Health inspection·December 10, 2025

F 0690 Level of Harm - Actual harm Residents Affected - Few . There is also no documentation that urinary catheter output was routinely measured or monitored during this period prior to 12/04/2025.A nursing note dated 11/16/2025 at 12:47 PM documents that R49 had no urine output, low blood pressure and pulse, difficulty speaking and swallowing, altered mental status, lethargy, and labored breathing. R49's temperature was 99.1 F, pulse 29 beats per minute, respirations 18 per minute, and blood pressure 102/57. The physician was notified on 11/16/2025 at 6:51 AM.R49's Hospital History and Physical dated 11/16/2025 documents admission for urosepsis, septic shock, catheter-associated UTI, acute kidney injury, bilateral hydronephrosis, and bilateral renal cysts. R49's creatinine was 3.9 on arrival, compared to a baseline of approximately 0.8. R49 presented with lethargy, pulse rates in the 130s, and systolic blood pressure in the 80s despite fluid administration. R49 had urinary retention upon arrival; the catheter was changed with a return of nearly 900 milliliters of purulent urine. R49 has a history of multidrug-resistant bacterial infections. A physician progress note dated 11/21/2025 documents urine culture results of greater than 100,000 colony-forming units (CFU)/mL of mixed bacteria, continued IV antibiotics, and placement of bilateral urinary stents on 11/17/2025.On 12/08/2025 at 1:47 PM, V5 and V6, CNAs, were questioned regarding EBP. V6 stated PPE is worn whenever entering the room. V5 stated that for catheter care, gown and gloves are worn and that staff identify residents on precautions by posted signage and PPE supplies. V5 correctly described catheter cleaning as a downward motion approximately four inches from the insertion site. V5 and V6 confirmed that gowns were not worn during R49's transfer and catheter care. At 1:59 PM, V7 confirmed she did not clean the four inches of catheter tubing and did not wear a gown during catheter care.On 12/09/2025 at 10:33 AM, V9, Infection Preventionist (IP), stated that catheter changes are completed per physician orders and documented in nursing notes or on the MAR or Treatment Record. On 12/10/2025 at 9:35 AM, V9 stated that the purpose of EBP is to protect residents from staff-transmitted germs and that staff are expected to wear gown and gloves when EBP is in place, particularly for residents with urinary catheters.On 12/09/2025 at 10:36 AM, V10, Licensed Practical Nurse/Wound Nurse, stated that per the 10/03/2025 urology note, R49's catheter was to be changed monthly. V31, MDS Coordinator, stated that she rounded with V33, R49's primary physician, who changed the catheter order to as needed without consulting the urology office. V10 stated that urine output monitoring would be documented on CNA task sheets. At 12:22 PM, V10 stated R49 was seen by urology in April, May, October, and November 2025. V10 further stated that R49's catheter was last changed on 06/23/2025 and that there was no documentation of catheter changes until 11/16/2025, no follow-up with urology regarding the order change, and no documentation of urine output monitoring until 12/04/2025, when an audit was completed by V2, Director of Nursing.On 12/09/2025 at 12:02 PM, V34, Urology Nurse for V35, stated that R49 was seen as a new patient in April 2025 and again in October 2025, and that V35 saw R49 during hospitalizations in May and November 2025. Provider notes indicated that R49's catheter was to be changed monthly, and no catheter changes were completed in the clinic. V34 stated that the facility should monitor for UTI signs such as changes in urine color or characteristics, cloudiness or blood, and complaints of flank pain. Standard nursing practice also includes measuring, recording, and monitoring urinary catheter output. Decreased output may indicate UTI. Failure to change a catheter can contribute to UTIs, and delayed identification or treatment of UTI can lead to sepsis. V34 stated that if these interventions had been performed, R49's hospitalization may have been prevented.On 12/10/2025 at 11:04 AM, V36, LPN, stated that she sent R49 to the hospital in November after the night nurse, V37, LPN, reported that during the 5:00 AM medication pass R49 was mumbling and experiencing swallowing difficulties. V36 stated she assessed R49's vital signs due to concern for possible sepsis given R49's history. R49 had minimal urine output, low pulse and blood (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145422 If continuation sheet Page 2 of 7 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 12/10/2025 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 0690 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete pressure, and labored breathing.On 12/10/2025 at 11:41 AM, V37 stated that R49 appeared stable until approximately 5:30 AM, when a CNA reported that R49 was shaking and did not look well. Vital signs were checked and reported as normal, and the information was passed on in report. V37 stated she could not recall R49's urinary output that night, as nurses do not routinely document urine output.2.) On 12/09/2025 at 1:25 PM, V38 and V39, CNAs, transferred R2 from the toilet to her wheelchair in the 200-unit shower room. V38 pushed R2's wheelchair across the hall into R2's room, and R2's urinary catheter tubing was observed dragging on the floor, as confirmed by V39. A clip was attached to the tubing but was not used to keep the tubing off the floor. V39 removed R2's urinary collection bag from beneath the wheelchair and held it above the level of R2's bladder, causing urine to drain back toward the bladder, then placed the bag on R2's lap. Cloudy sediment was observed in R2's urine.V38 and V39 transferred R2 into bed using a full mechanical lift. The CNAs did not wear gowns during the transfers or while handling R2's urinary catheter, despite signage outside R2's room indicating Enhanced Barrier Precautions and the requirement to wear gowns for high-contact care. V39 acknowledged that the clip could be used to keep tubing off the floor and confirmed that the urinary collection bag had been raised above the bladder.R2's care plan dated 09/24/2025 documents use of a urinary catheter. A urine culture and sensitivity dated 12/08/2025 documents 50,000-99,999 CFU/mL of Escherichia coli (ESBL) and 25,000-50,000 CFU/mL of vancomycin-resistant Enterococcus faecalis.3.) On 12/08/2025 at 9:54 AM, V40, R5's family member, stated concerns that R5 experiences frequent UTIs and that nursing staff do not always follow up in a timely manner when urinalysis is requested. V40 stated that nurses must request orders from the physician and that results sometimes take weeks.R5's MDS dated [DATE] documents severe cognitive impairment, total bowel and bladder incontinence, and dependence on staff for toileting hygiene.A nursing note dated 09/17/2025 documents that V40 reported R5 complained of burning with urination and foul-smelling urine. The physician was notified; however, there is no documentation that a urine sample was collected until 09/19/2025, nor are results documented from that sample. Nursing notes document that another urine sample was collected on 09/24/2025, with results received on 09/26/2025 (nine days after symptom onset). Orders were received for Keflex 500 mg twice daily for 10 days.R5's urine culture and sensitivity dated 09/26/2025 documents 50,000-99,999 CFU/mL of E. coli.On 12/09/2025 at 12:14 PM, V31, MDS Coordinator, stated that laboratory pickup occurs Monday through Friday and that on weekends staff must transport specimens to the local hospital. V9, Infection Preventionist, and V31 were asked to provide documentation that R5's 09/19/2025 urine sample was sent to the laboratory.On 12/09/2025 at 3:06 PM, V2, Director of Nursing, stated that no additional documentation was available regarding R5's urine samples or results. Event ID: Facility ID: 145422 If continuation sheet Page 3 of 7 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 12/10/2025 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 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 implement appropriate infection control practices during medication administration, failed to wear appropriate (Personal Protective Equipment (PPE)) when caring for residents on EBP or Contact Precautions, failed to post proper signage for residents requiring EBP or Contact Precautions, failed to ensure PPE supplies were readily available outside resident rooms for ten (R2, R7, R8, R18, R21, R30, R49, R56, R64, R89) out of ten residents reviewed for Infection Prevention and Control on a sample list of 49. These failures have the potential to compromise resident safety and increase the risk of transmission of infectious agents. Findings include: Residents Affected - Some 1.) R56's Electronic Medical Record (EMR) contained culture results dated 11/20/25 documenting that R56's urine was positive for Escherichia coli (Extended Spectrum Beta-Lactamase [ESBL]) and Providencia stuartii (P. stuartii). R56's Physician Order Sheet, dated November 2025, documented an order for R56 to remain on Contact Isolation for urinary ESBL E. coli and P. stuartii every shift until 12/14/25, or until cleared by the physician. On 12/07/2025 at 8:57 AM, Contact Isolation signage was posted on the door of the shared room for R56 and R64. No personal protective equipment (PPE) container was observed in or near the room. R56 stated staff did not wear gowns or gloves when entering the room or providing care. On 12/07/2025 at 8:57 AM, V27, Certified Nursing Assistant (CNA), entered the room shared by R56 and R64 without donning a gown or gloves. V27 stated she was unsure whether R56 was on Contact Isolation. R56 stated she was on isolation while on antibiotics but was no longer taking them. V27 stated staff may have forgotten to remove the sign. On 12/09/2025 at 10:04 AM, the Contact Isolation sign remained posted on the door to R56 and R64's room. No PPE was observed outside or near the room. R56 stated she had recently completed antibiotics for a urinary tract infection (UTI), her symptoms had resolved, and she believed she was no longer on isolation. On 12/10/25 at 11:05 AM, V9, Registered Nurse (RN) and Infection Preventionist (IP), stated staff should have continued using Contact Isolation for R56 because the facility could not confirm clearance of the infection following completion of antibiotics. V9 confirmed she entered the order to continue Contact Isolation through 12/14/25 until a physician order was received to discontinue isolation. V9 stated R56 remained in the shared room with R64 due to lack of available private rooms. V9 stated staff should have worn PPE when entering R56's room. 2.) On 12/07/2025 at 8:25 AM, R89 was observed lying in bed with a nasal oxygen cannula in place and a urinary catheter hanging on the left side of the bed. R89 stated no one had changed the catheter tubing and that it had been lying down. R89's Minimum Data Set (MDS), dated [DATE], documented that R89 has an indwelling catheter and is cognitively intact. No physician order for Enhanced Barrier Precautions (EBP) was present until 12/10/25. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145422 If continuation sheet Page 4 of 7 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 12/10/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 12/07/2025 at 9:05 AM, R21 was observed lying in bed and stated she was admitted with a pelvic fracture and had a urinary catheter. No Enhanced Barrier Precautions signage or PPE was present. R21's MDS, dated [DATE], documented she is cognitively intact and has an indwelling catheter. R21's physician orders and care plan did not include Enhanced Barrier Precautions. On 12/07/2025 at 9:58 AM, R18 was observed lying in bed with a gauze dressing on the left foot. Documentation identified the wound as a blister. No Enhanced Barrier Precautions signage or PPE (gowns or gloves) was present on the door. Follow-up observations on 12/08/2025 at 1:18 PM and 12/09/2025 at 9:49 AM continued to show no Enhanced Barrier Precautions signage or PPE for R18. On 12/07/2025 at 11:00 AM, R30's room door displayed a Contact Precautions sign. Physician orders dated 11/07/2025 documented Methicillin-Resistant Staphylococcus aureus (MRSA) in R30's left leg wound. R30's MDS documented he is cognitively intact. R30 stated staff did not wear gowns or gloves when providing care. On 12/08/25 at 11:46 AM, V12, CNA, obtained vital signs for residents in Rooms 321-1 and 321-2 using the same vital signs machine without disinfecting it between residents. V12 exited the room wearing her gown, pushed the vital signs machine to the nurses' station, went to the tray cart, then entered the linen room and removed the gown. V12 stated she should not have worn the gown outside the resident room. V12 stated she was only educated that Enhanced Barrier Precautions apply to residents with Foley catheters or infections. On 12/08/25 at 1:05 PM, V1, Director of Nursing, confirmed that Enhanced Barrier Precautions require use of gowns and gloves and that vital signs equipment must be disinfected with bleach wipes between residents. V1 stated the facility was completing facility-wide education on Enhanced Barrier Precautions. V1 stated R30, R18, R21, and R89 should all have been on Enhanced Barrier Precautions and staff should have worn gowns and gloves during care. On 12/09/2025 at 9:51 AM, V10, Wound Nurse, stated R18 should have been on Enhanced Barrier Precautions due to the left foot wound. 3.) On 12/07/2025 at 8:13 AM, R49 was observed lying in bed with a urinary catheter secured to the bed frame. A sign near the doorway indicated R49 was on Enhanced Barrier Precautions, requiring gown and gloves for high-contact care activities, including catheter care and transfers. A PPE container was present outside the room. At 1:04 PM, R49 stated he had the catheter for a long time and that it was last changed approximately one month prior during hospitalization for a UTI. On 12/08/25 at 10:55 AM, V5 and V7, CNAs, entered R49's room with a full mechanical lift while R49 was seated in a wheelchair. Neither CNA donned a gown upon entry. At 11:04 AM, R49 was in bed, and V5, V6, and V7 provided catheter care without wearing gowns. All three performed hand hygiene, applied gloves, and completed catheter care without gowns. On 12/08/25 at 1:47 PM, V5 and V6 were interviewed regarding Enhanced Barrier Precautions. V6 stated PPE is worn whenever entering a resident's room. V5 stated gown and gloves are worn for catheter care and that staff identify residents on precautions by signage and PPE carts. V5 demonstrated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145422 If continuation sheet Page 5 of 7 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 12/10/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some catheter care technique. V5 and V6 confirmed gowns were not worn during R49's transfer or catheter care. At 1:59 PM, V7 confirmed she did not clean approximately four inches of catheter tubing and did not wear a gown during catheter care. On 12/10/2025 at 9:35 AM, V9 stated the purpose of Enhanced Barrier Precautions is to protect residents from transmission of microorganisms. V9 stated staff are expected to wear gowns and gloves when Enhanced Barrier Precautions are in place. 4.) On 12/07/2025 at 10:19 AM, no signage was observed outside R7's room indicating Enhanced Barrier Precautions. A PPE cart was present outside the room. R7 was observed lying in bed with a gastrostomy tube. At 10:25 AM, V3, CNA, stated R7 was on Enhanced Barrier Precautions due to the gastrostomy tube and confirmed signage should have been posted. 5.) On 12/07/2025 at 10:10 AM, no signage indicating isolation or Enhanced Barrier Precautions was observed outside R2's room. V42, RN, stated R2 had a Foley catheter and a left leg wound and should have been on Enhanced Barrier Precautions. V42 confirmed signage should have been posted. On 12/09/25 at 1:25 PM, V38 and V39, CNAs, transferred R2 from the toilet to her wheelchair in the 200-unit shower room and then to bed using a full mechanical lift. V39 handled R2's urinary drainage bag. Neither CNA wore a gown during care, as confirmed by V39. A sign outside R2's room indicating Enhanced Barrier Precautions was reviewed with V39, who stated she believed gowns were only required during wound or catheter care. R2's urine culture and sensitivity dated 12/08/25 documented 50,000–99,999 CFU/mL Escherichia coli (ESBL) and 25,000–50,000 CFU/mL Vancomycin-Resistant Enterococcus faecalis (VRE). From 12/07/25 through 12/10/25, R2 shared a room with R8. On 12/10/25 at 11:05 AM, V9 stated R2 should have been placed on Contact Precautions rather than Enhanced Barrier Precautions due to the presence of ESBL and VRE in urine. 6.) On 12/08/2025 at 10:48 AM, V4, LPN, prepared 2 units of Novolog (100 units/mL) and 10 units of Lantus (100 units/mL) using separate syringes. V4 did not disinfect the vial stoppers prior to needle insertion and administered the insulin to R49's abdomen without performing hand hygiene or applying gloves. At 10:55 AM, V4 confirmed she did not disinfect the vials and did not perform hand hygiene or wear gloves prior to administration. On 12/08/2025 between 11:28 AM and 11:45 AM, V4 prepared and administered R2's oral medications. V4 placed R2's pills directly into her hands before placing them into a medication cup. V4 drew up 2 units of lispro insulin (100 units/mL), placed the uncapped syringe in her pocket, entered R2's room, and administered the insulin using the same syringe. On 12/09/25 at 3:06 PM, V2, Director of Nursing, stated insulin vials must be disinfected with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145422 If continuation sheet Page 6 of 7 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 12/10/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some alcohol prior to each use, hand hygiene must be performed before and after medication administration, gloves must be worn when administering insulin, and needles must not be placed in pockets. The facility's Insulin Administration Policy (April 2007) requires handwashing, disinfecting vial tops with alcohol, withdrawing the prescribed dose, administering insulin, and disposing of needles in designated sharps containers. The facility's Handwashing/Hand Hygiene Policy (November 2013) identifies hand hygiene as the primary method to prevent infection transmission and requires hand hygiene before handling medications, before and after resident contact, and prior to nonsurgical invasive procedures. The facility's Infection Prevention and Control Manual – Transmission-Based Precautions (2020) states Enhanced Barrier Precautions are used to prevent transmission of multidrug-resistant organisms, require gowns and gloves during high-contact care for residents with wounds or indwelling devices, require posted signage and PPE availability, and include cohorting residents with the same infectious organism. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145422 If continuation sheet Page 7 of 7