Health inspection·September 11, 2024

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 monitor medication room freezer temperatures and failed to store medications separately from food. This failure affects all 47 residents residing in the facility. Findings include: The facility's Storage of Medications policy with a revised date of 9/10/24 documents, Medication requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications must be stored in a separate compartment from food. On 9/10/24 at 10:15 AM, V3 Licensed Practical Nurse opened the medication storage room refrigerator and there was food and drink in the refrigerator. There was bisacodyl suppositories and acetaminophen suppositories in the bottom drawer of the refrigerator and there was a medication card of Florastor (probiotic) for R251 in the top shelf of the refrigerator door. V3 opened the freezer and there was no thermometer in the freezer. The freezer contained individual ice cream cups and popsicles. V3 confirmed there was no thermometer in the freezer and confirmed there was no log to monitor the temperatures of the freezer. V3 also confirmed that the food and drinks in the refrigerator and freezer were for the residents. V3 confirmed there was another smaller refrigerator in the medication room that contained more medications. R251's Order Summary dated 9/10/24 documents an order for Florajen Acidophillus Oral Capsules (probiotic) with a start date of 8/22/24. On 9/10/24 at 11:08 AM, V2 Director of Nursing provided a list of items in the medication room refrigerator and confirmed that food and medications were contained in the same refrigerator. This list documents the medication refrigerator contained nutritional drinks, nutritional/extra calorie shakes, juice, soda, pudding, yogurt, apple sauce and sandwiches. This list documents the medications contained in the medication refrigerator were Bisacodyl Suppositories, Acetaminophen Suppositories, Hydrocortisone cream and Probiotic. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 9/9/24 documents 47 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145794 If continuation sheet Page 2 of 3 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 145794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairview Haven 605 North 4th Street Fairbury, IL 61739 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 initiate Enhanced Barrier Precautions for one (R14) of sixteen residents reviewed for infection control in a sample list of 34. Residents Affected - Few Findings include: The facility's policy Enhanced Barrier Precautions dated 9/10/24 documents Enhanced Barrier Precautions expand the use of Personal Protective Equipment and refer to the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of Multidrug Resistant Organisms (MDROs) to staff hands and clothing. MDROs may be indirectly transferred from resident to resident during these high contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization As well as for residents with MDRO infection or colonization. R14's physician's orders dated 9/6/24 documents, R14 was readmitted to facility with an order for an indwelling urinary catheter. These orders did not contain an order for enhanced barrier precautions. On 9/9/24 at 10:00 AM, R14 was in bed with the indwelling urinary catheter secured on the side of the bed. There was clear yellow urine contained in the bag and tubing. There was no Personal Protective equipment outside R14's door. There was no sign posted outside R14's door to indicate Enhanced Barrier Precautions were being implemented for R14. On 9/10/24 at 2:00 PM, V2 Director of Nursing stated (R14) has a urinary catheter and he definitely should be on Enhanced Barrier Precautions. V2 verified R14 has not been placed on Enhanced Barrier Precautions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145794 If continuation sheet Page 3 of 3