Health inspection·January 7, 2026

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete PM, R13 stated they don't have enough staff, they have to wait a long time for staff to answer call lights.4. R14's admission Record with a print date of 1/7/26 documents R14 was admitted to the facility on [DATE] with diagnoses that include diabetes, osteoarthritis, hypertension, and heart disease.R14's MDS dated [DATE] documents a BIMS score of 15, indicating R14 is cognitively intact.R14's current Care Plan documents a Focus area of, I am always incontinent of bladder and bowel. Date Initiated: 03/09/2023. This Focus area includes the intervention of, Ensure call light is within reach and answered promptly. Date Initiated: 3/9/2023.On 1/5/26 at 2:28 PM, R14 stated when they don't have enough staff, she has to wait 30 to 45 minutes for care.On 1/5/26 at 4:19 PM, V8 (CNA/Certified Nursing Assistant) stated they don't have enough staff to meet the needs of the residents timely. V8 stated she works 2 pm to 10 pm. V8 stated around 4 pm they have to get residents ready for supper and answer call lights. V8 stated call lights aren't always answered timely.On 1/5/26 at 4:30 PM, V12 (CNA) said answering call lights timely can be an issue on the 2 pm to 10 pm shift when they only have four CNA's working.On 1/7/26 at 10:40 AM, V14 (anonymous) stated the call lights are answered as timely as they can be. V14 stated they have a lot of residents who require two persons assist and if the staff is tied up in one room and the nurses are doing a medication pass it may take a while for the call lights to be answered.On 1/6/26 at 1:09 PM, V2 (Assistant Director of Nurses) stated every place has a problem of call lights not being answered timely, at times. V2 stated they definitely have gotten better about answering the call lights timely. V2 stated they still have room for improvement, but it is getting better.On 1/6/26 at 1:28 PM, V1 (Administrator) stated they had an improvement in call lights being answered timely according to the last resident council meeting. V1 stated it is a work in progress but as of last month resident council meeting it had improved.The facility Answering the 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. 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 01/07/2026 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 0558 Reasonably accommodate the needs and preferences of each resident. 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 appropriate sized incontinence briefs for 2 of 4 (R2 and R13) residents reviewed for accommodation of needs in the sample of 13.Findings Include: 1.R2's admission Record with a print date of 1/6/25 documents R2 was admitted to the facility on [DATE] with diagnoses that include morbid obesity, unsteadiness on feet, heart disease, and osteoarthritis.R2's MDS (Minimum Data Set) dated 10/31/25 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R2 is cognitively intact. This same MDS documents R2 is occasionally incontinent of bowel and bladder.R2's current Care Plan documents a Focus area of I am occasionally incontinent of bowel and bladder. Date Initiated: 11/01/2025. This Focus area includes interventions of, Apply barrier cream after each incontinent episode Date Initiated: 11/01/2025.Check and Change Q (every)2-3H (hours) and PRN (as needed). Date Initiated: 11/01/2025.On 1/5/26 at 11:38 AM, R2 stated recently they did not have the correct size incontinence briefs for him to wear. R2 stated the briefs they had were too tight. R2 stated they have the correct size now. R2 stated he would have to rip the sides of the briefs so they would fit him.On 1/7/26 at 10:17 AM, V3 (Certified Nursing Assistant/CNA Supervisor) stated R2 wears extra-large incontinence briefs.2. R13's admission Record with a print date of 1/7/26 documents R13 was admitted to the facility on [DATE] with diagnoses that include acute pyelonephritis, heart failure, hypertension, respiratory failure, stiffness of left knee, and right shoulder, and scoliosis.R13's MDS dated [DATE] documents a BIMS score of 13, indicating R13 is cognitively intact. This same MDS documents R13 is dependent on staff for toileting and is always incontinent of bowel and bladder.R13's current Care Plan documents a Focus area of, I am incontinent of bowel and bladder. Date Initiated: 05/31/2019. This same Focus area includes the following interventions, Apply barrier cream after each incontinent episode. Date Initiated: 05/31/2019. Clean peri-area with each incontinent episode. Date Initiated: 05/31/2019.On 1/5/26 at 2:25 PM, R13 stated she wears incontinence briefs, and they never have the right size. R13 stated they use what they have and then she wets through them.On 1/5/26 at 1:50 PM, V3 (CNA Supervisor) stated they have enough supplies, but she is aware some CNA's bring their own supplies to the facility to use. When asked why they would do that, V3 stated because some CNAs like to use a lot or leave them in rooms and then forget where they left them. V3 stated they have enough of the correct size briefs and if they don't have them inside, they have them in the shed outside. When asked if they had recently been out of different sized briefs, V3 stated they had not. This surveyor reviewed with her R2 and R13's interview stating they didn't have the correct size briefs and V3 stated it must have been a CNA not knowing which size to use.On 1/5/26 at 4:52 PM, V2 (Assistant Director of Nurses) walked with this surveyor to the supply's closets, shower rooms, and tub room looking for incontinence briefs. One supply closet held 8 packages of size large briefs, 5 packages of size medium briefs, and two individual extra-large briefs. There were partial packages of large and medium briefs located on linen carts in each hallway. There were no packages of small, extra-large, or double extra-large incontinence briefs.On 1/5/26 at 4:55 PM, V3 (CNA Supervisor) stated R13 uses extra large briefs. This surveyor walked with V3 to R13's room and there were three incontinence briefs located in her room.On 1/5/26 at 4:19 PM, V8 (CNA) stated they didn't always have the correct size incontinence briefs for the residents. V8 stated she had brought her own in to use at times.On 1/5/26 at 4:30 PM, V12 (CNA) stated they don't always have the correct size of incontinence briefs and residents have to use incorrect sizes.On 1/5/26 at 4:43 PM, V9 (CNA) stated they run low on supplies right before the order comes in. V9 stated she can usually find the correct size incontinence briefs to use for the residents.On 1/7/26 at 10:17 AM, V3 (CNA Supervisor) Residents Affected - Few (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 01/07/2026 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete stated she makes a list of any items they need on Monday's and gives it to the receptionist who orders the needed items. V3 stated the order is made on Monday and delivered to the facility around 10 am on Tuesday. V3 stated they typically receive all items ordered. When asked if there were any incontinence briefs located in the storage shed on 1/5/26 at the time of the observations, V3 stated there were not. When asked why she believed they didn't have incontinence briefs in size large and extra-large, V3 stated she went back to the rooms after this surveyor left and located more briefs. V3 stated the residents don't wear briefs to bed at night and so they would have had enough to make it until the order was delivered. V3 stated they don't have any residents who wear size small incontinence briefs.On 1/7/26 at 10:42 AM, V15 (RN/Registered Nurse) stated she had not had any complaints/concerns brought to her related to not having the correct size incontinence briefs for residents. When asked if residents wore incontinence briefs to bed, V15 stated she thought a lot of them did.On 1/6/26 at 1:09 PM, V2 (Assistant Director of Nurses) stated she had not had any concerns reported to her related to not having the correct size incontinence briefs.On 1/6/26 at 1:28 PM, V1 (Administrator) stated she had not had any concerns reported to her related to not having the correct size incontinence briefs for residents. 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 01/07/2026 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 residents skin was free from moisture associated skin damage (MASD) for 2 of 3 (R2 and R3) residents reviewed for skin care in the sample of 14.Findings Include:Findings Include:1.R2's admission Record with a print date of 1/6/25 documents R2 was admitted to the facility on [DATE] with diagnoses that includes morbid obesity, unsteadiness on feet, heart disease, and osteoarthritis.R2's MDS (Minimum Data Set) dated 10/31/25 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R2 is cognitively intact. This same MDS documents R2 is occasionally incontinent of bowel and bladder.R2's current Care Plan documents a Focus area of I am occasionally incontinent of bowel and bladder. Date Initiated: 11/01/2025. This Focus area includes interventions of, Apply barrier cream after each incontinent episode Date Initiated: 11/01/2025.Check and Change Q (every)2-3H (hours) and PRN (as needed). Date Initiated: 11/01/2025.On 1/5/26 at 3:38 PM, V9 (CNA/Certified Nursing Assistant) and V3 (CNA Supervisor) provided peri care to R2. R2's buttocks, scrotum, and upper thighs were red, irritated, and had open bleeding spots. When asked about the irritation, R2 stated they put cream on it at times, but he wasn't sure how often they did it. V3 left the room and got V2 (Assistant Director of Nurses/Wound Nurse) to assess R2's buttocks. When V2 entered the room, R2 stated they were supposed to tell you about this days ago. V2 stated, this is the first I have heard of it. V2 cleaned the areas and applied cream. V2 stated it was moisture associated skin damage (MASD).R2's Progress Note dated 1/5/26 at 4:14 PM documents, Staff notified this nurse of bleeding noted to buttocks. This nurse assessed resident et (and) noted MASD to bilateral buttocks, upper thighs, et scrotum. Non emergent sent to (name of physician). Will have (name of wound specialist) pick resident back up for wound. Zinc oxide cream applied to areas.R2's Skin Observation Tool dated 1/1/26 documents yes next to the question, One or more wounds or injuries present. There is no identification of the type of wound, where the wound is located, or an assessment of the wound documented.R2's Treatment Administration Record (TAR) dated 12/1/25 to 12/31/25 documents a physician order for Calmoseptine External Ointment (Menthol-Zinc Oxide) to be applied to buttocks every day and night shift for excoriation, with a start date of 10/28/25. This physician order is signed as administered each day and night shift throughout the month of December. This same TAR documents the following physician order, Skin assessment weekly one time a day every Tue (Tuesday), Sun (Sunday) if skin is not intact, document findings in Progress Notes under Skin note type. Start Dated 11/02/2025. This order is signed as completed every Tuesday and Sunday with an n documented on each day except 12/30/25 where yes is documented. There is no corresponding progress note documenting an assessment of skin breakdown on 12/30/25.R2's TAR dated 1/1/26 to 1/31/26 documents a physician order for Calmoseptine External Ointment to be applied to buttocks topically every day and night shift with a start date of 10/28/25. This order is signed as administered every day and night shift from 1/1/26 to 1/6/26 except on 1/2/26 day shift, which has no initials indicating the treatment was not administered on that day and time. This same TAR does not document a physician order for weekly skin assessments.On 1/6/26 at 1:09 PM, V2 (ADON/Assistant Director of Nurses) stated she was not aware R2 had MASD until she assessed him during the observation on 1/5/26 at 3:38 PM. V2 stated R2's skin was red when he admitted , and he had an order for cream to be applied twice daily to prevent further skin breakdown. V2 stated she spoke with R2's nurse on 1/5/26 and she stated she was not aware of the MASD. When asked what caused MASD, V2 stated R2 was incontinent, and it looked like moisture associated breakdown. V2 stated the last time she assessed R2's buttocks was 12/30/25. V2 stated they do skin assessments weekly but when they switched systems the order didn't get carried Residents Affected - Few (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 01/07/2026 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete over to every resident's record. V2 stated they have been working on getting that corrected. V2 stated if the nurse was applying the cream as ordered they should have assessed the areas and documented the assessment. V2 was not able to locate any new skin assessments documenting the MASD on R2's buttocks.2. R3's admission Record with a print date of 1/6/26 documents R3 was admitted to the facility on [DATE] with diagnoses that include diabetes, malignant neoplasm of left breast, osteoarthritis, hypertension, and stress incontinence.R3's MDS dated [DATE] documents a BIMS score of 09, indicating a moderate cognitive deficit. This same MDS documents R3 is dependent on staff for toileting and is always incontinent of bowel and bladder.R3's current Care Plan documents a Focus area of, I have a potential for impairment to skin integrity r/t (related to) aging/disease process redness/Gaulding to buttocks. Date Initiated: 07/14/2023. This Focus area includes the following interventions, Assess/record changes in skin status Date Initiated: 07/14/2023.On 1/5/26 at 3:17 PM, V3 (CNA Supervisor) and V7 (CNA) provided incontinence care to R3. While cleaning R3's peri area R3 stated the area was sore and asked if it was red. V3 (CNA Supervisor) told her it was a little red and she would get her some cream for it. This surveyor observed R3's peri area to be red and irritated in appearance.On 1/6/26 at 1:09 PM, V2 (Wound Nurse/Assistant Director of Nursing) stated V3 and/or V7 had not reported to her that R3's peri area was red, irritated, and sore. When asked if she would expect them to, V2 stated, Absolutely.R3's Progress Note dated 11/19/25 documents, (name of wound specialist company) MD (physician) in facility this am to perform facility wide skin sweep. No new skin issues noted. There is no documentation in R3's progress notes related to the peri area being red and sore during the observation on 1/5/26.On 1/6/26 at 1:28 PM, V1 (Administrator) stated she had not had any complaints/concerns brought to her related to skin issues.The facility Pressure/Skin Breakdown-Clinical Protocol dated January 2017 documents, .In addition, the nurse shall assess and document/report the following: a. Full assessment of skin condition including but not limited to location, stage or partial/full thickness, length, width, presence of exudate or necrotic tissue. 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 01/07/2026 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure incontinence care was provided using current standards of practice for 2 of 2 residents (R2 and R13) reviewed for incontinence care in the sample of 14.Findings Include:1. R2's admission Record with a print date of 1/6/25 documents R2 was admitted to the facility on [DATE] with diagnoses that includes morbid obesity, unsteadiness on feet, heart disease, and osteoarthritis.R2's MDS (Minimum Data Set) dated 10/31/25 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R2 is cognitively intact. This same MDS documents R2 is occasionally incontinent of bowel and bladder.R2's current Care Plan documents a Focus area of I am occasionally incontinent of bowel and bladder. Date Initiated: 11/01/2025. This Focus area includes interventions of, Apply barrier cream after each incontinent episode Date Initiated: 11/01/2025.Check and Change Q (every)2-3H (hours) and PRN (as needed). Date Initiated: 11/01/2025.On 1/5/26 at 3:38 PM, V9 (CNA/Certified Nursing Assistant) and V3 (CNA Supervisor) provided peri care to R2. R2's incontinence brief was removed and was saturated with urine. V9 used wash cloths with warm water and no rinse peri care solution to clean R2's penis, groin, and scrotum. V9 wiped up and down turning the cloth multiple times and at times using the same side of the cloth to clean different areas. V9 changed her gloves after cleaning R2's groin/penis area and before cleaning R2's buttocks. V9 changed her gloves after cleaning R2's buttocks and before drying the area. V9 did not hand sanitize between glove changes. R2's buttocks, scrotum, and upper thighs were red, irritated, and had open bleeding spots. When asked about the irritation, R2 stated they put cream on it at times, but he wasn't sure how often they did it. V3 left the room and got V2 (Assistant Director of Nurses/Wound Nurse) to assess R2's buttocks. When V2 entered the room, R2 stated they were supposed to tell you about this days ago. V2 stated, this is the first I have heard of it. V2 cleaned the areas and applied cream. V2 stated it was moisture associated skin damage (MASD).On 1/5/26 at 4:43 PM, V9 stated she did not hand sanitize between glove changes because she forgot to.On 1/6/26 at 1:09 PM, V2 (ADON/Assistant Director of Nurses) stated she was not aware R2 had MASD until she assessed him during the observation on 1/5/26 at 3:38 PM. V3 stated R2's skin was red when he admitted , and he had an order for cream to be applied twice daily to prevent further skin breakdown. V2 stated she spoke with R2's nurse on 1/5/26 and she stated she was not aware of the MASD. When asked what caused MASD, V2 stated R2 was incontinent, and it looked like moisture associated breakdown.On 1/6/26 at 1:28 PM, V1 (Administrator) stated she had not had any complaints/concerns brought to her related to incontinence care. 2. R13's admission Record with a print date of 1/7/26 documents R13 was admitted to the facility on [DATE] with diagnoses that include acute pyelonephritis, heart failure, hypertension, respiratory failure, stiffness of left knee, and right shoulder, and scoliosis.R13's MDS dated [DATE] documents a BIMS score of 13, indicating R13 is cognitively intact. This same MDS documents R13 is dependent on staff for toileting and is always incontinent of bowel and bladder.R13's current Care Plan documents a Focus area of, I am incontinent of bowel and bladder. Date Initiated: 05/31/2019. This same Focus area includes the following interventions, Apply barrier cream after each incontinent episode. Date Initiated: 05/31/2019. Clean peri-area with each incontinent episode. Date Initiated: 05/31/2019.On 1/5/26 at 3:28 PM, V8 (CNA) and V3 (CNA Supervisor) provided incontinence care to R13 using current standards of practice. V8 changed her gloves after cleaning R13's peri area, after cleaning R13's buttocks, and after drying the areas. V8 did not hand sanitize after removing soiled gloves and/or before donning clean gloves.On 1/5/26 at 4:19 PM, V8 stated she didn't hand sanitize between glove changes because she (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 01/07/2026 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete just forgot.On 1/7/26 at 3:45 PM, V2 (ADON) stated she would expect staff to hand sanitize between glove changes.The facility Hand-Washing/Hand Hygiene Policy dated March 2020 documents, Policy: It is the policy of the facility to assure staff practice recognized hand-washing/hand hygiene procedures as a primary means to prevent the spread of infections among residents, personnel, and visitors. Alcohol based hand rubs (ABHR) can be used for hand hygiene when hands are not visibly soiled or contaminated with blood or bodily fluids.When hands are not visibly soiled, employees may use an alcohol-based hand rub (foam, gel, liquid) contained at least 60% alcohol in all of the following situations.h. before and after putting on and upon removal of PPE (personal protective equipment), including gloves. 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 01/07/2026 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 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 they had sufficient staff to meet the needs of the residents timely for 4 of 4 (R1, R2, R13, and R14) residents reviewed for staffing in the sample of 14. This has the potential to affect all 67 residents who currently reside at the facility.Findings Include:The facility Resident Matrix dated 1/5/2026 documents 67 residents currently reside at the facility.1. R2's admission Record with a print date of 1/6/26 documents R2 was admitted to the facility on [DATE] with diagnoses that includes morbid obesity, unsteadiness on feet, heart disease, and osteoarthritis.R2's MDS (Minimum Data Set) dated 10/31/25 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R2 is cognitively intact. This same MDS documents R2 is occasionally incontinent of bowel and bladder.R2's current Care Plan documents a Focus area of I am occasionally incontinent of bowel and bladder. Date Initiated: 11/01/2025. This Focus area includes interventions of, Apply barrier cream after each incontinent episode Date Initiated: 11/01/2025.Check and Change Q (every)2-3H (hours) and PRN (as needed). Date Initiated: 11/01/2025.Ensure call light is within reach and answer promptly. Date Initiated: 11/01/2025.On 1/5/26 at 3:38 PM, V9 (CNA/Certified Nursing Assistant) and V3 (CNA Supervisor) provided peri care to R2. R2's incontinence brief was removed and was saturated with urine. R2's buttocks, scrotum, and upper thighs were red, irritated, and had open bleeding spots. When asked about the irritation, R2 stated they put cream on it at times, but he wasn't sure how often they did it. V3 left the room and got V2 (Assistant Director of Nurses/Wound Nurse) to assess R2's buttocks. V2 stated it was moisture associated skin damage (MASD).On 1/5/26 at 11:38 AM, R2 stated it sometimes took a long time for facility staff to answer his call light. R2 stated he had waited an hour and a half once but was unable to recall the date or specific details of this occurrence.2. R1's admission Record with a print date of 1/6/26 documents R1 was admitted to the facility on [DATE] with diagnoses that include myasthenia gravis, diabetes, heart disease, unsteadiness on feet, neuropathy, and atrial fibrillation.R1's MDS dated [DATE] documents a BIMS score of 15, indicating R1 is cognitively intact. This same MDS documents R1 is dependent on staff for toileting and is continent of urine and occasionally incontinent of bowel.R1's current Care Plan documents a Focus area of, I am frequently incontinent of bowel and occasionally incontinent of bladder. Date Initiated: 04/23/2025. This Focus area includes interventions of, Check and change Q(every)2-3H (hours) and PRN (as needed). Date Initiated: 04/23/2025.Ensure call light is within reach and answer promptly. Date Initiated: 04/23/2025.On 1/5/26 at 12:20 PM, R1 was observed lying in bed. V5 (Family Member) was at R1's side. R1 did not respond to this surveyors' questions but shook his head giving approval for this surveyor to speak with V5. V5 stated they are short staffed on the weekends at times.On 1/5/26 at 12:24 PM, R12 stated he was R1's roommate and it had taken an hour before for the staff to answer the call light after R1 had pottied himself. R12 stated the unknown CNA's excuse at the time was they only had four CNA's working. R12 stated this occurred in mid-December was unable to remember the exact date.R12's admission Record with a print date of 1/7/26 documents R12 was admitted to the facility on [DATE]. R12's MDS dated [DATE] documents a BIMS score of 15, indicating R12 is cognitively intact.3. R13's admission Record with a print date of 1/7/26 documents R13 was admitted to the facility on [DATE] with diagnoses that include acute pyelonephritis, heart failure, hypertension, respiratory failure, stiffness of left knee, and right shoulder, and scoliosis.R13's MDS dated [DATE] documents a BIMS score of 13, indicating R13 is cognitively intact. This same MDS documents R13 is dependent on staff for toileting and is always incontinent of bowel and bladder.R13's current Care Plan documents a Focus area of, I am incontinent of bowel and (continued on next page) 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 01/07/2026 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete bladder. Date Initiated: 05/31/2019. This same Focus area includes the following interventions, Apply barrier cream after each incontinent episode. Date Initiated: 05/31/2019. Clean peri-area with each incontinent episode. Date Initiated: 05/31/2019.Ensure call light is within reach and answer promptly. Date Initiated: 05/31/2029.On 1/5/26 at 2:25 PM, R13 stated they don't have enough staff. R13 stated when they don't have enough staff, they have to wait a long time for staff to answer call lights. R13 stated when that happens, she has to wait a long time to get up in the morning. R13 stated she has to wait a couple of hours for incontinence care at night.4. R14's admission Record with a print date of 1/7/26 documents R14 was admitted to the facility on [DATE] with diagnoses that include diabetes, osteoarthritis, hypertension, and heart disease.R14's MDS dated [DATE] documents a BIMS score of 15, indicating R14 is cognitively intact.R14's current Care Plan documents a Focus area of, I am always incontinent of bladder and bowel. Date Initiated: 03/09/2023. This Focus area includes the intervention of, Ensure call light is within reach and answered promptly. Date Initiated: 3/9/2023.On 1/5/26 at 2:28 PM, R14 stated when they don't have enough staff, she has to wait 30 to 45 minutes for care.On 1/5/26 at 4:19 PM, V8 (CNA/Certified Nursing Assistant) stated they don't have enough staff to meet the needs of the residents timely. V8 stated she works 2 pm to 10 pm. V8 stated around 4 pm they have to get residents ready for supper and answer call lights. V8 stated call lights aren't always answered timely.On 1/5/26 at 4:30 PM, V12 (CNA) stated she works 2 pm to 10 pm. V12 stated they sometimes have enough staff to meet the needs of the residents timely. V12 stated on weekends they have four CNA's, that is one per hall. V12 stated it is hard when there is a person who requires assist of two staff. V12 stated it can be hard to find someone to help assist. V12 stated getting the residents who take two assists to bed after dinner can be delayed and answering call lights timely can be an issue. V12 stated if she is a room for an excessive amount of time trying to meet a resident needs the call lights getting answered can be delayed.On 1/7/26 at 10:40 AM, V14 (anonymous) stated the call lights are answered as timely as they can be. V14 stated they have a lot of residents who require two person assist and if the staff is tied up in one room and the nurses are doing a medication pass it may take a while for the call lights to be answered. V14 stated she didn't think they had enough staff to meet the needs of the residents timely. V14 stated call lights aren't answered timely, and resident have to sit longer after incontinence episodes before care is provided.On 1/6/26 at 10:42 AM, V15 (Registered Nurse/RN) stated they have enough staff to provide care timely. When asked about staffing from 2 pm to 6 pm, V15 stated they have at least four CNA's and three nurses. V15 stated supper is around 5 pm and medications are administered from 4 to 5 pm. When asked if four CNA's were enough to assist residents to the dining room, answer call lights, provide incontinence care, and pass meal trays, V15 stated it is a very busy time frame and they could honestly use a couple more CNA's. V15 stated it is not always doable.On 1/6/26 at 1:09 PM, V2 (Assistant Director of Nurses) stated every place has a problem of call lights not being answered timely, at times. V2 stated they definitely have gotten better about answering the call lights timely. V2 stated they still have room for improvement, but it is getting better. V2 stated they have enough staff to meet the needs of the residents timely.On 1/6/26 at 1:28 PM, V1 (Administrator) stated they haven't changed anything in their staffing since the last time this surveyor was at the building. Event ID: Facility ID: 145918 If continuation sheet Page 10 of 10