Health inspection·August 15, 2024

F 0584 The facility's undated Resident Rooms Routine Cleaning-Daily policy documents the daily cleaning includes sweeping the floor, emptying waste cans, mopping, and cleaning the bathroom. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146017 If continuation sheet Page 2 of 14 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 146017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haven of Champaign 1315 Curt Drive, Suite B Champaign, IL 61821 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 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide scheduled showers for one (R4) of seven residents reviewed for Activities of Daily Living in the sample list of 13. Residents Affected - Few Findings include: On 8/13/24 at 1:56 PM, R4 stated R4 prefers to have showers weekly, but R4 has not received a shower for two weeks since the facility has a COVID-19 (Human Coronavirus Infection) outbreak. R4's Minimum Data Set, dated [DATE] documents R4 is cognitively intact and is dependent on staff for bathing. The facility's Shower List dated 4/15/24 documents R4's showers are scheduled on Thursdays. R4's August 2024 shower sheets were requested from the facility on 8/15/24. On 8/14/24 at 9:21 AM, V6 Registered Nurse stated there was a staffing shortage due to the COVID-19 outbreak on the second week of August, around the 9th, which affected showers being given. On 8/15/24 at 11:11 AM, V8 Certified Nursing Assistant provided R4's shower sheet dated 8/1/24. V8 confirmed V8 is the facility's assigned shower aide. V8 stated that was the last day that R4 was given a shower, and R4 did not receive a shower last Thursday due to the COVID-19 outbreak. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146017 If continuation sheet Page 3 of 14 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 146017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haven of Champaign 1315 Curt Drive, Suite B Champaign, IL 61821 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review the facility failed to staff a Registered Nurse (RN) for eight consecutive hours per day. This failure has the potential to affect all 46 residents residing in the facility. Residents Affected - Many Findings include: The facility's August 2024 Nurse Schedule and Nursing Daily Sheets dated 8/4/24 and 8/7/24 do not document an RN was scheduled to work. On 8/14/24 at 1:51 PM-2:47 PM the facility's staffing and daily sheets were reviewed with V2 Director of Nursing. V2 reviewed employee time cards and schedules, and confirmed the facility did not have an RN on duty on 8/4/24 and 8/7/24. V2 stated V6 RN is the full time RN, V15 RN works as needed, V3 Minimum Data Set Coordinator is also an RN, and V2 fills in on the weekends when RN coverage is needed. V2 stated V2 and V3 were out sick with COVID-19, which is why there was no RN coverage on 8/4/24 and 8/7/24. The facility's Room Roster dated 8/13/24 document 46 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146017 If continuation sheet Page 4 of 14 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 146017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haven of Champaign 1315 Curt Drive, Suite B Champaign, IL 61821 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have adequate dietary staff to ensure meals are served timely. This failure affects four (R1, R4, R5, R6) of five residents reviewed for meals in the sample list of 13. This failure has the potential to affect all 46 residents residing in the facility. Findings include: On 8/13/24 at 11:10 AM, R1 stated kitchen staff was out sick with COVID-19 (Human Coronavirus Infection), so the meals weren't served on time for two days before the facility had additional staff come in to help. R1 stated breakfast was served at 11:00 AM instead of 8:00 AM, lunch was around 3:00 PM, and supper was at 7:00 PM. On 8/13/24 at 1:56 PM, R4 stated: Meals aren't served timely. This weekend it was 10:00 AM for breakfast and 1:00-1:30 PM for lunch. Meals aren't served timely. On 8/13/24 at 2:28 PM, R5 stated recently the facility has lost many kitchen staff and meals are served two to three hours later than scheduled. On 8/13/24 at 3:45 PM, R6 stated breakfast is served around 9:30 AM and supper around 6:15-6:30 PM. R1's Brief Interview for Mental Status Score dated 7/30/24 documents R1 as cognitively intact. R4's Minimum Data Set (MDS) dated [DATE] documents R4 is cognitively intact. R5's MDS dated [DATE] documents R5 has moderate cognitive impairment. R6's MDS dated [DATE] documents R6 is cognitively intact. On 8/13/24 at 11:32 AM, V4 Licensed Practical Nurse stated the weekend of August 3rd and 4th meals were served late, breakfast was served at 9:00 AM, and an unidentified Certified Nursing Assistant had to help in the kitchen that day. V4 stated snacks were given to the residents during that time and additional staff was brought in for the lunch and supper meals. On 8/13/24 at 11:55 AM, V10 Dietary Manager stated V10 has been employed at the facility for three weeks and things are slowly improving. V10 stated the facility had staffing issues previously and during the COVID-19 outbreak, but V10 has more staff this week. At 12:35 PM, V10 stated V10 considers meals timely if served within 25 minutes of the scheduled time. On 8/13/24 at 1:20 PM, V13 Social Services Director stated during the last part of July and beginning of August 2024 V13 had to help in the kitchen prep the meal trays and wash dishes for a week or longer until the facility got additional kitchen staff. V13 stated the dietary manager had been replaced and we needed time to get staff trained. V13 stated there was one day that breakfast was served around 10:30-11:00 AM. V13 stated V13 made the third person working in the kitchen with a cook and dietary aide, and usually the facility has three dietary staff working at a time. On 8/14/24 at 9:21 AM, V6 Registered Nurse stated there was one day that breakfast was served around 10:00 AM and lunch was served late around 4:00 PM. V6 stated V6 held insulin until the meals were served and blood sugars were not affected. V6 states it seems like the meals are generally served (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146017 If continuation sheet Page 5 of 14 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 146017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haven of Champaign 1315 Curt Drive, Suite B Champaign, IL 61821 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 0802 Level of Harm - Minimal harm or potential for actual harm about an hour late. V6 stated some days they are short of staff in the kitchen and V13, along with other staff, have to help in the kitchen. The facility's list of meal times provided by V1 Administrator, documents meals are scheduled at 8:00 AM, 12:00 PM, and 5:00 PM. Residents Affected - Many The facility's August 2024 Dietary Schedule documents between 8/4/24 and 8/11/24 there were six days with one kitchen staff and two days when V10 Dietary Manager was the second kitchen staff working for the 6:00 AM/7:00 AM-2:00 PM shift. The facility's Facility assessment dated [DATE] documents the facility's staffing plan includes one food and nutrition supervisor, one cook, and one dietary aide for weekdays on day and evening shifts; and one cook and one dietary aide on the weekends. The facility's Room Roster dated 8/13/24 documents 46 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146017 If continuation sheet Page 6 of 14 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 146017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haven of Champaign 1315 Curt Drive, Suite B Champaign, IL 61821 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 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. Based on observation, interview, and record review the facility failed to follow a physician ordered diet for one (R1) of five residents reviewed for diet in the sample list of 13. Residents Affected - Few Findings include: On 8/13/24 at 11:10 AM, R1 stated R1 is a diabetic, but is not on a special diet. R1 states R1 just monitors what R1 eats. On 8/13/24 at 11:55 AM and 12:35 PM, V10 Dietary Manager served all of the residents' meal trays. R1's meal tray consisted of Salisbury steak, gravy, mashed potatoes, one slice of bread, sunshine carrots, and ice cream. R1's meal tray card documented regular diet. V10 stated low concentrated sweets and controlled carbohydrate diets are similar, and the bread is not served for those diets for this meal. R1's Brief Interview for Mental Status dated 7/30/24 documents R1 is cognitively intact. R1's August 2024 Physician's Order Summary (POS) documents R1's diagnoses include Type 2 Diabetes Mellitus and R1's diet is Controlled Carbohydrate. On 8/14/24 at 3:50 PM, V10 confirmed R1's meal tray card documents regular diet and the prescribed diet on the POS should be what is documented on the resident's tray card. V10 stated V10 will have R1's tray card updated to reflect controlled carbohydrate diet. V10 confirmed R1 was served a regular diet which included mashed potatoes, bread, and ice cream for the noon meal on 8/13/24. At 3:53 PM, V10 provided R1's Diet Order Form dated 7/29/24 which documented under special notes Carb (carbohydrate) Control, and regular diet was checked. The line next to consistent carbohydrate diet did not have a check mark. V10 stated this form was provided by nursing and the Controlled Carbohydrate diet was not caught because the box next to the Controlled Carb diet was was not marked. The facility's Week 1 Regular Menu dated April 2024 documents the noon meal as Salisbury steak, mashed potatoes, brown gravy, sunshine carrots, bread/margarine, and ice cream. This menu documents for 1800 Controlled Carbohydrate Diet (CCD) give fruit for dessert, skim milk, and no extra margarine; the 1500 CCD give fruit for dessert, 4 ounces skim milk, no extra margarine, 4 ounces juice at breakfast, and no extra breads/rolls with lunch and supper. The facility's Therapeutic & Mechanically Altered Diets dated April 2006 documents diets are ordered by the physician and should be prepared and served as planned. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146017 If continuation sheet Page 7 of 14 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 146017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haven of Champaign 1315 Curt Drive, Suite B Champaign, IL 61821 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 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 maintain a clean and sanitary kitchen. This failure has the potential to affect all 46 residents residing in the facility. Residents Affected - Many Findings include: On 8/13/24 at 9:50-9:57 AM, the kitchen was toured with V10 Dietary Manager. There was dust and debris on the floor and dirt built up on the floor around the range and prep table. There were dark, dried splatters on the side of the range and on the wall near the three sink washing station. On 8/13/24 at 11:55 AM-12:35 PM, V10 served the noon meal trays for all of the residents. V14 Dietary Aide swept the floor and there was a large pile of dirt and debris. There was dark dirt build up on the floor around the range and prep table, and there were dark, dried splatters on the side of the range and wall near the three sink station. This was confirmed with V10 and V11 Dietary Aide. V11 stated the floors are suppose to be swept and mopped at the end of each shift and should have been done last evening. V10 stated the kitchen is cleaned daily and a deep clean is done weekly, but V10 does not have a cleaning log or schedule. The facility's Cleaning Schedule dated October 2014 documents: The Food Service Manager shall develop a cleaning rotation form that lists all cleaning tasks required for proper sanitation of the food preparation and serving areas. Tasks are divided into categories that must be completed daily, weekly, and monthly. Each position in the Dietary Department is assigned certain cleaning tasks to be completed at a particular frequency. The facility's Room Roster dated 8/13/24 documents 46 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146017 If continuation sheet Page 8 of 14 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 146017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haven of Champaign 1315 Curt Drive, Suite B Champaign, IL 61821 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to implement infection control measures to prevent the spread of COVID-19 (Human Coronavirus Infection) by failing to maintain a supply of N95 respirators, ensure staff wear appropriate Personal Protective Equipment (PPE), ensure staff wear PPE correctly, and routinely disinfect high touch surfaces during a COVID-19 Outbreak. This failure affects seven (R3, R5, R2, R10, R11, R12, R13) of seven residents reviewed for Infection Control in the sample list of 13. These failures have the potential to affect all 46 residents residing in the facility. Residents Affected - Many Findings include: 1.) The facility's August 2024 Staff Infection Control Log documents 16 employees tested positive for COVID-19 between 8/2/24 and 8/6/24. The Facility's August 2024 Resident Infection Control Log documents 24 residents tested positive for COVID-19 between 8/1/24 (when the outbreak began) and 8/8/24. Positive residents included R2, R3, R11, R12. On 8/13/24 at 9:58 AM, V19 Resident Care Coordinator stated 24 residents have contracted COVID-19 during this outbreak that began on 8/1/24. V19 confirmed the outbreak affected all halls and there are COVID-19 positive and negative rooms on each hall. There was a sign posted on the entrance to the North Hall that stated this was a red zone and PPE is to be worn. The North Hall was toured on 8/13/24 at 10:02-10:12 AM. There was a PPE cart located in the hallway that only contained isolation gowns. COVID-19 positive rooms and negative rooms were on this hall. Positive room doors contained droplet and contact isolation signage that instructed to don/doff (apply/remove) gown and gloves when entering/leaving the room, and remove face protection before room exit. V4 Licensed Practical Nurse (LPN) was administering medications and wearing a KN95 mask. V21 Housekeeper was cleaning COVID-19 positive and negative rooms working her way down the hall while wearing a KN90 mask with the bottom strap worn loosely below V21's chin. V21 entered R3's room wearing a KN90 mask, face shield, gown and gloves. V21 removed the gown and gloves, exited R3's room, and entered R10's room (a COVID-19 negative room) without changing her mask and disinfecting/changing eye protection. The East Hall was toured on 8/13/24 at 10:12-10:27 AM. There were COVID-19 positive and negative rooms and the PPE cart in the hallway only contained isolation gowns. V20 Certified Nursing Assistant (CNA) was working on this hall wearing a KN90 mask. V9 Housekeeping Supervisor was working on this hall wearing a KN95 mask. The South Hall was toured on 8/13/24 at 10:27 AM. There were COVID-19 positive and negative rooms, and the PPE cart in the hallway only contained isolation gowns. On 8/13/24 at 10:36 AM, V8 CNA was on the East Hall wearing a KN90 mask. V8 stated V8 recently returned to work after having COVID-19. On 8/13/24 at 11:22 AM, V8 entered COVID-19 positive rooms while wearing a KN90 mask. On 8/13/24 at 11:29 AM, V8 CNA stated there is a supply of masks and face shields kept at the nurse's station (which was outside of the North/East/South Hall Red Zones). V8 stated face shields are changed daily and masks are changed every four hours. V8 confirmed V8 provides care for both COVID-19 positive and negative residents, and masks and eye protection are not changed or disinfected between positive and negative rooms. V8 confirmed a KN90 mask was worn in positive rooms. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146017 If continuation sheet Page 9 of 14 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 146017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haven of Champaign 1315 Curt Drive, Suite B Champaign, IL 61821 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 8/13/24 at 11:03 AM, V21 Housekeeper mopped R11's/R12's (COVID-19 positive) room and then entered R13's room (negative room) without changing V21's mask or disinfecting/changing face shield. The lower strap of V21's mask was hanging loose underneath of V21's chin, and not secured behind V21's head. On 8/13/24 at 11:45 AM, V21 confirmed V21 was not changing V21's mask and eye protection between positive and negative rooms. On 8/13/24 at 1:54 PM, V21 stated V21 does not wear the lower strap of V21's mask because it causes the mask to be too tight. V21 stated, V21 has not received any training on how to properly wear a mask and V21 recently returned to work after having COVID-19 last week. On 8/13/24 at 11:20 AM, V22 CNA was wearing a KN90 mask while working in the facility. On 8/13/24 at 2:20 PM, V22 was wearing a KN90 mask. V22 stated V22 wears this mask (referring to the mask worn) in the COVID-19 positive rooms and referred to the mask as being an N95 mask. V22 stated a supply of these masks are kept at the facility's entrance and face shields are kept in boxes at the nurses station. A bag of KN90 masks was located at the time clock entrance and V22 confirmed this type of mask is what the facility provides. On 8/13/24 at 11:32 AM, V4 LPN confirmed V4 provides care for both COVID-19 positive and negative residents, and V4 has not been changing V4's mask and eye protection between positive and negative rooms. V4 stated staff have been wearing these masks (pointed to V4's KN95 mask) and eye protection for all residents since the outbreak began. V4 stated V4 has worked in other facilities where masks were changed more frequently. On 8/13/24 at 12:43 PM, V18 CNA was walking the halls of the facility wearing a KN90 mask and the lower strap was worn loosely below V18's chin, and not secured behind V18's head. On 8/13/24 at 2:24 PM, V5 LPN was wearing an N95 mask. V5 stated V5 bought her own supply of N95 masks and is only changing the mask daily and when soiled. V5 confirmed V5 is not changing her mask when going from positive and negative rooms, and V5 stated V5 was not instructed to do so. On 8/13/24 at 2:42 PM, V23 CNA wore a KN90 mask into R2's room (positive room). On 8/13/24 at 3:11 PM, V16 and V17 CNAs entered R3's room (positive room) and provided incontinence cares. V16's mask was a KN90 mask. At 3:22 PM, V16 and V17 left R3's room without changing their masks. V16 did not disinfect or change V16's face shield upon or after providing R3's cares. On 8/14/24 at 9:21 AM, V6 RN was leaving the South Hall wearing a surgical mask and face shield. The entrance door to the hallway indicated red zone. V6 stated, only today V6 has been wearing surgical masks in addition to gown, gloves, and eye protection into the COVID-19 positive rooms. On 8/14/24 at 9:36 AM, V18 CNA entered R2's room (positive room) wearing a KN90 mask and eye protection. The bottom strap of the mask hung loosely underneath of V18's chin. V18 did not apply gown or gloves prior to entering the room. On 8/14/24 at 9:43 AM, R2 stated V18 had COVID-19 on 8/3/24. V18 confirmed V18 was not wearing the lower strap of V18's mask. V18 stated there wasn't a reason for not wearing the strap other than V18 gets in a hurry when applying masks. V18 confirmed V18 has been wearing the KN90 masks into positive rooms. V18 stated V18 did not provide any cares while V18 was in R2's room. V18 confirmed V18 was not wearing a gown in the room. V18 stated V18 wasn't aware R2 was COVID-19 positive, but I guess there is an isolation sign on R2's door. On 8/14/24 at 9:54 AM, V7 LPN was working on the North Hall and wearing a KN90 mask. V7 confirmed the KN90 mask is worn in COVID-19 positive rooms and referred to the mask as being an N95 mask. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146017 If continuation sheet Page 10 of 14 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 146017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haven of Champaign 1315 Curt Drive, Suite B Champaign, IL 61821 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 8/14/24 at 10:16 AM, V2 Director of Nursing the facility had a limited supply of N95 masks when the COVID-19 outbreak began. V2 stated V2 had not been routinely ordering N95 masks since the facility had not routinely had any COVID-19 outbreaks. V2 stated the staff quickly went through the N95 masks, and V2 confirmed the facility has been without N95 masks during the outbreak once the supply ran out. V2 was asked what steps were taken to attempt to obtain a supply of N95 masks. V2 stated V2 contacted the local health department on 8/2/24 to request N95 masks since the facility had ran out. V2 stated the local health department provided the facility with a supply of KN95 and KN90 masks. V2 stated V2 had tried to order a supply from the facility's supplier, but the N95 masks were unavailable and V2 does not have documentation of this. V2 stated the facility only has a contract with one supplier so V2 did not attempt to obtain N95 masks from another supplier company. V2 stated V2 has not attempted to order N95 masks again after the initial attempt at the beginning of the outbreak. V2 stated N95 masks are the preferred mask to be worn in the COVID-19 positive rooms, and staff have been trained on the expectation that masks will be changed and eye protection disinfected between when leaving positive rooms prior to entering negative rooms. V2 confirmed gown and gloves should also be worn in COVID-19 positive rooms and the bottom strap of masks should be worn to ensure snug fit. 2.) On 8/13/24 at 11:03 AM, V21 Housekeeper mopped R11's/R12's (COVID-19 positive) room and then entered R13's room (negative room). On 8/13/24 at 11:45 AM, V21 stated there is no certain routine for cleaning COVID-19 rooms, V21 just works her way up and down the hall going from room to room. On 8/14/24 at 9:05 AM, V24 Laundry Aide stated V24 has been having to assist with housekeeping since V9 Housekeeping Supervisor and V21 Housekeeper were out sick. V24 stated, resident rooms are disinfected/cleaned daily and the hallway railings and high touch surfaces are disinfected every other day. On 8/14/24 at 9:16 AM, V21 stated high touch surfaces such as light switches and door knobs are disinfected every other day. On 8/13/24 at 10:20 AM, V9 Housekeeping Supervisor stated: We haven't had housekeeping fully staffed for awhile, until this week. We schedule two each day, but have been working with one on the weekends. On 8/13/24 at 4:20 PM, V9 stated resident rooms are to be cleaned daily and was not sure the rooms were getting cleaned daily when the facility only had one housekeeper on duty. On 8/14/24 at 10:47 AM, V9 stated isolation rooms should be cleaned/disinfected last and high touch surfaces should be disinfected three times per day. V9 stated V9 is responsible for disinfecting high touch surfaces. V9 stated there should be two laundry staff and two housekeepers scheduled daily and the laundry staff have been having to cover housekeeping while staff were out sick with COVID-19. V9 stated one employee would work in laundry while the other worked as housekeeping. The facility's August 2024 Housekeeping/Laundry Schedule documents there were no housekeeping staff working 8/2/24-8/5/24, and there were two laundry staff working during this time. The facility's Room Roster dated 8/13/24 documents 46 residents reside in the facility. The facility's COVID-19 Control Measures policy dated 5/19/23 documents during an outbreak staff must wear an N95 and eye protection during resident care and when in an area where residents may be encountered until 14 days have passed with no additional positive cases. This policy documents to wear an N95 mask, eye protection, gown and gloves when caring for COVID-19 positive residents. This policy documents to increase the frequency of cleaning and disinfecting high touch areas and to clean all resident rooms daily. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146017 If continuation sheet Page 11 of 14 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 146017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haven of Champaign 1315 Curt Drive, Suite B Champaign, IL 61821 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 0880 Level of Harm - Minimal harm or potential for actual harm The Centers for Disease Control and Prevention Facemask Do's and Don'ts for Healthcare Personnel dated 6/2/20 documents not to allow a mask strap to hang down below your chin, and to secure the straps at the middle and base of your head. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146017 If continuation sheet Page 12 of 14 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 146017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haven of Champaign 1315 Curt Drive, Suite B Champaign, IL 61821 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 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 maintain functioning call lights for four (R3, R5, R8, R9) of four residents reviewed for call lights in the sample of 13. Residents Affected - Some Findings include: 1.) On 8/13/24 at 2:28 PM, R5 was lying in bed and there was a handheld bell on R5's bed beside R5. R5's room did not contain a call light cord attached to the call light box in R5's room. There was contact and droplet isolation signage posted on R5's room door. On 8/15/24 at 11:03 AM, R5 was in R5's room with a handheld call bell beside her. There was no call light cord plugged into the call light box in R5's room. R5 stated the other night R5 kept ringing the handheld bell and it took a long time for staff to answer, and usually R5 has to wait 30 minutes or more for staff to respond. R5 stated the staff told R5 that they didn't know where the bell sound was coming from. On 8/13/24 at 3:22 PM, V17 Certified Nursing Assistant (CNA) stated R5's call light hasn't been working for a few weeks. R5's Minimum Data Set (MDS) dated [DATE] documents R5 has moderate cognitive impairment, is frequently incontinent of bowel and bladder, and requires substantial/maximal assistance of staff for toileting. 2.) On 8/13/24 at 2:53 PM, R3 was lying in bed with a handheld bell next to R3. R3 stated R3's call light hasn't worked for a long time and that is why R3 has a handheld bell. R3 stated R3 started with a cough on 8/8/24, was told she had COVID-19, and was placed on isolation. R3 stated the staff can't hear the bell when R3's door is shut, and recently R3 had to wait an hour for R3's bell to be answered while R3 was lying in urine and feces. R3's call light was tested and it was not functioning. On 8/13/24 at 3:06 PM, V16 CNA, stated R3's call light hasn't been working for a couple of weeks. R3's MDS dated [DATE] documents R3 is cognitively intact, is frequently incontinent of bowel and bladder, and is dependent on staff for toileting assistance. 3.) On 8/14/24 at 9:33 AM, R8 was lying in bed and R8's call light was on. There was a handheld bell on R8's night stand beside R8's bed. R8 stated, R8's call light doesn't work causing the call light to stay on all of the time. R8's MDS dated [DATE] documents R8 has severe cognitive impairment, is always incontinent of bowel and bladder, and requires substantial/maximal staff assistance for toileting. 4.) On 8/14/24 at 10:10 AM, R9 was lying in bed and there was a handheld bell on R9's night stand. R9's MDS dated [DATE] documents R7 has severe cognitive impairment and is dependent on staff for Activities of Daily Living. On 8/13/24 at 3:26 PM, V5 Licensed Practical Nurse stated R5 and R8 do not have functioning call lights which is why they are using handheld bells. V5 stated, V5 worked on 8/11/24 and R5's and R8's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146017 If continuation sheet Page 13 of 14 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 146017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haven of Champaign 1315 Curt Drive, Suite B Champaign, IL 61821 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 0919 call lights were not working at that time. Level of Harm - Minimal harm or potential for actual harm On 8/14/24 at 9:43 AM, V18 CNA stated R5 and R8 do not have functioning call lights and are using handheld bells. V18 stated R5's room doesn't even have a call light plugged into the wall, because it doesn't work. V18 stated it recently affected the North Hall, R3's and R9's call lights, but it has been affecting the South Hall (R5's and R9's rooms) for awhile. Residents Affected - Some On 8/14/24 at 10:30 AM, V1 Administrator stated there are four call lights that aren't functioning and are stuck on; and they haven't been working correctly since V1's employment began in February 2024. V1 stated corporate and sister facility maintenance staff have been in the facility to evaluate the call lights. V1 stated an electrician is needed and either the call light system needs revamped or a whole new system, and the facility's budget hasn't allowed for that. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146017 If continuation sheet Page 14 of 14