Health inspection·June 20, 2024

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R2's MDS dated [DATE] documents a BIMS score of 14, which indicates R2 is cognitively intact. This same MDS documents R2 is dependent on staff for toileting and is always incontinent of bowel and bladder. R2's current Care Plan documents a Focus area of I have 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) Disease Process (CP/cerebral palsy), Limited Mobility. This Focus area includes the intervention, Toilet hygiene- My usual performance is dependent. On 6/17/24 at 11:04 AM, R2 stated it takes a little while for staff to answer his call light. R2 stated they need more help here; they don't have enough CNA's. R2 stated sometimes it takes longer than 20 minutes. When asked if he had ever had to lay in urine/feces due to it taking loner, R2 stated not because he had to wait but just because he urinates a lot. 3. R6's Transfer/Discharge Report with a print date of 6/17/24 documents R6 was admitted to the facility on [DATE] with diagnoses that include abnormal posture, chronic kidney disease, mild intellectual disability, diabetes, and schizoaffective disorder. R6's MDS dated [DATE] documents a BIMS score of 12, which indicates a moderate cognitive deficit. This same MDS documents R6 requires substantial/maximal assistance with toileting and is occasionally incontinent of bladder and frequently incontinent of bowel. R6's current Care Plan documents a Focus area of, I have an ADL self-care performance deficit r/t Mild intellectual disabilities and lack of coordination. This Focus area includes the intervention, Toilet Use: (R6) requires extensive assistance by 2 staff with toileting at all times. On 6/17/24 at 1:32 PM, V15 (CNA) stated she had worked with three CNA's on night shift (6 PM to 6 AM). When asked if she was able to do bed checks every two hours, V15 stated she thought they did them every three hours. On 6/17/24 at 12:16 AM, V8 (Licensed Practical Nurse/LPN) stated she works 6 PM to 6 AM and the normal staffing is two nurses and two CNA's per side (total of four CNA's). V8 stated she has worked with less than that but not recently. V8 stated the 6 PM to 10 PM time frame is difficult with two CNA's on one side. V8 stated they probably don't provide every two-hour incontinence care during that time frame. On 6/16/24 at 11:08 PM, V5 (Registered Nurse/RN) stated he works night shift 6 PM to 6 AM. V5 stated the normal staffing each night shift, is two nurses and four certified nursing assistants (CNA's). V5 stated two CNAs on each side is the minimum staffing to be able to meet the resident needs. V5 stated he had worked with just three CNA's but not for 3-4 weeks. V5 stated all the care was provided but it was slow. On 6/17/24 at 1:45 PM, V16 (CNA) stated they were currently working with five trained CNA's and one trainee. V16 stated that isn't enough to meet the needs of the residents. V16 stated showers don't always get done. When asked if call lights were answered timely, V16 stated, Probably not. When asked if there was a negative impact related to working with less staff, V16 stated being short-staffed effects everything. When asked if incontinence care was provided timely, V16 stated when she is there, she gets it done. When asked if she had any residents complain they weren't provided timely incontinence care, V16 stated R1 and R6. When asked if she had ever seen anyone who appeared like they (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146000 If continuation sheet Page 2 of 7 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 06/20/2024 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 had been laying in urine/feces for a long period of time, V16 stated at shift change and identified R6 as one of the residents. On 6/20/24 at 12:31 PM, V2 (Director of Nurses/DON) stated she would expect bed checks to be done every two hours and incontinence care provided as needed. Residents Affected - Few On 6/17/24 at 3:59 PM, V1 (Administrator) stated he hadn't had any concerns related to incontinence care being provided timely, call lights answered timely, and/or residents left in feces/urine for long periods of time. V1 stated he would say three CNA's wouldn't be able to do it, but they also have administration staff stay or come in and assist. The facility Incontinence Care policy dated 4/20/21 documents, Purpose: to prevent excoriation and skin breakdown, discomfort and maintain dignity. Guidelines: Incontinent resident will be checked periodically in accordance with the assessed incontinence episodes or approximately every two hours and provided perineal and genital care after each episode . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146000 If continuation sheet Page 3 of 7 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 06/20/2024 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 and record review, the facility failed to provide enough staff to meet residents' needs and provide timely assistance with care. This failure has the potential to affect all 59 residents currently residing at the facility. Findings Include: The facility Midnight Census Report dated 6/16/24 documents 59 residents currently reside at the facility. 1. R1's Transfer/Discharge Report dated 6/17/24 documents R1 was admitted to the facility on [DATE] with diagnoses that include diarrhea, hypertension, clostridium difficile, flaccid neuropathic bladder, and morbid obesity. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has a Brief Interview for Mental Status (BIMS) score of 14, which indicates R1 is cognitively intact. This same MDS documents R1 is dependent on staff for toilet transfers, is occasionally incontinent of urine, and frequently incontinent of bowel. R1's current Care Plan does not document a focus area for incontinence care/toileting. On 6/17/24 at 2:52 PM, V4 (Care Plan/MDS Coordinator) stated he just missed it when he did R1's care plan. On 6/17/24 at 10:50 AM, R1 stated his call light hadn't been working so they gave him a different kind of call light that beeps at the nurse's station. R1 stated if the button gets turned off on his call light, he just calls the nurse's station. R1 stated sometimes at night the call light doesn't get answered and they don't answer the phone. R1 stated the time it takes them to answer, varies. R1 stated when they are short staffed it can take forever. R1 stated he has told the CNA's and the nurse's but hadn't talked to administration about it. R1 stated he was stuck on the bed pan for over two hours waiting for them to assist him recently. R1 stated he called, and it rang for over 100 minutes per his phone screen. R1 stated then he called the local police station to see if they could get in touch with anyone at the facility. R1 stated after the third call to the police they were able to get in touch with someone from administration. R1 stated he has had bowel surgery and can't say it would make a difference if they got to him quicker after the incontinence episodes, but he has laid for up to two hours. On 6/17/24 at 2:57 PM, V16 (Certified Nurse Assistant/CNA) exited R1's room with dirty linens, V16 (CNA) and V18 (CNA) returned to R1's room to provide incontinence care. R1 was assisted to roll to his side. R1's buttocks were red and excoriated. V18 stated when they removed his bed pan, they took the bed pad that was under him, and it had a brown ring of urine on it. This indicates R1 had not been checked or changed for a long period of time. R1 stated no one had been in his room to provide care since this surveyor had been in there at 10:50 AM. This indicates no incontinence care was provided from 10:50 AM until 2:57 PM. 2. R2's Transfer/Discharge Report with a print date of 6/17/24 documents R2 was admitted to the facility on [DATE] with diagnoses that include heart failure, morbid obesity, acute kidney failure, cerebral palsy, chronic kidney disease, hypertension, and scoliosis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146000 If continuation sheet Page 4 of 7 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 06/20/2024 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 R2's MDS dated [DATE] documents a BIMS score of 14, which indicates R2 is cognitively intact. This same MDS documents R2 is dependent on staff for toileting and is always incontinent of bowel and bladder. R2's current Care Plan documents a Focus area of I have 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) Disease Process (CP/cerebral palsy), Limited Mobility. This Focus area includes the intervention, Toilet hygiene- My usual performance is dependent. On 6/17/24 at 11:04 AM, R2 stated it takes a little while for staff to answer his call light. R2 stated they need more help here; they don't have enough CNA's. R2 stated sometimes it takes longer than 20 minutes. When asked if he had ever had to lay in urine/feces due to it taking loner, R2 stated not because he had to wait but just because he urinates a lot. 3. R5's Transfer/Discharge Report with a print date of 6/17/24 documents R5 was admitted to the facility on [DATE] with diagnoses that include heart disease, chronic fatigue, hypertension, heart failure, unsteadiness on feet, and diabetes. R5's MDS dated [DATE] documents a BIMS score of 15, which indicates R5 is cognitively intact. This same MDS documents R5 is always incontinent of bowel and bladder. R5's current Care Plan does not include a Focus area for incontinence care. On 6/17/24 at 9:59 AM, R5 stated it can take more than 30 minutes for the staff to answer the call lights. R5 stated it happens at all times of the day because they don't have enough staff. R5 stated they try but they just don't have enough staff. 4. R6's Transfer/Discharge Report with a print date of 6/17/24 documents R6 was admitted to the facility on [DATE] with diagnoses that include abnormal posture, chronic kidney disease, mild intellectual disability, diabetes, and schizoaffective disorder. R6's MDS dated [DATE] documents a BIMS score of 12, which indicates a moderate cognitive deficit. This same MDS documents R6 requires substantial/maximal assistance with toileting and is occasionally incontinent of bladder and frequently incontinent of bowel. R6's current Care Plan documents a Focus area of, I have an ADL self-care performance deficit r/t Mild intellectual disabilities and lack of coordination. This Focus area includes the intervention, Toilet Use: (R6) requires extensive assistance by 2 staff with toileting at all times. On 6/16/24 at 11:08 PM, V5 (Registered Nurse/RN) stated he works night shift 6 PM to 6 AM. V5 stated the normal staffing each night shift, is two nurses and four certified nursing assistants (CNA's). V5 stated two CNAs on each side is the minimum staffing to be able to meet the resident needs. V5 stated he had worked with just three CNA's but not for 3-4 weeks. V5 stated all the care was provided but it was slow. On 6/17/24 at 12:11 PM, V6 (CNA) stated she works from 6 PM to 6 AM. V6 stated they have two CNA's on each side on night shift, a total of four CNA's per 12-hour shift. V6 stated there were times they only had three CNA's working and when that happened, she was able to provide the care needed but call lights weren't answered timely. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146000 If continuation sheet Page 5 of 7 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 06/20/2024 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 On 6/17/24 at 12:14 AM, V7 (CNA) stated she normally works from 6 AM to 6 PM. V7 stated they have two CNA's on each side on that shift as well. V7 stated it isn't enough to meet the needs of the residents. V7 stated showers don't get done and call lights aren't answered timely. On 6/17/24 at 12:16 AM, V8 (Licensed Practical Nurse/LPN) stated she works 6 PM to 6 AM and the normal staffing is two nurses and two CNA's per side (total of four CNA's). V8 stated she has worked with less than that but not recently. V8 stated the 6 PM to 10 PM time frame is difficult with two CNA's. V8 stated they probably don't provide every two-hour incontinence care during that time frame. On 6/17/24 at 12:22 AM, V9 (CNA) stated two CNA's on the Alzheimer's unit is enough with the residents they currently have. V9 stated she has worked by herself on that unit, and she wasn't able to meet the needs of the residents. On 6/17/24 at 1:32 PM, V15 (CNA) stated she had worked with three CNA's on night shift (6 PM to 6 AM). When asked if she was able to do bed checks every two hours, V15 stated she thought they did them every three hours. On 6/17/24 at 1:45 PM, V16 (CNA) stated they were currently working with five trained CNA's and one trainee. V16 stated that isn't enough to meet the needs of the residents. V16 stated showers don't always get done. When asked if call lights were answered timely, V16 stated, Probably not. When asked if there was a negative impact related to working with less staff, V16 stated being short-staffed effects everything. When asked if incontinence care was provided timely, V16 stated when she is there, she gets it done. When asked if she had any residents complain they weren't provided timely incontinence care, V16 stated R1 and R6. When asked if she had ever seen anyone who appeared like they had been laying in urine/feces for a long period of time, V16 stated at shift change and identified R6 as one of the residents. On 6/17/24 at 1:54 PM, V17 (CNA) stated they have five CNA's and a trainee working. V17 stated two on the Alzheimer's unit is pretty good but two on the other units is a little rough. V17 stated they try to do the best they can. V17 stated it is sometimes hard to get showers and the little extra things done. The facility Daily Staffing Sheet dated 6/12/24 documents two CNA's worked from 6 PM to 8 PM and three CNA's from 8 PM to 6 AM. The untitled, handwritten, undated sheet provided to this surveyor documents V2 (Director of Nurses/DON) stayed at the facility until 9:45 PM and V3 (Assistant Director of Nurses/ADON) stayed at the facility until 9:30 PM. This leaves three CNA's with no administrative assistance from 9:45 AM until 6:00 AM. his facility Daily Staffing Sheet dated 6/13/24 documents three CNA's in the facility from 6 PM to 6 AM and four CNA's from 10:50 PM to 2:50 AM. The untitled, undated handwritten sheet with V2 and V3's extra hours documents V2 stayed at the facility until 6:00 PM, and V3 stayed until 8:00 PM. This leaves three CNA's with no administrative assistance from 8:00 PM until 10:50 PM, and from 2:50 AM until 6:00 AM. On 6/17/24 at 3:22 PM, V2 (DON) stated she has not had any complaints/concerns brought to her related to call lights being answered timely and/or incontinence care being provided timely. V2 stated they try to have five CNA's on day shift- two in the back (Alzheimer's unit) and three in the front. V2 stated that is enough staff to meet the needs of the residents. This surveyor reviewed the schedule with V2 and asked about the days there were only two or three CNA's on the schedule for night shift, V2 stated V3 (ADON) is the one who does the schedules so she would have to check with her. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146000 If continuation sheet Page 6 of 7 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 06/20/2024 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 On 6/17/24 at 3:30 PM, after reviewing the CNA schedule with V3 (ADON), she stated she stays late on Friday nights and does rounds with the wound specialist, so she is at the facility on those nights to assist the CNA's. When asked if she stayed after midnight since there were only two or three CNA's working during that time frame, V3 stated she would have to get the times she and V2 worked for this surveyor. V3 stated she always writes her times down since she doesn't clock in/out. The untitled undated handwritten document that was provided documents V2 (DON) and V3 (ADON) stayed until 3:00 AM on 6/16/24. This same document notes V2 and V3 left the facility between 6:00 and 9:45 PM on 6/10, 6/11, 6/12, 6/13, and 6/14 and didn't stay late on 6/15/24. On 6/17/24 at 3:59 PM, V1 (Administrator) stated he hadn't had any concerns related to incontinence care being provided timely, call lights answered timely, and/or residents left in feces/urine for long periods of time. V1 stated he would say three CNA's wouldn't be able to do it, but they also have administration staff stay or come in and assist. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146000 If continuation sheet Page 7 of 7