Health inspection·December 3, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few results received and physician notified. New order to send to emergency room for evaluation and treatment. V3 notified of results and new orders. V2 (Director of Nursing) notified of x-ray results.R1's x-ray report dated [DATE] documented under section titled Impression subcapital right femoral neck fracture with varus angulation and proximal displacement.R1's Neuro Check assessment in the Electronic Health Record documents a date and time of evaluation of [DATE] at 5:50 (am) and a Lock Date of [DATE], documents R1 was alert, pupils were reactive, hand grasps were equal, and R1 could move all extremities.On [DATE] at 1:48 P.M. V4 (Registered Nurse) stated she was the nurse caring for R1 the morning of [DATE]. V4 stated she was passing the early am medications somewhere around 5 am and R1 was observed sitting on the edge of his bed tinkering with his wheelchair. V4 stated this was a normal behavior for R1. V4 stated she did not see R1 fall or see R1 on the floor. V4 stated the staff working said that it occurred. V4 stated she assessed him, and he had no complaints of pain. V4 stated she does not consider R1's behavior of sitting on the floor a fall. V4 stated she knows there is no behavior care plan for R1 sitting on the floor. V4 stated I guess they are considering him sitting in the floor a fall. V4 stated she did not do a fall assessment or an incident report because she did not consider it a fall. V4 stated when she was leaving around 6:30 A.M. on [DATE] R1 was going to the dining room and was not having any pain. V4 stated she does not know the time that R1 was on the floor. V4 stated that the cna's got him up and put him in bed without notifying her. V4 stated the cna's told me after the fact that it happened. V4 stated that is why she did an assessment when she went in to give R1 his morning medications. V4 stated it is her expectation that the cna's tell her immediately so she can do an assessment on the resident before they move him. V4 stated that R1 was known to be in the floor working on chairs, doors etc. V4 stated after V2 discussed the fall with her and educated her, she went back and completed a nurse note and neuro check on what she observed on [DATE].On [DATE] at 10:00 A.M. V12 (Certified Nurse Assistant) stated her and another aide were doing a bed check between 12:00 A.M. and 1:00 A.M on [DATE]. V12 stated that when they got to R1's room he was sitting in the floor fixing his wheelchair. V12 stated she got V4, and V4 came and assessed R1. V12 stated her and another aide got R1 up, took him to the bathroom to change his clothes and placed him in bed. V12 stated she provided care for R1 at 4:00 A.M. and he was in bed and had no complaints.On [DATE] at 1:57 P.M. V11 (Certified Nurse Assistant) stated she was working the night that R1 was in the floor. V11 stated somewhere around 4:00 A.M., she went into R1's room with V12 (Certified Nurse Assistant) and observed R1 on the floor. V11 stated she stayed with R1 while V12 went to get V4. V11 stated that R1 was on the floor and was not moved until V4 assessed R1. V11 stated after V4 assessed R1, Her and V12 got R1 up with a gait belt and took him to the bathroom. V11 stated that R1 was his normal self and there was no indications of pain or that there was a problem. V11 stated after taking R1 to the bathroom, he was placed in his bed to rest. V11 stated R1 had no complaints of pain at the time.On [DATE] at 1:55 P.M. V5 (Licensed Practical Nurse) stated he was the oncoming nurse on [DATE]. V5 stated his shift started at 6:00 A.M. V5 stated R1 took his medications that morning and did not appear to be in pain. V5 stated there are days that R1 needed more help than other days. V5 stated on that day, R1 needed more assistance to get out of bed, but with R1's dementia that was not abnormal. V5 stated later in the morning before lunch, staff came and told him that R1 was having more pain than normal and there was something wrong. V5 stated that he did an assessment and could tell that R1 was having pain in his hip area. V5 stated that is when he called the physician and got an order for x-rays. V5 stated that visually R1 was not rotated but upon assessment of his hips and trying to move them he would have severe pain. V5 stated the x-ray results came back after V5 left for the day. V5 stated the cna's notified him of the change in R1 after breakfast. V5 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146000 If continuation sheet Page 2 of 5 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 12/03/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated when he was placed in bed after breakfast, he required more assistance than he normally would. V5 stated he did an assessment and started making phone calls immediately. V5 stated R1 would have pain he could not be specific as to where it was. V5 said that R1 could not communicate, for example, that my left foot hurts when I stand on it but he could say my left foot hurts. V5 said R1 could not give specific details about pain.On [DATE] at 2:40 P.M. V9 (Certified Nurse Assistant) stated on [DATE] she went to get R1 up for breakfast. V9 stated R1 was his normal self. V9 stated R1 was stiff and tired that morning. V9 stated she had been told by the night shift staff that R1 had been up most of the night. V9 stated she took R1 to the dining room for breakfast. V9 stated after breakfast she placed R1 in his bed to rest. V9 stated she went to get R1up for lunch and R1 was complaining of pain like he had never complained before. V9 stated that she went and immediately told V5 that there was an issue with R1.On [DATE] at 9:13 A.M. V10 (Certified Nurse Assistant) stated she came in at 05:00 A.M. on [DATE]. V10 stated the off going night shift had told her R1 had been up most of the night and R1 finally went to sleep around 3:00 A.M. V10 stated when R1 was up for breakfast he appeared tired and more stiff than normal. V10 stated some days R1 would need minimal assist but on days where he had been up all night, R1 would need more assist. V10 stated she thought since R1 had been up all night he was just tired. V10 stated when he was laid down after breakfast, and was rolling him, that is when R1 complained of pain. V10 stated she went and got V5 (Licensed Practical Nurse) and asked him to look at R1 because something was wrong. V10 stated that V5 immediately came and assessed R1.On [DATE] at 1:03 P.M. V2 (Director of Nursing) stated R1's fall was not initially treated as a fall. V2 stated It should have been treated as a fall because R1 was not care planned to have behaviors of sitting on the floor. V2 stated that R1 has had several falls and each time a new intervention is put into place. V2 stated she was not sure if R1 was out of bed the morning of [DATE]. V2 stated V5 (Licensed Practical Nurse) observed the changes in R1 and did an assessment. V2 stated that V5 called the doctor and received orders for an x-ray. V2 stated she was coming in the night of [DATE] to help with the medication pass so she was out the facility and immediately started investigating what caused the fracture to R1. V2 stated through her investigation it was determined that R1 was sitting on the edge of the bed during early morning medication pass. Sometime after that, R1 was observed sitting in the middle of the floor in his room. V2 stated that V4 (Registered Nurse) was called and asked what had happened the prior night. V2 stated V4 said R1 did not have a fall but was observed sitting in the floor. V2 stated that V4 did not consider this a fall and did not complete a fall incident report or notify anyone of the event. V2 stated that V4 had been educated on this matter and now knows that any time a resident has a change in plane, it is considered a fall. V2 stated that R1 did not come back, he was admitted on Hospice at the hospital and died on the skilled care unit. V2 stated her expectation is if the resident is on the floor, it is to be counted as a fall. V2 stated V4 should have completed neuro checks per the policy. V2 stated when V4 was educated on what a fall was, she went back and completed a neuro check because V4 told V2 that she had assessed R1.On [DATE] at 12:48 P.M. V1 (Administrator) stated the situation with R1 was immediately investigated once he was made aware of the fracture. V1 stated that V4(Registered Nurse) kept saying that R1 never had a fall. V1 stated he was never aware of R1 having behaviors of being in the floor. V1 stated that V4 has been educated on what a fall is, and the fall policy on proper notifications. On [DATE] at 8:37 A.M. V16 (Nurse Practitioner) stated if a resident has a fall, no obvious injuries and the resident is not complaining of pain, then she would not send them for treatment at the emergency department. V16 stated that when V5 (Licensed Practical Nurse) called about R1, she was not told that the resident had any falls or any real reason for the pain. V16 stated when V15 (Registered Nurse) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146000 If continuation sheet Page 3 of 5 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 12/03/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few called with the x-ray results she was told after further investigation it was noted that R1 had been observed on the floor during the previous night. V16 stated if she would have been notified immediately, she would not have sent R1 for an evaluation if R1 was not complaining of any pain. V16 stated as soon as V5 was made aware of the pain, she was notified, and she ordered x-rays immediately. V16 stated as soon as V16 made her aware of the X-ray results she sent R1 to the hospital for an evaluation. V16 stated the night nurse should have reported R1 being in the floor to the oncoming nurse. V16 stated that even if the nurse thought it was a normal behavior, the day shift nurse would have known to do an assessment or keep a closer watch on R1. V16 stated there was no delay in care for R1 because as soon as he was having pain, it was addressed.On [DATE] at 8:20 A.M. V3 (Family Member) stated R1 passed away on [DATE]. V3 stated that R1 wouldn't get out of bed on the day of [DATE] and was complaining of terrible pain. V3 stated the facility notified her of his pain and that they were going to get an x-ray. V3 stated at this time no one told her that R1 had had a fall. V3 stated that she received a call around 6:30 P.M. - 6:45 P.M. on [DATE] stating that R1 had a fractured hip. V3 stated at that time V2 (Director of Nursing) stated that she spoke with the night shift staff and was made aware that R1 had been in the floor twice during the night. V3 stated that V2 explained that R1 was telling the staff he was working on his wheelchair. V3 stated with R1's dementia diagnosis and the extensive amount of help that he required she does not feel that R1 would get out of bed and sit in the floor. V3 stated during the initial phone call, the facility nurse could not tell her why R1 was having so much pain. V3 stated it wasn't until it was found that R1 had a fracture that anyone knew what happened. V3 stated there is no way R1 could get off the floor by himself and several staff members had to help him. V3 stated the staff that helped get him off the floor knew he had a fall and did not notify her of the fall. V3 stated after the x-ray showed a fracture, R1 was sent to the local hospital for evaluation. V3 stated that R1 was admitted to the hospital for pain control and surgery was not an option. V3 stated the decision was made to move R1 to Skilled Care Unit where R1 was placed on Hospice.A Facility Policy titled Assessing Falls and Their Causes with a revised date of [DATE] under Documentation states When a resident falls, the following information should be recorded in the resident's medical record: 1. The condition in which the resident was found (e.g., resident found lying on the floor between bed and chair). 2. Assessment data, including vital signs and any obvious injuries. 3. Interventions, first aid, or treatment administered. 4. Notification of the physician and family, in an appropriate time frame as indicated. 5. Completion of a falls risk assessment. 6. Appropriate interventions taken to prevent future falls. 7. The signature and title of the person recording the data. Under Reporting documents 1. Notify the following individuals when a resident falls: a. The resident's family; in an appropriate time frame b. The Attending Physician (timing of notification may vary, depending on whether injury was involved); c. The Director of Nursing Services.Prior to the survey date, the facility took the following actions to correct the deficient practice:A 1.Quality Assurance and Performance Improvement (QAPI) meeting was held on [DATE]. In attendance - V1, V2, V7 (Regional Nurse), and V17 (MDS Nurse).2 2.Process/Steps to identify others having the potential to be impacted by the same deficient practice: All residents have the potential to be affected. It was noted that an accident / incident that occurred was not reported timely to R1's representative/family, and improper identification of what a fall is. 3 3.Measures put into place/systematic changes to ensure the deficient practice does not recur: All nursing staff were in serviced by V2 regarding timely notification of an accident / incident, what is considered a fall, and that resident's should be assessed immediately to ensure there is no delay in care completed on [DATE] and [DATE]. QA tool has been developed for all accidents / incidents to be reviewed to ensure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146000 If continuation sheet Page 4 of 5 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 12/03/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm timely notification of responsible party, proper identification of falls, and that nursing assessment was completed immediately.4 4.Plan to monitor performance to ensure solutions are sustained: QA Fall Audit Tool completed for each fall times 30 days by V2 and reviewed by V1. First QA Audit completed on [DATE]. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146000 If continuation sheet Page 5 of 5