Health inspection·May 28, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm 3. R113's Face Sheet documents an admission date to the facility on [DATE]. R113's BIMS dated [DATE] documents R113's BIMS score is a 15 out of 15 indicating R113 is cognitively intact. On [DATE] at 1:30 PM, R113 stated the facility staff never discussed his advanced directive preferences when he was admitted to this facility. Residents Affected - Few R113's EHR did not contain documentation of an Advanced Directive for R113. R113's Face Sheet, under the section labeled Advance Directive is left blank. R113's POS for [DATE] also does not include an order for Advanced Directives. On [DATE] at 12:10 PM, V2 (Director of Nursing/DON) said R113's Advanced Directives must have been missed when he was admitted to this facility, but she was contacting R113's previous facility for a copy of it. Facility policy titled Advanced Directives with last revision date of [DATE], documents the following in part: At the time of admission, each resident will be asked if they have made advanced directives and provided educational information regarding state and federal law. The resident, legal representative or the individual who has been authorized as the resident's health care representative will be asked if an advanced directive has been executed. Documentation concerning this inquiry and the individual response shall include the date the entry was made and the individual making this inquiry. This information shall be included in the resident's medical record. Copies of the resident's advanced directives shall be made and maintained in the resident's EHR and financial folder. A written physician's order is required in response to the resident's advanced directives. Physician's order shall be specific and address each advanced directive. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146000 If continuation sheet Page 2 of 24 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 146000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairfield Senior Living & Rehabilitation LLC 305 N.W. 11th Street Fairfield, IL 62837 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview and record review, the facility failed to provide a clean, homelike environment for 10 of 38 residents (R57, R113, R2, R15, R16, R19, R57, R214, R11, R22) reviewed for homelike environment in a sample of 38. On 5/20/2024 at approximately 9:45 AM, R2 was noted sitting in his bedside recliner. R2's bedroom floor had food debris and paper trash scattered about and trailed out into the hallway. On the morning of 5/20/2024, 5/21/2014 and 5/22/2024 at 2:00 PM, R2's bathroom was noted to have dark yellow odorous urine in the toilet bowl and two urine soaked adult briefs were noted in the bathroom trash can. One of the two urine soaked briefs were marked in ink with surveyor's initials on the edge of the brief on 5/20/2024 and the same ink mark was present on the brief on 5/21/2024 at 2:00 PM. On 5/20/2024 at approximately 10:00 AM, R113 was observed laying in his bed in his room with a finished breakfast tray sitting on his bedside table. Food debris and paper trash was noted about the floor in R113's room. A urine soaked adult brief was noted in R113's bedroom trash can and one on the floor under the end of his bed. Food debris and paper trash was seen scattered on the floor and around R113's bed linens. The toilet in R113's bathroom had dark odorous urine noted in the toilet bowl with a urine soaked adult brief noted in the trash can of the bathroom. On 5/20/2024 at 11:37 AM, R57 still had a half eaten breakfast tray sitting on the bedside table. R57's bed was not made and a pile of urine soiled sheets were wadded up and sitting in R57's bedside chair. At 11:40 AM, V4 (Licensed Practical Nurse/LPN) verified the linens were soiled with dried brown urine rings and were from R57's bed. R57's private bathroom was noted to have two urine soaked briefs/pads in the trash can and a strong scent of urine was present in the room and bathroom. On 5/21/2024 at 1:00 PM, R15 said the facility is very short staffed and needs more help. R15 said the facility isn't getting cleaned properly and is always dirty. R15's (Brief Interview for Mental Status) BIMS score dated 2/18/24 documents R15 scored 15 out of 15, indicating R15 is cognitively intact. On 5/23/2024 at 11:37 PM, V14 (Registered Nurse/RN) said the facility has frequent staff call-ins and is often short staffed so residents' rooms don't always get cleaned as scheduled. On 5/20/2024 at 1:00 PM, R16, R214, R2, R11, R22, R15, R57 and R19's beds were noted to still not be made from the night's sleep. On 5/21/2024 at 1:37 PM, R16, R214, R2, R11, R22, R15, R57 and R19's beds were noted to still not be made from the night's sleep. On 5/21/2024 at 2:45 PM, 15 dirty noon meal trays were noted to still remain on the [NAME] and Tulip hallways waiting to be cleaned up. V28 (Activity Aide) said the CNAs (Certified Nursing Assistants) are supposed to pick up the finished hall trays and make all the beds, but the facility is frequently short staffed and often the trays sit around for a long period of time after meals are finished and beds don't get made. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146000 If continuation sheet Page 3 of 24 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 146000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairfield Senior Living & Rehabilitation LLC 305 N.W. 11th Street Fairfield, IL 62837 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 5/21/2024 at 8:45 AM, V30 (Ombudsman) said she has been notified by several residents of the facility being dirty and malodorous, but could not share who the residents were due to confidentiality requests made by the residents. V30 said residents have complained to her about meal trays not getting picked up timely and sitting about the facility for extremely long periods of time. Facility document titled Concern/Compliment Form dated 4/10/2024 documents the following resident concern: Housekeeping not grabbing trash on the weekends. Another form dated 3/13/2024 documented the following: Only spot cleaning room instead of cleaning the entire room and Tulip hall is hit or miss. They might clean one to two rooms then skip the rest of the rooms on that hall. Trash not being taken out in rooms and bathrooms. Trash overflow in kitchenette. Facility document titled Complaint Resolution Form dated 4/10/2024 documents the following concern: Diabetic testing strips that have been used are being found all throughout the hallway floors. On 5/21/2024 at 12:00pm, a substance that appeard to be dried bowel movement was observed in the floor of the Daisy/Tulip hall shower room. V7 (CNA) verified it was bowel movement and should have been cleaned up immediately, but was missed somehow. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146000 If continuation sheet Page 4 of 24 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 146000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairfield Senior Living & Rehabilitation LLC 305 N.W. 11th Street Fairfield, IL 62837 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on interview and record review, the facility failed to obtain a PASRR (Preadmission Screeening and Resident Review) level two screening for a resident with a newly diagnosed Severe Mental Illness for 1 (R11) of 2 residents reviewed for PASRR in a sample of 38. R11's Face Sheet dated 5/23/24 documents an admission date of 03/10/2014 with a diagnosis of Schizoaffective disorder. R11's OBRA (Omnibus Budget Reconciliation Act) I Initial Screen documentation dated 03/05/2014 lists Reasonable Basis to Suspect a Mental Illness .The individual has been formally diagnosed with a mental illness which substantially impairs the person's cognitive, emotional and /or behavioral functioning with a corresponding box that is marked No. R11's Physician Order documents an order on 08/04/22 to add Schizoaffective Disorder to R11's diagnosis list as evidenced by assessment with behaviors. On 05/23/24 at 2:10 PM, V8 (Social Service Director/SSD) stated that a new PASRR screen should have been completed when R11 received the new diagnosis of Schizoaffective Disorder on 8/4/2022. V8 stated that she was currently working on getting the screening completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146000 If continuation sheet Page 5 of 24 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 146000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairfield Senior Living & Rehabilitation LLC 305 N.W. 11th Street Fairfield, IL 62837 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 observation, interview and record review, the facility failed to provide showers as scheduled for residents who require assistance for 4 (R113, R48, R11, R214) of 5 residents reviewed for assistance with Activities of Daily Living in a sample of 38. Residents Affected - Some Findings included: 1. R113's Face Sheet documented an admission date to the facility on 5/8/2024 with diagnoses of hemiplegia and hemiparesis following cerebral infarction. R113's Brief Interview for Mental Status (BIMS) dated 5/9/2024 documents R113 scored 15 out of 15 total, indicating R113 is cognitively intact. R113's Minimum Data Set (MDS) dated [DATE] documents R113 needs substantial/maximum assistance from staff for bathing, dressing and transferring. On 5/20/2024 at approximately 10:00 AM, R113 was observed laying in his bed in his room. R113's appearance was disheveled, had greasy dirty hair and had a strong scent of urine and body odor about his person. On 5/22/2024 at 12:46 PM, V2 (Director of Nursing/DON) said R113 has not received a shower since being admitted to this facility, but the staff were giving him one now. V2 verified R113 needed staff assistance to shower and cannot shower independently. V2 said the facility could only produce bathing documentation for the one shower given that day and no other documentation was available. On 5/22/2024 at 1:30 PM, R113 said he just received his first shower since being admitted to this facility on 5/8/2024. R113 said he uses a wheelchair to propel about the facility due to not being able to walk. R113 said he needs staff assistance to get a shower and cannot shower independently. 2. R2's Face Sheet documented an admission date to the facility on 1/3/2024 with a diagnosis of Cerebral Palsy. R2's BIMS dated 4/2/2024 documents a score of 14 out of 15 total, indicating R2 is cognitively intact. R2's MDS dated [DATE] section GG documents R2 is dependent on staff for bathing, toileting, dressing and transferring. On 5/20/2024 at approximately 9:45 AM, R2 was noted sitting in his bedside recliner with oily disheveled hair, moderate beard growth with food in his beard and on his clothing. R2 had a strong scent of urine body odor about his person. R2 stated he would like to take a shower every day, but he is lucky to get one per week and sometimes doesn't get that. R2 said the facility needs more workers and this is why he doesn't get showered as scheduled. The facility shower list, with revision date of 5/22/24, documents R2 is to be showered on Tuesdays and Fridays. A review of R2's shower documentation for March, April and May 2024 revealed R2 received four showers in March (3/3, 3/7, 3/12, 3/22), four showers in April (4/2, 4/5, 4/12, 4/23) and two showers in May (5/3, 5/10). On 5/23/2024 at 10:40 AM, V3 (Assistant Director of Nursing/ADON) said the residents are supposed to get two showers offered per week, but staff calling off causes the showers to not get completed in a timely manner. 3. R11's Face Sheet documents an admission date of 03/10/2014 with diagnoses in part of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146000 If continuation sheet Page 6 of 24 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 146000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairfield Senior Living & Rehabilitation LLC 305 N.W. 11th Street Fairfield, IL 62837 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 Residents Affected - Some Parkinson's, Morbid (Severe) Obesity, Type 2 Diabetes Mellitus, Hypertension, Chronic Kidney Disease, and Benign Prostatic Hyperplasia without lower urinary tract infections. R11's Minimum Data Set (MDS) dated [DATE] documents in section C a BIMS score of 9, which indicates moderate cognitive impairment. Section GG documents that R11 is dependent for toileting, bathing/showering and personal hygiene and R11 needs substantial/maximum assist with transfers. R11's Current Care Plan documents R11 has limited physical mobility r/t (related to) H/O (history of) CVA (Cerebral Vascular Accident) and Parkinson's with interventions of provide supportive care, assistance with mobility as needed. R11 has ADL (Activities of Daily Living) self-care performance deficit with interventions in part of Bathing/Showering, R11 requires physical help in part of showering x 1 staff member to provide shower. The Facility Shower list dated 05/14/24 documents that R11 is to have showers on Tuesday and Fridays every week. R11's Shower documentation/skin assessment sheets were reviewed on 5/22/24 and document showers completed on 4/2/24, 4/5/24, 4/9/24, 4/10/24, 4/16/24,4/23/24, 4/26/24, 4/30/24, 5/7/24, 5/14/24, 5/17/24, 5/21/24. No shower documentation was found for 04/12/24, 04/19/24 or 05/10/24. R11 was documented to refuse a shower on 05/03/24. On 05/22/24 at 11:28 AM, R11 was observed to have oily looking hair and clothes appeared wrinkled and soiled with food stains. R11 had a body odor smell about his person. On 05/22/24 at 1:30 PM R11 who was alert and oriented to person, place and time, stated he is lucky to get a shower once a week. R11 said that they tell him often that it's his shower day, which is on Tuesday and Friday, but never come back to get him for the shower. R11 said that most of the time he feels like he maybe gets a shower once a week. R11 said they could use some more help and maybe he would get his showers like he is supposed to. R11 stated that he has not had a shower now in over a week. 4. R214's admission Record dated 05/23/24 documents an admission date of 05/16/24 with diagnoses in part of End Stage Renal Disease, Type 2 Diabetes Mellitus, dependence on renal dialysis, Anemia, Hypertension, Seizures, Hyperkalemia, and Hyperprolactinemia. R214's MDS dated [DATE] is currently in progress and does not document anything in section C or GG. R214's Care Plan which was also currently in progress documents on 05/20/24 that R214 is capable of independently choosing programs in which to participate. The Facility Shower list dated 05/14/24 was reviewed on 5/22/24 and does not document R214's name on the shower list. R214's shower sheets/skin assessment documents on 05/17/24 bed bath given; no other shower sheets could be provided up request. On 05/20/24 at 12:30 PM, R214 who was alert and oriented to person, place and time stated she has only been washed up by staff since she has been at the facility. R214 stated she would love to take a shower, but they haven't given her one yet. R214 stated that she arrived at the facility on 05/16/24. R214 said that she needs assistance of two staff with transfers and with showering. On 05/22/24 at 11:30 AM, R214 stated that she still has not received a shower. R214 said that she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146000 If continuation sheet Page 7 of 24 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 146000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairfield Senior Living & Rehabilitation LLC 305 N.W. 11th Street Fairfield, IL 62837 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 has even asked for one, but staff said they would get to her later and they never have. Level of Harm - Minimal harm or potential for actual harm The Facility Bathing policy with revision date of 1/31/18, documents the following in part: To ensure resident's cleanliness to maintain proper hygiene and dignity. A shower, tub bath or bed bath will be offered according to the resident's preference two times per week. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146000 If continuation sheet Page 8 of 24 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 146000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairfield Senior Living & Rehabilitation LLC 305 N.W. 11th Street Fairfield, IL 62837 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide additional nourishment as ordered in the form of nutritional supplements and fortified foods for five (R50, R31, R36, R44, and R45) of 12 residents reviewed for nutrition in a sample of 38. This failure resulted in R50 experiencing a significant weight loss of 17.5% in 3 months, and R31 experiencing a significant weight loss of 6.68% in 1 month or 8.58% in 3 months. Residents Affected - Few Findings Include: 1. R50's Transfer/Discharge report documents an admission date of 01/26/24 with diagnoses including: Alcohol abuse with alcohol induced mood disorder, Alcohol Dependence with alcohol induced persisting dementia, Cognitive Communication Deficit, Unspecified Dementia, Wernicke's Encephalopathy, Chronic Obstructive Pulmonary Disease (COPD), and Mood Affective Disorder. R50's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 04, indicating severe cognitive impairment. R50's MDS section GG documents eating ability as: supervision or touching assistance - helper provides verbal cues and or touching/steading and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. R50's Order Summary Report documents orders including: general diet: Regular texture, regular consistency, fortified foods with meals, ice cream with lunch and supper with a start date of 01/26/24, no end date documented; and house nutrition supplement - three times a day in between meals with a start date of 05/16/24 and no end date listed. R50's Care Plan documents a Focus Area dated 03/05/24 documenting: R50 has a nutritional problem or potential nutritional problem regarding the diagnosis of Dementia, Wernicke's Encephalopathy, COPD, and Mood Affective Disorder. R50's care plan documents interventions of: Administer medications as ordered. Monitor/Document for side effects and effectiveness, Encourage PO (by mouth) intake of meals and snacks, Invite the resident to activities that promote additional intake, Obtain and monitor lab/diagnostic work as ordered. Report results to MD (Medical Doctor) and follow up as indicated, provide, serve diet as ordered. Monitor intake and record with meal, and RD (Registered Dietician) to evaluate and make diet change recommendations PRN (as needed), all interventions are dated 03/05/24. R50's Electronic Medical Record (EMR) documents weights as: 162.8 pounds (lbs.) on 01/26/2024, 161.4 lbs. on 02/07/2024, 161.0 lbs. on 3/18/2024, 139.5 lbs. on 4/9/2024, and 133.0 lbs. (pounds) on 5/15/2024. The weights documented indicate a 17.6 % weight loss in 3 months. On 05/20/24 at 11:00 AM, V22 (Cook) made mashed potatoes with creamy classic mashed potatoes and hot water. No fortified potatoes were observed to be prepared. The recipe titled power potatoes documents ingredients: milk 2%, milk non fat dry, potato, mashed instant, sour cream, margarine, and salt. On 05/20/24 at approximately 12:00 PM during lunch service, there was only one pan of mashed potatoes on the steamtable. Regardless if dietary cards listed fortified potatoes, the creamy classic mashed potatoes were observed to be served to all residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146000 If continuation sheet Page 9 of 24 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 146000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairfield Senior Living & Rehabilitation LLC 305 N.W. 11th Street Fairfield, IL 62837 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 0692 On 05/20/24 at 12:40 PM, R50 did not receive fortified potatoes or ice cream with his lunch tray. Level of Harm - Actual harm On 05/20/24 at 1:30 PM V16 (Dietary Manager) stated the nutritional supplements came in on the truck that morning and they are frozen, they will have to give them out at snack time. Residents Affected - Few On 05/20/24 at 2:00 PM, V22 (Cook) stated that the mashed potatoes that were made for lunch were made with the potato flakes and hot water, and they were the only potatoes made and served that day. On 05/20/24 at 2:40 PM, V28 (Activity Aide/Certified Nurse Aide/CNA) passed afternoon snacks. On this date between 2:30 - 3:15 PM, R50 did not receive the ice cream during snack time. On 05/21/24 at 12:40 PM, R50 did not receive ice cream with his lunch tray. .At 2:35 PM, R50 did not receive ice cream during snack time. On 05/22/24 at 1:00 PM, R50 did not receive ice cream with his lunch tray. On 05/22/24 at 1:25 PM, R50 had eaten all of the food on his plate and R50 started reaching out for other residents' food. V28 (Activity Aide/CNA) was assisting R28 with her lunch. V28 attempted redirecting R50 and telling him it was not his food. After several attempts at redirecting and R50 starting to get aggressive, V28 asked R50 if he was still hungry and R50 answered yes. V28 went to the snack room and placed some cheese puffs onto a small plate and brought them back for R50. On 05/22/24, R50 did not receive ice cream during snack time. On 05/29/24 at 11:10 AM, V29 (Registered Dietician) stated she was aware of R50's weight loss between March and April and on 04/26/24 she noted she had requested a re-weigh for R50. V29 stated, in her note from 05/16/24, May's weight was consistent with April's weight and she ordered the supplements for R50. 2. R31's Face Sheet documents an admission date of 07/23/20 with diagnoses in part of Heart Failure, Type 2 Diabetes Mellitus, Malignant Neoplasm of Prostate, Hypertension, and Hyperlipidemia. R31's MDS dated [DATE] documents in Section C a BIMS score of 12, which indicates moderate cognitive impairment. Section GG documents that R31 requires set-up and clean-up assistance with eating. R31's Care Plan dated 05/02/24 documents R31 has an ADL (Activities of Daily Living) self-care/mobility performance (functional abilities) deficit that may fluctuate with activity throughout the day r/t (related to) a diagnosis of CHF (Congestive Heart Failure), DM (Diabetes Mellitus), AFIB (Atrial Fibrillation), MDD (Major Depression Disorder) and HTN (Hypertension) with interventions in part of Eating- My usual performance is set-up. Risk for Depression/Decreased appetite. R31 able to consume regular consistency food with interventions of Monitor and record intake q (Every) shift, monitor for sign/symptoms of aspiration, monitor weight as indicated monthly and PRN (as needed), position for eating and drinking safely, provide diet as ordered, regular diet with super cereal, nutritional shakes with meals as desired, and refer to ST (Speech Therapy) R31's Weight summary in part documents the following weights: 12/21/23 - 200 lbs., 01/17/24 -197.5 lbs., 02/17/24 - 197 lbs., 3/18/24 - 196 lbs., 4/18/24 - 193 lbs., and 05/20/24 180.1 lbs. R31 has had a 6.68% weight loss in 1 month from April to May and 8.58% weight loss in 3 months from February (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146000 If continuation sheet Page 10 of 24 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 146000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairfield Senior Living & Rehabilitation LLC 305 N.W. 11th Street Fairfield, IL 62837 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 0692 to May. Level of Harm - Actual harm R31's Physician Order documents general diet, regular texture, thin consistency, house nutritional supplement with meals ordered 01/04/24. Residents Affected - Few R31's Nutritional Progress note dated 04/28/24 documents RD (Registered Dietitian) consult for -5.0% change (Comparison Weight 03/30/2024, 195.4 Lbs., -5.1%, -9.9 Lbs. April. Wt. (weight) 186# BMI (Body Mass Index) 34.2 overweight per standards. On 05/20/24 at 11:30 AM, R31 was sitting in the Dining Room in his wheelchair falling asleep at the lunch table. At 12:30 PM, R31 was still sleeping at the lunch table, still waiting on a lunch tray. At 12:33 PM, R31 was taken out of the dining room and placed in the hallway with no tray served to him. At 1:52 PM, R31 was placed in his recliner in his room. At 1:58 PM, V7 (Certified Nurse Assistant/CNA) was asked if R31 had received a lunch tray yet. V7 stated that she was unsure if R31 had eaten yet. At 1:59 PM, V7 looked on the hall tray cart and was unable to find a tray with R31's kitchen card on it. At 2:00 PM, V7 went to the kitchen and asked kitchen staff about R31's lunch tray. V7 stated that the kitchen staff told her they had lost R31's lunch ticket and that they did finally find it. At 2:05 PM, V7 went to R31's room to ask R31 what he would like to eat and R31 stated he would like some soup and crackers with a drink. At 2:15 PM, R31 was served a lunch tray by V7. R31's Order Summary dated 05/21/24 documents send to local hospital emergency room r/t (related to) decline in condition no appetite and lethargy. R31's Progress note dated 05/21/24 at 5:02 PM documents in part, Patient (R31) is going to be admitted to local hospital with dx (diagnosis) of hyponatremia, hypercalcemia and AKI (Acute Kidney Infection). On 05/28/24 at 11:00 AM, V16 (Dietary Manager) stated that she found out last week that the program she uses to print meal tickets wasn't printing off all the meal tickets. V16 said some of the residents' meal tickets were missing. V16 stated that this is the main way they serve residents their meals, by the meal tickets, so if one was missing, they didn't know to serve that resident. V16 said that when she found out the program wasn't printing all of the resident meal tickets, she started to double check to make sure they were all there. V16 said that she must go in and manually print just one or two resident tickets sometimes on her own if they didn't print up with all the other residents' meal tickets. V16 stated sometimes residents can also get missed during mealtimes if a meal ticket gets stuck together. V16 said that she is working on trying to get a better system going so they don't miss any meal tickets or residents' trays. V16 said she wasn't aware of residents missing nutritional supplements last week. V16 said they were very short last week and that could be the reason many of the supplements were forgotten. V16 said that usually the supplements, such as the nutritional shakes and nutritional supplement ice cream comes out of the kitchen served on the tray and the person serving should double check the ticket to make sure that it is correct. V16 said they didn't have a lot of staff last week, she even had to work in the kitchen on 05/23/24 because she was short staffed. V16 stated that she knows that R31 is on a nutritional supplement and doesn't know why he didn't get the supplement or why they forgot his tray. On 05/28/24 at 11:54 AM, V29 (Registered Dietitian) stated she was not aware that R31 was not served a tray on 05/20/24 until staff had to ask for one. V29 stated that she was not aware of V16 having trouble with not being able to print all the residents' meal tickets out and that some of the residents' tickets would be missing and they may not be served a tray. V29 stated R31 was to receive a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146000 If continuation sheet Page 11 of 24 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 146000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairfield Senior Living & Rehabilitation LLC 305 N.W. 11th Street Fairfield, IL 62837 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 0692 Level of Harm - Actual harm Residents Affected - Few nutritional supplement with meals related to him having a weight loss. V29 said R31 would take the supplement sometimes, but other times he would refuse them. V29 said R31 was on comfort care and that they offer R31 supplements as he desires. V29 said she knew R31 has recently had a 5% weight loss in a month. V29 stated she was going to work with the kitchen to help straighten out some of the problems that they had going on with residents not receiving all the supplements that are ordered for them and making sure all residents get their meals. 3. R36's Transfer/Discharge Report documents an admission date of 10/04/19 with diagnoses including: Schizoaffective Disorder, Dementia, and Major Depressive Disorder. R36's Minimum Data Set (MDS) dated [DATE] documents no Brief Interview for Mental Status (BIMS) was performed due to resident is rarely/never understood. Section GG documented for R36's eating ability, substantial/maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half the effort) is needed. R36's Order summary report documents and order dated 03/30/2022 with no end date listed for: General diet - mechanical soft texture. Thin consistency, plate guard with pureed vegetable, extra gravy, fortified foods and ice cream with afternoon and evening meals. Another order dated 01/17/23 with no end date listed documents an order for health shakes two times a day in between meals at 7:00 AM and 3:00 PM. R36's Care Plan documents a Focus Area that R36 is unable to consume regular consistency foods and requires a mechanically altered diet with fruit and vegetables pureed. R36 has cognitive impairment and difficulty swallowing/chewing with a date of 04/25/21. The interventions documented are: monitor and record intake every shift, monitor for signs/symptoms of aspiration with a date of 09/07/2020, monitor weight as indicated monthly and PRN (as needed) with a date of 09/07/2020, position for eating and drinking safely with a date of 09/07/2020, provide diet as ordered, mechanical soft with pureed fruits and vegetables, fortified foods, extra desserts, heath shakes, 1 time daily with meals or as desired, whole milk at all meals. Plate guard provided to encourage self feeding with a date of 05/14/2021. Provide medications for hyperlipidemia and monitor for side effects and adverse reactions and report to MD if noted, with a date of 04/25/2021. Refer to ST (Speech Therapy) for evaluation and treat as indicated with a date of 09/07/2020. On 05/20/24 at 11:00 AM, V22 (Cook) made mashed potatoes with creamy classic mashed potatoes and hot water. No fortified potatoes were observed to be prepared. The recipe titled power potatoes documents ingredients: milk 2%, milk nonfat dry, potato, mashed instant, sour cream, margarine, and salt. On 05/20/24 at approximately 12:00 PM during lunch service, there was only one pan of mashed potatoes on the steamtable. Regardless if dietary cards listed fortified potatoes, the creamy classic mashed potatoes were observed to be served to all residents. On 05/20/24 at approximately 12:45 PM, R36 received a #10 dip of regular mashed potatoes, no fortified mashed potatoes, no extra gravy and no ice cream on his lunch tray. On 05/20/24 at 2:00 PM, V22 (Cook) stated that the mashed potatoes that were made for lunch were made with the potato flakes and hot water, and they were the only potatoes made and served that day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146000 If continuation sheet Page 12 of 24 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 146000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairfield Senior Living & Rehabilitation LLC 305 N.W. 11th Street Fairfield, IL 62837 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 0692 Level of Harm - Actual harm Residents Affected - Few On 05/20/24 at 2:40 PM V28 (Activity Aide/CNA) passed afternoon snacks and there were no nutritional house supplements/shakes or ice cream on the snack cart. At approximately 3:00 PM, V28 was done passing snacks and moved the snack cart from the dining room. On 05/20/24 between 2:20 PM and 3:30 PM, R36 did not receive a health shake and no ice cream was given during snack time either. On 05/21/24 at approximately 12:40 PM, R36 received ground philly chicken sandwich, soft tater tots, and soft chopped fruit salad, R36 did not receive a nutritional house supplement, a fortified food item or ice cream with his lunch tray. On 05/21/24 at 2:30 PM, V28 passed afternoon snacks and there were no nutritional house supplements on the snack cart. At approximately 3:00 PM, V28 was done passing snacks and moved the snack cart from the dining room. On 05/21/24 between 2:35 PM - 3:15 PM, R36 did not receive a nutritional house supplement or ice cream during snack time. On 05/22/24 at 1:00 PM, R36 did not receive a nutritional house supplement, a fortified food item or ice cream with his lunch tray. On 05/22/24 at 2:35 PM, V28 passed afternoon snacks and there were no nutritional house supplements/shakes on the snack cart. At approximately 3:00 PM, V28 was done passing snacks and moved the snack cart from the dining room. On 05/22//24 between 2:35 PM - 3:15 PM, R36 did not receive a nutritional house supplement or ice cream. 4. R44's Transfer/Discharge Report documents an admission date of 08/03/20 with diagnoses including: Alzheimers's Disease with early onset, Disorientation, Essential Hypertension, Hypothyroidism, Unspecified Psychosis not due to a substance or known physiological condition, Dehydration, Fracture of unspecified part of neck of right femur subsequent encounter for closed fracture with routine healing, Seizures, and Rhabdomyolysis. R44's MDS dated [DATE] documents no BIMS was conducted due to R44 is rarely/never understood. Section GG indicates R44 is dependent for eating. R44's Physician Order Sheet documents an order for house nutrition supplement two times a day for nutritional supplement iso source 1.5 give 90cc (cubic centimeters) BID (twice a day) with an order date of 04/18/2024. R44's dietary card documents: lunch- nutritional ice cream in a bowl, power pudding, health shake for all meals. R44's Care Plan documents a Focus Area of R44 is unable to consume regular consistency foods with toast or breads all meals. R44 needs total assistance with all her meals with a revision date of 06/13/23 with interventions documented as: monitor and record intake every shift with a date of 11/06/20, monitor for sign/symptoms of aspiration dated 11/06/20, monitor weight as indicated weekly and prn dated 12/16/20, provide diet as ordered, mechanical soft with breads or toast with all meals, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146000 If continuation sheet Page 13 of 24 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 146000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairfield Senior Living & Rehabilitation LLC 305 N.W. 11th Street Fairfield, IL 62837 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 0692 Level of Harm - Actual harm Residents Affected - Few adding nutritional ice cream one time daily with meal of choice, health shake three times a day with meals, diet supplemented with 120 mls (milliliters) med pass TID (three times a day) dated 06/13/23, and refer to ST for evaluation and treat as indicated dated 11/06/20. On 05/20/24 at 12:40 PM, R44 did not receive nutritional ice cream in a bowl, power pudding, or a health shake. On 05/21/24 at 12:40 PM, R44 did not receive nutritional ice cream in a bowl, power pudding, or a health shake. On 05/22/24 at 1:00 PM, R50 did not receive nutritional ice cream in a bowl, power pudding, or a health shake. 5. R45's Transfer/Discharge Report dated 5/22/24 documents an admission date of 04/16/21 with diagnoses in part of Cognitive Communication Deficit, Dysphagia, Alzheimer's Disease, Lack of Coordination and Contracture of left hand. R45's MDS dated [DATE] documents in Section C a BIMS score of 0, indicating R45 was unable to complete the BIMS. Staff assessment for mental status was completed and documents short term memory problems and long-term memory problems with moderately impaired decision making, which indicates that R45 makes poor decisions. Section GG documents R45 requires supervision or touching assistance with eating. R45's Care Plan undated, documents an ADL (Activities of Daily Living) self-care/mobility performance (functional abilities) deficit that may fluctuate with activity throughout the day r/t (related to) Alzheimer's disease process. Interventions for eating include in part, R45's usual performance is substantial or maximal assistance. R45 is able to consume regular consistency foods .provide diet as ordered R45's Physician Orders document an order dated 11/29/23 of nutritional ice cream supplement with lunch and dinner and resident (R45) to have house stock nutritional supplement TID (Three times a day) with meals. An order dated 1/28 24 documents general diet mechanical soft texture, regular consistency, nutritional supplement TID (3 times daily), and nutritional ice cream at lunch and supper. On 05/20/24 at 1:15PM, R45 was served a mechanical soft tray with no nutritional supplement shake or ice cream. On 05/21/24 at 12:20PM, R45 was served a mechanical soft tray with no nutritional supplement shake or ice cream. On 05/22/24 at 12:20PM, R45 was served a mechanical soft tray with no nutritional supplement shake or ice cream. On 05/29/24 at 11:10 AM, V29 (Registered Dietician) stated, she would expect all supplements and fortified foods that were ordered to be served as ordered. The dietary policy dated 2020 titled, Fortified Food, Supplements, and Snacks documents: Residents who cannot consume adequate amounts of regular foods at meals to meet their nutritional needs may be considered for Fortified Foods, snacks or supplements in order to increase nutritional intake. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146000 If continuation sheet Page 14 of 24 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 146000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairfield Senior Living & Rehabilitation LLC 305 N.W. 11th Street Fairfield, IL 62837 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 0692 Level of Harm - Actual harm Commercially prepared supplements and nutritional interventions may be ordered by the food service manager, dietician, or nursing staff. Fortified foods, house supplements, or snacks will be provided within the specifications of the diet order and may be substituted with nutritionally equivalent interventions if a specific brand or type of supplement in unavailable. Residents Affected - Few The facility policy titled, weights dated 10/17/19 documents: 3. Re-weight should be obtained if there is a difference of 5# (pounds) or greater (loss or gain) since previously recorded weight. 4. Re-weight should be taken as soon as possible after an unanticipated weight change is noted and prior to calling the physician. (Usually within 72 hours). 5. Efforts should be made to obtain all weights and re-weights by the 10th of each month. 6. Undesired or unanticipated weight gains/loss of 5% in 30 day, 7.5% in three months, or 10% in six months shall be reported to the physician, dietician and/or dietary manager as appropriate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146000 If continuation sheet Page 15 of 24 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 146000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairfield Senior Living & Rehabilitation LLC 305 N.W. 11th Street Fairfield, IL 62837 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, record review and observation, the facility failed to provide enough staff to meet residents needs and provide timely assistance with care. This has the potential to effect all 67 residents residing at this facility. Findings included: 1. On 5/20/2024 at 11:37 AM, R57 still had a half eaten breakfast tray sitting on the bedside table. R57's bed was not made and a pile of urine soiled sheets were wadded up and sitting in R57's bedside chair. At 11:40 AM, V4 (Licensed Practical Nurse/LPN) verified the linens were soiled with dried brown urine rings and were from R57's bed. R57's private bathroom was noted to have two urine soaked briefs/pads in the trash can and a strong scent of urine was present. 2. R113's Face Sheet documented an admission date to the facility on 5/8/2024 with diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction. R113's Brief Interview for Mental Status (BIMS) dated 5/9/2024 documented a score of 15, indicating R113 is cognitively intact. R113's Minimum Data Set (MDS) dated [DATE] documents R113 needs substantial/maximum assistance from staff for bathing, dressing and transferring. On 5/20/2024 at approximately 10:00 AM, R113 was observed laying in his bed in his room with a finished breakfast tray sitting on his bedside table. Food debris and paper trash was noted about the floor in R113's room. R113 was disheveled, had greasy dirty hair and had a strong scent of urine and body odor about his person. On 5/22/2024 at 1:30 PM, R113 said he just received his first shower since being admitted to this facility on 5/8/2024. R113 said he uses a wheelchair to propel about the facility due to not being able to walk. R113 said he needs staff assistance to get a shower and cannot shower independently. R113 said the facility needs more staff to help with resident care and often there isn't any staff to clean his room. During this interview, a urine soaked adult brief was noted in R113's bedroom trash can and one on the floor under the end of his bed. Food debris and paper trash was also seen on the floor and around R113's bed linens. 3. R2's Face Sheet documented an admission date to the facility on 1/3/2024 with a diagnosis of Cerebral Palsy. R2's BIMS dated 4/2/2024 documents a score of 14, indicating R2 is cognitively intact. R2's MDS (dated 4/2/24) section GG documents R2 is dependent on staff for bathing, toileting, dressing and transferring. On 5/20/2024 at approximately 9:45 AM, R2 was noted sitting in his bedside recliner with oily disheveled hair, moderate beard growth with food in his beard and on his clothing. R2 had a strong scent of urine body odor about his person. R2 said he would like to take a shower every day, but he is lucky to get one per week and sometimes doesn't get that. R2 said the facility needs more workers and this is why he doesn't get showered as scheduled. R2 stated at times he also has to wait up to 45 minutes for his call light to be answered. 4. R52's Transfer/Discharge report dated 5/23/24 documents an admission date of 01/13/23 with diagnoses in part of Anemia, Chronic Kidney Disease, Drug Induced Subacute Dyskinesia, Hyperlipidemia, Type 2 Diabetes Mellitus, Dementia, and Multiple Myeloma not having achieved remission. R52's MDS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146000 If continuation sheet Page 16 of 24 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 146000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairfield Senior Living & Rehabilitation LLC 305 N.W. 11th Street Fairfield, IL 62837 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 dated [DATE] documents in Section C a BIMS score of 3, which indicates severe cognitive impairment. Section GG documents R52 is dependent for eating, oral hygiene, dressing, personal hygiene, and positioning. R52's undated Care Plan documents an ADL (Activities of Daily Living) self-care /mobility performance (Functional Abilities) deficit that may fluctuate with activity throughout the day r/t (Related to) dementia, disease progress. Interventions include in part for Eating that R52's usual performance is dependent. On 05/22/24 at 12:00PM, R52 was served his lunch tray with no staff sitting at the table to assist him with his food tray covered. At 12:15 PM, V19 (Medical Records) attempted to wake R52 up to assist him with eating, but no bites were given. At 12:18 PM, V19 got up from the table and another staff member came in to assist R52. A male unknown staff member sat down and started to talk to R52 to wake him up, but another unknown female staff member came into the dining room and told the unknown male staff member, who was getting ready to assist R52, that she didn't have any help on the hall and needed his assistance with another resident. At 12:20PM, the unknown male staff member left without giving R52 a bite. At 12:21 PM, V19 came back into the dining room and sat back down with R52 and again started to assist him with eating. 5. On 5/20/2024 at 11:40 PM, R6's call was observed to be activated. At 12:16 PM, V7 (CNA) entered R6's room and answered the call light. V7 stated the facility is frequently short staffed due to call-ins. V7 said residents have to wait for care due to the facility being short staffed. V7 said she finds it hard to get all of the residents' care done due to the facility having several staff call-ins. 6. R11's Face Sheet documents an admission date of 03/10/2014 with diagnoses in part of Parkinson's, Morbid (Severe) Obesity, Type 2 Diabetes Mellitus, Hypertension, Chronic Kidney Disease, and Benign Prostatic Hyperplasia without lower urinary tract infections. R11's MDS dated [DATE] documents in section C a BIMS score of 9, which indicates moderate cognitive impairment. Section GG documents that R11 is dependent for toileting, bathing/showering and personal hygiene and R11 needs substantial/maximum assist with transfers. R11's Current Care Plan documents R11 has limited physical mobility r/t (related to) H/O (history of) CVA (Cerebral Vascular Accident) and Parkinson's with interventions of provide supportive care, assistance with mobility as needed. R11 has ADL (Activities of Daily Living) self-care performance deficit with interventions in part of Bathing/Showering, R11 requires physical help in part of showering x 1 staff member to provide shower. The Facility Shower list dated 05/14/24 documents that R11 is to have showers on Tuesday and Fridays every week. R11's Shower documentation/skin assessment sheets were reviewed on 5/22/24 and show no shower documentation found for 04/12/24, 04/19/24 or 05/10/24. On 05/22/24 at 11:28 AM, R11 was observed to have oily looking hair and clothes appeared wrinkled and soiled with food stains. R11 had a body odor smell about his person. On 05/22/24 at 1:30 PM, R11 who was alert and oriented to person, place and time at the time of questioning, stated he is lucky to get a shower once a week. R11 said that they tell him often that it's his shower day, which is on Tuesday and Friday, but never come back to get him for the shower. R11 said that most of the time he feels like he maybe gets a shower once a week. R11 said they could use some more help and maybe he would get his showers like he is supposed to. R11 stated that he has (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146000 If continuation sheet Page 17 of 24 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 146000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairfield Senior Living & Rehabilitation LLC 305 N.W. 11th Street Fairfield, IL 62837 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 not had a shower now in over a week. Level of Harm - Minimal harm or potential for actual harm 7. R214's admission Record dated 05/23/24 documents an admission date of 05/16/24 with diagnoses in part of End Stage Renal Disease, Type 2 Diabetes Mellitus, dependence on renal dialysis, Anemia, Hypertension, Seizures, Hyperkalemia, and Hyperprolactinemia. Residents Affected - Many R214's MDS dated [DATE] is currently in progress and does not document anything in section C or GG. R214's Care Plan which was also currently in progress documents on 05/20/24 that R214 is capable of independently choosing programs in which to participate. The Facility Shower list dated 05/14/24 was reviewed on 5/22/24 and does not document R214's name on the shower list. R214's shower sheets/skin assessment documents on 05/17/24 bed bath given; no other shower sheets could be provided up request. On 05/20/24 at 12:30 PM, R214 who was alert and oriented to person, place and time stated she has only been washed up by staff since she has been at the facility. R214 stated she would love to take a shower, but they haven't given her one yet. R214 stated that she arrived at the facility on 05/16/24. R214 said that she needs assistance of two staff with transfers and with showering. On 05/22/24 at 11:30 AM, R214 stated that she still has not received a shower. R214 said that she has even asked for one, but staff said they would get to her later and they never have. On 5/20/2024 at 1:00 PM, R16, R214, R2, R11, R22, R15, R57 and R19's beds were noted to still not be made from the previous night's sleep. On 5/21/2024 at 1:00 PM, R15 stated the facility is very short staffed and needs more help. R15 said the facility isn't getting cleaned and the residents are waiting long periods of time for care to be provided. R15's BIMS dated 2/18/24 documents a score of 15, indicating R15 is cognitively intact. On 5/21/2024 at 1:37 PM, R16, R214, R2 R11, R22, R15, R57 and R19's beds were noted to still not be made from the previous night's sleep. On 5/21/2024 at 2:45 PM, 15 dirty meal trays were noted to still remain on the [NAME] and Tulip hallways, and V28 (Activity Aide) said the CNAs (Certified Nursing Assistants) are supposed to pick up the finished hall trays and make all the beds but the facility is frequently short staffed, and often the trays sit around for a long period of time after meals are finished and beds don't get made. On 5/23/2024 at 10:40 AM, V3 (Assistant Director of Nursing) said the residents are supposed to get two showers offered per week, but staff calling off causes the showers to not get completed in a timely manner. On 5/23/2024 at 11:37 AM, V14 (Registered Nurse) stated the facility has frequent care staff call-ins and is often short on resident care staff. A facility form titled Complaint Resolution Form dated 3/13/2024 documents the following: Problem-Too many call in's causing them not to have staff on the floor. Need to come down on CNAs about too (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146000 If continuation sheet Page 18 of 24 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 146000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairfield Senior Living & Rehabilitation LLC 305 N.W. 11th Street Fairfield, IL 62837 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 many call in's. Level of Harm - Minimal harm or potential for actual harm The Resident List Report dated 05/20/24 documents 67 residents residing at the facility Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146000 If continuation sheet Page 19 of 24 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 146000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairfield Senior Living & Rehabilitation LLC 305 N.W. 11th Street Fairfield, IL 62837 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 - Many 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 follow the approved menu and failed to make a reasonable effort to provide menus in accordance with religious/cultural needs of residents. This failure has the potential to effect all 67 residents residing at the facility. Finding include: 1. The facility's Diet Spreadsheet dated Day 16 Monday documents: Lunch: Regular: beef & broccoli Stir fry #8 dip x 2, steamed rice #8 dip, vegetable blend 4 oz spdl, egg roll 1, blushing pears 4 oz spdl. Pureed: pureed beef & broccoli stir fry with sauce #8 dip x 2, pureed rice with gravy or sauce #10 dip with gravy, pureed vegetable blend #12 dip, pureed egg roll #10 dip, pureed blushing pears #10 dip. On Monday 05/20/24 at 11:15 AM, V22 (Cook) stated they were not having the beef and broccoli stir fry listed on the menu for lunch because they did not have it. V22 stated it should be on the truck that arrived today, so they are having fish instead and the substitute is the leftover pot stickers from last night. The facility's Diet Spreadsheet dated Day 13 (Friday) documents: Lunch: Regular: Baked Fish 2oz (ounces) Beans & [NAME] #8 dip, cheesy spinach 4oz spdl (spoodle), fudge brownie 2 (inch) x 4 svg (serving), bread/margarine 1 slice/1 tsp (teaspoon). Pureed: pureed baked fish #12 dip, pureed rice beans & rice #8 dip, pureed cheesy spinach #12 dip, pureed brownie #10 dip. On 05/20/24 at 11:52 AM, R14 stated they don't really serve them much food. On 05/20/24 at approximately 12:00 PM, V21 (Cook) served 1 piece of baked fish, #12 dip of steamed rice, #8 scoop of stuffing, and 4 oz spdl pears for the regular diet and pureed pot stickers casserole #16 dip, pureed stuffing #16 dip, mashed potatoes #10 dip, and 4 oz applesauce for the pureed diet. On 05/20/24 at 1:16 PM, V16 (Dietary Manager) weighed a piece of fish that was being served and it weighed 1.3 ounces. At this time, V16 stated she thought the serving of fish looked a little small. On 05/20/24 at 2:47 PM, V16 (Dietary Manager) stated she does not know why they did not have a vegetable with lunch, or why they did not puree any fish, rice, or pears. On 05/21/24 at 10:30 AM, V16 (Dietary Manager) stated she does not have a recipe for the needed serving size for the pot sticker casserole that was served, so she does not know how much protein would be in a serving. V16 stated she was recently informed that the potstickers were from activities, so they probably should not have used them as part of the meal on 5/20/24. On 05/28/24 at 11:10 AM, V29 (Registered Dietician) stated she would expect the menu to be followed or if a substitute day's menu was being used, for the portion sizes from that menu to be followed. She stated she would have expected 2 ounces of the fish to be served and for a vegetable to be served. V29 stated she would have expected the same portion of rice to be served as listed on the menu and for the fish to have been pureed for the pureed menu. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146000 If continuation sheet Page 20 of 24 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 146000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairfield Senior Living & Rehabilitation LLC 305 N.W. 11th Street Fairfield, IL 62837 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 - Many 2. R45's Transfer/Discharge Report dated 5/22/24 documents an admission date of 04/16/21 with diagnoses in part of Cognitive Communication Deficit, Dysphagia, Alzheimer's Disease, Lack of Coordination and Contracture of left hand. R45's MDS dated [DATE] documents in Section C a BIMS score of 0, indicating R45 was unable to complete the BIMS. Staff assessment for mental status was completed and documents short term memory problems and long-term memory problems with moderately impaired decision making, which indicates that R45 makes poor decisions. Section GG documents R45 requires supervision or touching assistance with eating. R45's Care Plan undated, documents a focus are of R45 practices the Hindi culture. R45 prefers to eat on the floor, legs crossed, with her tray in front of her. R45 is also Vegan but will sometimes drink milk and eat plain yogurt. R45 has another focus area of ADL (Activities of Daily Living) self-care/mobility performance (functional abilities) deficit that may fluctuate with activity throughout the day r/t (related to) Alzheimer's disease process. An intervention listed documents Eating: My usual performance is substantial or maximal assistance. An additional Focus Area documents R45 is able to consume regular consistency foods, R45 is Vegan. R45 does not eat meats or dairy products. R45 will occasionally drink milk, but would like to request it when R45 desires, R45 requests not to eat after 7:00 PM, only drink water after that time. Interventions listed include to provide diet as ordered, Regular/Vegan, adding rice/beans/peanut butter when desired. R45's Physician Orders document nutritional ice cream supplement with lunch and dinner order date of 11/29/23, Resident (R45) to have house stock nutritional supplement TID (Three times a day) with meals order date of 11/29/23, and General diet mechanical soft texture, regular consistency, nutritional supplement TID, nutritional ice cream at lunch and supper order date of 01/18/24. On 5/20/24 at approximately 12:40 PM, V21 (Cook) wasn't sure what to serve R45. V16 (Dietary Manager) said give R45 fish, she will eat that sometimes. V16 stated they give R45 fruit loops a lot. When V16 was asked if they had a specific menu for R45, she stated no but they probably should have. On 05/20/24 at 1:15PM, R45 was served a mechanical soft tray which included fish. R45 was not served her ordered nutritional supplement shake or ice cream. On 05/29/24 at 11:10 AM, V29 (Registered Dietician) stated, she would expect all supplements and fortified foods that were ordered to be served as ordered. V29 stated the company did not have a vegetarian or vegan menu but R45's husband has stated that she will sometimes eat dairy, some meat and grilled cheese. The Resident Council minutes for 04/10/24 documented: Dietary: portion control is all over the place. The Resident List Report dated 05/20/24 documents 67 residents residing at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146000 If continuation sheet Page 21 of 24 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 146000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairfield Senior Living & Rehabilitation LLC 305 N.W. 11th Street Fairfield, IL 62837 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. 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 food at an appetizing temperature for 4 (R214, R38, R48 and R3) of 4 residents reviewed for palatable temperatures in a sample of 38. Residents Affected - Some Findings include: 1. R214's admission Record documents an admission date of 05/16/24 with diagnoses in part of End Stage Renal Disease, Type 2 Diabetes Mellitus, dependence on renal dialysis, Anemia, Hypertension, Seizures, Hyperkalemia, and Hyperprolactinemia. R214's Minimum Data Set (MDS) dated [DATE] is currently in progress and does not document anything in section C or GG. On 05/20/24 at 12:30PM, R214 was alert and oriented to person, place and time and stated that the food is always cold if she eats in her room. R214 said that she only ate in her room a couple of times, but that the food was always cold when she did. R214 said that she started going to the dining room just so she could have a warm meal. 2. R38's Transfer/Discharge report, undated documents an admission date of 07/06/23 with diagnoses in part of Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Acute Kidney Failure, Morbid Obesity, Depression, Atrial Fibrillation, Iron Deficiency Anemia, Unsteadiness on Feet, Lack of Coordination, and Unspecified Injury of Right Achilles Tendon. R38's Minimum Data Set (MDS) dated [DATE] documents in Section C a Brief Interview for Mental Status (BIMS) score of 14, indicating R38 is cognitively intact. Section GG documents for eating, R38 requires set-up and clean-up assistance. R38 is dependent for transfers and propelling wheelchair. R38's Care plan dated 04/24/24 documents R38 has a potential nutritional problem. Interventions include in part, to encourage PO (oral) intake of meals and snacks, provide, serve diet as ordered. Monitor intake and record q (Every) meal. R38 has Anemia and interventions include in part, encourage intake of foods high in iron, vitamin c, review diet and make recommendations as required. On 05/20/24 at 10:35AM, R38 stated that she eats her tray in her room most of the time. R38 said that her food is always cold when she gets it. R38 said there are times she won't get a tray at the normal lunch times, it may be an hour later. R38 said that she has asked a couple of the certified nurse assistants to warm her food up for her because it's so cold. R38 could not remember off hand which certified nurse assistants warmed up the food for her. 3. On 05/20/24 at 10:50 AM, R48 was alert to person, place and time and stated the food can be cold at times. 4. On 05/20/24 at approximately 11:45 AM while waiting for lunch to be served, R3 stated the food is usually cold. A Concern/Complaint form submitted by R3 dated 04/10/24 documents: at times in the lunch dining room food isn't hot. On 05/20/24 at 10:30 AM a digital metal stemmed thermometer used for taking temperatures for this survey was checked for accuracy using the ice-point method and was accurate within +/- 2 degrees (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146000 If continuation sheet Page 22 of 24 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 146000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairfield Senior Living & Rehabilitation LLC 305 N.W. 11th Street Fairfield, IL 62837 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 0804 Fahrenheit. Level of Harm - Minimal harm or potential for actual harm On 05/20/24 at 1:54 PM when the last hall tray was being delivered, the tray was refused. In the presence of V19 (Medical Records/CNA), the refused tray was measured for temperatures. The fish was 81 degrees Fahrenheit, the rice was 96 degrees Fahrenheit, and the stuffing was 90.5 degrees Fahrenheit. The food was then tasted and all items tasted cold. Residents Affected - Some On 05/22/24 at 11:00 AM a digital metal stemmed thermometer used for taking temperatures for this survey was checked for accuracy using the ice-point method and was accurate within +/- 2 degrees Fahrenheit. On 05/22/24 at 1:31 PM when the last hall tray was being delivered, this tray was also refused and was therefore measured for temperatures. The hamburger steak was 115 degrees Fahrenheit, the scalloped potatoes were 112 degrees Fahrenheit, and the broccoli was 103 degrees Fahrenheit. The food was then tasted and all items tasted cold. On 05/28/24 at 11:03 AM, V29 (Registered Dietician) stated, she would expect the food to be served at an appetizing temperature to the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146000 If continuation sheet Page 23 of 24 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 146000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairfield Senior Living & Rehabilitation LLC 305 N.W. 11th Street Fairfield, IL 62837 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to prepare and serve food in a safe and sanitary environment and on sanitary dishes. This has the potential to effect all 67 residents residing at the facility. Findings include: On 05/20/24 at 9:30 AM, upon the initial tour of the kitchen, the large stand mixer had dried food splashes on the head of the mixer. In the cooler, there was a bowl of what appeared to be pudding that was undated and unlabeled and a container of sliced meat that was undated and unlabeled. There was a large can of opened sweet potatoes that was undated and unlabeled and a partial pan of what appeared to be lasagna in the cooler that was unlabeled and undated. On 05/20/24 at 11:15 AM, V22 (Cook) stated items in the cooler should be labeled, the kitchen is messy, they are doing the best they can. On 05/20/24 at 9:30 AM, there were five plastic portion cups, a fork, a plastic drinking cup, a plastic bag and a pudding cup on the floor under the prep table. Under the second prep table there were three portion cups, two butter packets, and a pudding cup. There were crumbs on the floor under both prep tables, the stove, and under the mixer. On 05/20/24 at 2:47 PM, there was a portable stand fan that had an accumulation of dirt on the front cage and blades blowing on the clean dishes across from the dish machine. On 05/20/24 at 2:47 PM, there were still five plastic portion cups, a fork, a plastic drinking cup, a plastic bag and a pudding cup on the floor under the prep table. Under the second prep table there were three portion cups, two butter packets, and a pudding cup. There were crumbs on the floor under both prep tables, the stove, and under the mixer. On 05/20/24 at 2:47 PM, V22 (Cook) stated they probably should not have a dirty fan blowing on the clean dishes. The Resident List Report dated 05/20/24 documents 67 residents residing at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146000 If continuation sheet Page 24 of 24