Health inspection·September 20, 2024

F 0677 Level of Harm - Minimal harm or potential for actual harm On 9/17/24 at 10:25am, R2 was alert and oriented to person, place, and time. R2 stated she is not always getting a shower or bath twice a week. 3. R3's Face Sheet documented an admission Date of 1/3/24 and listed Diagnoses including Cerebral Palsy, Heart Failure, and Hypertension. Residents Affected - Some R3's Current Care Plan a problem area,I have alteration in urinary elimination, urinary incontinence, related to impaired mobility, and lack of sensation, with a corresponding interventions, Ensure call light is within reach and answer promptly, monitor for incontinence and change as needed. R3's Minimum Data Set, dated [DATE] documented that R3 is totally dependent on staff for toileting and showering/bathing and is always incontinent of bowel and bladder. On 9/17/24 at 9:55am, R3 was alert and oriented to person, place, and time. R3 stated he thinks night shift is especially short staffed, it can take over an hour for his call light call light and stated he is sometimes wet for hours at a time. 4. R6's Face Sheet documented an admission Date of 3/31/24 and listed Diagnoses including COPD, Morbid Obesity, and Diabetes Type 2. R6's Current Care Plan a problem area, I have an ADL self-care/mobility performance (functional abilities) deficit that may fluctuate with activity throughout the day, with a corresponding intervention,Shower/Bathing self: I take a shower and my usual performance is set up/clean up assistance (from staff). R6's Minimum Data Set, dated [DATE] documented that R6 requires set up or clean up assistance from staff for showering/bathing and is always continent of bowel and bladder. R6's August 2024 Shower Sheets document R6 received one shower on the week of 8/18/24. On 9/18/24 at 10:45am, R6 was alert and oriented to person, place, and time. R6 stated call lights are not answered quickly enough, especially on the 6pm to 6am shift, and, There are always residents yelling for help for extended periods of time, and the emergency call lights in the bathroom are going off for up to 15 minutes because nobody is answering them. R6 stated she is independent for showering except she needs staff to dry her feet, and she is afraid she will fall if she has wet feet. R6 stated she, Turns on the shower room call light, which is an emergency light, and has to wait there til somebody comes, which might be 15 minutes later, or not at all. Last week nobody came so I sat on the chair part of my walker and scooted up to the nurses station for help. 5. R7's Face Sheet documented an admission Date of 9/5/24, and listed diagnoses including Dementia, Severe, with Agitation, Hypertension, and Anxiety Disorder. R7's Current Care Plan a problem area, I have potential for altered activity pattern related to Dementia. R7's Minimum Data Set, dated [DATE] documented that R7 is dependent on staff for toileting and showering/bathing and is always incontinent of bowel and bladder. On 9/18/24 at 11:45am, R7 was alert only to herself, and she was being fed a puree meal by her (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 09/20/2024 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 Residents Affected - Some family member V7. V7 stated R7 has lived at the facility, For a couple of weeks. V7 stated R7 is incontinent and is not being changed often enough. V7 stated she visits several times a day at different times of the day, and has found R7 soaking wet with wet clothes multiple times. On 9/19/24 at 12:50pm, V2, Director of Nurses, stated residents are to get two shower per week and in between as desired or needed. On 9/20/24 at 2:00 pm, V2 stated it is her expectation that all call lights for assistance should be answered within three minutes. A Resident Council Meeting note dated 9/12/24 documented, New business: Nursing-hard to find (staff) when needing assistance. An Incontinence Care Policy dated 11/28/12 documented, Incontinent residents will be checked periodically in accordance with the assessed incontinent episodes or every two hours and provided perineal and genital care after each episode. A Shower and Tub Bath Policy dated 11/28/12 stated,A shower, tub bath,or bed/sponge bath will be offered according to the resident's preference two times per week or according to the resident's preferred frequency and as needed or requested. 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 09/20/2024 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a safe mechanical lift transfer for 1 of 1 resident (R1) reviewed for falls in a sample of 12. This failure resulted in R1 becoming scared she would fall and anxious during the transfer and becoming afraid of of future mechanical lift transfers. Findings include: R1's Face Sheet documented an admission Date of 7/6/23 and listed Diagnoses including Chronic Obstructive Pulmonary Disorder, Diabetes Type 2, and Anxiety disorder. R1's Care Plan dated 8/20/24 documented problem areas,I have an ADL (Activities of Daily Living) self-care/ mobility performance (functional abilities) deficit, and, I use anti anxiety medications. R1's Minimum Data Set, dated [DATE] documented that R1 has minimal deficits in cognition and is totally dependent on staff for transfers. On 9/17/24 at 10:55am, R1 was alert and oriented to person, place, and time. R1 stated that on the morning of 9/16/24, V4, Certified Nursing Assistant, was getting her out of bed and ready for a doctors appointment. R1 stated she had two family members present at the time. R1 stated V4 transferred R1 out of the bed into the wheelchair via mechanical lift. R1 stated V4 was the only staff member present during the transfer. R1 stated, Thank God those two (V10, V11, family members) were in the room to help because I about got dumped out of the (lift) sling. I don't think (V4) knows how to use a (mechanical lift). R1's was upset and distressed while discussing this. R1 stated she was extremely upset and scared that she was going to be dumped out of the sling. R1 stated now she is scared for staff to transfer her via mechanical lift and that is the only way for her to be transferred out of the bed. On 9/17/24 at 1:00pm V10 stated she was present during the above referenced transfer. V10 stated she and V11 assisted V4 with the transfer as V4 was the only staff member present. V10 stated she and V4 stood at the wheelchair while V11 worked the controls on the mechanical lift. V10 stated V4 was giving the directions about what to do. V10 stated the mechanical lift started heavily leaning to one side and R1 was hovering over the wheelchair in a nearly laying down position. V10 stated V10 and V11 got R1 under the arms and lowered R1 into the chair. V10 stated R1 was, Upset and scared to death. On 9/18/24 at 1:50pm, V4 corroborated R1 and V10's accounts of the transfer as stated above. V4 stated they were short staffed that day, and she could not find any staff to help with the transfer so V10 and V11 assisted, with V11 working the controls. V4 stated later V4 was called in by administrative staff because R1 told others about what happened and that she was scared. V4 stated,They told me next time if I cant find somebody come get administrative staff. On 9/19/24 at 12:50pm, V2, Director of Nurses, stated the incident with R1's transfer had come to her attention and she talked to V4 about it. V2 stated V4 said she couldn't find anybody to help, and was told to ask administrative staff to help next time. V2 confirmed it is against facility policy for there to be fewer than 2 staff members present and for family members to assist with a mechanical lift transfer. V2 stated she did not complete an incident report. (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 09/20/2024 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 0689 Level of Harm - Actual harm A Mechanical Gait Belt and Mechanical Lift Policy dated 11/28/12 documented,The transferring needs of residents will be assessed on an ongoing basis and designated into one of the following categories: H: Mechanical lift (trade name) with 2 caregivers. Residents Affected - Few 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 09/20/2024 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 - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on interview and record review, the facility failed to provide direct care staff in adequate numbers to ensure safe and timely resident care. This has the ability to affect all 34 residents living on the [NAME] and Daisy/Tulip halls. Findings include: A Resident Council Meeting note dated 9/12/24 documented, New business: Nursing-hard to find (staff) when needing assistance. A Room Roster dated 9/14/24 documented a total of 34 residents living on the [NAME] and Daisy/Tulip halls. A Daily Staff Schedule for Friday 8/31/24 documented one nurse and two CNAs (Certified Nursing Assistants) working the [NAME] and Daisy/Tulip halls on the 6am to 6pm shift. A Daily Staff Schedule for Sunday 9/15/24 documented one nurse and one CNA working the [NAME] and Daisy/Tulip halls on the 6pm to 6am shift. A Daily Staff Schedule for Monday 9/16/24 documented one nurse and 3 CNAs working the [NAME] and Daisy/Tulip halls on the 6am to 6pm shift. On 9/17/24 at 9:55am, R3 was alert and oriented to person, place and time. R3 stated night shift (6pm to 6am) is especially short staffed because call lights can take over an hour to be answered. R3 stated medications are frequently passed late, and it happens on all shifts, both through the week and one weekends. On 9/17/24 at 10:25am, R2 was alert and oriented to person, place, and time. R2 stated, They are definitely short staffed all the time, through the week and on the weekend, and on days and nights both. On 9/17/24 at 10:55am, R1 was alert and oriented to person, place, and time. R1 stated that on the morning of 9/16/24, V4, Certified Nursing Assistant, transferred R1 out of the bed into the wheelchair via mechanical lift without another staff member present. On 9/18/24 at 10:15pm, V12, Registered Nurse, stated there are always enough CNAs (Certified Nursing Assistants) scheduled, but there are daily call ins, both through the week and on weekends. On 9/18/24 at 10:45am, R6 was alert and oriented to person, place, and time. R6 stated, Staffing is hit or miss as to whether they have enough staff, weekends are worse, they seem to have a lot of call ins, both day and night shift. R6 stated medications on the 6pm to 6am shift are frequently passed late, both through the week and on the weekends. On 9/18/24 at 1:50pm, V4 stated she works both the 6am to 6pm and 6pm to 6am shifts both through the week and on weekends. V4 stated they are, Always short staffed because of last minute call ins. V4 confirmed she transferred R1 via mechanical lift on 9/16/24 without another staff member present. V4 stated on that date on the 6am to 6pm shift, she could not find any direct care staff to help with (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 09/20/2024 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 - Some the transfer because they were working short staffed V4 stated residents complain about medications being passed late on the 6pm to 6am shift. On 9/18/24 at 2:20pm, V5, CNA, stated the facility frequently runs short of CNA's. V5 stated on 8/31/24 she worked 6am to 6pm with V8, CNA, and V13, Licensed Practical Nurse, on the Daisy/Tulip halls. V5 stated another CNA had also come in at 6am but had to leave due to a family emergency, so V6, Registered Nurse/Minimum Data Set Coordinator, came in to work as a CNA at around 9 am. V 5 stated V13 walked out without giving notice at around 2pm, leaving V6 to cover the nursing duties. V5 stated that left only V5 and V8 to provide direct care for the remainder of the shift. On 9/18/23 at 2:40pm, V8 confirmed V5's report of 8/31/24. V8 stated it is not the only occasion she and V5 have worked alone on [NAME] and Daisy/Tulip. V8 stated they are supposed to have at least 4 CNAs on [NAME] and Daisy/Tulip on both shifts. V8 stated she works the 6am to 6pm shift Monday through Friday and every other weekend. V8 stated she has heard complaints from residents about medication pass running late. On 9/19/24 at 11:10am, V4, Licensed Practical Nurse, stated she is the staff member responsible for scheduling the CNA staff, and V2, Director of Nurses, is the staff member responsible for scheduling nursing staff. V4 stated in addition to their own staff, the facility utilizes a staffing company that provides contractual licensed and CNA staff. V4 stated for both the 6am to 6pm and 6pm to 6am shifts, she schedules 4 or 5 CNAs and V2 schedules two nurses for the [NAME] and Daisy/Tulip halls, and one nurse and 2 CNAs for the [NAME] hall memory care unit. V4 stated administrative staff frequently have to work the floor both to cover licensed staff and CNA staff due to call ins. V4 stated the 2 CNAs on [NAME] hall very rarely float to [NAME] and Daisy/Tulip halls. V4 stated there have been occasions where there may have only been two CNAs to cover [NAME] Daisy/Tulip for an hour or so, until coverage could be obtained. On 9/19/24 at 12:50pm, V2, Director of Nursing, stated she believed the facility is meeting or exceeding minimum staffing requirements. V2 stated CNA call ins are an issue but coverage can usually be found. V2 stated she had to pass medications the morning of 9/17/24 due to staff member calling in. V2 stated morning medication pass usually starts about 6:30am with getting supplies ready, but she did not get started until about 7:30am. V2 stated as far as she is aware medications are being passed timely and she has not heard any complaints from residents about medications being late. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146000 If continuation sheet Page 7 of 7