Inspection·August 22, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete were documented by V1, Administrator/ Abuse Prevention Coordinator. Each of the above reports document that the Power of Attorney was notified, as the facility abuse prevention policy directs.On 8/22/25 at 12:40 pm V1 Administrator/Abuse Prevention Coordinator said the nurses should be documenting accurately if they aren't getting a hold of a family and the doctor. The nurses are to report to the families about any resident-to-resident altercations/abuse. The facility Abuse Policy dated as revised 01/09/24 documents the following: The Facility will report all allegations of abuse immediately to the Administrator and timely, to the proper authorities to include IDPH (Illinois Department of Public Health), Ombudsman, Local P.D (Police Department), POA (Power of Attorney), and M.D. (Physician) in a timely manner. Event ID: Facility ID: 145469 If continuation sheet Page 2 of 14 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 08/22/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect residents' right to be free from witness, resident to resident physical abuse. This failure affects four of nine residents (R3, R4, R5 and R6), reviewed for abuse on the sample list of 18.Findings include:1.) R3's Minimum Data Set (MDS) dated [DATE] documents the following: R3's Brief Interview of Mental Status score of 00 (zero) out of a possible score of 15, which indicates severe cognitive impairment. The same MDS documents R3 has had Verbal behaviors directed towards others (e.g. screaming at others, threatening others, and cursing at others). These verbal behaviors occurred four to six days a week of the lookback period of the MDS assessment.The same MDS documents R3 also had other Behavioral symptoms not directed towards others: (e.g., smearing physical food or symptoms bodily such wastes, as or hitting or verbal/vocal scratching symptoms self, pacing, like rummaging , public sexual acts, disrobing in public, throwing or smearing food or bodily waste, or verbal/vocal symptoms like screaming and disruptive sounds). These other behaviors occurred daily during the lookback period of the MDS assessment.R3's Care Plan dated as last revised 01/22/24 with a target date of 01/10/25 documents the following, (R3) has the potential for abuse/neglect due to invading other's space and property, rummaging through belongings or wandering in and out of other's spaces. She has a history of being physically abused, psychiatric diagnosis or manifestations, including delusions, paranoia and hallucinations, Underlying factors that increase vulnerability; including such as dementia, confusion, poor judgment, wandering and giving away personal property. (R3) will experience no present/future problems related to abuse/mistreatment/violation. Revision on: 01/22/2024, Target Date: 01/10/2025. R4's MDS dated [DATE] documents the following: R4's Brief Interview of Mental Status score of eight out of a possible score of 15, which indicates moderate cognitive impairment . The same MDS documents R4 has had Physical (e.g. Hitting, kicking pushing, scratching, grabbing or abusing others sexually) and verbal behaviors directed towards others (e.g. screaming at others, threatening others, and cursing at others), and Behavioral symptoms not directed towards others: (e.g., smearing physical food or symptoms bodily such wastes, as or hitting or verbal/vocal scratching symptoms self, pacing, like rummaging , public sexual acts, disrobing in public, throwing or smearing food or bodily waste, or verbal/vocal symptoms like screaming and disruptive sounds). These behaviors of verbal and physical, and others behaviors occurred one to three days during the lookback period of the MDS assessment.R4's Care Plan dated as last revised 7/7/25 documents the following: (R4) has a DX (diagnosis) anxiety disorder, unspecified, DX: Dementia in other diseases, unspecified severity, with other behavioral disturbances. The resident is/has potential to be physically aggressive (hitting, kicking, pinching) r/t (related/to) Dementia, History of harm to others, Poor impulse control. The facility's Illinois Department of Public Health initial and final investigation report dated 07/05/25 documents the following: Brief description of the incident/event: It was reported that resident (R4) grabbed resident (R3) by the arm/shirt sleeve. As resident (R3) was trying to get her arm away, she made contact with (R4's) cheek area. The same investigation report documents: Summary of Investigative findings through discussions with Individuals with direct knowledge and review of the resident clinical record, include the report of incident and post-occurrence IDT (Interdisciplinary Team) walking rounds. A comprehensive investigation was initiated, review of video, and found that on 7/5/25 resident (R4) and (R3) were seated next to each other. Resident (R3) had a verbal outburst with a loud noise, which is her baseline. This appeared to startle (R4) and she (R4) was observed to grab (R3's) forearm and then (R3's) shirt sleeve. The staff member did intervene quickly and while attempting to separate the 2 (two) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145469 If continuation sheet Page 3 of 14 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 08/22/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some residents, (R3) was flailing her (R3's) arm/hand about, trying to get (R4) to let go of her (R3's) shirt. With this movement (R3's) hand did make contact with (R4's) cheek. Both residents were immediately assessed with no injuries noted. The incident did not appear to be malicious in any manner and more of a matter of the loud verbal outbursts startling(R4) and (R3) not wanting (R4) to be holding/grabbing her arm/shirt. A root cause was identified, and an appropriate intervention has been put into place. Resident (R4) was provided close supervision and the residents were kept separated. Neither resident could recall the incident, and neither resident shows any signs of mental anguish. The facility finds the allegation of willful abuse unsubstantiated related to there being no malicious intent with one resident trying to get the other resident's hand off of her. Follow-Up Actions Taken: The resident plan of care was updated as needed (as noted above R3's and R4's Care Plan were not updated to reflect this report intervention to increase supervision).The same report documents the physician, the power of attorney, police department, and the ombudsmen were notified (confirmed in interviews with V3, Medical Director, V24, Power of Attorney, V9, Supervisor Police Department and V20, Ombudsman that they had not been notified).R3's Occurrence Note dated 7/5/25 at 1:33 pm documents the following: Note Text: Incident Note: Resident (R3) to resident (R4) altercation abuse protocol initiated. When this writer (V32, Licensed Practical Nurse) was inside of the med (medication) room two CNAs (V5 and V6, Certified Nursing Assistant/CNA) witnessed another resident have a hold of this resident's(R3) shirt.(R3) then grabbed a hold of the other resident's left arm. CNA was attempting to separate them, and (R3) had slapped the other resident (R4) in the left side of their face and walked away. No injuries noted/reported. No c/o (complaint/of) pain or discomfort. Resident unable to relay what had happened. Attempted to get VS (Vital Signs measurement) on resident but resident was uncooperative and refused. On call has been notified, Administrator (V1, Abuse Prevention Coordinator) notified, POA notified, and Dr. notified. NNO (No new orders) at this time.On 8/19/25 at 3:00 pm V5, CNA started she worked the day (7/5/25) when R3 slapped R4. V5,CNA said R3 and R4 were seated just on the other side of the nurse's station. V5, CNA points to several other residents and R3 seated in front of the nurses station. R3 was expressing unintelligible words, loudly. V5,CNA stated R4 grabbed the sleeve of R3's shirt in response to R3 making loud sounds. R5 was not really saying anything. V5 stated this is R3's normal. V5 said V5 stood up to come around the nurse's station to separate the residents. V5 said by then, R3 had grabbed R4's shirt. V5 said V5 watched R3 pulled back her other hand, and deliberately swung at R4 face. V5 said it was a full smack. V5 said she saw it, and she heard it. V5 said R4, walked away from R3. We increased supervision of both residents. V5 said V5 reported all of this immediately to V1, Administrator/Abuse Prevention Coordinator after V5 made sure the residents were both separated and safe. V5 said V6, Certified Nursing Assistant was working and helped keep R3 and R4 separated.2.) R4's MDS dated [DATE] documents the following: R4's Brief Interview of Mental Status score of eight out of a possible score of 15, which indicates moderate cognitive impairment . The same MDS documents R4 has had Physical (e.g. Hitting, kicking pushing, scratching, grabbing or abusing others sexually) and verbal behaviors directed towards others (e.g. screaming at others, threatening others, and cursing at others), and Behavioral symptoms not directed towards others: (e.g., smearing physical food or symptoms bodily such wastes, as or hitting or verbal/vocal scratching symptoms self, pacing, like rummaging , public sexual acts, disrobing in public, throwing or smearing food or bodily waste, or verbal/vocal symptoms like screaming and disruptive sounds). These behaviors of verbal and physical, and others behaviors occurred one to three days during the lookback period of the MDS assessment.R4's Care Plan dated as last revised 7/7/25 documents the following, (R4) has a DX (diagnosis) anxiety disorder, unspecified, DX: Dementia in other diseases, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145469 If continuation sheet Page 4 of 14 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 08/22/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some unspecified severity, with other behavioral disturbances. The resident is/has potential to be physically aggressive (hitting, kicking, pinching) r/t (related/to) Dementia, History of harm to others, Poor impulse control.R5's MDS dated [DATE] documents R5's BIMS score of 00 out of a possible 15 indicating severe cognitive impairment. The same MDS documents R5 has had no behaviors during the lookback period of this assessment.R5's Care Plan dated as last revised 1/6/25 documents R5 is at times physically aggressive related to dementia. R5 will not harm self or others through the review date. Target Date for review: 05/06/2025. R5 will have fewer episodes of physical aggression through the review date.The facility's Illinois Department of Public Health investigation report dated 06/21/25 documents the following: Summary of Investigative findings through discussions with Individuals with direct knowledge and review of the resident clinical record, include the report of incident and post-occurrence IDT (Interdisciplinary Team) walking rounds. A comprehensive investigation was initiated and found that on 6/21/25 resident (R4) swatted (R5's) back, as she was walking past her. A staff member was immediately present with another resident ( unidentified) and very quickly intervened and redirected. Both residents were immediately assessed with no injury. The incident did not appear to be malicious in any manner and more of a matter of attempt to get the other resident's attention. A root cause was identified, and an appropriate intervention has been put into place. Neither resident could recall the incident, and neither resident shows any signs of mental anguish. The facility finds the allegation of willful abuse unsubstantiated related to there being no malicious intent with One resident trying to get the other resident's attention. The same investigation report documents the plan of care was updated as needed. The facility will continue to monitor residents as needed: resident post incident assessment will continue.The same investigation report above also documents Power of Attorney, Physician and Ombudsman were notified. Interviews conducted with R4 and R5's POA, V3, Medical Director, and V20, Ombudsman stated they were not notified.On 8/19/25 at 3:00 pm V5, Certified Nursing Assistant (CNA) said R4 had an altercation with R5, on the same day as an incident with R4 and R6. V5, CNA said R4 did not walk very fast. R5 hit R4 in the back, and left a ‘full-red hand print on R4's low back V5, CNA also stated as soon the altercation occurred V5 called the on-call number and talked to V1 Administrator/Abuse Prevention Coordinator.3.) R4's Minimum Data Set (MDS) dated [DATE] documents the following: R4's Brief Interview of Mental Status (BIMS) score of eight out of a possible score of 15, which indicates moderate cognitive impairment . The same MDS documents R4 has had Physical (e.g. Hitting, kicking pushing, scratching, grabbing or abusing others sexually) and verbal behaviors directed towards others (e.g. screaming at others, threatening others, and cursing at others), and Behavioral symptoms not directed towards others: (e.g., smearing physical food or symptoms bodily such wastes, as or hitting or verbal/vocal scratching symptoms self, pacing, like rummaging , public sexual acts, disrobing in public, throwing or smearing food or bodily waste, or verbal/vocal symptoms like screaming and disruptive sounds). These behaviors of verbal, physical, and others' behaviors occurred one to three days during the lookback period of the MDS assessment.R4's Care Plan dated as last revised 7/7/25 documents the following, (R4) has a DX (diagnosis) anxiety disorder, unspecified, DX: Dementia in other diseases, unspecified severity, with other behavioral disturbances. The resident is/has potential to be physically aggressive (hitting, kicking, pinching) r/t (related/to) Dementia, History of harm to others, Poor impulse control. R6's MDS dated [DATE] documents R6' has a BIMS score of 11 out a possible 15, indicating moderate cognitive impairment. The same MDS documents that R6 has had no physical or verbal behaviors directed at herself or others during the look back period of this assessment.R6's Care Plan dated 12/26/24 with a target date for review/revise of 1/10/25. R6's care plan documents R6 has impaired function/dementia or impaired thought (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145469 If continuation sheet Page 5 of 14 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 08/22/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some process related to Dementia. R6's Medication Administration Record dated June1-30, 2025 documents R6 had pain on 6/18/25 ( the same day R4 grabbed R6's wrist and left fingernail indentations), twice, at a level of eight (indicating moderate-high) on a scale of 1-10. R6 required a combination medication; Hydrocodone (narcotic analgesic) -Tylenol (analgesic) 5 milligrams-325 milligrams, one by mouth every six hours as needed for pain. R6 was administered one dose at of Hydrocodone - Tylenol at 12:25 pm and again at 6:01 pm. There was no other doses recorded as administered, between 6/16/25 start date of the order, and 6/30/25.The facility's initial Illinois Department of Public Health (IDPH) investigation report dated 06/18/25 at 12:45 pm documents R4 and R5 (not R4 and R6) were involved in a resident-to-resident altercation and was witnessed by V5, Certified Nursing Assistant. That report goes on to documents R6's initials and states that the altercation occurred while (R6's initials and R4 initials) walking in the hallways from the dining room, when R4 (indicated by initials) grabbed R6's (indicated by initials) shirt. V1 Administrator interview below said they are related to R4 and R6, not R4 and R5 and she would resubmit to IDPH an updated report.The second report to IDPH dated 06/18/25 at 12:45 pm (the same date as above) documents a resident-to-resident altercation and that was witnessed by V7, Certified Nursing Assistant. This report documents R4 grabbed R6's shirt as leaving the dining room (not in R6's room documented on the third investigation below). The initial and final investigation does not document R6's wrist was grabbed in the altercation and there is no mention R4 coming into R6's room (as documented on the third investigation initial and final report below). The third IDPH initial and final investigation report also dated 6/18/25 at 12:45 pm, documents a resident-to-resident altercation between R4 and R6 that was witnessed by V5, Certified Nursing Assistant and V12, Licensed Practical Nurse. This third report documents the following: Summary of Investigative findings through discussions with Individuals with direct knowledge and review of the resident clinical record including the Report of Incident and the post occurrence IDT Walking Rounds: A comprehensive investigation was initiated and found that on 6/18/25 resident (R4) entered resident (R6's) room. Resident (R6) asked resident to leave but she declined to do so. Resident (R4) was then observed to hold other resident's (R6) wrists. A root cause was identified, and an appropriate intervention has been put into place. (R4) was transported to (local named -Hospital Emergency Room) on 6/19 due to behavioral issues and sent to (Private Psychiatric hospital on 6/22/25). Resident (R6) recalled that ‘She (R6) just grabbed my wrist when I wanted to leave my room. Neither resident shows any signs of mental anguish. The facility finds the allegation of willful abuse unsubstantiated related to there being no malicious intent as it appeared that (R4) thought she was in her own room, in her own bed, when resident (R6) startled her.On 8/19/25 at 3:00 pm V5, Certified Nursing Assistant (CNA) witnessed the resident-to-resident altercation between R4 and R6. V5, CNA said R4 had an altercation with R6. V5, CNA said the incident occurred the same weekend in June, as when R4 got smacked on the back by R5 (see above Saturday, 6/21/25 (which is documented as 6/18/25 on the three investigation above). V5, CNA said R4 went into R6's room and grabbed R6's wrist and it left fingernail marks on R6 wrist. V5, CNA said she was able to take R4's hand off R6's wrist easily. V5, CNA also said you could see R4 had to have held onto R6's wrist firmly to leave fingernail marks On 8/19/25 at 3:20 pm R6, said the lady (identified as R4 in above, V5 interview) that wanders, came into my room and tried to lay down in my roommates bed. I told her she needed to leave our room. The lady (R4) grabbed my (R6) wrist. (R6) held up her left wrist. Her left wrist had a knotted deformity on the lateral wrist. R6 also said This was the wrist, but she didn't cause the bump. I fracture that a long time ago and the doctor said they could not fix it. When she (V4) grabbed my wrist, it hurt. I knew not to pull away or she would have grabbed it harder. I told her to let go. I said it loud, and a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145469 If continuation sheet Page 6 of 14 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 08/22/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Nurse (unidentified) and CNA (V5, Certified Nursing Assistant) came in and had her (R4) let go. I have not been mistreated any other time.On 8/22/25 at 8:40 am V1, Administrator/Abuse Prevention Coordinator V1 stated that the 6/18/25 abuse allegations above was not R5 and R4. V1 said V1 fixed the report and gave it (the second report) to this surveyor the day before. V1 said the investigation was the altercation between R4 and R6 and V1 has not sent an updated report to IDPH. V1 said she 'should probably do that'. V1 said V12, Licensed Practical Nurse did the skin assessment and said there was no injury to R6's skin. On 8/22/25 at 9:25 am V1, Abuse Prevention Coordinator/ Administrator provided the third resident to resident investigation report. V1 said all three of the abuse investigation reports dated 6/18/25 regarding R4 and R6 provided on survey, are the same occurrence. The last one included that R4 did grabbed R6's wrist and That should have been in the investigation report to begin with. Each of the IDPH abuse investigations reports dated 6/18/25 document the Ombudsman, and POA, were notified.R6's Nursing Note dated 6/18/2025 at 2:46 pm documents the following: Note Text: Upon responding to alarm sounding in room across the hall from resident; a staff member observed this resident standing from W/C (wheelchair) and grasping another female resident by both wrists. Staff immediately separated the residents and notified the appropriate supervisor and abuse coordinator. Placed a phone call to (V28, R4's Healthcare Power of Attorney/HPOA) and informed of the observation of resident having ahold of another female (R6) by both wrists and that per protocol was also reported to PCP (Primary Care Provider) and all appropriate IDT (Interdisciplinary Team) members. HPOA expressed understanding and appreciation for the call and stated will not be coming to visit today due to the inclement weather but plans to come tomorrow. HPOA has no concerns or other questions. The facility abuse policy dated 1/9/24 document the following: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation, which includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. Event ID: Facility ID: 145469 If continuation sheet Page 7 of 14 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 08/22/2025 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed repeatedly to operationalize their abuse prevention policy by failing to notify the Ombudsman of abuse allegations. This failure affected seven of nine residents (R3 -R7) reviewed for abuse on the sample list of 18. Findings include:1. R'4s/R3's IDPH resident to resident physical abuse investigation report dated 7/5/25 documents R3 smacked R4's face, and the Ombudsman was notified, as the facility abuse prevention policy directs.2. R4/R5 IDPH resident to resident physical abuse investigation report dated 6/21/25 documents R4 swatted R5's back, and the Ombudsman was notified, as the facility abuse prevention policy directs. 3. R4/R6 IDPH resident to resident physical abuse investigation report dated 6/18//25 documents R4 grabbed R6's wrist, and the Ombudsman was notified, as the facility abuse prevention policy directs. 4. R7's IDPH report dated 8/19/25 documents R7 was handling rough by an unidentified nursing staff named ( V11, Nursing staff) causing a bruise to R7's arm, and the Ombudsman was notified, as the facility abuse prevention policy directs. All of the above reports were documented by V1, Administrator/ Abuse Prevention Coordinator. Each of the above reports document that the Ombudsman was notified of the alleged abuse.On 8/21/25 at 11:13 AM V20, Ombudsman discussed the the above alleged abuse investigation reports with the corresponding dates. V20 said V20 reviewed all V20's correspondence with the facility over this time frame and associated dates. V20, Ombudsman stated he was not notified by the facility of any of the above allegations. V20, said V20 reviewed his notes, emails and phone calls. V20 also stated he was in the facility last week and was present during the facility Resident Council Group meeting. V20 stated the facility did not notify V20 in person, of any of the abuse/injury of unknown allegations documented above.The facility Abuse Policy dated as revised 01/09/24 documents, The Facility will report all allegations of abuse immediately to the Administrator and timely to the proper authorities to include IDPH ( Illinois Department of Public Health), Ombudsman, Local P.D (Police Department), POA ( residents Power of Attorney), and M.D. (Physician) in a timely manner. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145469 If continuation sheet Page 8 of 14 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 08/22/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based interview and record review, the facility failed to report allegations of resident to resident physical abuse, staff to resident physical abuse, and injuries of unknown origin to the police department and physician, in accordance with the facility policy. This failure affected five of nine residents (R3-R7) reviewed for abuse on the sample list of 18.Findings include: 1. R'4s/R3's IDPH resident to resident physical abuse investigation report dated 7/5/25 documents R3 smacked R4's face, and the local police department and physician were notified. 2. R4/R5 IDPH resident to resident physical abuse investigation report dated 6/21/25 documents R4 swatted R5's back, and the local police department and physician were notified. 3. R4/R6 IDPH resident to resident physical abuse investigation report dated 6/18//25 documents R4 grabbed R6's wrist, and the local police department and physician were notified. 4. R7's IDPH report dated 8/19/25 documents R7 was handling rough by an unidentified nursing staff causing a bruise to R7's arm, and the local police department and physician were notified. All of the above reports were documented by V1, Administrator/ Abuse Prevention Coordinator. Each of the above reports document that the local police department and the physician were notified, as the facility abuse prevention policy directs.On 8/21/25 at 10:20 AM, V19, Supervisor, Local Police Department stated the police department has no records, reports or dispatch calls of the facility contacting them regarding any of the above report.On 8/22/25 at 1:10 PM, V3, Medical Director/Physician (MD) reviewed V3, MD's records, facsimiles and phone calls on each of the above allegations of abuse. V3 said had not been notified of any of the above allegations. V3,MD also said that on-call physicians report all events in the facility to V3, MD. V3 said he does not see any evidence from the on-call providers that reflects they were notified of the above abuse investigations.On 8/22/25 at 12:40 pm V1 Administrator/Abuse Prevention Coordinator stated I called the police, and they asked if I wanted them to come out and I said no. I have nothing to show that I called and I don't keep my phone calls on my cell phone. I have no proof. I will have to get proof from now on. I will get a name or report number from the Police. V1 also stated As far as family and the physician, the nurses should be documenting accurately if they aren't getting a hold of a family and the doctor. That is what I go by in my investigation. I know I talked to (V23 Power of Attorney/R6's Family) about other things. The nurses are to report to the families about any resident-to-resident altercation. I guess I can't prove that either.The facility Abuse Policy dated as revised 01/09/24 documents the following: investigation has been complete. The Facility will report all allegations of abuse immediately to the Administrator and timely to the proper authorities to include IDPH ( Illinois Department of Public Health), Ombudsman, Local P.D (Police Department), POA ( residents Power of Attorney), and M.D. (Physician) in a timely manner. Event ID: Facility ID: 145469 If continuation sheet Page 9 of 14 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 08/22/2025 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to complete a thorough investigation by failing to interview families that are frequently in the facility, and other residents residing in the facility, that may have knowledge of alleged abuse. This failure had the potential to affect five of nine residents (R3- R7) reviewed for abuse on the sample list of 18. Findings include:R'4s/R3's IDPH resident to resident physical abuse investigation report dated 7/5/25 documents R3 smacked R4's face. The facility investigation determined this allegation to be unfounded, though no families or other residents were interviewed. 2. R4/R5 IDPH resident to resident physical abuse investigation report dated 6/21/25 documents R4 swatted R5's back. The facility investigation determined this allegation to be unfounded, though no families or other residents were interviewed. 3. R4/R6 IDPH resident to resident physical abuse investigation report dated 6/18//25 documents R4 grabbed R6's wrist. The facility investigation determined this allegation to be unfounded, though no families or other residents were interviewed. 4. R7's IDPH report dated 8/19/25 documents R7 was handling rough by an unidentified nursing staff causing a bruise to R7's arm. The facility investigation determined this allegation to be unfounded, though no families or other residents were interviewed. On 8/22/25 at 8:40 am V1, Administrator confirmed the abuse investigation ( R3-R7) provided throughout the survey (8/19/25 - 8/22/25) are complete. V1 then confirmed she did not interview families that visit the facility frequently, or other residents who may have knowledge of alleged abuse incidents. The facility's Abuse Policy dated as revised 01/09/24 documents the following, The facility immediately and thoroughly investigates all allegations of abuse to include but not limited to interviews of residents and staff, visitors, vendors. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145469 If continuation sheet Page 10 of 14 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 08/22/2025 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 timely review and revise care plans for four of nine residents ( R3, R4, R5, and R6) reviewed for abuse on the sample list of 18. Findings include: R'4s/R3's final IDPH resident to resident physical abuse investigation report dated 7/5/25 documents R3 smacked R4's face. The same report documents R3 and R4's care plan was reviewed/revised. R3's Care Plan dated as last revised 01/22/24 (twenty- four) with a target date of 01/10/25 (twenty -five) documents the following: (R3) has the potential for abuse/neglect due to invading other's space and property, rummaging through belongings or wandering in and out of other's spaces. She has a history of being physically abused, psychiatric diagnosis or manifestations, including delusions, paranoia and hallucinations, Underlying factors that increase vulnerability; including such as dementia, confusion, poor judgment, wandering and giving away personal property. (R3) will experience no present/future problems related to abuse/mistreatment/violation. Revision on: 01/22/2024, Target Date: 01/10/2025. There are no review or revision on R3's Care Plan as indicated above in the investigation report.R4's re-admission Care Plan dated as last revised 7/7/25 documents the following: (R4) has a DX (diagnosis) anxiety disorder, unspecified, DX: Dementia in other diseases, unspecified severity, with other behavioral disturbances. The resident is/has potential to be physically aggressive (hitting, kicking, pinching) r/t (related/to) Dementia, History of harm to others, Poor impulse control. R4's same care plan does not document R4's care plan was reviewed or revised, related to abuse, in a timely manner on 7/5/25 , as documented on the abuse investigation report above. 2. R4/R5 final IDPH resident to resident physical abuse investigation report dated 6/21/25 documents R4 swatted R5's back. The same report documents R4 and R5's care plan was reviewed/revised. R4's re-admission Care Plan dated as last revised 7/7/25 documents the following: (R4) has a DX (diagnosis) anxiety disorder, unspecified, DX: Dementia in other diseases, unspecified severity, with other behavioral disturbances. The resident is/has potential to be physically aggressive (hitting, kicking, pinching) r/t (related/to) Dementia, History of harm to others, Poor impulse control. R4's same care plan does not document R4's care plan was reviewed or revised related to abuse, in a timely manner on 6/21/25, as documented on the abuse investigation report above. R5's Care Plan dated as last revised 01/6/25 documents R5 is at times physically aggressive related to dementia. R5 will not harm self or others through the review date. Target Date for review: 05/06/2025. R5 will have fewer episodes of physical aggression through the review date. R4's same care plan does not document R5's care plan was reviewed or revised, on 6/21/25, as documented on the abuse investigation report above. 3. R4/R6 final IDPH resident to resident physical abuse (second) investigation report dated 6/18//25 documents R4 grabbed R6's wrist. The same report documents R4 and R6's care plan was reviewed/revised. R4's re-admission Care Plan dated as last revised 7/7/25 documents the following: (R4) has a DX (diagnosis) anxiety disorder, unspecified, DX: Dementia in other diseases, unspecified severity, with other behavioral disturbances. The resident is/has potential to be physically aggressive (hitting, kicking, pinching) r/t (related/to) Dementia, History of harm to others, Poor impulse control. R4's same care plan does not document R4's care plan was reviewed or revised related to abuse, on 6/18/25, as documented on the abuse investigation report above. R6's Care Plan dated 12/26/24 with a target date for review/revise of 1/10/25. R6's care plan documents R6 has impaired function/dementia or impaired thought process related to Dementia. The same care plan does not document R4's care plan was reviewed or revised in a timely manner on 6/18/25 as documented on the abuse investigation report above. On 8/21/25 at 3:05 pm V16, Regional Administrator/Licensed Professional Nurse reviewed R3-R7's Care Plans and confirmed R3- R7's care plans have not been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145469 If continuation sheet Page 11 of 14 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 08/22/2025 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 0657 Level of Harm - Minimal harm or potential for actual harm updated as they were supposed to be and new interventions should have been documented after each of the abuse allegations.The facility's Abuse Policy dated as revised 01/09/24 documents the following: Implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent future occurrences. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145469 If continuation sheet Page 12 of 14 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 08/22/2025 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on observation, interview, and record review, the facility failed to provide a full-time director of nurses to oversee and coordinate nursing services provided within the facility. This failure has the potential to affect all 83 residents residing in the facility.Findings include:During the survey 8/19/25 through 8/22/25 there was no Director of Nursing (DON) in the building.On 8/19/25 at 10:10 am V1, Administrator/Abuse Prevention Coordinator stated V2, previous Director of Nursing's last day employed for the facility was Friday 8/15/25. V1 stated she has not hired a Registered Nurse for the DON position, nor does the facility have an Acting DON to provide oversite of the nursing services.The facility resident roster dated 8/19/25 documents 83 residents reside in the facility. Event ID: Facility ID: 145469 If continuation sheet Page 13 of 14 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 08/22/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review, the facility failed repeatedly to maintain complete and accurate medical records for one of nine residents ( R6) reviewed for abuse/injury of unknown origin on the sample list of 18.Findings include:R6's Physician Adult Health Exam, Routine Nursing Home Follow-Up. notes dated 2/20/25, 4/10/25, 4/17/25, 6/19/25 and 7/10/25 document R6 was assessed by V3, Medical Director (Physician). These notes were signed by V3, Medical Director. V3, MD documented R6 'Integumentary (skin)' assessments indicates R6 had left cheek and left, lower rib cage bruises on each of these assessment. On 8/22/25 at 1:10 PM V3, Medical Director reviewed R6's medical record documentation and said he now recognized his documentation was not accurate in V3, MD Nursing home visit notes that he documented on 2/20/25, 4/10/25, 4/17/25, 6/19/25 and 7/10/25. V3 confirmed R6 had a fall in December 2024 and continued with bruises in January but did not have bruising on the above mentioned dates. V3, MD acknowledged this was a documentation error. V3, MD also said V3, MD will add an addendum to each of those progress notes.R6's revised Progress notes dated 2/20/25, 4/10/25, 4/17/25, 6/19/25 and 7/10/25 have the following addendum signed by V3, MD: C: PHC NH (Point Click Care Nursing Home) Addendum: Integumentary: Bruising noted to left cheek and left lower ribs was added to chart due to documentation error. ZOO.DO: Encounter for general adult medical examination without abnormal findings. Event ID: Facility ID: 145469 If continuation sheet Page 14 of 14