Inspection·May 20, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm stated she had incontinent episodes waiting on staff to assist her to toilet. R21 stated, it happens all the time. On 5/13/25 at 11:22 AM, V10 (CNA/Certified Nursing Assistant) stated they don't have enough staff to meet the needs of the residents timely. V10 stated the call lights aren't always answered timely. Residents Affected - Some On 5/14/25 at 2:45 PM, V13 (transport CNA) stated call lights aren't answered timely and toileting isn't always timely. On 5/14/25 at 1:00 PM, V2 (Director of Nurses) stated they don't have enough staff to meet the needs of the residents timely. V2 stated they have issues with staffing on nights and weekends. V2 stated with two CNA's on the skilled care unit it would be hard to answer the call lights timely. The facility Answering Call Light policy dated 8/2008 documents, The purpose of this procedure is to respond to the resident's requests and needs 8. Answer the resident's call as soon as possible . 3. On 5/15/25 at 9:00 AM, R20 was sitting outside the facility, under the pavilion, smoking cigarettes, with peers and staff present. R20 was wearing a plastic safety apron that went from his neck/shoulder area to his knees. R20's current Care Plan documents a Focus Area of (R20) desire to continue to be a cigarette smoker. This same Focus Area documents the following interventions, Assist (R20) with his money management for his cigarette use and other things he desires to do .(R20) does need assistance to smoking area but does not need supervision while smoking Facility smoking assessments to be completed to determine if (R20) can manage his own tobacco products and smoke safely Instruct about smoking risks and hazards and about smoking cessation aids that are available Observed clothing and skin for signs of cigarette burns R20's Smoking-Safety Screen report dated 4/14/25 documents R20 does not need adaptive equipment and/or the facility to store the lighter and cigarettes. This same screening documents R20 is safe to smoke independently. On 05/15/25 at 10:55 AM, R20 stated, ever since the guy burnt himself the smokers have had to wear smoking aprons. R20 stated he does not like to wear the apron; he would prefer not to. R20 stated he had never burned himself or had any accidents. R20 stated he had not been reassessed that he was aware of since mid April. 4. R6's admission Record documents an admission date of 10/30/24 with diagnoses including: type 2 diabetes mellitus with ketoacidosis without coma, dysphagia, lack of coordination, major depression disorder, dementia, depression, anxiety disorder,and acute kidney failure. R6 Minimum Data Set (MDS) dated [DATE] documents a BIMS summary score (Brief Interview of Mental Status) of 12 indicating resident is moderately cognitively impaired. On 05/15/25 at 11:35 AM, R6 stated she has to wear an apron now to smoke and does not know why. She does not want to wear it and she did not before. She does not know what changed. She has not burned herself. R6's Smoking Safety Screen dated 04/14/25 documents: 7. resident need for adaptive equipment with 7a. smoking apron, 7b. cigarette holder, 7c. supervision, and 7d. one-on-one assistance listed and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145857 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 145857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of St. Elmo 221 East Cumberland St Elmo, IL 62458 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some none marked. 7e. other has nothing typed in the box, 9. service plan is used to assure resident is safe while smoking with yes marked. Letter F. can be supervised if needed 2. team decision: 1. safe to smoke without supervision is marked 3. rationale/conditions: can be supervised if needed typed in. R6's care plan documents a focus area of R6 has the desire to smoke cigarettes with a date initiated of 06/22/2024 with an intervention of resident will require supervision while smoking with an initiated date of 06/22/2024. 5. R39's admission Record documents an admission date of 01/14/25 with diagnoses including: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, muscle wasting and atrophy, lack of coordination, type 2 diabetes mellitus, anxiety disorder, and cerebral infarction. On 05/07/25 at 2:30 PM, R39 was outside smoking wearing a smoking apron. On 05/08/25 at 9:30 AM, R39 was outside smoking wearing a smoking apron. R39's Smoking Safety Screen dated 04/14/25 documents: 7. resident need for adaptive equipment with 7a. smoking apron, 7b. cigarette holder, 7c. supervision, and 7d. one-on-one assistance listed and none marked. 7e. other has she needs help lighting her cig typed in. 8. does resident need facility to store lighter and cigarettes with no marked, 9. service plan is used to assure resident is safe while smoking with no marked. Letter F. resident does need assistance to light cig in windy conditions 2. team decision: 1. safe to smoke without supervision is marked 3. rationale/conditions: she is safe knows how to handle her cig just lighting it in windy condition is hard and needs assistance in and out of the building typed in. R39's Smoking Risk Observation dated 04/14/25 documents: 11. Identify if resident is with A. Independent smoker marked and signed by V28 (Social Services Director). On 05/15/25 at 11:40 AM, R39 is alert and oriented to person, place, and time stated, she has to wear an apron to smoke now and she does not like it. She doesn't like wearing the apron. She has never burned herself before or had any problems but after another resident burned themselves they all had to wear an apron to smoke. She does not remember being reassessed after the incident with the other guy but after that happened she has to wait to go out and has to wear an apron. R39's care plan documents: a focus area of: R39 desires to continue to smoke cigarettes with a date initiated of 03/12/2025 with interventions of: utilize smoking apron per doctor's orders with an initiated date of 04/23/25 and will follow smoking schedule with a date initiated of 03/13/2025. On 5/15/25 at 2:22 PM, V4 (Care Plan Coordinator) stated he did not put on R39's care plan, that was V28 (social Services) that put that her care plan. On 5/15/25 at 2:15 PM, V28 (Social Services Director) stated she redid all of the smoking assessments a few weeks ago for the change of ownership. V28 stated they had an incident with a resident burning himself while he was smoking. V28 stated he had been assessed as being safe to smoke independently but burnt himself one day while she was off work so she didn't have all of the details. V28 stated when she came back to work she was notified of the incident and she spoke with V1 (Administrator). V28 stated V1 told her to order smoking aprons for every resident, they took all of their smoking (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145857 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 145857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of St. Elmo 221 East Cumberland St Elmo, IL 62458 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete paraphernalia and locked it up, and they all had to smoke at the same time with staff supervision. V28 stated R38 was seen by the wound specialist and the area healed with no issues. V28 stated she can see where that is taking their rights away and she didn't think R38, R20, and/or R6 required an apron or staff supervision to smoke safely. On 05/19/25 at 8:10 AM V1 (Administrator) stated, the physician order on R38's physician order sheet and care plan was due to the fact the facility called the physician and asked for the order for the smoking apron, they will have the order removed from her record. Event ID: Facility ID: 145857 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 145857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of St. Elmo 221 East Cumberland St Elmo, IL 62458 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure toileting assistance was provided timely for 2 of 3 (R20 and R21) residents reviewed for activities of daily living in the sample of 39. Residents Affected - Few Findings Include: 1. R20's admission Record with a print date of 5/14/25 documents R20 was admitted to the facility on [DATE] with diagnoses that include hypertension, repeated falls, pain, and kidney stones. R20's MDS (Minimum Data Set) dated 2/20/25 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R20 is cognitively intact. This same MDS documents R20 requires supervision or touching assistance for toilet transfer and partial/moderate assistance for toilet hygiene. R20's current Care Plan documents a Focus area of Due to (R20)'s general weakness and unsteadiness, He is in need of staff assistance to meet his toileting needs. Date Initiated: 07/03/2023. The interventions documented for this Focus area include, .Provide assistance for toileting due to (R20)'s general weakness and history of falling and to ensure proper toileting hygiene. Date Initiated: 07/03/2023. The facility Activities of Daily Living policy dated 2/2023 documents, Purpose: Based on comprehensive assessment of the resident and consistent with the resident's needs and choices, our facility provides necessary care and services to ensure that a resident's abilities in activities of daily living (ADL) living do not diminish unless the circumstances of the individual's clinical condition demonstrates that such decline was unavoidable. On 5/12/25 at 1:37 PM, R20 stated they don't have enough staff, especially on the weekend. R20 stated takes up to a half hour for them to answer the call light at times. R20 stated he had incontinent episodes waiting for staff to assist him to toilet. 2. R21's admission Record with a print date of 5/14/25 documents R21 was admitted to the facility on [DATE] with diagnoses that include muscle wasting and atrophy, lack of coordination, acute kidney failure, and chronic pain syndrome. R21's MDS dated [DATE] documents a BIMS score of 15, which indicates R21 is cognitively intact. This same MDS documents R21 requires substantial/maximal assistance for toilet hygiene and toilet transfer. R21's current Care Plan documents a Focus area of, Due to (R21)'s general weakness, unsteadiness and endurance, she is in need of staff assistance to meet her toileting needs. Date Initiated: 04/13/2023. This Focus area includes, .Assist (R21) to the restroom every 2 hours or sooner upon request. Date Initiated: 04/13/2023 . On 5/12/25 at 10:58 AM, R21 stated it takes a long time for staff to answer the call lights. R21 stated she had incontinent episodes waiting on staff to assist her to toilet. R21 stated, it happens all the time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145857 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 145857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of St. Elmo 221 East Cumberland St Elmo, IL 62458 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 0677 Level of Harm - Minimal harm or potential for actual harm On 5/13/25 at 11:22 AM, V10 (CNA/Certified Nursing Assistant) stated they don't have enough staff to meet the needs of the residents timely. V10 stated the call lights aren't always answered timely. On 5/14/25 at 2:45 PM, V13 (transport CNA) stated call lights aren't answered timely and toileting isn't always timely. Residents Affected - Few On 5/14/25 at 1:00 PM, V2 (Director of Nurses) stated they don't have enough staff to meet the needs of the residents timely. V2 stated they have issues with staffing on nights and weekends. V2 stated with two CNA's on the skilled care unit it would be hard to answer the call lights timely. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145857 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 145857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of St. Elmo 221 East Cumberland St Elmo, IL 62458 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure sufficient staff to provide timely care to the residents. This has the potential to affect all 42 residents who currently reside at the facility. Findings Include: The facility Resident Matrix dated 5/12/25 documents 42 resident currently reside at the facility. 1. R20's admission Record with a print date of 5/14/25 documents R20 was admitted to the facility on [DATE] with diagnoses that include hypertension, repeated falls, pain, and kidney stones. R20's MDS (Minimum Data Set) dated 2/20/25 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R20 is cognitively intact. This same MDS documents R20 requires supervision or touching assistance for toilet transfer and partial/moderate assistance for toilet hygiene. R20's current Care Plan documents a Focus area of Due to (R20)'s general weakness and unsteadiness, He is in need of staff assistance to meet his toileting needs. Date Initiated: 07/03/2023. The interventions documented for this Focus area include, .Provide assistance for toileting due to (R20)'s general weakness and history of falling and to ensure proper toileting hygiene. Date Initiated: 07/03/2023. On 5/12/25 at 1:37 PM, R20 stated they don't have enough staff, especially on the weekend. R20 stated it takes up to a half hour for them to answer the call light at times. R20 stated he had incontinent episodes waiting for staff to assist him to toilet. 2. R21's admission Record with a print date of 5/14/25 documents R21 was admitted to the facility on [DATE] with diagnoses that include muscle wasting and atrophy, lack of coordination, acute kidney failure, and chronic pain syndrome. R21's MDS dated [DATE] documents a BIMS score of 15, which indicates R21 is cognitively intact. This same MDS documents R21 requires substantial/maximal assistance for toilet hygiene and toilet transfer. R21's current Care Plan documents a Focus area of, Due to (R21)'s general weakness, unsteadiness and endurance, she is in need of staff assistance to meet her toileting needs. Date Initiated: 04/13/2023. This Focus area includes, .Assist (R21) to the restroom every 2 hours or sooner upon request. Date Initiated: 04/13/2023 . On 5/12/25 at 10:58 AM, R21 stated it takes a long time for staff to answer the call lights. R21 stated she had incontinent episodes waiting on staff to assist her to toilet. R21 stated, it happens all the time. On 5/13/25 at 11:22 AM, V10 (CNA) stated they don't always have enough staff to meet the needs of the residents. V10 stated the call lights aren't always answered timely. On 5/14/25 at 2:45 PM, V13 (Transport CNA) stated she works day shift and on a good day they have two to three CNA's working on the skilled unit and one CNA on the Alzheimer's unit. V13 stated multiple times they have had non-certified staff monitoring the residents on the Alzheimer's unit. This surveyor reviewed the staffing sheets that document they always have three or more CNA's on skilled and one CNA on the Alzheimer's unit and V13 stated it was probably due to call in's and the staffing sheets not being updated. V13 stated call lights aren't answered timely and toileting isn't always timely. V13 stated she isn't sure how care gets provided on the Alzheimer's unit when the staff monitoring the unit at times aren't certified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145857 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 145857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of St. Elmo 221 East Cumberland St Elmo, IL 62458 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 5/14/25 at 11:17 AM, V15 (Housekeeper) stated she has monitored the residents on the Alzheimer's unit when they haven't had certified staff to do it. V15 stated she doesn't provide care for them she just monitors them. V15 stated she had only done it once for 2-3 hours. V15 stated she had not been trained on behaviors and couldn't provide care such as bed checks. V15 stated she passed ice and cleaned while she was monitoring the residents. V15 stated she would glance in the resident rooms to check on them while she was sweeping. On 5/14/25 at 10:36 AM, V19 (Housekeeping/Laundry) stated they always cover call in's when they have them. V19 stated she had come in when they were short staffed and monitored the Alzheimer's unit but couldn't remember the specific day. V19 stated she cleaned on the unit while she was monitoring it. V19 stated she covered the unit from 8 PM to 3 AM. V19 stated the CNA's from the skilled unit did the bed checks and there were no issues/concerns while she was monitoring the unit. On 5/14/25 at 1:00 PM, V2 (Director of Nurses) stated they don't have enough staff to meet the needs of the residents timely. V2 stated they have issues with staffing on nights and weekends. V2 stated there was one day they only had one agency CNA (Certified Nursing Assistant) from 7:00 to 7:30. When asked if two CNA's could timely provide care to the residents on the skilled care unit, V2 stated it would be hard to answer the call lights timely. V2 stated they are supposed to have a shower aid but they don't always. V2 stated then they were supposed to have a CNA that floated to assist both units but that also fell through the cracks. V2 stated two CNA's are not enough to meet the needs of the residents timely. V2 stated they have approximately 34 residents on skilled care and 5 or 6 of them require assist of two staff for care. On 5/15/25 at 3:04 PM, V1 (Administrator) reviewed the May 2025 schedules with this surveyor and stated they had three CNA's working on day shift. V1 compared the daily staffing sheet to the schedule and stated the daily staffing sheets were not accurate. V1 stated three CNA's are not enough to meet the needs of the residents timely. V1 stated the daily staffing sheets should reflect the accurate staffing numbers and they are not. The facility April 2025 schedule document one CNA working from 7 AM to 7 PM and one CNA working from 10 AM to 7 PM on 4/14/25 and one CNA working from 7 PM to 7 AM on 4/4/25 and 4/18/25. The facility May 2025 schedule documents one CNA working from 7 AM to 7 PM and one CNA working from 11 AM to 7 PM on 5/9/25. The Facility Assessment Tool dated 2/24/25 documents the facility average daily census is 40-45 residents with 18 beds on the alarmed dementia unit and 42 long term care beds. The Tool documents they Total number needed or average range for certified nursing assistants is four from 7 AM to 7 PM and three from 7 PM to 7 AM. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145857 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 145857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of St. Elmo 221 East Cumberland St Elmo, IL 62458 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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a plan of care for a resident with dementia for one (R6) of one resident reviewed for dementia care in a sample of 39. Residents Affected - Few Findings include: R6's admission Record documents an admission date of 10/30/24 with diagnoses including: type 2 diabetes mellitus with ketoacidosis without coma, dysphagia, lack of coordination, major depression disorder, dementia, depression, anxiety disorder,and acute kidney failure. R6 Minimum Data Set (MDS) dated [DATE] documents a BIMS summary score (Brief Interview of Mental Status) of 12 indicating resident is moderately cognitively impaired. R6's current Care Plan does not document any area addressing a diagnosis of dementia or care needs resulting thereof. On 05/12/25 at 10:17 AM, R6 was observed just sitting in the dining room on the Dementia unit at the table. R6 had nothing in front of her and was doing nothing but sitting. On 05/14/25 at 11:15 AM, R6 was observed just sitting in the dining room on the Dementia unit at the table. R6 had nothing in front of her and was doing nothing but sitting. On 05/15/25 at 11:40 AM, V13 (Certified Nurse Assistant) stated, R6 has her good days and R6 has her bad days with her cognition. On 05/15/2025 at 2:10 PM, V4 (Minimum Data Set Coordinator/Care Plan Coordinator) stated he would have to check R6's BIMS and her diagnoses to see if she should have a care need addressed on her care plan addressing the dementia. V4 stated R6 does not have anything on her care plan addressing her diagnosis of dementia or care needs regarding her dementia. On 05/19/25 at 8:10 AM, V1 (Administrator) stated, R6 should have had a plan for her dementia, they are reviewing all the care plans now, they are going to get a plan of care in place for R6. The facility policy dated 04/07 titled, Dementia-clinical protocol documents: 3. The staff and physician will evaluate individuals with new or progressive cognitive impairment and help identify symptoms and findings that differentiate dementia from other causes. 4. The staff and physician will review the current physical, functional, and psychosocial status of each individual with dementia to formulate an accurate overall picture of the individual's condition, related complications, and functional impairments. 5. The staff and physician will jointly define the decision-making capacity of someone with dementia, including the extent to which the individual can participate in making everyday decisions and considerations about healthcare treatment choices, including life-sustaining treatments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145857 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 145857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of St. Elmo 221 East Cumberland St Elmo, IL 62458 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to administer sliding scale insulin and monitor blood sugars as directed per physician's orders for 1 (R6) of 1 resident reviewed for insulin in a sample of 39. This failure resulted in R6 being sent to the emergency room for hyperglycemia. Residents Affected - Few Findings include: R6's admission Record documents an admission date of 10/30/24 with diagnoses including: type 2 diabetes mellitus with ketoacidosis without coma, dysphagia, lack of coordination, major depressive disorder, dementia, anxiety disorder, and acute kidney failure. R6's Minimum Data Set (MDS) dated [DATE] documents a BIMS (Brief Interview of Mental Status) score of 12 indicating R6 has moderate cognitive impairment. R6's Progress Note dated 12/25/24 at 6:30 AM documents res (resident) accu check results read Hi called V26-Physician) on call service (Nurse Practitioner) gave order to send to ER for eval and tx (treatment). R6's Progress Note dated 12/30/24 at 2:10 PM documents res (resident) transported back to facility per (name of local hospital) transport readmitted to special care (room #) R6's Clinical Physician Orders with a print date of 5/14/25 documents an order for HumaLOG KwikPen 100 unit/ML solution pen injector with directions listed as: inject as per sliding scale: if 150-199 = 2 units; 200-249 = 4 units; 250-299 = 6 units; 300-349 = 8 units, greater than 349 administer 10 units retest your blood glucose in 4 hours recorrect if necessary, subcutaneously before meals and at bedtime related to type 2 diabetes mellitus with ketoacidosis without coma with an order and start date of 12/31/2024. R6's December 2024 MAR (Medication Administration Record) documents the order for HumaLOG KwikPen 100 unit/ML solution pen injector per sliding scale as documented on the Clinical Physician Order Sheet does not document any initials indicating that the sliding scale insulin was not administered at 0600 (6:00AM), 1100 (11:00AM), 1600 (4:00 PM), and 2100 (9:00 PM) on 12/31/24. R6's January 2025 MAR documents the order for HumaLOG KwikPen 100 unit/ML solution pen injector per sliding scale as documented on the Clinical Physician Order Sheet does not document any initials indicating that the sliding scale insulin was not administered at 0600 (6:00AM), 1100 (11:00AM), 1600 (4:00 PM), and 2100 (9:00 PM) on 1/1/25, 1/2/25, 1/3/25 and at 0600 (6:00 AM) on 1/4/25. R6's December 2024 and January 2025 MAR's both document that R6 was receiving the following insulin as ordered: HumaLOG KwikPen 100 unit/ML solution pen injector, inject 5 units subcutaneously before meals with an order date of 12/30/24 and Insulin Glargine Solostar 300 unit/mL solution, inject 40 units subcutaneously at bedtime with an order date of 12/5/24. R6's December 2024 and January 2025 MAR and R6's Weights and Vitals Summary documents the following blood sugars: 12/31/24 at 1800 (6:00 PM) 216 and 1/1/25 at 1800 (6:00 PM) 225. R6's Progress Note dated 01/02/25 at 6:36 PM documents (R6's) BS (blood sugar) was 541. (V26-Physician) wanted her sent to the hospital. This nurse (V24-Registered Nurse) had not been doing sliding scale insulin due to order not being acknowledged. Therefore, order looked discontinued. There were no other blood sugars (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145857 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 145857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of St. Elmo 221 East Cumberland St Elmo, IL 62458 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 0760 documented on12/31/25 through 1/2/25 when R6 was sent to the hospital for further evaluation. Level of Harm - Actual harm R6's Progress Note dated 01/03/25 at 12:29 AM documents: patient arrived back at facility at approximately 9:34 PM via (ambulance service) from ED (Emergency Department) gave 10 units of humalog while there, no new orders given. Patient pants were soaked in urine upon arrival. Blood sugar is 314. Patient was changed and washed and is laying in bed with eyes closed. All safety protocols in place at the time of exiting. Residents Affected - Few R6's hospital After Visit Summary dated 1/2/25 documents the reason for visit as hyperglycemia and a diagnosis of diabetes. Under Medications Given it documents Insulin regular (Novolin R/Humulin R) last given at 7:41PM. On 05/15/25 at 1:05 PM, V20 (Licensed Practical Nurse) stated she has worked frequently at the facility for about the last three months, since mid January. After reviewing R6's Electronic Health Record, V20 stated she can see where R6 went to the hospital due to high blood sugars. V20 stated she can see where she had an order for sliding scale dated 12/31/24 and it was discontinued and another order dated 12/31/04 that was not confirmed until the 01/04/25 and she did not receive any sliding scale for those days. V20 said she does not know why the order was not confirmed in the Electronic Health Record on 12/31/24 and she does not know why she was not receiving the sliding scale insulin because R6 is a brittle diabetic. On 05/16/25 at 3:23 PM, V26 (Physician) stated he would not know specifically without looking at R6's record to know if not receiving her sliding scale insulin would have prevented R6 from going to the emergency room, but she does have an order for sliding scale insulin. V26 said he would expect R6 to receive the order as directed and if her blood glucose was low she would not get insulin. R6 is a delicate diabetic and her blood glucose is hard to manage in an outpatient setting. On 05/19/25 at 8:10 AM, V1 (Administrator) stated the orders that residents had prior to going to the hospital should always be reviewed when the orders are reentered into the system to make sure that none are missed. R6 should have received the sliding scale insulin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145857 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 145857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of St. Elmo 221 East Cumberland St Elmo, IL 62458 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure enhanced barrier precautions were followed for 2 of 3 (R12 and R34) residents reviewed for pressure ulcers in the sample of 39. Residents Affected - Few Findings Include: 1. R12's admission Record with a print date of 5/15/25 documents R12 was admitted to the facility on [DATE] with diagnoses that include a Stage 4 pressure ulcer of the sacrum. R12's MDS (Minimum Data Set) dated 2/17/25 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R12 is cognitively intact. R12's current Care Plan documents a Focus area of Enhanced barrier precautions r/t (related to) chronic wounds and indwelling catheter Date Initiated: 04/24/2024. This same Focus area includes the following interventions, .Gown and glove during high contact resident care activities such as dressing, bathing, showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care/use, wound care (any chronic skin opening). Date Initiated: 04/24/2024 . R12's Physician Order Sheet dated 10/15/24 documents a physician order of Enhanced Barrier Precautions indwelling foley cath (catheter) chronic wound, with a revision date of 4/3/25. On 5/14/25 at 1:30 PM, V14 (Licensed Practical Nurse/LPN) and V17 (Certified Nursing Assistant) were observed providing treatment to the Stage 4 pressure ulcer located on R12's sacrum. V14 and V17 donned gloves and administered the treatment per current standards of practice. V14 and V17 performed hand hygiene per current standards of practice during the treatment. V14 and V17 did not don a gown during the administration of the treatment. 2. R34's admission Record with a print date of 5/15/25 documents R34 was admitted to the facility on [DATE] with diagnoses that include Stage 3 pressure ulcer of right hip, blister left foot, and laceration right foot. R34's MDS dated [DATE] documents a BIMS score of 03, indicating R34 has a severe cognitive deficit. R34's current Care Plan documents a Focus area of, Enhanced barrier precautions r/t chronic wounds Date Initiated: 05/06/2025. This same Focus area includes the intervention, .Gown and glove during high contact resident care activities such as dressing, bathing, showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care/use, wound care (any chronic skin opening). Date Initiated: 05/06/2025. R34's undated Physician Order Sheet documents a physician order for, Enhanced barrier precautions dx (diagnosis) chronic wound, with a revision date of 4/3/25. On 5/14/25 at 1:43 PM, V14 (LPN) and V18 (CNA) were observed administering treatment to R34's right heel. V14 administered the treatment per current standards of practice. V14 and V18 performed hand hygiene using current standards of practice. V14 and V18 did not don a gown while administering the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145857 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 145857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of St. Elmo 221 East Cumberland St Elmo, IL 62458 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 treatment. Level of Harm - Minimal harm or potential for actual harm On 5/15/25 at 10:30 AM, V14 (LPN) stated R12 and R34 are on enhanced barrier precautions and the should have worn a gown, gloves, mask, and goggles. Residents Affected - Few The sign located outside R12 and R34's room documents, Enhanced Barrier Precautions Everyone must: clean their hands, including before entering and when leaving the room. Providers and staff must also: wear gloves and a gown for the following high contact resident care activities. Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy. Wound care: any skin opening requiring a dressing. The facility Enhanced Barrier Precautions policy dated 3/21/24 documents, It is the practice of this facility to implement enhanced barrier precautions for the preventions of transmission of multidrug-resistant organisms. Definitions: Enhanced Barrier Precautions: refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO (multi-drug resistant organism) as well as those at increased risk of MDRO acquisition . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145857 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 145857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of St. Elmo 221 East Cumberland St Elmo, IL 62458 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide at least 80 square feet per resident in two multiple occupancy resident bedrooms for 4 of 4 residents (R5, R20, R145, R146) reviewed for room size in a sample of 39. Findings include: Observation on 5/14/2025 at 9:00am revealed R5 and R20 share a bedroom with two beds, two dressers, a recliner, two walking assistive devices, two over the bed tables and had limited area to move around inside the room. Observations on 5/14/2025 at 9:05am revealed R145 and R146 share a bedroom with two bed, three small dressers, two over the bed tables, one recliner and had limited area to move around inside the room. On 5/14/2025 at 9:30am R5, R20, R145 and R146 all voiced no concerns with the size of their rooms during interviews. During a tour with V3 (Maintenance Director) on 5/14/2025 at 9:00am, V3 was asked to measure R5, R20, R145 and R146's bedroom sizes. V3 used a measuring tape to measure the length and width of R5 and R20's bedroom and stated, 11 by 14 feet (which is the equivalent to 154 sq. ft. (square feet)/77 sq. ft. per resident bed). At approximately 9:05am, V3 measured R145 and R146's bedroom with a tape measure and stated, 11 by 13.7 feet (which is the equivalent to 150.7 sq. ft./75.4 sq. ft. per resident bed). On 5/14/2025 at approximately 10:15am, V1 (Administrator) was asked if residents were notified during admission that some of the rooms in the facility did not meet the requirement of having 80 sq ft per resident, V1 stated no. V1 said rooms 19-31 did not meet the required 80 sq ft per resident bed and rooms 19-31 are all certified for double occupancy and were dually certified for Medicare and Medicaid. The facility's matrix with print date of 5/12/2025 documents verified that R5, R20, R145 and R146 currently reside in room [ROOM NUMBER]-31. Inquiries regarding the size of these rooms during the survey from 5/12/2025 to 5/15/2025 found no concerns or negative interviews from residents or families of residents who reside in the waivered rooms. Observations and measurements of these rooms during the survey, determined adequate space exists to meet the medical and personal needs of the residents living in these waivered rooms. Review of Resident Council Minutes form the past 6 months indicated no concerns related to the size of the rooms included in the waiver. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145857 If continuation sheet Page 14 of 14