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. Page 1 of 3 146032 146032 06/15/2023 Fairview Rehab & Healthcare 602 East Jackson Du Quoin, IL 62832

F 0912 Level of Harm - Potential for minimal harm room [ROOM NUMBER] measured at 221 1/2 x 149 1/4 which equals 229.57 sq feet, which indicates 76.53 sq feet per person. room [ROOM NUMBER] measured at 221 3/8 x 150 1/2 which equals 231.11 sq feet, which indicates 77.12 sq feet per person. Residents Affected - Many room [ROOM NUMBER] measured at 148 1/2 x 150 1/2 which equals 155.20 sq feet, which indicates 77.60 sq feet per person. B hall room [ROOM NUMBER] and 5 measured at 142 1/2 x 150 1/2 which equals 148.93 sq feet, which indicates 74.47 sq feet per person. room [ROOM NUMBER] measured at 142 x 150 1/2 which equals 148.41 sq feet which indicates 74.20 sq feet per person. room [ROOM NUMBER] and 9 measured at 141 1/4 x 151 which equals 148.11 sq feet, which indicates 74.06 sq feet per person. room [ROOM NUMBER] measured at 142 1/2 x 151 which equals 149.43 sq feet, which indicates 74.71 sq feet per person. room [ROOM NUMBER] measured at 141 1/2 x 150 1/2 which equals 147.89 sq feet, which indicates 73.94 sq feet per person. room [ROOM NUMBER] measured at 140 1/4 x 150 1/2 which equals 146.58 sq feet, which indicates 73.29 sq feet per person. room [ROOM NUMBER] measured at 142 1/4 x 150 3/8 which equals 148.30 sq feet, which indicates 74.27 sq feet per person. room [ROOM NUMBER] measured at 140 1/2 x 150 1/2 which equals 146.84 sq feet, which indicates 73.42 sq feet per person. room [ROOM NUMBER] measured at 223 x 150 which equals 232.29 sq feet, which indicates 77.43 sq feet per person. room [ROOM NUMBER] measured at 148 1/2 x 149 3/4 which equals 154.43 sq feet, which indicates 77.21 sq feet per person. This surveyor observed all of the rooms that were measured, and they each had one or two beds, one or two nightstands, dressers, and over the bed tables. Some of the rooms observed/measured contained adaptive equipment such as wheelchairs and walkers, and some contained recliners. The Resident Census List dated 6/12/23 documents R1-R6, R8-R15, R17-R22, R24-R27, R29, R31-R34, R36- R39, R41-R46, R49, R50, and R111 live in rooms 1-12, 14, 15 on A Hall and rooms 1-10, 12 and 13 on B Hall. 146032 Page 2 of 3 146032 06/15/2023 Fairview Rehab & Healthcare 602 East Jackson Du Quoin, IL 62832

F 0912 On 6/14/23 at 2:50 PM, R18 stated she had enough space in her room for her belongings Level of Harm - Potential for minimal harm On 6/14/23 at 3:04 PM, R14 stated he had enough space in his room. Residents Affected - Many On 6/14/23 at 3:13 PM, R29 stated he didn't really have enough space in his room because his roommate had a wheelchair that took up the space. On 6/14/23 at 3:17 PM, R9 denied concerns with the space in her room. On 6/14/23 at 3:25 PM, R6 stated he had enough space, but it does get a little crowded when they put another bed in it. R6 stated his current roommate sleeps in a recliner so right now there is only one bed. On 6/14/23 at 3:25 PM, V5 stated, the following rooms were licensed for three residents, B12, A12, and A14. On 6/15/23 at 8:57 AM, V1 (Administrator) stated the following rooms have less than the required 80 square foot per resident and are Medicaid certified beds, A hall- rooms 1-12 and rooms [ROOM NUMBERS], B hall rooms 1-10 and rooms [ROOM NUMBERS]. V1 stated rooms [ROOM NUMBERS] on A hall and room [ROOM NUMBER] on B hall are licensed for 3 residents but they only have two residents in each of those rooms. V1 stated she hasn't had any concerns brought to her that residents don't have enough space in their rooms for the necessary items and is not aware of any falls/injury related to the space of the resident rooms. 146032 Page 3 of 3