Inspection·September 19, 2025

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete door open to the hallway. R12's urine collection bag was visible from the hallway, partially filled with yellow-colored urine, and was not contained in a privacy cover. On 9/18/2025 at 3:00PM, R12 was seated in a wheelchair in R12's room with the door open to the hallway. R12's urine collection bag was visible from the hallway, partially filled with yellow-colored urine, and was not contained in a privacy cover. On 9/19/2025 at 11:50AM, R12 was seated in a wheelchair in the hallway outside of R12's room. R12's urine collection bag was visible, partially filled with yellow-colored urine, and was not contained in a privacy cover. The facility's Dignity policy (October 2009) documents facility staff shall promote dignity and assist residents as needed by helping residents keep urinary catheter bags covered. Event ID: Facility ID: 145469 If continuation sheet Page 2 of 13 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 09/19/2025 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 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to post an accurate notice for the location of the survey results book and failed to identify the survey book. This failure has the potential to affect all 81 residents residing in the facility.Findings include: On 9/16/25 at 1:00 PM during a resident group interview, R27, R52, R59 all stated they had no knowledge of where the survey results book was located. Each of these residents stated no facility staff had informed them where the survey results book was. On 9/16/25 at 2:05 PM, the was an eight and one half inch by eleven inch sign posted in the front hallway documenting the survey inspection results book could be found in a plastic holder outside the front office. There was not a plastic holder outside of the administrative office, the reception office, nor the conference room, which were visible from the location of this posted sign. There was a plastic holder outside of the human resources office which was empty of any contents. On 9/16/25 at 2:07 PM, V1, Administrator, located a 4-inch-thick black notebook inside the glass doors of a small cabinet in the resident and family lounge room. This notebook was not labeled to identify it as the survey results book. V1 stated the plastic holder referred to the plastic file holder outside of the human resources office, but the book was too thick to fit into that holder. V1 concluded by stating she would need to change the posted sign and also to review the location of the survey book in the resident council. The facility's Long Term Care Facility Application for Medicare and Medicaid dated 9/18/25 documents 81 residents reside in the facility. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145469 If continuation sheet Page 3 of 13 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 09/19/2025 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility repeatedly failed to maintain nebulizer respiratory equipment in a clean sanitary manner, change oxygen nasal canula and tubing in a timely manner, provide an oxygen humidification water bottle, failed to obtain an oxygen administration order, and failed to care plan respiratory status, interventions for the monitoring of oxygen administration, and for safe and sanitary practices for R43. The facility also failed to provide an oxygen humidification water bottle for (R64). These failures affected two of three residents (R43 and R64) reviewed for respiratory care and medication administration on the sample list of 30.Findings include: Residents Affected - Some 1.R43's Physician Order Sheet (POS) dated 9/18/25, (time stamp at 10:27 am when copied, prior to an updated version), documents: Elevate head of bed to avoid shortness of breath when lying flat R/T (related to) COPD (Chronic Obstructive Pulmonary Disease), every shift. Start date 8/7/25.The same POS documents: Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (milligrams/ milliliters) one vial inhale (per nebulizer) , three times daily. The same POS does not document a Physician Order for the administration of oxygen direction for use or monitoring. R43's Care Plan dated 8/25/25 does not document R43 has a compromised respiratory status, that require respiratory interventions for monitoring of oxygen administration, , positioning to prevent shortness of breath, and measurements of blood oxygen level per standards of practice or maintaining respiratory equipment for safe and sanitary practices. On 9/18/25 at 9:10 am R43's undated, clear plastic nebulizer mask was soiled with a build-up of opaque white splatter on the inside of the mask, and something beige and sticky on the outside of the mask. The nebulizer mask was lying in top draw of R43's bedside dresser with the undated tubing dangling to one approximately one inch of the floor.R43's bedside oxygen concentrator had an empty, disposable humidifier bottle attached to the nipple of the actively running oxygen concentrator, The empty humidifier bottle was dated 8/31/25. R43's oxygen was infusing at three liters per nasal canula. The nasal canula/tubing was undated. During the same observation at 9:10 am, V11, Registered Nurse (RN) removed R43's soiled nebulizer mask from R43's dresser drawer. V11 RN filled R43's medication apparatus cup with one vial of Ipratropium-Albuterol Inhalation Solution and placed the respiratory medication inhalation therapy mask on residents' face. R43 told V11 he has done his nebulizers treatments at home and does not have a problem with turning off the machine when the administration is complete in approximately 15 minutes. On 9/18/25 at 9:30 am V11 RN turned off R43's nebulizer inhalation therapy treatment. V11 confirmed the nebulizer mask was soiled and should not have been used to administer the medication. V11 also confirmed nebulizer mask and tubing were undated as required to ensure they are changed weekly. V11 also verified the oxygen tubing and nasal canula was undated and R43's humidifier botte was empty and outdated 8/31/25. V11 stated All this equipment is supposed to be changed every week, dated and the humidifier bottle should be changed before it runs dry. On 9/18/25 at 11:20 am V8, Acting Director of Nursing/RN, V2, Assistant Director of Nursing (ADON)/Licensed Practical Nurse (LPN) and V9 LPN were in their shared office. V8, V2 and V9 all reviewed R43's electronic medical records and confirmed R43 has no physician order for oxygen administration order, no respiratory care planned interventions to maintain respiratory status and care of the equipment as required. V2, ADON/LPN stated R43 just returned from the hospital. The orders were missed on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145469 If continuation sheet Page 4 of 13 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 09/19/2025 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some readmission. V8 confirmed the respiratory equipment is to be changed weekly and as needed for all residents on oxygen. 2. On 9/17/25 at 1:34 PM, R64 was lying in bed receiving oxygen therapy through a room air concentrator at four liters per minute through a nasal tubing (cannula). R64's oxygen humidifier bottle was totally dry and was dated 9/8/25. R64's oxygen nasal tubing was undated to indicate when the last time the tubing was changed. At this same time, R64 stated the bottle runs dry all the time. On 9/18/25 at 3:55 PM, R64's oxygen humidifier bottle was still dry and still dated 9/8/25. R64's current Physician Order Sheet dated 9/17/25 documents for the oxygen tubing and humidifier bottle to be changed every week on Sunday nights. The facility's policy Oxygen Administration dated as revised 3/17/22 documents humidifier bottles, oxygen masks, and oxygen tubing are needed equipment for oxygen administration. This same policy documents oxygen will be administered in accordance with physician orders. This policy documents the mask, tank, and other equipment to ensure proper working order. This policy documents humidifier bottles will be changed as needed. This policy documents a cautionary statement that constant flow of oxygen can cause drying and thickening of normal secretions resulting in laryngeal ulcerations (open sores in the throat). This policy documents an oxygen mask or tubing not in use will be placed inside a plastic bag. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145469 If continuation sheet Page 5 of 13 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 09/19/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review the facility failed to maintain a supply of a house-stock probiotic medication (to prevent antibiotic -associated diarrhea, and protect against Clostridium-difficle infection that can develop after antibiotic use,) for a resident (R43) currently on an intravenous antibiotic medication for Extended-Spectrum Beta-Lactamase (ESBL), (antibiotic resistant bacterial infection) of a wound. R43 is one of seven resident reviewed during medication administration, on the sample list of 30. Findings include:R43's current Physician Order Sheet (POS) documents the following: Florastor (Saccharomyces boulardii), (Yeast based, probiotic medication, that are ten times larger than bacterial based probiotic) Capsule 250 milligrams (mg) , Give one capsule by mouth, two times a day, for Prophylactic (to prevent disease).R43's same POS documents the following; Ertapenem (broad-spectrum antibiotic to treat serious bacterial infections) one gram (reconstituted in 100 milliliters of normal saline) intravenously, over a one hour period, give every 24 hours for 14 days.R43's same POS documents: Contact Isolation for ESBL related to Wound ( Acquired Absence Left Above Knee Amputation infected surgical site).R43's Medication Administration Record dated 9/01/25 - 9/30/25 documents: R43's Florastor Capsule 250 milligrams (mg), Give one capsule by mouth, two times a day at 8:00 am and 8:00 pm. V11's Registered Nurse's (RN) initials, and MN, are documented to indicate the medication is not available 9/18/25.09/18/2025 9:00 am V11, RN initiated the one hour administrations of R43's Ertapenem medication one gram reconstituted via R43's right upper arm, Midline-Peripherally Inserted Central Catheter (intravenous access).On 9/18/25 at 9:21 am V11, RN had prepared R43's oral medications for administration. V11 stated there was no supply of R43's Florastor Capsule 250 MG in the medication cart. V11 went to the medication room, and the medication stock room and verified all house stock medications. V11 stated there was no Florastor 250 mg capsule in stock to give R43.On 9/18/25 at 11:20 am V2 Assistant Director of Nursing (ADON) stated R43's Florastor 250 mg capsules should have been available in stock. V2, ADON also stated she will purchase these today.On 9/19/25 at 8:45 am V2, ADON stated We were not able to purchase (9/18/25) the correct dose (250 mg) of the probiotic Florastor . That is why it was not given 9/18/25 (scheduled 8:00 am and 8:00 pm) . V2 also stated We are working on getting an order (physician) for a different probiotic since we can't get the Florastor 250 mg (capsule). Event ID: Facility ID: 145469 If continuation sheet Page 6 of 13 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 09/19/2025 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to follow pharmacy instruction for the administration of physician ordered medication, for two of seven resident (R3 and R43) reviewed during medication observation. The facility had three medication errors, out of 32 opportunities, resulting in an 9.38 percent medication error rate.Findings include:1. R3's current Physician Order Sheet (POS) documents: Ferrous Sulfate Oral Tablet, Delayed Release 324 (65 FE (65 milligrams iron) MG (milligrams). Give 1 (one) tablet by mouth two times a day for Supplement.R3's same POS documents: Cefdinir Oral Capsule 300 MG (antibiotic). Give 1 capsule by mouth two times a day for leukocytosis, bacteremia for 10 Days. Give with or without meals. No iron/antacids within 2 hours.On 9/19/25 at 8:00 am V13, Licensed Practical Nurse administered R3's Iron, and Cefdinir at the same time, in direct contrast to the physician order and pharmacy directions on the prescription label. V13, Licensed Practical Nurse confirmed she had given Cefdinir antibiotic with Ferrous Sulfate and did not wait two hours, as the physician order and the pharmacy label directs.2. R3's current POS also documents: Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 200-62.5-25 MCG/ ACT (Fluticasone-Umeclidinium-Vilanterol) (micrograms per actuation), one puff, inhale orally, one time a day for respiratory (airway exchange). Rinse mouth thoroughly after each use. Discard after six weeks once foil is opened.On 9/19/25 during the 8:00 am medication administration pass, after R3 had taken oral medications, V13,Licensed Practical Nurse (LPN) administered R3's Trelegy Ellipta Inhaler. V13 LPN did not provide water for R3 to rinse R3's mouth after the Trelegy Ellipta inhalation medication administration. R3 stated They have never told me to rinse after taking this inhaler. Should I rinse? V13, Licensed Practical Nurse acknowledged to R3 that R3 should rinse R3's mouth thoroughly, after the administration of Trelegy Ellipta inhaler administration. V13,LPN then stated, I should have caught that (directions on physician order and pharmacy label to rinse thoroughly after administration). 3. R43's Current Physician Order documents the following: R43 Florastor (yeast based probiotic) Capsule 250 MG (Saccharomyces boulardii). Give 1 tablet by mouth two times a day for PROPHYLACTIC.On 9/18/25 at 9:21 am V11, Registered Nurse (RN) had prepared R43's oral medications for administration. V11 stated there was no supply of R43's Florastor Capsule 250 MG available for administration. V11 RN administered R43's other oral medications. V11 RN then searched the medication room on the north hall unit, and the facility-wide medication stock room. V11, RN confirmed there was no Floraster 250 mg in stock, to administer R43 Floraster.The facility policy Medication Administration Policy/Procedure dated as revised 9/27/22 documents the following:PURPOSETo ensure proper administration of oral medications.POLICYMedications will be administered safely to residents within the facility by licensed nurses at the specified time/timeframe, following the recommended administration method and will be documented as required.RESPONSIBILITYIt is the responsibility of all licensed nursing staff to safely administer medications to residents. 2. Remove the individual's medication(s) from the medication storage area. 8. Follow the specific instructions listed for each type of medication to be given. Offer adequate fluids with medications. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145469 If continuation sheet Page 7 of 13 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 09/19/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review the facility failed to store (R55's) Scheduled IV, Narcotic Controlled Substance in a locked refrigerator compartment to prevent the potential for drug diversion, and failed to ensure (R2 and R8's) opened, insulin injection pens were properly labeled, by the dispensing pharmacy with directions for safe administration. These failures affected three residents (R2, R8 and R55) reviewed during medication storage observation and are included on the sample list of 30.Findings include:1.) R55's current Physician Order Sheet (POS) documents the following: Lorazepam Intensol Oral Concentrate (Scheduled IV, Controlled Substance, liquid medication), two milligrams (mg) per milliliter (ml) (strength).Give 0.25 ml by mouth every 40 (facility typo clarified to be every four) hours as needed for Anxiety, Restlessness and Agitation (diagnoses) for 120 days, for end of life (Hospice care).On 9/18/25 at 12:20 pm V10, Licensed Practical Nurse (LPN) during medication storage observation, V10, LPN opened the South Hall medication room door. There was R55's 30-milliliter Lorazepam Intensol Oral Concentrate (Scheduled IV Controlled Substance), two milligrams per milliliter strength, unopened medication bottle. The bottle of Lorazepam Intensol Oral Concentrate was stored in the refrigerator door. The refrigerator does not have a lock to secure R55's controlled substance medication. V10, LPN stated Well, that should be in the locked box, in the refrigerator, so no one walks off with it. There may have been some confusion to the other nurses that work this hall. The key is on a different key ring then the med (medication) room, door key ring. That will be locked up now. The facility policy Storage of Controlled Substance dated a revised 08/2020 documents the following:PolicyMedications classified by the Drug Enforcement Administration (DEA) as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal, state, and other applicable laws and regulations. Procedure, 1. The Director of Nursing, in collaboration with the consultant pharmacist, maintains the facility's compliance with federal and state laws and regulations in the handling of controlled substances. Only authorized licensed nursing and pharmacy personnel have access to controlled substances. 2. Schedule ll (two) through Schedule V (five) medications and other medications subject to abuse or diversion are stored in either a permanently affixed, double looked compartment separate from all other medications or in accordance with state regulations. The access system to controlled medications is not the same as the access system for other medications (e.g., the key that opens the compartment is different from the key that opens the medication cart). If a key system is used, the medication nurse on duty maintains possession of the key to controlled substance storage areas. Back-up keys to all medication storage areas, including those for controlled substances, are kept by the Director of Nursing or designee. 3. Controlled substances that require refrigeration are stored within a locked box within the refrigerator. This box must be attached to the inside of the refrigerator and/or in accordance with state regulations and facility policy. 2.) R2's current Physician Order Sheet documents: (Lantus) Insulin Glargine-yfgn (sic) Subcutaneous Solution 100 units /ml (100 units/per milliliter), (Insulin Glargine-yfgn) (sic), Inject 23 unit subcutaneously, one time a day for DM (Diabetes Mellitus II).During the same medication storage observation on 9/18/25 at 12:20 pm V10, Licensed Practical Nurse (LPN) opened South Hall medication cart top drawer. There was a Lantus (100 units/per milliliter) insulin medication quick-injection pen. The Lantus insulin quick-injection pen documented R2's last name only, handwritten with permanent marker The insulin pen had no open date. R2's (presumed) Lantus insulin quick-injection pen had no pharmacy label with the directions for administration, prescribing physician, dispensing pharmacy, or a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145469 If continuation sheet Page 8 of 13 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 09/19/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete prescription number. V10, LPN stated We are going to be using a new pharmacy in a couple weeks. These pens (Lantus insulin) come all in one bag and are not labeled with the residents information or directions. We use the Medication Administration Record directions and put the residents name on a pen once we match up their orders. I am not sure who opened these, but they both (R2 and R8's below) should have been labeled when opened. 3.) R8's current POS documents: Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (100 units/per milliliter), (Insulin Glargine), Inject 36 unit subcutaneously at bedtime for DM.During the same medication storage observation on 9/18/25 at 12:20 pm V10, Licensed Practical Nurse (LPN) opened South Hall medication cart top drawer. There was a Lantus (100 units/per milliliter) insulin medication quick-injection pen. The Lantus insulin quick-injection pen documented R8's last name only, handwritten with permanent marker The insulin pen had no open date. R8's (presumed) Lantus insulin quick-injection pen had no pharmacy label with the directions for administration, prescribing physician, dispensing pharmacy, or a prescription number. V10, LPN stated We are going to be using a new pharmacy in a couple weeks. These pens (Lantus insulin) come all in one bag and are not labeled with the residents information or directions. We use the Medication Administration Record directions and put the residents name on a pen, once we match up their orders. I am not sure who opened these, but they both should have been labeled when opened.The facility policy Medication Storage dated 08/23/2022 documents the following:Purpose: To provide guidance to facility nursing staff on the proper storage of medication.Policy: The facility stores all drugs and biologicals in a safe, secure, and orderly manner and in accordance with state and federal regulations.Policy Interpretation and Implementation: 4. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals shall be returned to the dispensing pharmacy or destroyed. Event ID: Facility ID: 145469 If continuation sheet Page 9 of 13 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 09/19/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to observe and implement controlled temperature safeguards for potentially hazardous foods served to residents to prevent food borne illness (R30), failed to prevent the potential for physical cross-contamination of stored food, and failed to maintain sanitary dietary service floor areas. These failures have the potential to affect all 81 residents residing in the facility.Findings include: 1. On 9/16/25 at 11:48 AM, R13 was lying in bed with his breakfast tray in front of him on the over bed tray table. R13 was actively eating and drinking from this tray which contained scrambled eggs, oatmeal, and milk-based nutritional supplements. All of these items are included as high protein potentially hazardous foods with high water activity in the Food and Drug Administration Code 2017. On 9/16/25 at 12:00 PM, V4, Dietary Aide, stated the trays delivered to residents in their rooms are served prior to the residents in the dining room. V4 further stated the North Hall trays (where R13 resides) went out of the kitchen around 7:15 AM or so. V4, concluded by stating after four hours of food sitting around she would not want to be messing with that. On 9/16/25 at 12:03 PM, V3, Dietary Manager, stated it is the Certified Nursing Assistants working on the residential halls who serve the food trays and are supposed to be collecting them after the meal. On 9/16/25 at 12:15 PM, an insulated tray cart left the kitchen and was delivered to the residential North Hall. On 9/16/25 at 2:20 PM, V3 stated she would not let food sit out at room temperature for more than two hours and definitely not four hours as things start growing that can make people sick. V3 continued to state she would not even attempt to reheat food after two hours but would prepare something totally new. On 9/16/25 at 2:34 PM, R13 was lying in bed with his lunch tray on the over bed tray table actively eating and drinking from his tray which contained a hot dog, baked beans, and a milk-based nutritional supplement. These food items are also identified as high protein and high water activity potentially hazardous foods. At this time, R13 stated no one had ever talked to him about how long food can sit out at room temperature before it starts to go bad, and he had no knowledge about how long food can sit out before it goes bad. On 9/16/25 at 2:40 PM, V5 and V6, both Certified Nursing Assistants working on the North Hall, stated R13 takes a long time to eat and that R13 knows we will bring him something new or a snack, but he doesn't want to give up his tray. R13's Minimum Data Set, dated [DATE] documents R13 received a score of 9 out of a possible 15 for a Brief Interview for Mental Status, indicating moderate cognitive impairment. On 9/18/25 at 10:15 AM, R13 was lying in bed with his breakfast tray in front of him on the overbed tray table. R13 was actively eating from the tray which included crumbled pork sausage and gravy, and milk-based nutritional supplement, included as high protein and high water activity potentially (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145469 If continuation sheet Page 10 of 13 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 09/19/2025 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 0812 hazardous foods. R13's tray was not removed from in front of him until 10:50 AM. Level of Harm - Minimal harm or potential for actual harm On 9/18/25 at 3:29 PM, R13's lunch tray was removed form his over bed tray table and contained roast beef and gravy, potentially hazardous foods. Residents Affected - Many 2. On 9/16/2025 at 10:40AM, a disposable foam cup was being used as a food scoop and was located inside of a bulk dry food storage bin containing sugar. The cup was resting on its side in contact with the stored sugar. On 9/18/2025 at 12:30PM, V3 (Dietary Manager) observed the above cup and reported dietary staff should not use a foam cup as a food scoop. 3. On 9/16/2025 at 10:50AM, the flooring surfaces of the kitchen, pantry, and dishwashing room were soiled throughout with dark accumulations of food deposits located at the baseboard and floor junctions and along flooring threshold areas. Plastic and paper debris was scattered across the dish room floor area including beneath storage racks of clean dishes. Multiple dishwashing scrub pads were also located on the floor surface. On 9/18/2025 at 12:30PM, the above floor surfaces remained soiled. On 9/18/2025 at 2:54 PM, V3 reported food made in the kitchen is available for all residents in the facility to eat. The Long-Term Care Facility Application for Medicare And Medicaid (9/18/2025) documents 81 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145469 If continuation sheet Page 11 of 13 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 09/19/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure enhanced barrier precautions were utilized for residents with indwelling urinary catheters. This failure affects two residents (R1, R12) of five reviewed for infection control in the sample list of 30. Findings include:1. R1's diagnosis list (9/18/2025) documents diagnoses including Hemiplegia (paralysis of one side of the body), Hemiparesis (weakness on one side of the body), Epilepsy (brain disorder causing seizures), History of Traumatic Brain Injury, Parkinsonism (brain condition causing slow movements, stiffness, and tremors), Vascular Dementia with Agitation, Infection due to indwelling urinary catheter, and Sepsis (life-threatening condition that occurs when the body's immune system overreacts to an infection, leading to widespread inflammation and organ damage).R1's Resident Assessment (8/20/2025) documents R1 has severe cognitive impairment. The same record documents R1 uses a wheelchair for mobility, is dependent on staff to complete activities of daily living, uses an indwelling urinary catheter, and has impaired upper and lower extremity range of motion.R1's Orders sheet (9/18/2025) documents a medical order for an indwelling urinary catheter and urine collection bag and Enhanced Barrier Precautions during care. R1's Care Plan (9/19/2025) documents R1 is at risk for infections due to chronic urinary catheter use. The same record documents the intervention of using enhanced barrier precautions for R1 to reduce the potential for infections in R1.On 9/17/2025 at 12:30PM, R1's bedroom door was open and R1 was sitting in a wheelchair in R1's room and an indwelling urinary catheter and urine collection bag were present and attached to R1's wheelchair. No signage was present at the entrance to R1's bedroom indicating staff should use enhanced barrier precautions (EBP) when providing direct care to R1. No personal protective equipment (gowns, gloves) was present in or near R1's room. V15 (R1's family) was present and reported R1 had recently finished a prescription for antibiotics for a urinary tract infection. No alcohol-based hand rub (ABHR) was present in or immediately adjacent to R1's room.On 9/18/2025 at 3:00PM, R1 was seated in a wheelchair in R1's room. As above, EBP signage was absent at the entrance to R1's room and no personal protective equipment (PPE) was present for staff to implement enhanced barrier precautions when providing care to R1. On 9/19/2025 at 11:50AM, R1 was again seated in a wheelchair in R1's room. As above, EBP signage, PPE, and ABHR were not present in or near R1's room for staff to implement enhanced barrier precautions when providing care to R1.The facility infection log (September 2025) documents R1 had completed treatment on 9/14/2025 for a urinary tract infection2. R12's diagnosis list (9/19/2025) documents diagnoses including Hemiplegia (paralysis of one side of the body), Hemiparesis (weakness on one side of the body), Dementia, and Seizures. R12's Resident Assessment (7/3/2025) documents R12 has severe cognitive impairment. The same record documents R12 uses a wheelchair for mobility, is dependent on staff to complete activities of daily living and uses an indwelling urinary catheter.R12's Orders sheet (9/19/2025) documents a medical order for an indwelling urinary catheter and urine collection bag and an order for Enhanced Barrier Precautions.R12's Care Plan (9/19/2025) documents R12 is at high risk for urinary tract infection due to chronic urinary catheter use. The same record documents the intervention of using enhanced barrier precautions for R12 to reduce the potential for infections in R12.On 9/17/2025 at 10:57PM, R12's bedroom door was open and R12 was sitting in a wheelchair in R12's room and an indwelling urinary catheter and urine collection bag were present and attached to R1's wheelchair. No signage was present at the entrance to R12's bedroom indicating staff should use enhanced barrier precautions (EBP) when providing direct care to R12. No personal protective equipment (gowns, gloves) was present in or near R12's room. No alcohol-based hand rub (ABHR) was present in or immediately adjacent to R12's room. V10 (Licensed Practical Nurse) was present outside of R12's room and when the surveyor asked V10 if R12 Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145469 If continuation sheet Page 12 of 13 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 09/19/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete was on EBP, V10 glanced over at R12's room door and stated (R12) should be.On 9/18/2025 at 11:31AM, R12 was seated in a wheelchair in R12's room. As above, EBP signage was absent at the entrance to R12's room and no personal protective equipment (PPE) was present for staff to implement enhanced barrier precautions when providing care to R12. On 9/19/2025 at 3:00PM, R12 was again seated in a wheelchair in R12's room. As above, EBP signage, PPE, and ABHR were not present in or near R12's room for staff to implement enhanced barrier precautions when providing care to R12.The facility's Enhanced Barrier Precaution policy (7/12/2022) documents EBP signage, PPE, and ABHR should all be present at the point of care for residents receiving enhanced barrier precautions including residents with indwelling urinary catheters. Event ID: Facility ID: 145469 If continuation sheet Page 13 of 13