Health inspection·June 4, 2025

F 0677 Level of Harm - Minimal harm or potential for actual harm The Facility Skin/Bath/Shower Policy dated August 2022 states resident are to get showers two times a week. The Shower Sheets dated 6/2/25 state residents are scheduled to receive a shower two times a week either on morning shift or night shift and if a resident refuses the resident or Power of Attorney must sign the refusal and indicate why the resident refused. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145422 If continuation sheet Page 2 of 11 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 145422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fair Havens Senior Living 1790 South Fairview Avenue Decatur, IL 62521 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to accurately account for controlled medications and document shift to shift controlled medication counts for seven (R3, R4, R5, R9, R15, R16, R22) of seven residents reviewed for controlled medications in the sample list of 24. Findings include: The facility's Medication Ordering, Receiving, and Storage of Controlled Substances policy dated 5/1/14 documents nurses will count controlled medications at the end of each shift, with both the nurse coming on duty and the nurse going off duty counting together. This will be documented and discrepancies will be reported to the Director of Nursing (DON). The facility's Medication Administration policy dated 11/3/14 documents to review the medication and dosage on the Medication Administration Record (MAR) and medication label prior to administering medications, and document administration on the MAR directly after the medication is given. 1.) On 6/2/25 at 10:07 AM the station 3 medication cart was viewed with V20 Licensed Practical Nurse (LPN). The locked compartment contained controlled medications, including R22's Clonazepam 0.5 milligrams (mg) 14 tablets, R9's Tramadol 50 mg 26 tablets, R16's Tramadol 50 mg 28 tablets, and R4's Norco 5-325 mg 11 tablets. On 6/2/25 at 1:06 PM and on 6/3/25 at 11:38 AM the controlled medication binder for this medication cart did not contain a Controlled Substance Shift Change Count Sheet. This was confirmed with V20 on 6/2/25 at 1:15 PM. 6/2/25 at 10:22 AM the station 2 medication cart was viewed with V18 LPN. The locked compartment contained controlled medications, including a bottle of R3's Morphine 100 mg per milliliter, R3's Tramadol 50 mg 12 tablets, and R3's Lorazepam 0.5 mg 17 tablets. This was confirmed with V18. V18 stated controlled medications are counted between the nurses at each shift change and recorded on the form in the binder. At 1:00 PM the station 1 controlled medication binder was reviewed with V18. V18 confirmed the Count Sheet with date range 5/26/25-6/3/25 does not document two nurse signatures as indicated on 5/28/25, 5/29/25, and 6/2/25. V18 stated V18 completed shift count this morning with V30 LPN night shift nurse, but had not signed the form. The May-June 2025 Controlled Substance Shift Change Count Sheets for the facility's medications carts were requested on 6/3/25 and provided by V2 DON. There were no forms for the station 3 medication cart. There were only two forms for the station 1 medication cart ranging 5/16/25-6/3/25. There is no recorded entry for 5/25/25. The forms for station 2 with date range of 4/29/25-5/25/25 do not document count was completed on 5/3/25 or two nurse signatures on seven of these days. On 6/3/25 at 11:20 AM V2 DON confirmed controlled medication count should be done with two nurses at each change of shift/nurse and signed out on the form in the binder for that medication cart. V2 stated there should be a form for this in each controlled medication binder for each cart. On 6/4/25 at 10:00 AM V2 stated V2 provided all of the controlled substance shift count forms that V2 could locate for all three medication carts for May and June 2025. V2 confirmed none provided for station 3. 2.) R3's April, May and June 2025 MARS document R3 has not had an active order for Lorazepam since (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145422 If continuation sheet Page 3 of 11 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 145422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fair Havens Senior Living 1790 South Fairview Avenue Decatur, IL 62521 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4/16/25. R3's Controlled Drug Receipt/Record/Disposition Form dated 4/2/25, documents Lorazepam 0.5 mg 30 tablets were received. Dispensed doses are signed out on seven days between 5/7/25 and 6/1/25. R3's Controlled Drug Receipt/Record/Disposition Forms with date range of 4/25/25 through 6/1/25 for Tramadol 50 mg tablets, document doses were dispensed at 9:00 PM on 5/2/25, 5/3/25, 5/9/25, 5/13/25, at 10:15AM on 5/7/25, and 9:00 AM on 5/14/25. Four of these are signed out by V30 LPN. R3's May 2025 MAR documents to give Tramadol 50 mg one tablet every eight hours as needed from 4/3/25 until 5/14/25 when the order was changed to scheduled every eight hours. This MAR does not document Tramadol was given on 5/2/25, 5/3/25, 5/7/25, 5/9/25, 5/13/25 or at 9:00 AM on 5/14/25. On 6/2/25 at 2:09 PM V18 LPN confirmed R3 does not have an active Lorazepam order. V18 consulted with V35 Hospice RN (Registered Nurse). V35 stated R3 was admitted to hospice on 4/3/25 and R3's hospice orders include Lorazepam 0.5 mg one tablet every six hours as needed and there is no stop date for this medication. On 6/3/25 at 12:20 PM V30 LPN stated she had been giving R3 Ativan at bedtime due to R3 not sleeping through the night and complaints of leg spasms. V30 stated it was passed on in report to try the medication on a trial basis and follow up with hospice to get the order scheduled. V30 confirmed she administered doses on 5/30/25, 5/31/25, and 6/1/25. V30 stated V30 did not notice until the morning of 6/1/25 that R3 did not have an order for Ativan in the computer, so the medication was not able to be signed out on the MAR. V30 stated V30 had not looked in R3's electronic medical record to verify the Lorazepam order prior to 6/1/25. On 6/4/25 at 11:02 AM V36 LPN stated V36 administers the medications as signed out on R3's controlled medication records and V36 may have forgot to sign out the MAR. V36 stated V36 administered R3's Ativan, it was passed on in report that hospice wanted us to try giving it night due to anxiety, leg spasms, and R3 not sleeping well. V36 stated it should have been recorded on the MAR. On 6/3/25 at 11:20 AM V2 DON confirmed Controlled Drug Record form should match and coincide with the resident's MAR, with entries noted on both the count sheet and the MAR. 3.) R5's May 2025 MAR documents to give Norco 5-325 mg one tablet by mouth every six hours as needed for pain. R5's Controlled Drug Receipt/Record/Disposition Form dated 4/1/25 documents 21 tablets of Norco 5-325 mg were dispensed. This form documents doses were dispensed on 5/2/25, 5/3/25, 5/4/25, 5/24/25, 5/15/25, and 5/18/25. These doses are not signed out on R5's MAR. On 6/3/25 at 3:20 PM V2 DON confirmed R5's Norco controlled form entries do not match R5's MAR. 4.) R15's May 2025 MAR documents to give Norco 5-325 mg every eight hours. This order was discontinued on 5/30/25 per R15's Hospital Discharge Plan dated 5/30/25. R15's Controlled Drug Receipt/Record/Disposition Form dated 5/6/25 document doses were dispensed on 5/8/25 and 5/13/25 at 8:00 PM, and on 5/30/25 at 9:00 PM. These doses are not signed out on R15's MAR. On 6/3/25 at 9:30 PM V12 LPN stated there were two days in May that the facility had power issues and V12 was unable to sign out R15's Norco administration on R15's MAR. V12 stated R15's Norco was still listed as an active order on 5/30/25 since the prior shift nurse had not entered R15's hospital discharge orders including stopping Norco. V12 stated V12 administered the medication because it popped up on the MAR. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145422 If continuation sheet Page 4 of 11 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 145422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fair Havens Senior Living 1790 South Fairview Avenue Decatur, IL 62521 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 0755 . 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: 145422 If continuation sheet Page 5 of 11 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 145422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fair Havens Senior Living 1790 South Fairview Avenue Decatur, IL 62521 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to administer medications timely and as ordered and timely reorder medications resulting in significant medication errors for four (R3, R15, R16, R25) of five residents reviewed for medications in the sample list of 24. Residents Affected - Some Findings include: The facility's Medication Administration policy dated 11/3/14 documents the following: Verify the medication and order with the MAR prior to administration, and medications should be administered according to the physician's order. If a current ordered medication is unavailable then contact the pharmacy to obtained from the night box/emergency kit. Administer medications within 60 minutes of the scheduled time, unless otherwise ordered. Record medication administration on the MAR directly after giving the medication. Enter an explanatory note when withholding scheduled medications and notify the physician of consecutive withheld doses. Document the notification and physician response. 1.) R3's May and June 2025 Medication Administration Records (MARs) document an order dated 4/3/25 for Tramadol 50 milligrams (mg) one tablet every eight hours as needed (PRN). This order was discontinued and changed to Tramadol 50 mg scheduled three times daily 6:00 AM, 2:00 PM, and 8:00 PM on 5/14/25. R3's May MAR documents Tramadol was not administered on 5/21/25 at 6:00 AM and 2:00 PM, 5/22/25 at 6:00 AM and 10:00 PM, and on 5/23/25 at 6:00 AM. R3's Tramadol 50 mg Controlled Drug Receipt/Record/Disposition Form dated 4/3/25 documents 30 tablets were dispensed and the last tablet was dispensed on 5/20/25 at 10:00 PM. R3's Tramadol 50 mg Controlled Drug Receipt/Record/Disposition Forms dated 5/22/25 document 45 tablets were dispensed and the first recorded entry is dated 5/23/25 at 12:30 PM. R3's Tramadol is signed out four times on 5/31/25 and 6/1/25, not three times as ordered. R3's Nursing Note dated 5/22/25 at 7:47 PM documents still waiting on pharmacy for R3's Tramadol. R3's Nursing Note dated 5/23/25 at 5:15 AM documents an electronic facsimile was sent to the physician about needing to refill R3's Tramadol. Hospice was notified on 5/20/25 that R3 would be out of Tramadol on 5/21/25, and the facility was still waiting for this medication. On 6/2/25 at 2:09 PM V18 Licensed Practical Nurse (LPN) stated R3's medications come from the facility's pharmacy and not hospice. On 6/2/25 at 2:09 PM V35 Hospice Registered Nurse stated R3's Tramadol order was changed from PRN to scheduled three times daily on 5/14/25. On 6/3/25 at 11:53 AM V37 LPN confirmed V37 administered R3's Tramadol on 5/31/25 and 6/1/25 at 12:00 PM and 6:00 PM. V37 stated R3 had requested pain medication at those times and V37 thought R3 still had a PRN Tramadol order. On 6/3/25 at 3:20 PM V2 Director of Nursing (DON) stated the nurses should notify the physician, resident/representative and document in a progress note when a medication is not given. V2 stated the nurses should be reordering medications when supply is low to avoid running out of the medication. V2 confirmed R3's Tramadol Controlled Drug Forms do not document doses on 5/21/25 and 5/22/25. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145422 If continuation sheet Page 6 of 11 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 145422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fair Havens Senior Living 1790 South Fairview Avenue Decatur, IL 62521 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 6/4/25 at 10:15 AM V20 LPN stated R3 was out of Tramadol on 5/21/25, R3's hospice nurse was here that day and said the Tramadol would be ordered. V20 stated V20 told the hospice nurse that the facility's pharmacy does not deliver medications until morning. V20 stated the pharmacy did not send R3's Tramadol because a signed prescription was needed, Tramadol is in the backup medication system but the nurses aren't able to access it for controlled medications without a signed prescription. V20 stated R3's Tramadol order had been changed around that time from as needed to scheduled three times daily. On 6/4/25 at 11:49 AM V34 Pharmacist stated on 4/3/25 pharmacy sent 30 Tramadol tablets for R3, which was ordered as every eight hours at that time. V34 stated on 5/22/25 pharmacy sent 30 tablets that arrived at the facility on 5/23/25. V43 stated there were no doses of Tramadol dispensed from the facility's backup medication system in May 2025 for R3. V34 stated the pharmacy received the signed prescription from the facility on 5/22/25 and the only other signed script on file was dated 4/3/25 for 45 tablets. 2.) On 6/2/25 at 11:06 AM R15 stated the facility ran out of R15's Norco recently. R15's May and June 2025 MARs document to administer Norco 5-325 mg one tablet every eight hours. R15's Norco 5-325 mg Controlled drug Receipt/Record/Disposition Form dated 5/16/25 documents 30 tablets were delivered and the last tablet was signed out on 5/17/25 at 2:00 PM. R15's Norco 5-325 mg Controlled drug Receipt/Record/Disposition Form dated 5/18/25 documents 30 tablets were delivered and the first dispensed dose is signed out on 5/19/25 at 5:00 AM. R15's Nursing Note dated 5/17/25 at 9:01 PM documents a new signed script is needed for R15's Norco, per pharmacy. R15's Nursing Note dated 5/18/25 at 5:15 AM documents still waiting on pharmacy for Norco. R15's May and June 2025 MARs document to administer the following: Lantus insulin 10 units at 9:00 AM and 8 units at 5:00 PM. Gabapentin 200 mg twice daily. Hydralazine 25 mg three times daily. Isosorbide 20 mg three times daily. R15's Medication Administration Audit Report with date range of 5/1/25-6/4/25 documents between 5/20/25 and 6/4/25 there were eight occasions where these listed medications were given more than over an hour and thirty minutes past the scheduled time. This report documents additional occasions of this between the referenced date range. R15's nursing notes do not document communication with the physician in regards to R15's delayed medication administration times. On 6/3/25 at 12:20 PM V30 LPN stated R15 did not have a supply of Norco for the 6:00 AM dose on 5/18/25. V30 stated pharmacy was suppose to send it, but it may have arrived after her shift ended. V30 stated V30 tries to notify the physician if a medication isn't available or obtain the medication from the backup medication system. V30 stated controlled medications can only be obtain from the backup medication system if there is a signed script on hand. V30 was unsure if there was a signed script on file that day. On 6/4/25 at 11:30 AM V2 DON stated the expectation is for medications to be administered within the hour window before/after the scheduled medication time. V2 stated the standard of practice is to document at the time the medication is given. V2 stated if medications are given past that window, then the nurse should notify the physician and document this in a nursing note. On 6/4/25 at 11:49 AM V34 Pharmacist stated pharmacy sent out 30 tablets of Norco for R15 on 5/6/25. Another 60 tablets were sent out on 5/18/25, and the facility had placed this reorder on 5/18/25. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145422 If continuation sheet Page 7 of 11 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 145422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fair Havens Senior Living 1790 South Fairview Avenue Decatur, IL 62521 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some V34 stated Norco was not removed from the facility's backup medication system for R15 in May 2025. V34 stated R15's script dated 5/14/25 was for 80 tablets, but the facility did not send this script to the pharmacy until 5/18/25. 3.) R16's May 2025 MAR documents to administer Amlodipine 2.5 mg by mouth daily and administer Metoprolol Extended Release 25 mg daily. This MAR documents Amlodipine wasn't given on 5/17/25, 5/18/25, and 5/31/25. This MAR documents Metoprolol was not given on 5/14/25 and 5/17/25-5/19/25. R16's physician's orders do not include blood pressure or pulse parameters for withholding these medications. There is no documentation in R16's nursing notes that a physician was notified that these medications were held. On 6/4/25 at 9:43 AM V20 LPN confirmed V20 did not sign out R16's Amlodipine and Metoprolol as given on the dates listed above. V20 stated V20 was probably waiting for R16's blood pressure before giving the medications. V20 stated the facility only has one vital sign cart and it is difficult to find a blood pressure cuff. V20 stated V20 holds the medication for blood pressure less than 120/60, which is what R16's physician prefers. V20 confirmed R16's MAR does not document blood pressure and pulse for the dates V20 withheld these medications. On 6/4/25 at 10:00 AM V2 DON stated the nurses should notify the physician when holding a medication based on blood pressure without an order to do so, and the nurse should obtain orders for parameters. At 11:30 AM V2 confirmed R16 did not have physician ordered parameters for withholding Amlodipine and Metoprolol prior to today. 4.) On 6/3/25 at 10:18 AM R25 stated there were three nights in a row about a week or two ago, that R25 did not receive her 7:00 PM scheduled medications until 9:00 PM-10:15 PM. R25 stated the nurses get behind due to being new or if another resident falls. R25's Minimum Data Set, dated [DATE] documents R25 as cognitively intact. R25's May 2025 and June 2025 MARs document to administer Duloxetine 60 mg twice daily at 9:00 AM and 7:00 PM, administer Lisinopril 5 mg twice daily at 9:00 AM and 9:00 PM, and administer Metformin 500 mg twice daily at 9:00 AM and 7:00 PM. R25's Medication Administration Audit Report with date range of 4/1/25-6/4/25 documents between 5/20/25 and 6/4/25 these medications were administered over an hour and thirty minutes after the scheduled times on eight occasions. This report documents additional repeated occasions of this during the referenced date range. On 6/4/25 at 11:02 AM V36 LPN stated some nights are busier than others which can make it difficult to get medications administered within the hour window. On 6/4/25 at 11:30 AM V2 DON stated the expectation is for medications to be administered within the hour window before/after the scheduled medication time. V2 stated the standard of practice is to document at the time the medication is given. V2 stated if medications are given past that window, then the nurse should notify the physician and document this in a nursing note. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145422 If continuation sheet Page 8 of 11 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 145422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fair Havens Senior Living 1790 South Fairview Avenue Decatur, IL 62521 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 - Few 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. Based on observation, interview, and record review, the facility failed to ensure controlled medications were stored appropriately and destroy controlled medications when discontinued for two (R3, R15) of seven residents reviewed for controlled medications in the sample list of 24. Findings include: The facility's Medication Ordering, Receiving, and Storage of Controlled Substances policy dated 5/1/14 documents controlled substances will be stored in the medication room separate from non-controlled medications, in a locked container, which will be locked at all times except when accessed with a key or code to obtain resident medications. This policy documents the charge nurse will maintain the keys to the controlled substance medications, and two licensed nurses will destroy controlled medications as soon as possible when discontinued. 1.) R3's Physician Order dated 4/2/25 documents Morphine Sulfate 20 milligrams per milliliter (mg/ml) give 0.25 ml by mouth every hour as needed for shortness of breath or wheezing. R3's Controlled Drug Receipt/Record/Disposition Form dated 4/2/25 documents 5/11/25 at 7:00 PM as the only dose signed out for R3's 30 ml bottle of Morphine Sulfate. On 6/2/25 at 10:22 AM the Station 1 medication cart was viewed with V18 Licensed Practical Nurse (LPN). R3's Morphine was the only Morphine located in this medication cart, which was stored in the locked controlled medication compartment. Approximately 30 ml of Morphine remained in the bottle, and the corresponding controlled drug record dated 4/2/25, documented 29.75 ml as the remaining amount. V18 stated R3 was the only resident with Morphine for this medication cart. On 6/2/25 at 12:18 PM V27 Registered Nurse (RN) stated V7 Wound Nurse/LPN called V27 on 5/25/25 to ask where R3's bottle of Morphine was. V27 instructed V7 to search the medication cart and the Morphine was found in the bottom drawer of the Station 1 medication cart where inhalers are kept. On 6/2/25 at 2:40 PM V7 stated V7 was doing her own narcotic count on 5/25/25 and that is when V7 was unable to find R3's Morphine. V7 stated the night nurse, V13 RN, had done narcotic count with the other night nurse, V12 LPN, and V13 left prior to V7 arriving for her shift. V7 stated V7 found R3's Morphine in the bottom drawer of the medication cart where the inhalers are kept. V7 confirmed this drawer is not a locked compartment for controlled medication storage. On 6/3/25 at 3:40 PM V6 Assistant Director of Nursing stated controlled medications are suppose to be stored in the locked compartment of the medication cart. The May-June 2025 Controlled Substance Shift Change Count Sheets for the facility's medications carts were requested on 6/3/25 and provided by V2 DON. There were only two forms for the station 1 medication cart ranging 5/16/25-6/3/25. There is no recorded entry for 5/25/25. On 6/3/25 at 11:20 AM V2 DON confirmed controlled medication count should be done with two nurses at each change of shift/nurse and signed out on the form in the binder for that medication cart. V2 stated there should be a form for this in each controlled medication binder for each cart. On 6/4/25 at 10:00 AM V2 stated V2 provided all of the May and June 2025 controlled substance shift count forms that V2 could locate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145422 If continuation sheet Page 9 of 11 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 145422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fair Havens Senior Living 1790 South Fairview Avenue Decatur, IL 62521 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 for all three medication carts. Level of Harm - Minimal harm or potential for actual harm 2.) R15's Hospital Discharge Plan dated 5/30/25 documents to stop taking Norco 5-325 mg. R15's May 2025 Medication Administration Record (MAR) documents R15's order for Norco 5-325 mg one tablet every eight hours was discontinued on 5/20/25. R15's June 2025 MAR does not document an active order for Norco 5-325 as of 6/2/25. Residents Affected - Few On 6/2/25 at 1:39 PM there was a card of R15's Norco 5-325 mg with 19 tablets remaining located inside inside the locked compartment of the station 2 medication cart. V19 LPN verified the count of this medication comparing the card to the controlled record form. On 6/3/25 at 3:20 PM V2 Director of Nursing confirmed R15's Norco order was discontinued on 5/30/25. V2 stated this medication should have been pulled from the medication cart and destroyed since the order was discontinued. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145422 If continuation sheet Page 10 of 11 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 145422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fair Havens Senior Living 1790 South Fairview Avenue Decatur, IL 62521 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on Observation, Interview and Record Review the facility failed to provide sufficient linens to ensure a safe sanitary environment for residents. This failure has the potential to affect all 98 residents who reside in the facility. Findings Include: The facility's Daily Census dated 6/2/25 documents a total of 98 residents reside at the facility. On 6/2/25 at 8:50AM, one washing machine was working out of three in the facility and two driers were running and two were broken. In a locked cabinet in the laundry room and on 100 East Hall approximately three dozen each hand towels and washcloths where stored. On 6/2/25 at 8:50AM, V15, Housekeeping Aide stated that most of the time V15 hears the Certified Nursing Assistants asking for more linens and they run out especially on the weekend. On 6/2/25 at 8:55AM, V17, Laundry Aide stated laundry is short staffed with one aide in morning from 6am-2pm and one aide on the afternoon shift from 2-10p. V17 stated she tries to keep up and passes linen every hour and cleans the laundry room every hour, but sometimes V17 can't keep up. On 6/2/25 at 12:37PM, Resident Council was conducted with R1, R7, R19, R21 and R22. During this meeting R1, R7, R19, R21 and R22 stated they have not had showers in the past week, and staff state to the residents there are no linens and laundry is short staffed. The residents stated there has been no improvement and grievances have been filed after every monthly resident council meeting. R19 stated residents are to get a shower two days a week. All residents that were present stated that they do not. On 6/2/25 at 1:50PM, V2, DON, (Director of Nursing) stated they have a shortage of linens and staff in housekeeping, and they have to pull staff from the floor to complete laundry. The facility's policy for bathing dated August 2022 states equipment needed to prepare for shower/Tub Bath are face cloth, bath towels, and bath blanket. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145422 If continuation sheet Page 11 of 11