Inspection·July 16, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Sitting, rt (right) arm. Alert was triggered as follows: Diastolic Low of 60 exceeded.On 6/7//2025 at 8:28 am R1's blood pressure measured 112/54 mm/ Hg . Sitting, rt arm. Alert was triggered as follows: Diastolic Low of 60 exceeded.On 6/7//2025 at 5:19 pm R1's blood pressure, again, measured 112/54 mm/ Hg. Sitting, rt arm. Alert was triggered as follows: Diastolic Low of 60 exceeded.On 6/10/2025 at 11:26 am R1's blood pressure measured 112/52 mm/ Hg. Sitting, lt arm. Alert was triggered as follows: Diastolic Low of 60 exceeded.On 6/11/2025 at 12:23 pm R1's blood pressure measured 126/54 mm/ Hg . Sitting, lt arm. Alert was triggered as follows: Diastolic Low of 60 exceeded.On 6/12/2025 at 12:33 pm R1's blood pressure measured 116/54 mm/ Hg . Sitting, rt arm. Alert was triggered as follows: Diastolic Low of 60 exceeded.On 6/12/2025 at 8:04 pm R1's blood pressure measured 96/43 mm/ Hg. Sitting, lt arm. Alert was triggered as follows: Diastolic Low of 60 exceeded.On 6/14/2025 at 8:23 pm R1's blood pressure measured 101/45 mm/ Hg. Sitting, rt arm. Alert was triggered as follows: Diastolic Low of 60 exceeded.On 6/15/2025 at 7:48 pm R1's blood pressure measured 108/56 mm/ Hg. Sitting, lt arm. Alert was triggered as follows: Diastolic Low of 60 exceeded.On 6/21/2025 at 9:03 pm R1's blood pressure measured 82/66 mm/ Hg. Sitting, rt arm. A new alert was triggered for R1's systolic measurement as follows: Systolic Low of 90 exceeded.On 6/22/2025 at 9:43 am R1's blood pressure measured 86/42 mm/ Hg . Sitting, lt arm. A double alert triggered which included both systolic and diastolic blood pressure measurement as follows: Systolic Low of 90 exceeded. and Diastolic Low of 60 exceeded.On 6/22/2025 at 1:15 pm R1's blood pressure again measured 86/42 mm/ Hg . (does not indicate what position R1 was in, or what location on R1's body R1's blood pressure was measured). A double alert again, was triggered which included both systolic and diastolic blood pressure measurement as follows: Systolic Low of 90 exceeded. and Diastolic Low of 60 exceeded.On 6/22/25 at 9:45 pm R1's blood pressure measured 97/56 mm/ Hg . Sitting, lt arm. Alert was triggered as follows: Diastolic Low of 60 exceeded.On 6/22/25 at 9:53 pm eight minutes after the previous measurement R1's blood pressure was measures again at 96/56 mm/ Hg . Sitting, lt arm. Alert was again triggered as follows: Diastolic Low of 60 exceeded.On 6/22/25 at 11:22 pm one hour and 29 minutes after the previous measurement R1's blood pressure was measures again at 95/56 mm/ Hg . Sitting, lt arm. Alert was again triggered as follows: Diastolic Low of 60 exceeded.'On 6/23/25 at 9:42 am R1's blood pressure measured 99/58 mm/ Hg. Sitting, lt arm. Alert was triggered as follows: Diastolic Low of 60 exceeded.On 6/23/25 at 7:44 pm R1's blood pressure measured 100/56 mm/ Hg . Sitting, lt arm. Alert was triggered as follows: Diastolic Low of 60 exceeded.There was no documentation in R1's medical record that a nurse practitioner or physician was notified of the 19 abnormal blood pressure measurements documented above.On 7/16/25 at 10:40 am V2, Director of Nursing (DON) reviewed R1's medical records. V2, DON stated R1's abnormal systolic and diastolic blood pressure readings should have been called to the doctor as standard of practice. They should have been notified. I am not seeing anything that either doctors or a nurse practitioners were notified.On 7/16/25 at 2:20 pm V9, Medical Director (MD) reviewed R1's electronic medical records. V9, MD confirmed R1's Blood pressure readings were out of normal range and should have been reported to V9 or another provider so the drop in blood pressure could be reviewed for medication changes and addressed.On 7/16/25 at 4:16 pm V8, Wound Physician confirmed she had not been notified by the facility nurses of R1's abnormal blood pressure measurement.The facility policy Change of Condition date 1/23/23 documents the following: PURPOSE:To provide facility guidance when a change of condition occurs with a resident.POLICY: This facility shall identify and treat residents with acute change of conditions.POLICY INTERPRETATION AND IMPLEMENTATION:5. The physician will help identify medications and medication combinations that are associated with adverse consequences that could cause significant changes in condition.The same policy directs the nursing staff to l (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145469 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 145469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of Paris 1011 North Main Street Paris, IL 61944 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 0580 contact the physician for changes in resident conditions or contact the on-call physician based on the urgency of the situation. 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: 145469 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 145469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of Paris 1011 North Main Street Paris, IL 61944 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility repeatedly failed to report changes in condition to a provider, for a resident with hypotension. These repeated failures resulted in a delay in treatment and hospitalization to stabilize residents blood pressure. This failure affected one of three residents (R1) reviewed for a change in condition on the sample list of three. Findings include:R1's Current Diagnoses List includes the following: Type II Diabetes with Other Specified Complications, Type II Diabetes With Other Diabetic Neurological Complications, Chronic Ischemic Heart Disease, Unspecified, Hypertensive Heart Disease With Heart Failure Presence Of Automatic Implantable Cardiac Defibrillator, Peripheral Vascular Disease Unspecified, Atherosclerotic Heart Disease Of Native Coronary Artery Without Angina Pectoris, Non-rheumatic Tricuspid Insufficiency, Acute Kidney Disease, Essential Hypertension, Chronic Obstructive Pulmonary Disease, Unspecified Dementia, Unspecified Severity Without Behavioral Disturbance, Mood Disturbance and Anxiety, Encounter for Orthopedic Aftercare Following Surgical Amputation, Gangrene, Not Elsewhere Classified, Acquired Absence Of Left Great Toe, and Chronic Osteomyelitis Left Ankle and Foot.R1's Minimum Data Set, dated [DATE] documents R1's Brief Interview of Mental Status score of five out of a possible 15 indicating severe cognitive impairment.R1's Current Physician Order Sheet (POS) documents the following: Cipro (antibiotic) Oral Tablet 500 MG (milligrams) (Ciprofloxacin HCI), Give 1 tablet by mouth, two times a day related to GANGRENE, NOT ELSEWHERE CLASSIFIED, (administer) until 08/02/2025 . Start date 06/02/25.R1's same POS documents: Entresto (combination heart failure medication that relaxes blood vessels, and prevents blood vessels from constricting which helps lower blood pressure), Oral Tablet 24-26 MG (Sacubitril-Valsartan) Give 1 tablet by mouth two times a day for Congestive Heart Failure. Start dated 05/16/25.R1's Nurses Note dated 6/5/2025 at 11:51 am, documents the following: Note Text: Resident was seen today by (the) wound clinic. It was noted that resident had (an) allergy to Cipro. (V8, Wound Physician ) requested clarification from (V9, Medical Director's) office to hold Entresto while on Cipro. (V9) did not want to hold Entresto. Per (V8, Wound Physician) since resident is tolerating medication well, monitor blood pressure every shift. Will continue to monitor (the) resident.R1's same POS above, documents: Monitor blood pressure every shift for antibiotic while on antibiotic therapy. Start date 6/05/25, End date 6/27/25.R1's Electronic Vital Sign medical record includes blood pressure measurements. The same Electronic medical record indicates an alert to the nursing staff, when the measurement is outside the normal range. R1 ‘s Electronic Vital Sign record documents the following, out of normal range, blood pressure measurements:On 6/5/2025 at 10:09 pm R1's blood pressure measured 107 (systolic)/ 59 (diastolic) mm/ Hg (millimeters of mercury), Sitting (position the resident was in when the blood pressure was measured), Rt (Right) arm (location on the residents body where the reading was obtained). Alert was triggered as follows Diastolic Low of 60 exceeded.On 6/6//2025 at 10:44 am R1's blood pressure measured 118/59 mm/ Hg. Sitting, lt (left) arm. Alert was triggered as follows: Diastolic Low of 60 exceeded.On 6/6//2025 at 9:35 pm R1's blood pressure measured 105/49 mm/ Hg. Sitting, rt (right) arm. Alert was triggered as follows: Diastolic Low of 60 exceeded.On 6/7//2025 at 8:28 am R1's blood pressure measured 112/54 mm/ Hg . Sitting, rt arm. Alert was triggered as follows: Diastolic Low of 60 exceeded.On 6/7//2025 at 5:19 pm R1's blood pressure, again, measured 112/54 mm/ Hg. Sitting, rt arm. Alert was triggered as follows: Diastolic Low of 60 exceeded.On 6/10/2025 at 11:26 am R1's blood pressure measured 112/52 mm/ Hg. Sitting, lt arm. Alert was triggered as follows: Diastolic Low of 60 exceeded.On 6/11/2025 at 12:23 pm R1's blood pressure measured 126/54 mm/ Hg . Sitting, lt arm. Alert was triggered as follows: Diastolic Low of 60 exceeded.On 6/12/2025 at 12:33 pm R1's blood pressure Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145469 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 145469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of Paris 1011 North Main Street Paris, IL 61944 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 0684 Level of Harm - Actual harm Residents Affected - Few measured 116/54 mm/ Hg . Sitting, rt arm. Alert was triggered as follows: Diastolic Low of 60 exceeded.On 6/12/2025 at 8:04 pm R1's blood pressure measured 96/43 mm/ Hg. Sitting, lt arm. Alert was triggered as follows: Diastolic Low of 60 exceeded.On 6/14/2025 at 8:23 pm R1's blood pressure measured 101/45 mm/ Hg. Sitting, rt arm. Alert was triggered as follows: Diastolic Low of 60 exceeded.On 6/15/2025 at 7:48 pm R1's blood pressure measured 108/56 mm/ Hg. Sitting, lt arm. Alert was triggered as follows: Diastolic Low of 60 exceeded.On 6/21/2025 at 9:03 pm R1's blood pressure measured 82/66 mm/ Hg. Sitting, rt arm. A new alert was triggered for R1's systolic measurement as follows: Systolic Low of 90 exceeded.On 6/22/2025 at 9:43 am R1's blood pressure measured 86/42 mm/ Hg . Sitting, lt arm. A double alert triggered which included both systolic and diastolic blood pressure measurement as follows: Systolic Low of 90 exceeded. and Diastolic Low of 60 exceeded.On 6/22/2025 at 1:15 pm R1's blood pressure again measured 86/42 mm/ Hg . (does not indicate what position R1 was in, or what location on R1's body R1's blood pressure was measured). A double alert again, was triggered which included both systolic and diastolic blood pressure measurement as follows: Systolic Low of 90 exceeded. and Diastolic Low of 60 exceeded.R1's Occurrence Note dated 6/22/2025 at 9:30 pm documents the following: Note Text: Incident Note: called to residents' room by CNA (Certified Nursing Assistant, unidentified) upon entering room resident (R1) was sitting on floor on his coccyx, left arm resting on his recliner. When asked what happened (R1) stated I fell trying to get back in my chair. Asked if he hit his head he said no. Asked if he was hurting he said my left elbow a little. Thorough assessment of resident completed no injures noted but small abrasion to left elbow cleaned and band aid applied. Neuros (neurological assessment) initiated . VS (Vital signs) T97.2 (Temperature) P75 (Pulse) B/P 92/56 (Blood /Pressure) R 20 (Respirations) sat 97% (blood oxygen measurement of saturation) on RA (room air). (Full-body, mechanical lift transfer) with assist of two (staff) off floor and back into his chair. Currently sitting at nurses station. Notified the Nurse supervisor (V2, Director of Nursing) for the facility of the fall, notified his (R1's,Family Member/ Power of Attorney) and physician (unidentified) . No c/o (complaints/of) any voiced at this time.As documented above, in this occurrence note 6/22/25 at 9:30 pm, R1's blood pressure measured 92/56 mm/hg indicating R1's diastolic measurement was low due to a measurement below 60.As noted above on the Vitals Log above, R1 sustained a low blood pressure measurement for 24 hours and 27 minutes prior to the fall documented on the above occurrences report.Post R1's fall 6/22/25 at 9:30 pm documented in the occurrence note, R1 continued with abnormal blood pressure measurements after the fall as follows:On 6/22/25 at 9:45 pm R1's blood pressure measured 97/56 mm/ Hg . Sitting, lt arm. Alert was triggered as follows: Diastolic Low of 60 exceeded.On 6/22/25 at 9:53 pm eight minutes after the previous measurement R1's blood pressure was measured again at 96/56 mm/ Hg. Sitting, lt arm. Alert was again triggered as follows: Diastolic Low of 60 exceeded.On 6/22/25 at 11:22 pm one hour and 29 minutes after the previous measurement R1's blood pressure was measured again at 95/56 mm/ Hg . Sitting, lt arm. Alert was again triggered as follows: Diastolic Low of 60 exceeded.On 6/23/25 at 9:42 am R1's blood pressure measured 99/58 mm/ Hg. Sitting, lt arm. Alert was triggered as follows: Diastolic Low of 60 exceeded.On 6/23/25 at 7:44 pm R1's blood pressure measured 100/56 mm/ Hg . Sitting, lt arm. Alert was triggered as follows: Diastolic Low of 60 exceeded.There was no documentation in R1's medical record that a nurse practitioner or physician was notified of the 19 abnormal blood pressure measurements documented above. The fall occurrence note documents an unknown physician was notified of the fall 6/22/25. ( V9, Medical Director clarified in the interview documented below that he was notified of the fall but was not notified of the blood pressure drop.R1's Nurses Note date 6/25/25 at 1:36 pm documents the following: Note Text: Resident OOF (out f facility) via (by way of) the facility van to go to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145469 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 145469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of Paris 1011 North Main Street Paris, IL 61944 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 0684 Level of Harm - Actual harm Residents Affected - Few wound center for routine visit. Paperwork sent with the transporter and family will meet at the clinic. Resident (R1) was reported to have been up all night when shift change done this AM and obtained a new skin tear to an upper extremity that the previous nurse covered with a dressing.R1's Nurses Note dated 6/25/25 at 2:45 pm documents the following: Note Text: Transporter returned from the wound clinic with progress report from (V8, Wound Physician) and reported to this nurse that resident is currently in the emergency department per family wishes due to not acting like self. Noted in the report that per the RN (unidentified); resident left the appointment (wound clinic) in no pain via W/C (wheelchair) with transport assist and will RTC (Return to see the wound clinic) in 1 week for F/U (follow-up). Plan to follow up with ED (Hospital, emergency department) on resident's status prior to leaving the facility today.R1's Nurse's Note dated 6/25/25 at 8:50 pm documents the following: Note Text: Placed a call the ED and was informed that resident was noted to be hypotensive (low blood pressure) and hypothermic (low body temperature, sometimes exacerbated by hypotension) upon arrival in ER. Awaiting the hospitalist (unidentified, hospital physician) decision as to which hospital (R1) will be the admitting facility for inpatient stay for treatment and family in hopes that resident will remain in (name of local hospital) for their visitation convenience. Requested that the local hospital please call back to let the current nurse on duty know what was decided. Notified the on- call nursing supervisor (V2, Director of Nursing) of the above and resident current status.R1's Hospital Discharge Summary report dated 6/30/25 at 12:12 pm, signed by V9, Facility Physician/ Medical Director documents the following: Discharge Diagnoses: -Systemic Inflammatory Response Syndrome (serious inflammatory response, over reaction to stressors such infection, trauma, surgery) - Primary. Hospital CourseSpecified (age) year-old male with a medical history significant for coronary artery disease status post CABG (Coronary Artery Bypass Grafting surgery), cardiomyopathy status post PM/ICD (Pacemaker Implantable Cardioverter Defibrillator) placement with associated heart failure, peripheral artery disease, peripheral neuropathy, non-insulin-dependent diabetes mellitus, COPD, questionable dementia, and recent bout of left foot osteomyelitis (May 2025) (prior to facility admission), presented to the emergency room with chief complaint of altered mental status for several days. Patient's clinical picture was highly suspicious for septic shock. Patient was hypotensive (low blood pressure) and pressor (type of medication to increase blood pressure) dependent. He was started on broad-spectrum antibiotics. Patient has some baseline dementia. No clear source of infection but has history of chronic osteomyelitis of the left foot. Patient responded well to pressers, fluids and broad-spectrum antibiotics although no definitive source of infection was found. Patient has autonomic dysfunction which probably lead to hypothermia and hypotension. His cultures have so far remained negative. He was discharged (from the hospital 5/16/25) last admission to nursing home on IV (intravenous) antibiotics but he kept pulling his lines (IV catheters) out so podiatry (wound clinic) changed him to oral antibiotics for chronic (osteomyelitis). I again rechecked with lab and his blood cultured have panned out to be negative. At this point he is ready for discharge back to nursing home. He can continue oral antibiotics at the nursing home as he was previously taking. R1's General Note dated 6/30/25 at 5:01 pm documents R1 return to the facility from the hospital after a five day hospitalization. Note Text: documents a new physician ordered medication for Midodrine (that works by constricting blood vessels, thereby raising the blood pressure). The same General note documents R1 returned to the facility with vital signs within normal limits as follows: Vitals (measurements): (B/P) 120/70, (R)18, (02 saturation) 98%, (P) 80, (T) 97.7 (all vital signs measurement are within normal limits).On 7/16/25 at 2:20 pm V9, Medical Director (MD) reviewed R1's electronic medical records. V9, MD confirmed R1's Blood pressure readings were out of normal range and should have been reported. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145469 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 145469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of Paris 1011 North Main Street Paris, IL 61944 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 0684 Level of Harm - Actual harm Residents Affected - Few V9, MD stated The diastolic below 60 were not as concerning, until the measurement dropped below 50. Systolic readings below 90 should have been reported. The repeated low readings are the concern. Not necessarily a one- time event. Either way I should have been notified. V9, MD stated Myself or a Nurse Practitioner would have evaluated (R1) on day shift, had we been notified. (R1's) medications would have been reviewed and adjusted accordingly. On evening or night shift, the on-call provider should have been notified. They would have sent (R1) to the hospital for an evaluation and treatment. V9, MD stated (R1's) low blood pressure could have resulted in that fall. It is hard to know at this point. The potential for harm would be a fall with a fracture. That did not happen. The potential for great harm due to the fall is a [NAME]. Though this was a possibility. V9 also stated I was notified of the fall. I was not told of (R1's) blood pressure drop. I was told this was a no injury fall. V9, MD also stated I had previously been (R1's) physician. I know his family well. I explained in detail to the family (R1) was not in septic shock. It was necessary to rule this out. (R1) was hospitalized to identify the origin of (R1s) hypotension. Initially Septic Shock was considered. After all diagnostics were completed, (R1's) diagnosis is Orthostatic Hypotension. He has a history heart failure and multiple other co-morbidities. I adjusted his medication. He is now taking Midodrine for hypotension. Had the adjustment been made in the nursing home, a hospital admission may have been avoided. Of course, that is the best-case scenario. The facility policy Change of Condition date 1/23/23 documents the following: PURPOSE:To provide facility guidance when a change of condition occurs with a resident.POLICY: This facility shall identify and treat residents with acute change of conditions.POLICY INTERPRETATION AND IMPLEMENTATION:1, The interdisciplinary team, with the assistance of the physician, will help identify individuals with a significant risk for having acute changes of condition during their stay.2. Direct care staff, including nursing assistants, will be trained in recognizing subtle but significant changes in the resident and how to communicate these changes to the Nurse.The same policy documents:5. The physician will help identify medications and medication combinations that are associated with adverse consequences that could cause significant changes in condition.6. Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician, for example, the history of present illness and previous and recent test results for comparison. a. Phone calls to the attending or on-call physician should be made by an adequately prepared nurse who has collected and organized pertinent information including the resident/patient's current symptoms and status, history, current medications etc.7. The nursing staff will contact the physician based on the urgency of the situation. For emergencies they will call or page the physician and request a prompt response.8. The attending physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status.a. The nursing staff will contact the medical director for additional guidance and consultation if they do not receive a timely or appropriate response.9. The nurse and physician will discuss and evaluate the situation.a. The physician should request information to clarify the situation10. The staff and the physician will discuss possible causes of the change in condition based on factors including resident/patient history, current symptoms, medication regimen, and diagnostic test results.a, If necessary, the physician will order diagnostic tests and evaluate the patient directly.11. As needed, the physician will discuss with the staff and resident/patient and/or family the pros and cons of diagnosing and managing the situation in the facility or the need for hospitalization.a. Many acute changes of condition can be managed effectively in nursing facilities with outcomes that are comparable to those of hospitalization.b. This discussion should consider the patient's overall condition, prognosis, and wishes (either direct or as conveyed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145469 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 145469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of Paris 1011 North Main Street Paris, IL 61944 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 0684 by a substitute decision-maker). Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145469 If continuation sheet Page 8 of 8