Health inspection·June 15, 2023

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Many Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the required 80 square feet per resident bed for 42 residents of 42 residents (R1-R6, R8-R15, R17-R22, R24-R27, R29, R31-R34, R36R39, R41-R46, R49, R50, and R111) reviewed for room size in the sample of 52. Findings Include: On 6/14/23 beginning at 2:45 PM, V5 (Assistant Maintenance Director) accompanied by this surveyor measured resident rooms that didn't meet the required 80 square foot per resident. The measurements were as follows: A hall room [ROOM NUMBER], 2, and 3 measured at 141 1/2 (inches) x 150 1/8 which equals 147.52 square (sq) feet, which indicates 73.76 sq feet per person. room [ROOM NUMBER] measured at 150 x 150 1/8 which equals 156.38 sq feet, which indicates 78.19 sq feet per person. room [ROOM NUMBER] measured at 141 1/4 x 149 1/2 which equals 146.65 sq feet, which indicates 73.32 sq foot per person. room [ROOM NUMBER] measured at 146 x 150 which equals 152.08 sq feet, which indicates 76.04 sq feet per person. room [ROOM NUMBER] measured at 140 1/8 x 151 1/4 which equals 147.17 sq feet, which indicates 73.59 sq feet per person. room [ROOM NUMBER] measured at 138 1/4 x 150 1/2 which equals 144.49 sq feet, which indicates 72.24 sq feet per person. room [ROOM NUMBER] measured at 141 1/2 x 150 3/4 which equals 148.13 sq feet, which indicates 74.07 sq feet per person. room [ROOM NUMBER] and 11 measure at 140 1/2 x 150 1/2 which equals 146.84 sq feet, which indicates 73.42 sq feet per person. (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 3 Event ID: 146032 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 146032 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairview Rehab & Healthcare 602 East Jackson Du Quoin, IL 62832 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)