Inspection·April 24, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 4/24/25 at 9:57 AM, V3 stated she had interviewed V6 after the incident when R1 fell from the mechanical lift to ask V6 who was the second staff member with her when the incident happened. V3 stated that V6 claimed she didn't know she was supposed to have a second person with her. V3 stated that V6 had received the training and competency evaluation to operate the mechanical lifts, but the previous Director of Nursing no longer works at the facility and no one could locate the documents for the trainings or competency evaluations. On 4/24/25 at 11:50 AM, R1 clarified that prior to the incident of falling from the sit-to-stand lift, she had experienced a bowel incontinent episode and requested V6 transfer her back to the bed to get cleaned up. R1 further stated V6 raised her up with the sit-to-stand lift and began cleaning her incontinence. R1 again stated V6 did not use the safety belt and she was being lifted up on the lift with only her own arm strength. R1 stated she informed V6 she could not hold on to the grab bar on the mechanical lift for the length of time it took to get her cleaned but V6 did not listen to her. R1 stated she did not have any problem holding on to the grab bar on the mechanical lift for the time it took to go from her wheelchair to the bed, which was why she had asked V6 to transfer her to the bed to get cleaned. R1 stated that her hands lost grip of the grab bar and she grabbed hold to the center bar of the lift and again told V6 she could not hold on, but V6 did not listen and that is when she fell to the floor. R1 stated that V6 had been alone when the incident happened and did not have a second staff member present to assist in using the sit-to-stand lift. R1's Nurses Notes do not document the fall incident, but do document on 3/16/25 that R1 began to complain of excessive pain since falling out of the sit-to-stand on 3/9/25. This same note documents R1 was sent to the emergency room for an evaluation. The facility's Initial (3/16/25), Final (3/21/25), and Addendum (3/24/25) Reports to Illinois Department of Public Health document R1 experienced a fall incident on 3/9/25, began to complain of pain on 3/16/25, was sent to the emergency room and determined by x-ray to have a fracture of the left radius, later determined by computed tomography scans to rule out a fracture and diagnosed with Gout and new onset of Rheumatoid Arthritis. The facility policy Safe Lifting and Movement of Residents dated August 2008 documents the facility uses mechanical lifting devices to promote resident safety and quality of care. This policy documents mechanical lifting devices will be used for any resident who requires a two person assist, staff will be trained on the use of the mechanical lifts, staff competency in the use of the lifts will be conducted annually, and there will be sufficient staff present on every shift who have been trained in the use of the lifts. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146017 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 146017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm Based on observation, interview, and record review, the facility failed to effectively manage resident's pain according to physician orders, the resident care plan, and the resident's preference. This failure affects one resident (R1) out of three reviewed for pain on the sample list of five. This failure resulted in a decline in R1's ability to participate in routine activities of daily living. Residents Affected - Few Findings include: R1's Face Sheet dated 11/30/22 documents R1 was admitted to the facility on this date and is her own responsible party and financial guarantor. This same Face Sheet, along with R1's Medical Diagnoses List (undated) documents R1 experiences medical conditions including Generalized Weakness, Polyarthralgia, Lymphedema, Class 3 Obesity, Gout, Physical Debility, Osteoarthritis of Bilateral Knees, Hypertension, and Diabetes Mellitus Type 2. On 4/24/25 at 8:40 AM, R1 was lying in bed in her own room. R1 could not make a complete fist with her left hand which was visibly swollen with taught skin. R1 had a compression wrap on her visibly swollen left knee. On 4/24/25 at 11:50 AM, R1 could not touch the thumb of her left hand to any of the fingers of her left hand. R1 stated she is left handed which makes everything inconvenient. R1 stated, and demonstrated, she could not grasp the television remote control with her left hand. R1 stated she can not get out of bed when she wants to anymore because of pain in her left knee, and can not propel her own wheelchair due to her left hand being painful and swollen. R1 stated she did not get out of bed every day prior to the incident which caused her injuries, but did get out of bed when she wanted to go socialize and engage in Bible study, but now she can not get out of bed when she wants to because the staff can no longer use the sit-to-stand lift with her but have to use the full body lift because her knees are too painful to bear weight and she can not grip the grab bars on the sit-to-stand lift with her hand being so painful. R1 stated when being lifted with the full body lift, the carrying cradle lets her legs hang over the edge which causes her knees to bend which is very painful. R1 stated that prior to the incident, when she was up in her wheelchair, she could propel her own wheelchair, but now some staff member has to propel her wheelchair because her left hand is too painful to grip and push on the wheels. R1's Nurses Notes do not document the fall incident which resulted in R1's pain and swelling of her hand and knee, but do document on 3/16/25 that R1 began to complain of excessive pain since falling out of the sit-to-stand on 3/9/25. This same note documents R1 was sent to the emergency room for an evaluation. This same note documents R1 had been refusing to get out of bed due to the excessive pain since the fall incident. R1's Nurses Notes dated 3/20/25 document further complaints of pain, numbness and tingling of R1's left hand, left knee pain and swelling, and right wrist pain. This note documents R1's physician (V10) examined R1 and sent her to the emergency room for further evaluation. R1's Hospital Discharge Note dated 3/28/25 documents R1 was admitted to the hospital 3/20/25 through 3/28/25 for complaints of left wrist and hand pain, bilateral knee pain, and right wrist pain. These notes document R1 had received morphine for pain management at the hospital, and document a physician ordered increase in R1's prescription of Hydrocodone 5 milligrams with Acetaminophen 325 milligrams (Norco) from every 6 hours as needed to every 4 hours as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146017 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 146017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 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 0697 R1's Physician Order Sheet dated for April 2025 document R1's order for Hydrocodone was increased to every 4 hours as needed on 4/8/25. Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete R1's current Care Plan (void of dates) provided by V11, Minimum Data Set Coordinator, documents R1 likes to attend group activities. This Care Plan documents R1 experiences pain and has medication ordered which should be administered as ordered by the physician, and to assess if the pain intensity is acceptable to the resident. Event ID: Facility ID: 146017 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 146017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to acquire, dispense, and administer a resident's pain medication as ordered by the physician. This failure affects one resident (R1) out of three reviewed for pain on the sample list of five. Findings include: R1's Face Sheet dated 11/30/22 documents R1 was admitted to the facility on this date and is her own responsible party and financial guarantor. This same Face Sheet, along with R1's Medical Diagnoses List (undated) documents R1 experiences medical conditions including Generalized Weakness, Polyarthralgia, Lymphedema, Class 3 Obesity, Gout, Physical Debility, Osteoarthritis of Bilateral Knees, Hypertension, and Diabetes Mellitus Type 2. On 4/24/25 at 11:50 AM, R1 stated she had been experiencing increased pain in her left hand and knees ever since she fell off of the sit-to-stand mechanical lift on 3/9/25. R1 stated her doctor (V10) had prescribed Norco (Hydrocodone 5 milligrams with Acetaminophen 325 milligrams) that she is supposed to be able to have every 4 hours if she needs it. R1 further stated the facility had not had any supply of her pain medication for about a week. R1 stated she receives Tylenol (Acetaminophen) three times per day but it doesn't help anything. R1 concluded by stating that whoever is responsible for ordering the medication refills needs to order it in enough time ahead so it doesn't run out. R1's Physician Order Sheet dated April 2025 documents a physician order for R1 to be able to receive Norco 1 tablet every four hours as needed for pain. On 4/24/25 at 12:20 PM, V9, Licensed Practical Nurse, stated she was the nurse on duty for the hall R1 resides on. V9 stated she became aware this morning when she came on duty that R1 did not have any Norco present in the medication cart when the night shift nurse gave her report. V9 confirmed it had been 3 days since R1's Norco had run out of supply. On 4/24/25 at 12:20 PM, the medication cart for the hall R1 resides on did not have any of the Norco medication for R1. On 4/24/25 at 12:25 PM, R1's Medication Administration Record documents R1 had not received any Norco since 4/21/25 at 4:30 PM. On 4/24/25 at 12:25 PM, R1's Controlled Drug Receipt/ Record/ Disposition Form dated 4/9/25 documents R1 had received a refill of Norco which was sent from the pharmacy in an amount of 12 tablets. This form documents R1 had requested and received three or four tablets per day since the date of receipt until 4/21/25 at 4:30 PM when the tablet count reached zero. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146017 If continuation sheet Page 5 of 5