Health inspection·February 14, 2025

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident's call light was in working order for 1 (R8) of 3 residents reviewed for resident call system in a sample of 12. Residents Affected - Few Findings Include: R8's Face Sheet documented an admission date of 12/05/2024 with diagnoses that included weakness, unsteadiness on feet, unspecified abnormalities of gait and mobility, a unilateral primary osteoarthritis to right knee and personal history of transient ischemic attack. R8's Minimum Data Set (MDS) dated [DATE], documented under Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 13, indicating R8 is cognitively intact. Under Functional Abilities for Self Care, the MDS documented that R8 requires staff assistance for toileting hygiene, showering/bathing, and dressing. R8's current Care Plan documented a Focus Area of I have a self care deficit r/t (related to) osteoarthritis in right knee and weakness with a Goal of Assistance will be provided to meet needs. On 2/14/24 at 11:00 AM, R8 stated that her only concern is that the night shift does not answer her call light. At this time, surveyor pushed R8's call light and it did not light up. R8 stated she was unaware that her call light was broken. On 2/14/25 at 11:30 AM, V7 (Certified Nurse Assistant/CNA) entered R8's room. Surveyor showed V7 that R8's call light was not working. At this time, V7 clicked the call light quickly approximately 5 times and it turned on, but after that could not get it to work again. Surveyor then asked V7 if R8 would know to do that and V7 stated no. V7 confirmed the call light was not working as it should. On 2/14/25 at 1:00 PM, V7 stated that she had not yet informed anyone that R8's call light was broken. V8 (Regional Clinical Nurse) was present at this time and immediately went to get the maintenance man to fix the call light. On 2/14/25 at 2:00 PM, V17 (Regional Maintenance Director) stated there was a short in the cord that needed replaced and that has been done. On 2/4/2025 at 1:20 PM, V16 (Family) stated, there have been multiple times she had hit the call light with no staff member to answer it. V10 stated, one time it took 35 minutes for a staff member to answer the call light. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 146000 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 02/14/2025 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)