Health inspection·October 5, 2022

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify a resident's physician and resident's representative of a new pressure area. The facility also failed to notify a resident's representative of an increase in a psychotropic medication for two of 12 residents (R30, R40) reviewed for notification in the sample list of 24. Findings include: The facility's Notification of Change in Resident Condition or Status policy with a revised date of 12/7/17 documents, Policy: The facility and/or facility staff shall promptly notify appropriate individuals (i.e. {for example} Administrator, DON {Director of Nursing}, Physician, Guardian, HCPOA {Health Care Power of Attorney}, etc. {etcetera}) of changes in the resident's medical/mental condition and/or status. Procedure: 1. The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: f. A need to alter the resident's medical treatment significantly; o. Onset of pressure ulcers or stasis ulcers. 3. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. 5. The nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 1.) R40's Physician Order Sheet (POS) dated 10/1/22 through 10/31/22 documents diagnoses including Vascular Dementia without Behavior Disturbances, Osteoporosis, Cerebral Infarction, Alzheimer's and Bipolar Disorder. This POS documents the only skin orders as a skin check weekly and anti-fungal powder to the left arm pit prophylactically. R40's Nurse's Notes dated 9/29/22 at 1:00 AM documents a new pressure area to coccyx observed during rounds this shift. 2 cm (centimeters) x (by) 2 cm round pressure wound to coccyx. Newly acquired skin condition report started by writer. Will have next shift notify all parties and obtain orders. Signed by V12 (Licensed Practical Nurse.) On 10/4/22 at 10:54 AM, V2 (Director of Nursing) stated that V2's expectation of nurses when a new skin area is observed is that they would fill out a newly acquired skin sheet and give it to V2 and notify the resident's family and the physician. V2 confirmed V2 did not receive a new skin sheet for R40's new area. 2.) R30's Minimum Data Set (MDS) dated [DATE] documents R30 was diagnosed with Depression. R30's Physician Order Sheet (POS) dated 5/27/22 documents R30 was prescribed Sertraline (Antidepressant medication) 75 milligrams, one time per day for Depression. R30's Physician Order Sheet date 6/24/22 documents R30's prescribed Sertraline 75 milligrams was increased to 100 milligrams, one time per day for Depression. R30's Progress Notes do not document V19 (Power of Attorney for Health Care/HPOA) was notified of R30's increase of Sertraline from 75 milligrams to 100 milligrams a day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 2 of 11 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 146104 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of Farmer City 404 Brookview Drive Farmer City, IL 61842 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 10/4/22 at 1:30 PM V17 (Licensed Practical Nurse/Minimum Data Set Coordinator) said, R30 was sent to the hospital on 5/28/22 and returned on 6/24/22 with new orders to increase R30's Sertraline from 75 milligrams to 100 milligrams. V17 said, since R30 has a legal HPOA, the facility should have notified V19 (R30's HPOA) that R30's Sertraline was increased from 75 milligrams to 100 milligrams a day. V17 said, there is no documentation in R30's chart that the facility notified V19 of the increase in R30's medication dosage. V17 said, the facility should have informed V19 of this increase when R30 was admitted back into the facility. Event ID: Facility ID: 146104 If continuation sheet Page 3 of 11 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 146104 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of Farmer City 404 Brookview Drive Farmer City, IL 61842 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a resident's room in clean condition. This failure affects one (R26) of 16 residents reviewed for a clean environment on the sample list of 24 residents. Findings include: R26's Face Sheet (undated) documents R26 was admitted to the facility on [DATE]. On 10/2/22 at 9:17am, a dark black, kidney bean shaped, approximately 24 x 24 inches in size mark was noted on R26's floor. On 10/3/22 at 11:38am, R26 is currently in isolation but remains in same room. R26's floor observed with the same above noted marking and dark brown food debris noted on floor in front of R26's recliner. On 10/4/22 at 1:30pm, R26 observed sitting in recliner with bedside table next to recliner. On top of the bedside table was the following: four disposable drinking cups containing various fluids; the remnants of lunch on disposable plates stacked on top of each other and multiple open condiment wrappers. The garbage can next to R26's recliner was observed with no garbage can liner, reddish brown drip marks on the inside of the can, and various tissues/garbage inside. Also observed various food debris on the floor around R26's bedside table and recliner. A full black trash bag was observed next to the inside of R26's room door. The same dark black, kidney bean shaped mark was noted on R26's floor. R26 stated no one has been in here to clean recently. I know it's messy. On 10/4/22 at 1:58pm, V1 (Administrator) stated V18 (Housekeeping Supervisor) has been off on leave and V16 (Maintenance) has been cleaning also. V1 stated, I will have V16 come down and clean in here, resident rooms should be cleaned daily. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 4 of 11 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 146104 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of Farmer City 404 Brookview Drive Farmer City, IL 61842 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. 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 ensure residents remain free from physical restraints by failing to obtain an order for restraints and failing to accurately assess the resident's ability to release the safety belt for one of four residents (R21) reviewed for physical restraints in the sample list of 24. Residents Affected - Few Findings include: The facility's undated Physical Restraint/Enabler policy documents, Policy: To allow residents to be free of physical restraints which are not required to treat the resident's medical symptoms or as a therapeutic intervention. Physical restraints shall not be used for the purpose of discipline or convenience. R21's Minimum Data Set (MDS) dated [DATE] documents R21 was admitted to the facility on [DATE]. This MDS documents R21 has severe cognitive impairment and documents R21 has diagnoses including Medically Complex Conditions, Anxiety, Depression, Muscle Weakness and Alzheimer's Disease. This MDS documents that R21 has a Physical Restraint used daily. This MDS also documents that R21 requires extensive assistance of one staff member for transfers. R21's Physician Order Sheet dated 10/1/22 through 10/31/22 does not have an order documented for the self-releasing safety belt. R21's Physical Restraint/Enabler Consent form dated 7/15/22 documents the reason for the restraint is Posterior Pelvic Tile and leaning forward unsafely. This form documents the type of restraint as a self-releasing safety belt and documents alternatives tried as a (brand name) cushion, therapy and repositioning. R21's Physical Enabler/Restraint Use/Reduction Evaluation form documents an evaluation was completed on 7/15/22 and 8/3/22. This form documents the diagnoses used for this restraint as Alzheimer's and this form documents R21 can release the safety belt R21's self. R21's A.I.M. (Assess, Intercommunicate, Manage) report dated 7/14/22 documents R21 had a fall out of R21's wheelchair. This report documents the self-releasing safety belt was applied as an intervention for this fall. On 10/2/22 at 9:37 AM, R21 was in R21's room sitting in a recliner, V4 (Certified Nursing Assistant) was in R21's room feeding R21 and R21's roommates. On 10/2/22 at 12:20 PM R21 was in the dining room sitting at the dining table in R21's wheelchair feeding R21's self. R21 did not appear to be leaning at that time. On 10/3/22 at 8:31 AM, R21 was in the dining room at the dining table sitting in R21's wheelchair being fed by V5 (Certified Nursing Assistant). R21 was sitting up and not leaning at that time. On 10/3/22 at 8:42 AM, R21 was in R21's wheelchair sitting in the hallway outside of the dining room. R21 was sitting up and not leaning in the wheelchair. R21 did have the self-release safety on and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 5 of 11 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 146104 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of Farmer City 404 Brookview Drive Farmer City, IL 61842 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 0604 fastened in front of R21's waist. Level of Harm - Minimal harm or potential for actual harm On 10/4/22 at 10:54 AM, R21 was in R21's room with V10 and V5 (Certified Nursing Assistants). V10 asked R21 if R21 could remove the self-releasing safety belt. R21 did not acknowledge V10's request. V10 asked another time and told R21 they could remove it and stand up. R21 did not respond. R21 appeared to stare off into the room. At that time V5 approached R21 and pointed to the self-releasing safety belt and asked R21 if R21 could take it off. R21 did not respond. R21 stared off into the room and did not acknowledge their requests. Residents Affected - Few On 10/4/22 at 2:00 PM, V2 (Director of Nursing) stated that there was one fall in July and then R21 kept standing up out of the wheelchair, so they put the self-releasing seat belt on R21. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 6 of 11 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 146104 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of Farmer City 404 Brookview Drive Farmer City, IL 61842 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 thoroughly assess, monitor, and obtain a treatment for a newly identified pressure wound for one of four residents (R40) reviewed for pressure ulcers in the sample list of 24. Residents Affected - Few Findings include: The facility's Pressure Sore Prevention Guidelines policy with a revised date of 4/2006 documents, Procedure: The nurse will complete a skin assessment on all residents upon admission then weekly for four weeks. After the weekly assessments are completed, they must then be done with the annual and quarterly MDS (Minimum Data Set), with significant change in condition, or if a pressure sore develops. The following guidelines will be implemented for any resident assessed at a Moderate or High skin risk. Turn and reposition every two hours, Range of Motion, Special Mattress, Incontinence Care, Daily Skin Checks, Quarterly Review by the Dietary Manager, Nutritional Supplement and Care Plan Entry. Any resident scoring a High or Moderate risk for skin breakdown will be noted on the Treatment sheet and signed off by the nurse. In addition, a brief weekly narrative will be completed describing the resident's skin condition on the back of the treatment sheet. The facility's Decubitus Care/Pressure Areas policy with a revised date of 1/2018 documents, Policy: It is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer. Procedure: 1) Upon notification of skin breakdown, the QA (Quality Assurance) form for Newly Acquired Skin Condition will be completed and forwarded to the Director of Nurses. 2) The pressure area will be assessed and documented on the Treatment Administration Record or the Wound Documentation Record. 3) Complete all areas of the Treatment Administration Record or Wound Documentation Record. i) Document size, stage, site, depth, drainage, color, odor, and treatment (upon obtaining from physician). 4) Notify the physician for treatment orders. 5) Documentation of the pressure area must occur upon identification and at least once each week on the TAR (Treatment Administration Record) or Wound Documentation Form. The assessment must include: i) Characteristic (i.e. {for example} size, shape, depth, color, presence of granulation tissue, necrotic tissue, etc.) ii) Treatment and response to treatment. R40's Physician Order Sheet (POS) dated 10/1/22 through 10/31/22 documents diagnoses including Vitamin B deficiency, Vascular Dementia without Behavior Disturbance, Osteoporosis, Cerebral Infarction, Vitamin B12 deficient Anemia, Edema, Alzheimer's, and Congestive Heart Failure. This POS documents orders for skin checks weekly and an order for an antifungal for the left arm pit prophylactically. This POS documents R40 was admitted to the facility on [DATE]. R40's Braden Skin Risk assessment dated [DATE] and 9/21/22 documents R40 is a high risk for skin impairment. There are no further skin risk assessments as the policy documents there will be. R40's Nurse's Notes dated 9/29/22 at 1:00 AM, documents, new pressure are to the coccyx observed during round this shift 2 cm x 2 cm round, pressure wound to coccyx newly acquired skin condition report started by writer will have next shift notify all parties and obtain tx (treatment) orders. (Transparent) dressing applied as a nursing measure until tx orders can be obtained. R40's Nurse's Notes do not document any further notes. R40's Treatment Administration Record (TAR) dated 9/14/22 through 9/30/22 documents an order for weekly skin checks (not daily as the policy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 7 of 11 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 146104 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of Farmer City 404 Brookview Drive Farmer City, IL 61842 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 0686 Level of Harm - Minimal harm or potential for actual harm documents for high risk) and there are no days signed out as completed. 9/21/22 and 9/28/22 are highlighted but there is no signature in any dates for skin checks. There is no treatment order on the TAR for a pressure wound to the coccyx. R40's TAR dated 10/1/22 through 10/31/22 documents an order for weekly skin checks and a treatment order for an antifungal to the left arm pit prophylactically but no other treatments are documented on this TAR. There is no treatment order for a wound on R40's coccyx. Residents Affected - Few On 10/3/22 at 10:02 AM, R40 was in bed laying on R40's right side with a pillow between R40's knees. On 10/3/22 at 11:17 AM, V4 and V5 (Certified Nursing Assistants) prepared to perform incontinent care on R40. V4 and V5 removed R40's incontinent brief. There was an open area on R40's coccyx approximately 2 cm (centimeters) by 2 cm. V5 stated that V5 has been putting cream on the area. V5 stated that V5 thinks the nurses know about the area. V5 stated V5 would report any new areas to the nurse's if V5 found one. On 10/4/22 at 10:54 AM, V2 (Director of Nursing) stated that V2's expectation of nurse's when a new skin area is observed is that they would fill out a newly acquired skin sheet and give it to V2 then notify the family and the physician. V2 stated once V2 gets the sheet V2 assesses the area and sends a consult to the wound doctor. V2 confirmed that V2 has not gotten a skin sheet for R40 for the area on R40's coccyx. On 10/3/22 at 3:13 PM, V21 (Licensed Practical Nurse) stated that V21 did not see any information regarding the wound on R40's coccyx. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 8 of 11 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 146104 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of Farmer City 404 Brookview Drive Farmer City, IL 61842 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 provide a resident's oxygen humidifier bottle and change oxygen tubing according to physician orders and facility policy. This failure affects one resident (R13) of two residents reviewed for respiratory care on the sample of 24. Residents Affected - Few Findings include: On 10/3/22 at 10:24 am, the oxygen being supplied from R13's oxygen concentrator was not bubbling through the prefilled humidifier bottle because the water in the humidifier bottle was depleted. The prefilled humidifier bottle, oxygen extension tubing, and nasal cannula tubing were not labeled with a date for when they were last changed. On 10/3/22 at 10:26 am, R13 stated, I asked them for humidifier water last night and it looks like I will ask them again. R13 then stated, With me running at 6 liters (per minute), when those run out of water, it is really hard on my nose. R13 also stated, I couldn't tell you when the last time was, they changed my tubing. R13's Minimum Data Set (MDS) dated [DATE] documents R13 was admitted to the facility 7/4/18. This same MDS documents R13 scored 14 out of a possible 14 on the Brief Interview for Mental Status, rating R13 as cognitively intact with no short term or long-term memory problems and no disorganized thinking. R13's Physician Order Sheet dated for October 2022 documents physician orders for O2 (oxygen) 6 liters (per minute) nasal cannula continuously and Change O2 tubing and humidifier bottle weekly and PRN (as needed). On 10/3/22 at 11:28 am, V2 (Director of Nursing), stated The oxygen and tubing should be changed weekly, and the humidifier bottle should be checked and changed as needed. V2 also stated the oxygen tubing and humidifier bottle should be dated when it was changed. On 10/3/22 at11:35am V2 changed and dated R13's humidifier bottle and oxygen tubing. On 10/3/22 V2 said, R13's water bottle and tubing weren't dated like they should be, staff must have forgot change and date them or just forgot to date them. The facility's policy Oxygen Therapy dated 3/19 (March 2019) documents, Change oxygen tubing/mask/cannula/and/or tracheostomy mask on a weekly basis. If using an oxygen tracheostomy mask, wash with warm soap and water daily, and PRN (as needed) in between changing if needed. Date tubing changes and document on the treatment sheet. If humidification is indicated, date prefilled bottles when changed. Humidifier changes and cleaning is to be documented on the treatment sheet at the time of occurrence. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 9 of 11 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 146104 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of Farmer City 404 Brookview Drive Farmer City, IL 61842 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain pharmacy labels and open dates on insulin pens and failed to discontinue use of eyedrops after the expiration date for two residents (R5, R13) reviewed for medication storage in the sample list of 24. Findings include: The facility's Procurement and Storage of Medications policy with a revised date of 10/2006 documents, 5. All medications brought into the Facility shall be labeled with at least the following information: Name, address and phone number of dispensing pharmacy; resident name, physician name, name and strength of medication, directions for administering, last date dispensed and prescription number; both the brand and generic name if substitution is made; appropriate auxiliary labeling. 7. All medication containers shall be labeled with the date opened by the person breaking the container seal. 14. All discontinued/expired non-controlled medications are to be removed from the active medication storage area, and the quantity should be noted on the medication sheet. All medication should then be returned to pharmacy or destroyed per facility policy as soon as practical. 1.) R5's Physician Order Sheet (POS) dated [DATE] through [DATE] documents the diagnosis of Glaucoma. This POS documents an order for Latanoprost (Prostaglandin analog) 0.005% eye drops, instill one drop into both eyes at bedtime for the diagnosis of Glaucoma with a start date of [DATE]. On [DATE] at 2:45 PM, the North Medication cart review took place with V20 (Licensed Practical Nurse). In the top drawer of the medication cart where the eye drops were stored, there was an eye drop bottle with a pharmacy label for R5. This label documented instructions to discard 6 weeks after opening. The open date written on this bottle was [DATE] and the expiration date written on this bottle was [DATE] (6 weeks after opening). V20 confirmed this was the only bottle of eye drops for R5 and was the bottle that R5 was receiving R5's nightly eye drops from. V20 placed the Latanoprost eye drops back in the cart with the other eye drops. R5's Medication Administration Record (MAR) dated [DATE] through [DATE] documents R5's Latanoprost was signed out as given on [DATE] through [DATE] after the eye drops had expired. R5's MAR dated [DATE] through [DATE] documents R5's Latanoprost was signed out as given on [DATE], [DATE] and [DATE] after the eye drops expiration date. 2.) R13's POS dated [DATE] through [DATE] documents a diagnosis of Type 2 Diabetes Mellitus. This POS documents an order for Tresiba pen (insulin degludec) inject 15 units subcutaneous every morning with an order date of [DATE]. On [DATE] at 2:45 PM, the North Medication cart review took place with V20 (Licensed Practical Nurse). In the top drawer of the medication cart was a Tresiba insulin pen with no pharmacy label on it and no open date written on it. There was no identification on the pen at all. V20 stated that the pen belonged to R13. V20 placed the insulin pen back in the top drawer of the medication cart with the other insulin pens. R13's MAR dated [DATE] through [DATE] documents R13's Tresiba was signed out as given on [DATE], (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 10 of 11 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 146104 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of Farmer City 404 Brookview Drive Farmer City, IL 61842 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 0761 [DATE] and [DATE]. Level of Harm - Minimal harm or potential for actual harm On [DATE] at 12:26 PM, V2 (Director of Nursing) stated that V2's expectation regarding insulin pens for the nurses is that they label the date on them when they take them out of the refrigerator. V2 stated the insulin pens should have the resident's name on it and open date written on them. V2 stated regarding expired eye drops that the nurses should order a new bottle and dispose of the expired bottle. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 11 of 11