Health inspection·July 25, 2025

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to ensure medications were properly stored at appropriate temperatures and lock medication cart. This failure has the potential to affect all 47 residents residing in the facility. Findings Include:On 7/23/25 at 11:40 AM, V8 (Licensed Practical Nurse/LPN) was observed administering insulin to R10. V8 gathered her supplies from the medication cart, left the cart unlocked, and entered R10's room. The cart was out of V8's visual control during the administration of the insulin. No observations were made of residents or staff near the unlocked cart.A list of ambulatory residents living at the facility dated 7/25/25 documented a total of 8 ambulatory residents.On 7/24/25 at 3:20 PM, V2 (DON) stated she re-educated V8 about the importance of keeping the medication cart locked when out of the nurses visual control.The facility's Storage of Medications Policy dated April 2007 documented, #7.Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. The Long-Term Care Facility Application for Medicare and Medicaid form provided by the facility on 7/23/2025 documented there were 47 residents residing at the facility. Event ID: Facility ID: 146000 If continuation sheet Page 2 of 6 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 07/25/2025 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)

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a nutritional supplement in accordance with physician orders for one (R31) of three residents reviewed for dining in the sample of 31.Findings include:R31's admission Record documented an admission Date of 10/30/24 and included diagnoses of Vascular Dementia, Severe, with Agitation. R31's Minimum Data Set (MDS) assessment dated [DATE] documented that R31 has severe deficits in cognition. R31's Care Plan dated 5/8/25 documented a problem area of, I am at nutritional risk of weight loss related to poor intakes, secondary to Dementia, with a corresponding intervention, Supplements/alternates per order.R31's Current Orders documented a 5/22/25 diet order for regular texture, regular liquid consistency, add fortified pudding at lunch.On 07/22/2025 at 12:23 PM, lunch service was observed in the facility's dining room. R31, who was alert and oriented only to herself, received a regular texture lunch tray. The diet card specified the tray should contain fortified pudding at lunch, but there was none on the tray.On 7/22/25 at 12:44pm, V4 (Dietary Aide) stated all residents in the dining room had received their trays. When the surveyor asked if R31 should have received fortified pudding, V4 stated yes, and he would get her some. On 07/24/25 at 3:17 PM, V2 (Director of Nurses/DON) stated she was aware of R31 not receiving the fortified pudding and had already re-educated Certified Nursing Assistant staff to make sure the trays going out are consistent with the diet cards.The facility's Food and Nutrition Services Policy dated 3/22/20 documented, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization. A resident-centered diet and nutrition plan will be based on this assessment. Event ID: Facility ID: 146000 If continuation sheet Page 3 of 6 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 07/25/2025 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete 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 ensure the dish machine was effectively sanitizing dishes to prevent cross contamination. This has the potential to affect all 47 residents residing in the facility. The Findings Include:On 7/22/25 at 9:00 AM, during the initial kitchen observation, the dish machine was being used to wash dishes. V6 (Dietary Aide) was asked to check the sanitizer level in the dish machine at this time. V6 was unable to get the test strip to register a sanitizer level, so V7 (Dietary Manager) got a new set of test strips to check the level. V7 was unable to get a level of sanitizer to register on the new strips and instructed V6 to begin washing dishes in the 3-compartment sink. On 7/22/25 at 11:00 AM, V7 stated that they are to check the sanitizer level 3 times a day prior to washing each meals dirty dishes. V7 stated it should be checked before breakfast, lunch and dinner dishes to ensure it is properly sanitizing the dishes.The dish machine sanitizer log was provided on 7/22/25 at 11:00 AM, and no level was recorded for 7/22/25. V7 confirmed that there is not documentation that the sanitizer level was checked this morning, prior to starting the breakfast dishes. The Sanitizing Solution policy documents that employees shall refer to the manufacturer guidelines for the proper use of the sanitizer solutions. 1. The employee will prepare sanitizer solution in accordance with manufacturer guidelines. 2. If a dispensing system is used it will be tested daily to insure solution is dispensed a the appropriate concentration level .The Long Term Care Facility Application for Medicare and Medicaid dated 7/23/25, documents 47 residents residing in the facility. Event ID: Facility ID: 146000 If continuation sheet Page 4 of 6 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 07/25/2025 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)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure the building had effective pest control for flies an gnats. This has the potential to affect all 47 residents residing in the facility. Findings Include: Residents Affected - Many 1.On 7/22/25 on 9:00 AM, during the initial tour of the kitchen, the dish machine area had gnats and flies observed near the drain and the garbage disposal. At this same time, a wet towel was seen under the garbage disposal and crumbs and food debris were visible under the dish machine table as well. A this time, V4 (Dietary Aide) stated that the gnats and flies can get really bad down there if the floor is not kept clean and dry. V4 stated that they do pour bleach down the drain sometimes to help reduce the number of flies/gnats that accumulate down there. On 7/22/25 at 9:30 AM, the delivery door outside the kitchen entrance was observed to have a gap at the bottom as well as in the middle where the double doors meet, and the outside was visible through these gaps. These gaps leave a potential entrance for pests/flies to enter the building. 2. On 7/23/25 at 10:30 AM, R38 who was alert to person, place and time was observed in his room sitting in his wheelchair with flies and gnats flying around his wheelchair and floor. R38 stated that the flies and gnats are a nuisance, and he has them in his room all the time. 3. R1's admission Record documented an admission date of 5/29/24 and included diagnoses of dependence on wheelchair, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side, and chronic pain syndrome. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 was cognitively intact. On 7/22/25 at 10:05 AM, R1's room was observed to have 2 flies crawling on the privacy curtain and 1 fly in the window. On 7/23/25 at 9:47 AM, R1 said there were a lot of flies in the facility. R1 said the flies make it hard to sleep because they fly around his nose and ears. During this interview, R1 had a fly crawling on his arm and a fly crawling on his leg. 4. R19's admission Record documented an admission date of 7/12/24 and included diagnoses of ataxia following cerebral infarction, dysphagia, major depressive disorder, and anxiety disorder. R19's MDS dated [DATE] documented a BIMS score of 15, indicating R19 was cognitively intact. On 7/22/25 at 10:00 AM, R19 was sitting in a motorized wheelchair in his room with a fly swatter swatting at flies. Two dead flies were lying on the floor of R19's room. R19 said in the past week the facility had a lot of flies, but this was not a new thing. R19 said the facility had a lot of spiders and there were a lot of gnats flying around the sink in his room. At this time, gnats were observed flying around the sink in R19's room and crawling on the lip of the sink. 5. R26's admission Record documented an admission date of 5/10/24 and included diagnoses of Raynaud's syndrome, primary open-angle glaucoma, and heart failure. R26's MDS dated [DATE] documented a BIMS score of 15, indicating R26 was cognitively intact. On 7/23/25 at 9:56 AM, R26 said gnats and flies were bad throughout the facility. R26 said she did not have any gnat or fly traps in her room, but did have a fly swatter she tried to kill flies with. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146000 If continuation sheet Page 5 of 6 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 07/25/2025 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)

F 0925 The Long-Term Care Facility Application for Medicare and Medicaid dated 7/23/25, documents 47 residents reside in the facility. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146000 If continuation sheet Page 6 of 6