 3/23 and provided by V9 (Cook) on 03/12/23 at 06:45 a.m., documents, Instructions: Record temperatures for each cooler in the department (walk-ins and reach-in units). Record time and temperature, and provide initials, twice per day (AM & PM). The log has no documentation of temperature checks being completed on the following dates: 3/4 AM & PM; 3/5 AM, 3/6-3/11 AM & PM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145404 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 145404 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Farmington Village Nrsg 701 South Main Street Farmington, IL 61531 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many The facility's Temperature Log-Cook Cooler, dated 3/23 and provided by V9 (Cook) on 03/12/23 at 06:45 a.m., has no documentation of temperature checks being completed on the following dates: 3/4 AM & PM; 3/5 AM, 3/6-3/11 AM & PM. The facility's Temperature Log-Tray [NAME] Cooler, dated 3/23 and provided by V9 (Cook) on 03/12/23 at 06:45 a.m., has no documentation of temperature checks being completed on the following dates: 3/4 AM & PM; 3/5 AM, 3/6-3/11 AM & PM. The facility's Temperature Log-Little Freezer, dated 3/23 and provided by V9 (Cook) on 03/12/23 at 06:45 a.m., has no documentation of temperature checks being completed on the following dates: 3/4 AM & PM; 3/5 AM, 3/6-3/11 AM & PM. The facility's Temperature Log-Ice Cream Freezer, dated 3/23 and provided by V9 (Cook) on 03/12/23 at 06:45 a.m., has no documentation of temperature checks being completed on the following dates: 3/4 AM & PM; 3/5 AM, 3/6-3/11 AM & PM. The facility's Temperature Log-Walk-In Freezer, dated 3/23 and provided by V9 (Cook) on 03/12/23 at 06:45 a.m., has no documentation of temperature checks being completed on the following dates: 3/4 AM & PM; 3/5 AM, 3/6-3/11 AM & PM. The facility's daily spreadsheet week four, dated 1/29-2/4/23, has no documentation of food temperatures for the following meals: 1/29 breakfast & lunch, 1/30 breakfast & lunch, 1/31 breakfast & lunch, 2/1 breakfast, 2/2 breakfast, 2/3 breakfast & lunch, 2/4 breakfast and supper. The facility diet spreadsheet week one, dated 2/5-2/11/23, has no documentation of food temperatures for the following meals: 2/5 breakfast & lunch, 2/6 breakfast & lunch, 2/7 breakfast & lunch, 2/8 breakfast & lunch, 2/9 breakfast & lunch, 2/10 breakfast & lunch, 2/11 breakfast & lunch. The facility diet spreadsheet week two, dated 2/12-2/18/23, has no documentation of food temperatures for the following meals: 2/12 breakfast & lunch, 2/13 breakfast & lunch, 2/14 breakfast & lunch, 2/15 supper, 2/16 all three meals, 2/17 all three meals, 2/18 all three meals. The facility diet spreadsheet week three dated 2/19-2/25/23, has no documentation of food temperatures for any of the meals served during this week. The facility diet spreadsheet week four, dated 2/26-3/4/23, has no documentation of food temperatures for the following meals: 2/26 breakfast & lunch, 2/27 breakfast & lunch, 2/28 breakfast & lunch, 3/1 breakfast, 3/2 breakfast, 3/3 breakfast & lunch, 3/4 breakfast & supper. The facility diet spreadsheet week one, dated 3/5-3/11/23, has no documentation of food temperatures for the following meals: 3/5 breakfast, 3/6 breakfast, 3/7 supper, 3/8 breakfast, 3/9 breakfast & supper, 3/10 breakfast & lunch, 3/11 breakfast. On 03/12/23 at 06:34 AM, a cooler (cooks cooler) contained a large metal pain containing two large roasts. The pan was covered with foil and undated. V9 (cook) stated, I started cooking that yesterday, but I left at 1:30 p.m., so I'm not sure if they did a cool down on it or not. On 03/12/23 at 06:39 AM, a walk-in freezer that contained meat and vegetables had a foil wrapped round object with a sticker stating that it was a grilled turkey, and it was dated 3/11/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145404 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 145404 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Farmington Village Nrsg 701 South Main Street Farmington, IL 61531 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 03/12/23 at 06:42 AM, a compartment in the three-compartment sink had two packages of pork pieces sitting in a metal pan of water. V9 stated, I placed them in the water at about 6:15 a.m. I'm defrosting the meat for lunch today. I will keep in in the water until I'm ready to cook it in about an hour. On 03/12/23 at 07:21 AM, V8 (Dietary Manager) stated that the facility does not have a cool down log because they do not keep leftovers. V8 also stated, We shouldn't have a roast or a turkey in the cooler. I wasn't aware that the roast was cooked the day prior. The cool downs should be on a sheet on the cooler door if there was one, but that is not how we prepare our food. We do not have cool down logs for the turkey or the roast. V8 also stated, Our defrosting process is to place frozen meat into the refrigerator to defrost. V8 confirmed that pork was sitting in water in sink. Stated, If it's in the sink it should have cold water running on it. On 03/14/23 at 03:04 PM, V8 (Dietary Manager) confirmed the lack of documentation for the food temperatures, refrigerator/freezer temperatures, and level of sanitizer solution. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145404 If continuation sheet Page 8 of 8