Health inspection·July 27, 2023

F 0604 Level of Harm - Minimal harm or potential for actual harm contacted and further directions/orders requested to maintain a safe environment for the resident. If alternative measures have been unsuccessful and a determination that a physical restraint is necessary, then the use of the restraint including risks, possible negative outcomes, and benefits must first be explained to the resident, family member, or legal representative and written and/or verbal consent for use obtained. Residents Affected - Few On 07/25/23 at 8:54am, V2 (Director of Nurses) stated Restraint Assessments and Restraint Consents are to be updated quarterly per facility policy. V2 acknowledged R35's consent and assessment had not been updated per policy and provided a Physical Restraint Informed Consent and Restraint Evaluation Review both dated 7/24/23, which she stated she updated yesterday. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145918 If continuation sheet Page 2 of 10 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 145918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of Bridgeport 900 East Corporation Bridgeport, IL 62417 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to safely transfer and immediately report a fall for one (R22) of seven residents reviewed for risk of falls in the sample of 34. This failure resulted in R22 falling against the toilet during a one assist transfer and sustaining a rib fracture with resulting pain. This past noncompliance occurred between 6/17/23 and 7/12/23. Findings include: R22's Face Sheet documented an admission date of 6/10/23 and diagnoses including Alzheimer's Disease, Chronic Obstructive Pulmonary Disease, Diabetes Type 2, and Heart Failure. R22's 6/30/23 Care Plan dated documented a problem area, I am at risk for falls related to unsteady gait/balance, (and a) history of falls. R22's Fall Risk assessment dated [DATE] documented a score of 11, indicating that R22 is at risk for falls. R22's Minimum Data Set, dated [DATE] documented that R22 requires extensive assistance from at least two staff members for transfers and toileting. Nurses Notes documented the following: 6/17/23 at 5:46pm: Resident started complaining of left rib pain after being transferred from shower chair to wheelchair. Family requested that the resident be sent out to (hospital) for xrays of ribs. I contacted (V8, Physician) who is on call for (V9, Physician) this weekend and he gave orders for left side rib xray and chest xray. Resident left facility via our transportation department. 6/17/23 6:30pm: Resident returned from having xray of left rib area and chest. 6/18/23 at 4:58am: Nurse went to check on resident and she was observed holding her left side and moaning in pain, (as needed) pain med(ications) given for discomfort. 6/18/23 at 11:14am: This nurse got xray results back for resident and xray results showed a Left 11th thoracic rib fracture. This nurse reported to (V8) which had called to check up on resident which was the Medical Doctor that gave orders to get xray. This nurse called (V11, POA/Power of Attorney) to inform them of the results. This nurse did let (V8) know that resident was doing normal activities when this nurse got results back and went to check up on pain level, but resident was participating in church activity. At this time resident has (as needed) Tylenol as ordered for the pain. A Fall Investigation dated 6/17/23 at 5:30pm documented, Residents POA approached this nurse regarding this resident experiencing a significant amount of pain in the left side rib area. POA stated to this nurse that she spoke to (V10, Certified Nursing Assistant/CNA) and (V10) stated to POA that she (V10) was trying to transfer the resident by herself and was unable to transfer her completely and sat her roughly on the toilet. This was not reported to the nurse (me) until the POA brought this to my attention. I assessed the resident in the area she was complaining of pain in. I did not note any significant marks on the resident at the time. I called (V8) who was on call for (V9) this (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145918 If continuation sheet Page 3 of 10 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 145918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of Bridgeport 900 East Corporation Bridgeport, IL 62417 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 0689 weekend and explained the situation. (V8) gave orders to send the resident for xrays. Resident is unable to provide information at this time. Level of Harm - Actual harm Residents Affected - Few An Xray Report dated 6/17/23 documented, Exam Description: Xray ribs left chest. Reason for study: Left lower ribs hurt after an aid helped her up .Findings: Left anterior 11th rib fracture. R22's Physicians Orders for June 2023 and July 2023 documented an order for Acetaminophen Extra Strength Oral Tablet 500 mg (milligrams), give 1 tablet by mouth every 6 hours as needed for pain. A MAR (Medication Administration Record) for June 2023 documented that the Acetaminophen was given on the following dates: 6/17/23 at 9:57pm, pain level '3' (On a zero to ten scale). Administration effective. 6/18/23 at 5:02am, pain level '3' Administration effective. 6/18/23 at 4:53pm, pain level '7' Administration effective. 6/28/23 at 11:58pm, pain level '3' Administration effective. 6/30/23 at 7:20pm, pain level; '5' Administration effective. A MAR for July 2023 documented that the Acetaminophen was not administered from 7/1/23 through 7/25/23. A document entitled Behavior Reports dated 6/17/23 handwritten and authored by V10 documented the following: Had resident on the toilet, my partner had to go do something, (I) tried to stand her (R22) up to clean her off and she fell sideways onto the toilet. My partner was outside the door and (I) had her help me get her off the toilet. She can stand up sometimes, and sometimes she can't. On 07/23/23 at 10:55am, R22 was observed in her room, sitting in a high backed wheelchair. R22 was alert and oriented only to herself. R22 stated she does not think she has sustained any falls at the facility. R22 had no complaints. On 7/25/23 at 1:31pm, V2 (Director of Nurses) stated on 6/17/23 at some time in the morning, V10 was trying to get R22 off the toilet by herself and R22 fell backward onto the toilet. V2 stated the Nurses Note dated 6/17/23 at 5:46pm stating the transfer from shower chair to wheelchair is inaccurate. V2 stated R22 was to be transferred by two staff and that V10 should have been aware of that when V10 got report at the beginning of her shift that morning. V2 stated V10 did not report the incident to the nurse when it happened but did report it to V11 (POA) in the afternoon of the same day when R22 complained of rib pain, with V11 reporting it to R22's nurse. V2 stated V8, the Physician covering for V9 (R22's Physician) gave the order to send R22 for x-rays, where it was discovered R22 had fractured a rib. V2 stated the new intervention added after the fall is that R22 is always to be transferred with two staff to assist, and V2 stated all staff were re-educated to do this. V2 stated all staff were also educated that falls are to be reported immediately. V2 stated R22 did not display sequelae from the fracture with the exception of some complaints of pain immediately after which were resolved with administration of Acetaminophen. On 07/25/23 at 02:01 PM, V10 stated that on 6/17/23 at some point in the morning, she and another (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145918 If continuation sheet Page 4 of 10 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 145918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of Bridgeport 900 East Corporation Bridgeport, IL 62417 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 0689 Level of Harm - Actual harm Residents Affected - Few CNA transferred R22 onto the toilet and the other CNA then went to answer a call light. V10 stated R22 wanted to get off the toilet, so V10 stood her up, but R22 stumbled backward, and her buttocks hit the seat 'pretty hard.' V10 stated she did not witness R22's chest make contact with the toilet. V10 stated she waited till the other CNA returned and they then transferred R22 off the toilet without incident. V10 stated she was busy and did not report the incident to the charge nurse. V10 stated V11 reported to V10 that R22 was having rib pain, V10 told V11 about the transfer incident and V11 reported it to the charge nurse. V10 stated she does not know why the 6/17/23 Nurses Note stated the resident was being transferred from the shower chair to the wheelchair. V10 stated she was aware R22 was to be transferred with two staff. V10 stated after the incident, all staff were re-educated that R22 is to always be transferred by at least two staff members, and falls are to be reported immediately. On 7/26/23 at 1:54pm, V9 (Physician) stated R22 was admitted on [DATE] as a transfer from another facility. V9 stated the facility notified her about the 6/17/23 injury as described above. V9 stated it is definitely possible the rib fractured occurred during the 6/17/23 fall. V9 stated R22 has no known history of osteoporosis, and there was no sequelae associated with the fall except complaints of pain relieved by Tylenol. V9 stated to her knowledge, R22 had no previous rib fractures and no previous complaints of rib pain. On 7/26/23 at 2:35pm, V1 (Administrator) stated all nursing and CNA staff were re-educated that R22 is to be transferred with two staff, and falls are to be reported immediately to the charge nurse. V1 stated the Quality Assurance interdisciplinary team met and discussed the fall and implemented the action of adding residents' transfer status prominently in the CNAs charting section so that when they log into the residents record, the transfer status is immediately seen. V1 stated V2 (DON) met with V10 three times weekly and provided transfer observation on the floor which occurred without incident, and V1 stated V10 has met her re-training objectives. V1 stated V10 is a seasoned CNA, and a dependable employee and administrative staff believe there will be no further issues with V10 performing unsafe transfers. On 07/27/23 at 8:33am, V11 (POA) stated she came to see R22 around lunchtime on 6/17/23. V11 stated R22 began complaining that her left side hurt. When V11 questioned R22, R22 stated, I was going to the bathroom, and they dropped me. V11 stated she questioned V10, who initially denied anything had occurred. V11 stated V10 finally admitted , She was taking (R22) to the bathroom, and she slipped out of her (V10's) hands. V11 stated V10 admitted she had not told any other staff members about this. V11 stated she informed the charge nurse, who knew nothing about it, and R22 was sent for an xray, which showed a rib fracture. V11 stated R22 complained about pain for a few days, but the pain resolved. V11 stated R22 has no history of rib fractures or rib pain. V11 stated when R22 was admitted to the facility, she recalls specifically telling V10 that R22 required the assistance of two staff for transfers. V11 stated it is her understanding that administration re-educated staff that R22 is always supposed to be transferred with two staff, and falls are to be immediately reported. V11 stated she has now noticed there are always two staff present during R22's care. A Fall Prevention Program Policy dated 11/21/17 documented, Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary .All assigned nursing personnel are responsible for ensuring ongoing precautions are put into place and consistently maintained. Fall/safety interventions may include but are not limited to: .Transfer conveyances shall be used to transfer residents in accordance with the plan of care. Residents at risk of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145918 If continuation sheet Page 5 of 10 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 145918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of Bridgeport 900 East Corporation Bridgeport, IL 62417 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 0689 falling will be assisted with toileting needs as identified during the assessment process and as addressed in the plan of care. Level of Harm - Actual harm Prior to the survey date, the facility took the following actions to correct the non-compliance: Residents Affected - Few 1. From 6/23/23 through 6/30/23, all nursing and CNA staff were inserviced that R22's transfers are to be with the assistance of two staff at all times, and difficulty with any transfers are to be reported to the residents nurse immediately. Staff signed off on the attendance sheet, including V10. 2. For a total of four weeks, from 6/20/23 through 7/22/23, V10's resident transfers were audited three times weekly, with V10 demonstrating proficiency in all observations. 3. R22 is engaged in therapy services twice weekly to assist with core strengthening, transfers, and ADL's. (Activities of Daily Living). 4. The facility's electronic health records system has been updated so that when CNAs initially log into the system to document, resident's transfer status is prominently displayed. 5. On 7/12/23, the facility's Quality Assurance Committee met to review the above referenced fall. The Committee approved of the corrective Action Plan that had been submitted and reviewed the status of the plan without corrections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145918 If continuation sheet Page 6 of 10 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 145918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of Bridgeport 900 East Corporation Bridgeport, IL 62417 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the correct textured diet was provided to one (R9) of one resident reviewed for pureed diets in a sample of 34. This past non-compliance occurred on 06/26/23. R9's Diagnoses Sheet documents admission to this facility on 06/05/09 with a primary diagnosis of Alzheimer's dementia with hemiplegia, and an additional diagnosis of dysphagia dated 06/30/23. Her most recent Minimum Data Set (MDS) dated [DATE] indicates she is moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) of 8. She is assessed to require set-up with supervision only for eating. R9's Care Plan dated 02/16/15 and updated most recently includes - (R9) has a swallowing problem r/t (related to) loss of food/liquids from mouth while eating. NAS (no added salt), mechanical soft pureed meat, honey thickened liquids, patient may have one sip of liquid from cup at a time, staff to supervise during all intake, 8 oz (ounce) of fortified milk with meals, puree meats and fruits except bananas, add fortified pudding with lunch and supper - Revised 8/3/2022; (R9) has a swallowing problem r/t loss of food/liquids from mouth while eating. NAS, mechanical soft pureed meat, honey thickened liquids, patient may have one sip of liquid from cup at a time, staff to supervise during all intake, 8 oz of fortified milk with meals, puree meats and fruits except bananas, add fortified pudding or equivalent with lunch and supper - Revised 6/15/2023. R9's July 2023 Physician's Order Sheet (POS) documents - NAS diet, Mechanical Soft, pureed meat texture, honey consistency, pureed fruit except bananas, super cereal with breakfast and fortified pudding or equivalent with lunch and supper for diet, start dated 01/26/23. R9's meal card dated 07/26/23 documents the same orders as on the July 2023 POS. R9's facility Incident Report dated 06/26/23 at 12:32 PM includes - Incident Description: Observed resident holding her throat. Resident leaned forward and encouraged to cough. Resident spit up 2 large hunks of cantaloupe. Incident Location: Dining Room. Person Preparing Report: V15 (Licensed Practical Nurse/LPN) Resident Description: Swallowed cantaloupe. Immediate Action Taken: Vitals, lung sounds, encouraged to cough up cantaloupe. Resident Taken to Hospital: No. Injuries Observed at Time of Incident: No injuries observed at time of incident. Level of Consciousness: Alert. Mobility: Wheelchair bound. Mental Status: Alert to person. Injuries Report Post Incident: No injuries observed post incident . Notes: 06/26/23 - Observed resident holding her throat. Resident leaned forward and encouraged to cough. Resident spit up 2 large hunks of cantaloupe. V16 (Physician)/V2 (Director of Nursing - DON) made aware. 06/26/23 - Diet reviewed. Resident fruit to be pureed. Met with dietary department for education and alerts noted on menu card. Alert will be highlighted on resident's menu. R9's progress note dated 6/26/2023 at 12:25 PM by V15 (LPN) documents - . Resident choked on cantaloupe in the dining room. This nurse encouraged her to cough and lean forward. Resident spit up 2 chunks and was able to clear throat. Lungs clear at this time. Resident also spit up lots of clear phlegm. MD (Medical Doctor) and DON made aware. On 07/26/23 at 12:29 PM, V15 stated, I was down the hall passing meds and staff brought (R9) to the nursing station and she was kind of foaming at the mouth and gagging. I instructed (R9) to lean (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145918 If continuation sheet Page 7 of 10 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 145918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of Bridgeport 900 East Corporation Bridgeport, IL 62417 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few forward and cough to try and clear her throat. V15 stated R9 ultimately spit up/vomited and chunks of cantaloupe came up. V15 stated at that time she was not aware of R9's diet orders but when she checked with speech therapy, she confirmed she was supposed to be receiving pureed fruit other than bananas. V15 stated after R9's choking incident she listened to her lungs to ensure she hadn't aspirated any food. V15 stated she believed there was a new dietary staff in the kitchen that had passed R9's lunch tray that day and apparently was not aware of the orders. V15 stated for the next 2 days a respiratory assessment was performed on V9 with negative findings. R9's Respiratory Assessments dated 06/26/23 and 06/27/23 were reviewed with no residual effects documented after R9 choked on the pieces of cantaloupe. On 07/26/23 at 12:41 PM, V12 (Dietary Aide) stated, It was my first 3-4 days of working in the dining room by myself and I was very unfamiliar with who eats what and at that time we did not have a supervisor over us. I was going based off another lady's word. I had asked V14 (Former Cook) if I was able to give (R9) cantaloupe because she was asking for it. I had not been trained and did not really know it had to be pureed. The nursing supervisor was upset and brought it to our attention that (R9) was not supposed to have cantaloupe that was not pureed. We were educated on the orders and talked to about the incident. When asked if she had looked at the meal card that day, V12 stated she just missed where it said, pureed fruit other than bananas because the meal card was confusing. When asked if she knew the difference between the different texture consistencies such as mechanical soft versus puree and how to ensure the correct food was on the resident tray, V12 stated, I do now. On 07/26/23 at 12:57 PM, V7 (Dietary Manager) stated, I started here about 3 weeks ago as the Dietary Manager. I think the staff coming into this were not well educated on the differences in mechanical soft versus pureed. I am not aware of when (R9's) order was put into place, but cantaloupe would not have been appropriate unless it is puree as ordered. On 07/26/23 at 1:19 PM, R9 stated she does remember choking on the cantaloupe on 06/26/23 but confirmed she has no residual effects from that incident. She stated, It just happened and has not happened since then. On 07/26/23 at 1:49 PM, V2 (DON) confirmed R9's dietary card did document she was to have pureed fruit (other than bananas) on 06/26/23 but stated the cantaloupe had not been pureed as ordered that day. On 07/26/23, V1 (Administrator) provided documentation outlining the actions taken by the facility prior to this survey date to correct the noncompliance. Prior to the survey date, the facility took the following actions to correct the deficient practice: 1. An IDT (Interdisciplinary Team) meeting was held on 06/26/23 at 1:53 PM with the following management staff - V2 (DON), V5 (LPN/Wound Nurse), V15 (LPN), and V17 (ST - Speech Therapy). a) Summary of IDT meeting: Resident was observed holding her throat and choking in the dining room. Resident leaned over and was coughing. Resident encouraged to cough and clear airway. Chunks of cantaloupe was coughed up. Nurse immediately done (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145918 If continuation sheet Page 8 of 10 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 145918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of Bridgeport 900 East Corporation Bridgeport, IL 62417 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 0803 respiratory assessment. Resident could speak and had Level of Harm - Minimal harm or potential for actual harm no further complaints after incident. MD notified. Respiratory assessment each shift for the next 2 days. ST to eval and treat. Resident will be monitored at Residents Affected - Few all meals in the dining room. 2. A Quality Assurance and Performance Improvement meeting was held on 06/26/23. In attendance - V1, V2, and V7. Actions Steps Include: a) Provide education to dietary staff. Educated staff to read resident's dietary tray card with the actual food served at each meal. Responsible Person(s): V2, V7. Target Date: New hires monthly. B: Supervisor or designated staff will monitor dining room compliance. Responsible Person(s): V1, V2. Target Date: 06/26/23 and all meals. 3. Process/Steps to identify others having the potential to be impacted by the same deficient practice: All residents have the potential to be affected. 4. Measures put into place/systematic changes to ensure the deficient practice does not recur: V1 and V2 provided in-service with sign-in sheets to dietary staff regarding resident diet - Educate on diet types and alerts on place cards. Alerts to be highlighted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145918 If continuation sheet Page 9 of 10 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 145918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of Bridgeport 900 East Corporation Bridgeport, IL 62417 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to properly sanitize dishware. This has the potential to affect all 61 residents residing in the facility. Residents Affected - Many Findings include: On 07/23/23 at 11:30 AM, the chemical sanitizer level in the dish machine was checked by V13 (Dietary Aide) for chlorine sanitizer and did not register any sanitizer on the test strip. After looking at the container of sanitizer and seeing it was empty, V13 (Dietary Aide) stated, the container ran out last night (07/22/23). On 07/23/23 at 11:50 AM, a new container of sodium hypochlorite solution (chlorine) sanitizer was brought into the kitchen and utilized for the dish machine. V13 (Dietary Aide) had to purge the dish machine for approximately two minutes before the sanitizer was pulled from the sanitizer container to the output into the water of the dish machine, indicating there was no sanitizer in the line. On 07/23/23 at 1:00 PM, V7 (Dietary Manager) stated there should be sanitizer in the dish machine, they are working out new procedures with her being new and some of the staff being new, but they should have notified her it was out and it should have been changed. V7 stated the breakfast dishes were washed with no sanitizer and maybe some of the evening dishes, she is not aware of when the sanitizer ran out. They should be checking it at the beginning of each shift. The facility document dated 2020 titled, Sanitation of Dining and Food Service Area documents: The dining services staff will uphold sanitation of the dining areas according to a thorough, written schedule. 2. Tasks will be designated to specific departmental positions (refer to sample cleaning schedule forms - daily, weekly, and monthly). Sample cleaning schedule documents: 15. Prep. (preparation) equipment/dishes/uteensils are effectively sanitized and properlyy stored. The Resident Census and Conditions of Residents dated 07/23/23 documents 61 residents residing at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145918 If continuation sheet Page 10 of 10