Health inspection·November 13, 2023

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to identify repeated episodes of verbal abuse of R28 by V11 (R28's Spouse) and failed to protect the resident's right to be free from verbal, mental, and physical abuse by V11. These failures resulted in V11 being allowed unsupervised visits with R28, subjecting R28 to repeated incidents of verbal and mental abuse by V11, and R28 being hit in the mouth by V11 resulting in psychosocial harm. R28 is one of five residents reviewed for abuse in the sample list of 33. The Immediate Jeopardy began on 10/26/23 at 6:50 PM when V11 was witnessed hitting R28 in the mouth. V1 (Administrator) was notified of the Immediate Jeopardy on 11/8/23 at 9:30 AM. The surveyor confirmed through observation, interview, and record review that the Immediate Jeopardy was removed on 11/13/23, but noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: The facility's Abuse Prevention policy revised 11/28/16 documents: The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. The facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our residents. This facility is committed to protecting our residents from abuse by anyone including but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Mental Abuse includes, but is not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident(s), harassment, or humiliation and threats of punishment or deprivation. Physical Abuse including hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. The Facility Reported Incidents report form dated 10/27/23 at 5:27 PM documents on 10/26/23 V9 (Visitor) reported that V11 was feeding R28, R28 refused and pushed V11's hand away, and V11 hit R28 in the mouth. The facility's (State Surveying Agency) Notification Form dated 11/1/23 documents the incident between V11 and R28 occurred on 10/26/23 at 6:50 PM. This form documents the facility found no intentional abuse on V11's part. The facility instructed V11 not to feed R28 again, the staff will feed R28, and V11 was educated on Dementia and R28 not wanting to eat. The Incident Investigation Form dated 10/26/23 at 10:00 PM documents V2's (Director of Nursing/DON) interview. V2 was approached by V9 who reported that V11 struck R28 in the mouth with V11's hand at the dining room table, and V11 was swearing at R28. V2 immediately approached V11 and R28. V11 stated (R28) won't eat. (R28) don't got a brain in (R28's) head. V11 continued to belittle R28. V11 and R28 were separated. V11 went home. V2 asked R28 where V11 hit R28, and R28 pointed to R28's mouth. R28 had no signs of injury or pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 2 of 38 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 11/13/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few The Incident Investigation Form dated 10/27/23 at 9:45 AM documents: V1 interviewed V10 (Visitor), V10 witnessed V11 feeding R28 in the dining room, and R28 kept moving R28's head back not wanting to eat. R28 pushed V11's hand away and V11 hit R28 in the mouth and told R28 if you don't want to (expletive) eat, you (R28) can starve. The Incident Investigation Form dated 10/30/23 at 12:05 PM documents V1 interviewed V9 regarding the incident, and V9 stated that V9 witnessed V11 trying to force R28 to eat while R28 kept tilting R28's head back. It looked like V11 had food in V11's hand and was holding it up to R28's mouth. R28 said No, no I (R28) don't want it and V11 kept trying to feed R28. V11 then hit R28 in the mouth with V11's fist. V9 yelled out for V11 to stop and V9 sent V17 (Visitor) to get a nurse. The Incident Investigation Form dated 10/27/23 at 11:30 AM documents: V1 interviewed V11 regarding the incident, V11 denied hitting R28 and V11 said V11 was trying to feed R28 a cookie. V11 stated V11 might have cursed at R28. V11 said R28 is going to starve and V11 just wants R28 to eat, and R28 has not been the same since R28 fell at home and broke R28's hip. V1 tried to explain Dementia to V11 and will provide V11 with additional support. V1 asked for V16 (R28's Power of Attorney) to come to the facility with V11 after the investigation and put a plan in place to keep R28 safe while V11 visits. The Incident Investigation Form dated 10/27/23 at 2:00 PM documents: R28 was interviewed by V4 (Social Services Director). R28 was asked if R28 could remember V11 visiting the night before. R28 replied yes. R28 was asked if R28 could tell V4 what happened and R28 did not answer. R28 was asked if V11 hollered at R28 and R28 replied yes. R28 was asked if V11 hit R28 and R28 said no, that V11 fell on (R28). R28 was asked if V11 hit R28 at home and R28 replied yes all the time. R28 stated He has been hitting me since I was a little girl. The Incident Investigation Form dated 10/31/23 at 9:15 AM documents the Interdisciplinary Team reviewed the incident and agreed that V11 can continue to visit, but V11 is not to feed R28 during V11's visits. R28's admission Minimum Data Set, dated [DATE] documents R28 has severe cognitive impairment. R28's November 2023 Physician Order Summary documents R28 has Dementia. R28's medical record does not contain a comprehensive care plan to address R28's risk for abuse or incidents of abuse from V11. There is no documentation that the facility implemented increased supervision of R28 during V11's visits. V11 and R28 were in R28's room unsupervised and without staff present on 11/05/23 at 11:00 AM and 11:40 AM, on 11/6/23 at 9:43 AM, 9:58 AM, 10:00 AM, 10:15 AM, 11:03 AM, and on 11/7/23 at 10:48 AM. On 11/06/23 at 9:15 AM V7 (Certified Nursing Assistant/CNA) stated V11 and R28 are hateful towards each other and this was prior to the incident on 10/26/23. V7 stated V11 is no longer allowed to feed R28, and V11 visits with R28 in R28's room or in the dining room without staff supervision. On 11/6/23 at 9:22 AM V8 (CNA) stated V11 has been frustrated with R28 while feeding R28. V11 has called R28 stupid, idiot, [NAME] and R28 was tearful. V11 stated this used to happen daily during V11's visits prior to the physical abuse of V11 hitting R28 in the mouth. V8 stated R28 has told V8 that R28 and V11 have been together since R28 was 16 and that V11 has always been that way. V8 stated the incidents have occurred on second shift. V8 stated V8, V18 (CNA), and a few other unidentified CNAs on second shift have reported the incidents to V3 (Assistant DON) on several occasions and was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 3 of 38 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 11/13/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few told that V11 had been spoken to. At 10:39 AM V8 stated abuse allegations are reported immediately to V1 and usually V1 is gone in the evenings. V8 stated V3 was working in the facility when the incidents occurred, which is why V8 reported to V3. V8 confirmed V8 specifically told V3 the names that V11 called R28. V8 confirmed V8 did not report the incidents to V1. On 11/06/23 at 9:48 AM V9 stated during supper on 10/26/23 R28 was sitting at a table that was directly in front of (family member's) table where V9 was sitting, and V9 had a clear view of R28 and V11. V9 stated R28 moved R28's head back multiple times while V11 fed R28. V9 heard R28 say stop, stop, I don't want it. V9 stated V9 then witnessed V11 pull V11's hand back, there was no food in V11's hand, and V11 hit R28 in the mouth with V11's closed fist. V9 stated V9 told V11 to stop and sent V17 to get a nurse. V9 stated V17 did not witness the incident. V10 was also present and may have witnessed the incident. V9 stated there was no staff present in the dining room during the incident. V9 stated V11 said that R28 was worthless, made belittling comments, and said you're stupid to R28. V9 stated it was very mean what (V11) did to (R28). R28 was just quiet and did not say anything back to V11. At 1:03 PM V9 stated V9 did not know R28 or V11 prior to their family member being admitted to the facility. V9 stated V9 does not know V11 and R28 personally. On 11/06/23 at 10:10 AM V18 (CNA) stated prior to that night (10/26/23) on multiple occasions, almost every night V11 would feed R28, call R28 stupid, yell at R28 and degrade R28. V18 stated R28 would cry or go silent in response to V11's actions. One night V11 asked R28 why R28 was crying and R28 stated because you (V11) yelled at me (R28). V18 stated it was verbal abuse the way (V11) treated (R28). V18 stated V19 (CNA), V25 (CNA), V26 (CNA), and V27 (Unit Aide) have also witnessed these interactions as well. V18 stated V18 reported V11's actions to V3 (Assistant DON). V3 said V3 would talk with V1 (Administrator), and V3 later told V18 that V1 was made aware. V18 stated V18 asked V3 about separating V11 and R28 and was told that V11 is R28's spouse who pays for R28 to live in the facility. On 11/06/23 at 3:32 PM V19 (CNA) stated when V11 would feed R28, V11 would raise V11's voice at R28 and call R28 ignorant and stupid. V19 stated it happened often, and confirmed the incidents were prior to the 10/26/23 incident. V19 stated R28 would get upset and ask V11 why V11 was talking to R28 like that. V19 confirmed V19 did not report the incidents to V1. On 11/06/23 at 10:29 AM V3 was asked about V11's interactions with R28. V3 stated there are constant issues and V11 gets frustrated with R28 not wanting to eat. V3 stated unidentified staff mentioned in general to V3 that V11 would get frustrated and general concerns with how V11 would speak to R28. V3 stated V3 reminded V11 to be mindful of how V11 spoke to R28. V3 stated V3 discussed during the morning interdisciplinary team meetings to pay attention to V11's interactions with R28. V3 stated V3 would have reported immediately to V1 if staff told V3 that V11 called R28 names such as idiot, stupid, or [NAME]. On 11/6/23 at 10:44 AM V2 (DON) stated the night of the incident V17 reported to V2 that V11 was trying to force food into R28's mouth, R28 wouldn't eat, and V11 hit R28 in the mouth. V2 witnessed V11 say, with R28 present, that R28 doesn't have a brain, in reference to R28 not eating. V2 described V11 as being really frustrated that R28 would not eat, and R28 was sitting there with R28's eyes closed. V2 stated V2 asked R28 where V11 hit R28, and R28 pointed to R28's mouth. V2 stated V9's family member has only been in the facility for about a week, and V2 has no reason not to believe V9's description of the incident. On 11/06/23 at 11:06 AM V1 stated during a morning meeting, V3 mentioned that V3 had spoken to V11 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 4 of 38 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 11/13/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few about V11 getting overwhelmed with R28 not eating. V1 stated nothing was brought up about V11 being abusive towards R28. V1 confirmed calling a resident an idiot, stupid, [NAME] would be verbal abuse. V1 stated V1 would have initiated investigations into V11's interactions with R28 just like the incident on 10/26/23, suspended V11's visits during the investigations, restricted V11 from feeding R28, and V1 possibly would have implemented supervised visits for V11 and R28. V1 stated V1 interviewed V10 and V10 witnessed V11 trying to make R28 eat, as R28 moved R28's head away (V11) went like this, and V1 demonstrated a close fist touching her mouth. V1 confirmed V10 reported hearing V11 say you (R28) can (expletive) starve then. V1 stated V11 told V1 that V11 may have cursed at R28 but did not hit R28. V11 reported that V11 had a piece of a cookie pushed up against R28's mouth. V1 stated V1 interviewed V9 and V9 told V1 that V11 kept trying to feed R28, R28 did not want to eat, and V11 hit R28 in the mouth. V1 stated abuse was not substantiated; the incident was discussed with the interdisciplinary team, and it was decided that V11 is no longer allowed to feed R28. V1 confirmed the facility has not implemented supervised visits for V11 and R28 after the 10/26/23 incident. On 11/07/23 at 9:52 AM V16 (R28's Power of Attorney) stated R28 has Dementia, and this has affected R28's ability to recognize hunger. V16 stated V16 has tried to explain that to V11, but V11 thinks R28 will get better and return home. V16 was asked prior to R28's dementia, how would R28 have felt or responded to V11's verbal treatment and being hit in the mouth in front of other residents and visitors. V16 stated R28 would have yelled back at V11. V16 was asked if R28 would have felt humiliated, embarrassed, upset, or tearful and V16 replied R28 would have probably felt all those things. The Immediate Jeopardy that began on 10/26/23 was removed on 11/13/23 when the facility took the following actions to remove the immediacy: 1.) On 11/9/23 at 8:55 am, V1 (Administrator) confirmed the facility held a care plan meeting with V16 (R28's POA) on 11/8/23 to inform V16 that V11 (R28's spouse) will have to check in with the manager on duty before the start of each visit, only be allowed to visit in common areas, and that staff will check on R28 after each visit to ensure R28's safety. 2.) On 11/9/23 between 8:30 am - 8:55 am, V29 (Licensed Practical Nurse/LPN), V30 (CNA), V31 (Activity Director) and V1 all confirmed that a staff member would be assigned to make visual checks on R28 every 15 minutes while V11 was at the facility visiting. On 11/13/23, these visual checks were provided to the survey team. The visual checks dated 11/9/23, 11/11/23, and 11/12/23 document R28 was checked on every 15 minutes. On 11/13/23 between 9:00 AM and 9:30 AM, V1, V3, and V28 (Licensed Practical Nurse) stated that V11 did not visit on 11/10/23. 3.) On 11/9/23 at 1:10 PM, V1 provided an in-service sheet dated 11/8/23 that documents V41 (Regional Director of Clinical Operations) provided education to V1 and V2 regarding the facility Abuse and Neglect Policy. 4.) On 11/9/23 at 1:10 PM, V1 provided in-service sheets dated 11/8/23 and 11/9/23 that document all but six staff have been in-serviced by V1 and V2 on the facility Abuse Prevention Policy and Procedure. At this time, V1 stated the six staff that are not educated yet will not be allowed to work until they have received the education. On 11/13/23 at 9:15 am, V1 provided a phone listing for in-services completed over the phone for the remaining six staff. Five were provided education on 11/9/23 however one Agency CNA, V37, has not received the abuse in-service training. At this time, V1 explained V37 is an agency staff and has not returned the phone call, but that V37 will not be allowed to work at the facility until V37 has received the training. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 5 of 38 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 11/13/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 5.) On 11/9/23 at 2:00 PM, V1 provided Abuse Risk Assessments for all but two residents. V1 stated V1 was waiting for families to get back with V1 to complete the assessment for these residents. At this time, V1 also stated that any resident who answered yes to any of the questions will have an abuse risk care plan developed with specific interventions however that has not been done yet. On 11/13/23 at 9:00 am, V1 provided the Risk for Abuse Care Plans for all at risk residents and stated the facility is still waiting to complete two assessments. On 11/13/23 between 10:20 - 10:23 am, V1 provided the final two Abuse Risk Assessments dated 11/13/23, to make 100% of the residents now being assessed. 6.) On 11/13/23 between 9:00 am - 9:30 am, V1 stated V1 will continue to in-service staff on abuse monthly and the next in-service is schedule for 11/25/23. 7.) On 11/13/23 between 9:00 am - 9:30 am, V1 stated that no new employees have been hired, but that V1 is responsible for providing Abuse Prevention training for all new employees during their orientation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 6 of 38 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 11/13/2023 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 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Level of Harm - Actual harm Residents Affected - Some **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R45's Physician's Order Sheet (POS) for November 2023 includes the following diagnoses: Dementia with Behavioral Disturbance, Depression, Anxiety, Insomnia, and History of Fall with Hip Fracture. R45's Minimum Data Set (MDS) dated [DATE] documents R45 is severely cognitively impaired, is wheelchair bound, and requires moderate to maximum staff assistance to complete Activities of Daily Living (ADLs). R45's skilled nurse's note date 6/18/23 at 7:15AM documents Noted Bruising on (R45's) left hand that extends up to forearm. Area measures 21 centimeters by 14 centimeters. Purple and black in color. (R45) denies pain or discomfort. (R45) is unsure how (R45) obtained bruise. Staff will monitor for changes until resolved. Nurse Practitioner notified and family notified. Power of Attorney voiced understanding. R45's skilled nurse's note date 6/19/23 at 3:10PM documents CNA advised writer about large hematoma and bruising to left wrist. Writer observed (R45) to have a golf ball sized hematoma to left wrist and bruising covering most of the arm to the elbow. Resident complains of pain to the hematoma. Will advise day nurse to get X-ray orders from Nurse Practitioner. Writer attempted to apply ice pack. (R45) refused and wouldn't leave ice pack on. On 11/6/23 V1 (Administrator) stated I've checked with (V2) the Director of Nursing and this injury was not reported. We do not have an investigation for an injury of unknown origin. Based on interview and record review the facility failed to ensure repetitive allegations of verbal and mental abuse and an injury of unknown origin were reported to the administrator, and timely report an allegation of abuse to the state survey agency. These failures affect two (R28, R45) of five residents reviewed for abuse in the sample list of 33. These failures resulted in R28 being subjected to repeated incidents of verbal/mental abuse, and physical abuse by V11 (R28's Spouse) resulting in psychosocial harm for R28. Findings include: The facility's Abuse Prevention policy revised 11/28/16 documents: Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Mental Abuse includes, but is not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident(s), harassment, or humiliation and threats of punishment or deprivation. Physical Abuse including hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Employees are required to immediately report any occurrences of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property to a supervisor and administrator. Supervisors shall immediately inform the administrator or his/her designated representative (specified by the administrator in the case of a planned absence) of all reports of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property. The nursing staff is additionally responsible for reporting on a facility incident report the appearance of bruises, lacerations, other abnormalities, or injuries, of unknown origin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 7 of 38 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 11/13/2023 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 0609 as they occur. Upon report of such occurrences, the nursing supervisor is responsible for assessing the resident, reviewing the documentation and reporting to the administrator or designee. Level of Harm - Actual harm Residents Affected - Some 1.) The Facility Reported Incidents report form (initial notification to state survey agency) dated 10/27/23 at 5:27 PM documents on 10/26/23 a visitor (V9 Visitor) reported that V11 was feeding R28, R28 refused and pushed V11's hand away, and V11 hit R28 in the mouth. The facility's Notification Form dated 11/1/23 documents the incident between V11 and R28 occurred on 10/26/23 at 6:50 PM. The Incident Investigation Form dated 10/26/23 at 10:00 PM documents V2's (Director of Nursing/DON) written interview. V2 stated V2 was approached by V17 (Visitor) who reported that V11 struck R28 in the mouth with V11's hand at the dining room table and V11 was swearing at R28. V2 immediately approached V11 and R28 and V11 stated (R28) won't eat, (R28) don't' got a brain in (R28's) head. V11 continued to belittle R28. V11 and R28 were separated. V11 went home. V2 asked R28 where V11 hit R28, and R28 pointed to R28's mouth. The Incident Investigation Form dated 10/27/23 at 9:45 AM documents V1 interviewed V10 (Visitor) and V10 witnessed V11 feeding R28 in the dining room, and R28 kept moving R28's head back not wanting to eat. R28 pushed V11's hand away and V11 hit R28 in the mouth and told R28 if you don't want to (expletive) eat, you (R28) can starve. The Incident Investigation Form dated 10/30/23 at 12:05 PM documents V1 (Administrator) interviewed V9 regarding the incident and V9 witnessed V11 trying to force R28 to eat while R28 kept tilting R28's head back. It looked like V11 had food in V11's hand and was holding it up to R28's mouth. R28 said No, no I (R28) don't want it and V11 kept trying to feed R28. V11 then hit R28 in the mouth with V11's fist. V9 yelled out for V11 to stop and V9 sent V17 to get a nurse. V1 (Administrator) provided the facility's undated abuse log that was requested for September-November 2023. There is no documentation of abuse allegations involving V11 and R28 besides the incident on 10/26/23. R28's admission Minimum Data Set, dated [DATE] documents R28 has severe cognitive impairment. R28's November 2023 Physician Order Summary documents R28 has Dementia. On 11/6/23 at 9:22 AM V8 (Certified Nursing Assistant/CNA) stated V11 has been frustrated with R28 while feeding R28. V11 has called R28 stupid, idiot, [NAME] and R28 was tearful. V11 stated this used to happen daily during V11's visits prior to the physical abuse of V11 hitting R28 in the mouth. V8 stated R28 has told V8 that R28 and V11 have been together since R28 was 16 and that V11 has always been that way. V8 stated the incidents have occurred on second shift. V8 stated V8, V18 (CNA), and a few other unidentified CNAs on second shift have reported the incidents to V3 (Assistant DON) on several occasions. At 10:39 AM V8 stated abuse allegations are reported immediately to V1 and usually V1 is gone in the evenings. V8 stated V3 was working in the facility when the incidents occurred, which is why V8 reported to V3. V8 confirmed V8 specifically told V3 the names that V11 called R28. V8 confirmed V8 did not report the incidents to V1. On 11/06/23 at 9:48 AM V9 stated during supper on 10/26/23 R28 was sitting at a table that was directly in front of (family member's) table where V9 was sitting, and V9 had a clear view of R28 and V11. V9 stated R28 moved R28's head back multiple times while V11 fed R28. V9 heard R28 say stop, stop, I don't want it. V9 stated V9 then witnessed V11 pull V11's hand back, there was no food in V11's hand and V11 hit R28 in the mouth with V11's closed fist. V9 stated V9 told V11 to stop and sent V17 to get a nurse. V9 stated V17 did not witness the incident. V10 was also present and may have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 8 of 38 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 11/13/2023 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 0609 Level of Harm - Actual harm Residents Affected - Some witnessed the incident. V9 stated there was no staff present in the dining room during the incident. V9 stated V11 said that R28 was worthless, made belittling comments, and said you're stupid to R28. V9 stated it was very mean what (V11) did to (R28). R28 was just quiet and did not say anything back to V11. At 1:03 PM V9 stated V9 did not know R28 or V11 prior to their family member being admitted to the facility. V9 stated V9 does not know V11 and R28 personally. On 11/06/23 at 10:10 AM V18 (CNA) stated prior to that night (10/26/23) on multiple occasions, almost every night V11 would feed R28, call R28 stupid, yell at R28 and degrade R28. V18 stated R28 would cry or go silent in response to V11's actions. One night V11 asked R28 why R28 was crying and R28 stated because you (V11) yelled at me (R28). V18 stated it was verbal abuse the way (V11) treated (R28). V18 stated V19 (CNA), V25 (CNA), V26 (CNA), and V27 (Unit Aide) have also witnessed these interactions as well. V18 stated V18 reported V11's actions to V3 (Assistant DON). V3 said V3 would talk with V1 (Administrator), and V3 later told V18 that V1 was made aware. V18 stated V18 never spoke with V1 regarding V11's interactions with R28. On 11/06/23 at 3:32 PM V19 (CNA) stated when V11 would feed R28, V11 would raise V11's voice at R28 and call R28 ignorant and stupid. V19 stated it happened often, and confirmed the incidents were prior to the 10/26/23 incident. V19 stated R28 would get upset and ask V11 why V11 was talking to R28 like that. V19 confirmed V19 did not report the incidents to V1. On 11/06/23 at 10:29 AM V3 was asked about V11's interactions with R28. V3 stated there are constant issues and V11 gets frustrated with R28 not wanting to eat. V3 stated staff have mentioned in general that V11 would get frustrated and general concerns with how V11 would speak to R28. V3 stated V3 reminded V11 to be mindful of how V11 spoke to R28. V3 stated that staff did not specifically tell V3 what V11 said to R28. V3 stated V3 did not ask staff what V11 has said to R28. V3 stated V3 would have reported immediately to V1 if staff told V3 that V11 called R28 names such as idiot, stupid, or [NAME]. V3 stated V3 discussed during the morning interdisciplinary team meetings to pay attention to V11's interactions with R28. On 11/05/23 at 1:45 PM V2 (DON) stated on 10/26/23 around 6:00 PM V17 approached V2 and reported that V9 witnessed V11 hit R28 in the mouth. V2 stated V1 notified the police and sent in the initial report to the state survey agency. On 11/6/23 at 10:44 AM V2 stated on the night of 10/26/23 V2 went to separate V11 and R28 and witnessed V11 say, with R28 present, that R28 doesn't have a brain, in reference to R28 not eating. V2 described V11 as being really frustrated that R28 would not eat, and R28 was sitting there with R28's eyes closed. V2 stated V2 asked R28 where V11 hit R28, and R28 pointed to R28's mouth. V2 stated nothing had been reported previously about V11's treatment of R28. V2 stated V2 has not been attending morning meetings due to working night shift. On 11/05/23 at 2:40 PM V1 stated the initial report to the state survey agency for the incident on 10/26/23 was not sent in until 10/27/23. V1 stated it was a miscommunication and V1 thought V2 had submitted the report. V1 stated the time frame for reporting abuse allegations to the state survey agency is two hours. On 11/06/23 at 11:06 AM V1 stated during a morning meeting, V3 mentioned that V3 had spoken to V11 about V11 getting overwhelmed with R28 not eating. V1 stated nothing was brought up about V11 being abusive to R28. V1 confirmed calling a resident an idiot, stupid, [NAME] would be considered verbal abuse. V1 stated if staff had reported these prior incidents, V1 would have initiated investigations into V11's interactions with R28 just like the incident on 10/26/23, suspend V11's visits during the investigations, restricted V11 from feeding R28, and V1 possibly would have implemented supervised visits for V11 and R28. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 9 of 38 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 11/13/2023 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 0609 Level of Harm - Actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete On 11/07/23 at 9:52 AM V16 (R28's Power of Attorney) stated R28 has Dementia, and this has affected R28's ability to recognize feeling hungry. V16 stated V16 has tried to explain that to V11, but V11 thinks R28 will get better and return home. V16 was asked prior to R28's dementia, how would R28 have felt or responded to V11's verbal treatment and being hit in the mouth in front of other residents and visitors. V16 stated R28 would have yelled back at V11. V16 was asked if R28 would have felt humiliated, embarrassed, upset, or tearful and V16 replied R28 would have probably felt all those things. Event ID: Facility ID: 146104 If continuation sheet Page 10 of 38 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 11/13/2023 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 0610 Respond appropriately to all alleged violations. 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 thoroughly investigate an allegation of abuse. This failure affects one (R28) of five residents reviewed for abuse in the sample list of 33. Residents Affected - Few Findings include: The facility's Abuse Prevention policy revised 11/28/16 documents abuse allegation investigative procedures include interviewing staff, residents, visitors/family members who were in the vicinity of the incident, and interviewing staff to determine if they have ever witnessed other incidents of mistreatment. The Facility Reported Incidents report form (initial notification to state survey agency) dated 10/27/23 at 5:27 PM documents on 10/26/23 V9 (Visitor) reported that V11 (R28's Spouse) was feeding R28, R28 refused and pushed V11's hand away, and V11 hit R28 in the mouth. The facility's Notification Form dated 11/1/23 documents the incident between V11 and R28 occurred on 10/26/23 at 6:50 PM, the investigation was completed, and the facility did not substantiate abuse. The facility's investigative file for this incident was provided by V1 (Administrator). The file contained written interviews conducted with V17 (Visitor), V2 (Director of Nursing), V16 (R28's Power of Attorney), V10 (Visitor and witness of incident), V11, R28, V9 (Visitor and witness of incident), V33 and V34 Certified Nursing Assistants (CNAs) dayshift CNAs. There were no documented interviews with any second shift (shift the incident occurred on) staff or residents to determine if prior similar incidents were witnessed. R28's admission Minimum Data Set, dated [DATE] documents R28 has severe cognitive impairment. R28's November 2023 Physician Order Summary documents R28 has Dementia. On 11/6/23 at 9:22 AM V8 (CNA) stated V11 has been frustrated with R28 while feeding R28, and that V11 has called R28 stupid, idiot, moron and R28 was tearful. V11 stated this used to happen daily during V11's visits prior to the physical abuse of V11 hitting R28 in the mouth. V8 stated R28 has told V8 that R28 and V11 have been together since R28 was 16 and that V11 has always been that way. V8 stated the incidents have occurred on second shift and have been witnessed by residents. V8 stated V8, V18 (CNA) and a few other unidentified CNAs on second shift have reported the incidents to V3 (Assistant DON) on several occasions and was told that V11 had been spoken to. On 11/06/23 at 9:48 AM V9 stated during supper on 10/26/23 V9 was sitting at a table that was directly in front of R28's table, and V9 had a clear view of R28 and V11. V9 stated R28 moved R28's head back multiple times while V11 fed R28. V9 heard R28 say stop, stop, I don't want it. V9 stated V9 then witnessed V11 pull V11's hand back, there was no food in V11's hand and V11 hit R28 in the mouth with V11's closed fist. V9 stated V9 told V11 to stop and sent V17 to get a nurse. V9 stated V17 did not witness the incident. V10 was also present and may have witnessed the incident. V9 stated there was no staff present in the dining room during the incident, and there were a few residents in the dining room with their back to V11. V9 stated their family member was sitting with V9 when the incident happened, but (he/she) did not witness it. On 11/06/23 at 10:10 AM V18 (CNA) stated prior to that night (10/26/23) on multiple occasions, almost every night V11 would feed R28, call R28 stupid, yell at R28 and degrade R28. V18 stated R28 would cry or go silent in response to V11's actions. One night V11 asked R28 why R28 was crying and R28 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 11 of 38 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 11/13/2023 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated because you (V11) yelled at me (R28). V18 stated it was verbal abuse the way (V11) treated (R28). V18 stated V19 (CNA), V25 (CNA), V26 (CNA), and V27 (Unit Aide) have also witnessed these interactions as well, and other resident(s) may have witnessed it as well. On 11/06/23 at 3:32 PM V19 (CNA) stated when V11 would feed R28, V11 would raise V11's voice at R28 and call R28 ignorant and stupid. V19 stated it happened often, and confirmed the incidents were prior to the 10/26/23 incident. V19 stated R28 would get upset and ask V11 why V11 was talking to R28 like that. On 11/06/23 at 11:06 AM V1 stated V1 conducted the investigation of the 10/26/23 incident. V1 stated V33 and V34 were interviewed as part of the investigation. V1 stated R28 was the only resident besides the resident sitting in the dining room when the incident occurred. V1 confirmed V1 did not interview any second shift staff or other residents including the resident sitting in view of R28's table regarding the incident or prior interactions between V11 and R28. V1 stated the facility did not substantiate abuse, and V1 believes V11 did not intentionally hit R28 in the mouth. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 12 of 38 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 11/13/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a Level II PASARR (Preadmission Screening and Resident Review) was completed for one of one resident (R35) reviewed for PASARR in the sample list of 33. Findings include: R35's November 2023 Physician's Order Summary documents R35 admitted to the facility on [DATE], has a diagnosis of Bipolar and includes orders for Divalproex 250 milligrams (mg) three times daily for Bipolar and Mirtazapine 7.5 mg daily for Bipolar. R35's October and November 2023 Behavior Tracking Records document R35 has manic aggressive outbursts of yelling at staff. R35's undated Problem Detail documents R35 has an active diagnosis of Bipolar since 5/29/20. R35's Notice of PASARR Level 1 Screen Outcome dated 5/13/22 documents a Level II screen was not required due to no diagnoses of Serious Mental Illness, Intellectual Disability, or Related Condition. On 11/05/23 at 1:37 PM V4 (Social Services Director) stated V5 (Business Office Manager) sets up the OBRA (Omnibus Budget Reconciliation Act) screens (a screening form that helps identify reasonable basis to suspect an intellectual/developmental disability or mental illness). V4 stated the OBRA screens are usually completed at the hospital prior to admission and should be in the resident's medical record. V4 confirmed the 5/13/22 PASARR screen is the only documented PASARR in R35's medical record. On 11/06/23 at 2:28 PM V1 (Administrator) stated R35 admitted in June 2022 and V1 did not see a diagnosis of Bipolar on R35's admission history and physical. V1 stated Bipolar is listed as a diagnosis on R35's August 2022 hospital records. V5 (Business Office Manager) stated V5 does not set up OBRA/PASARR screens to be completed after a diagnosis of mental illness is added after admission. On 11/06/23 at 3:13 PM V3 (Assistant Director of Nurses) stated R35 has behaviors including yelling, verbal outbursts, and hallucinations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 13 of 38 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 11/13/2023 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop a baseline care plan to include fall risk and interventions for one (R28) of 13 residents reviewed for care plans in the sample list of 33. Findings include: On 11/05/23 at 10:54 AM V11 (R28's Spouse) stated R28 admitted to the facility after a fall at home with a hip fracture that required surgical repair. V11 stated R28 fell at the facility a few days after admission. R28's admission Minimum Data Set, dated [DATE] documents R28 has severe cognitive impairment and requires extensive assistance of one staff person for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. R28's Fall Investigations dated 9/28/23 at 7:20 PM, 10/7/23 at 6:25 AM, 10/17/23 at 7:45 PM, and 10/20/23 at 11:15 AM document R28's falls. These investigations document R28's fall interventions include hospital evaluation for stent placement, low bed, fall mat, bedroom furniture rearranged, and a pressure alarm. R28's Baseline Care Plan dated 9/25/23 documents R28 has Dementia, Cognitive Impairment, Type 1 Diabetes Mellitus, and includes activity interests. This care plan does not include R28's risk for falls, fall history, or fall interventions. On 11/07/23 at 3:37 PM V2 (Director of Nursing) confirmed R28's baseline care plan does not address R28's fall risk/history or fall interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 14 of 38 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 11/13/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record the facility failed to initiate care plans to include resident centered problems, goals, and interventions for four residents (R11, R15, R28) of 12 residents reviewed for care plans in a sample list of 33. Findings include: 1. R11's Physician's Order Sheet (POS) for November 2023 includes the following diagnoses: Parkinson's Disease, Depression, Anxiety and Chronic Fatigue Syndrome. R11's Minimum Data Set (MDS) dated [DATE] documents R11 is cognitively intact and requires staff assistance or is dependent on staff for Activities of Daily Living (ADLS). On 11/05/23 at 11:55 AM R11 was observed lying in her bed. There was a Stop sign on R11's door. R11 spoke in a very faint voice. R11 stated I can't move very much, and I can't talk very loud because I have Parkinson's Disease. I'm pretty weak. That woman (R15) comes in my room, and she has threatened me. That is why they have the stop sign that is on the door. She just takes it off and comes in anyway. She threatens to hit me. No care plan is documented to address R11's vulnerability to abuse. 2. R15's Physician's Order Sheet (POS) for November 2023 includes the following diagnoses: Mixed Alzheimer's Disease, Vascular Dementia with behavioral disturbances, Anxiety, and Major Depression. R15's MDS dated [DATE] documents R15 is moderately cognitively impaired and experiences verbal and physical behaviors directed toward others which put R15 and others at significant risk for physical injury. No care plan is documented to address R15's vulnerability to abuse or danger to other residents. On 11/9/23 at 2:24PM V2 (Director of Nursing/DON) confirmed Care Plans for R11's vulnerability to abuse, and R15's vulnerability to abuse and danger to others was not documented on their Care Plans and should have been addressed in the Care Plans. 3.) R28's admission Minimum Data Set (MDS) dated [DATE] documents R28 has severe cognitive impairment and requires extensive assistance of one staff person for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. R28's November 2023 Physician Orders Summary documents R28 has Type 1 Diabetes Mellitus, orders for scheduled short and long-acting insulin, and has blood glucose checks scheduled four times daily. R28's November 2023 Medication Administration Record documents R28's blood glucose varies, including being in the 400's (milligrams per deciliter), 500's (milligrams per deciliter), and high on 11/2/23. R28's Fall Investigations dated 9/28/23 at 7:20 PM, 10/7/23 at 6:25 AM, 10/17/23 at 7:45 PM, and 10/20/23 at 11:15 AM document R28's falls. These investigations document R28's fall interventions (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 15 of 38 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 11/13/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few include hospital evaluation for stent placement, low bed, fall mat, bedroom furniture rearranged, and a pressure alarm. The Facility Reported Incidents report form dated 10/27/23 at 5:27 PM documents on 10/26/23 a visitor (V9 Visitor) reported that V11 (R28's Spouse) was feeding R28, R28 refused and pushed V11's hand away, and V11 hit R28 in the mouth. The facility's Notification Form dated 11/1/23 documents the incident between V11 and R28 occurred on 10/26/23 at 6:50 PM. This form documents the facility found no intentional abuse on V11's part. The facility instructed V11 not to feed R28 again, the staff will feed R28, and on Dementia and R28 not wanting to eat. The Incident Investigation Form dated 10/27/23 at 9:45 AM documents V1 (Administrator) interviewed V10 (Visitor), V10 witnessed V11 feeding R28 in the dining room, and R28 kept moving R28's head back not wanting to eat. R28 pushed V11's hand away and V11 hit R28 in the mouth and told R28 if you don't want to (expletive) eat, you (R28) can starve. The Incident Investigation Form dated 10/30/23 at 12:05 PM documents V1 interviewed V9, and V9 witnessed V11 trying to force R28 to eat while R28 kept tilting R28's head back. It looked like V11 had food in V11's hand and was holding it up to V11's mouth. R28 said No, no I (R28) don't want it and V11 kept trying to feed R28. V11 then hit R28 in the mouth with V11's fist. There is no documentation in R28's medical record that a comprehensive care plan with problems, goals, and interventions was developed to address R28's abuse risk/history, Type 1 Diabetes Mellitus with insulin use and falls. On 11/6/23 at 2:33 PM V3 (Assistant Director of Nursing) stated the facility does not have an MDS/Care Plan Coordinator as of 11/1/23, and both V2 (Director of Nursing) and V3 (Assistant Director of Nursing) have been trying to update and complete care plans. On 11/7/23 at 9:47 AM V1 confirmed residents with dementia would be considered at risk for abuse. V1 stated I think that is part of the dementia care plan. On 11/07/23 at 3:37 PM V2 confirmed R28 does not have a comprehensive care plan to address R28's fall and Type 1 Diabetes Mellitus with insulin use. The facility's Abuse Prevention Program revised 11/28/16 documents As part of the resident social history assessment, staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify problems, goals, and approaches, which would reduce the chances of mistreatment, neglect, and abuse of these residents. Staff will continue to monitor the goals and approaches on a regular basis. The facility's Policy Comprehensive Care Plans revised 7/20/22 states The Comprehensive Care Plan (CCP) shall be developed within seven day of the completion of the RAI. a. The CCP shall be reviewed after each Annual, Significant Change, and Quarterly MDS and revised as necessary to reflect the resident's current medical, nursing, and mental and psychosocial needs as identified by the IDT (Interdisciplinary Team) b. The Care Plan shall be revised as necessary when the needs, problems and care and services specified in the plan of care no longer reflect those of the resident. c. The IDT may determine a Comprehensive revision of the Plan of Care may warrant a Significant Change MDS (Minimum Data Set). Documentation of such a decision shall be contained in the resident's record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 16 of 38 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 11/13/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to update a care plan to include a significant weight loss for two residents (R26, R45) of 12 residents reviewed for care plans in a sample list of 30. Findings Include: 1. R45's Physician's Order Sheet (POS) for November 2023 includes the following diagnoses: Dementia with Behavioral Disturbance, Depression, Anxiety, Insomnia, and History of Fall with Hip Fracture. The facility's Weight flow sheet for the preceding 12 months documents on 08/01/2023, R45 weighed 127 pounds (lbs.) and on 10/01/2023 R45 weighed 112 lbs. which is an 11.81 % Loss. On 11/6/23 from 11:30AM to 12:15PM R45 was observed sitting in the dining room and attempting to leave the table. When table mates were served before R45, R45 attempted to take food and drink off another resident's tray. R45's Care Plan does not address significant weight loss or interventions to address R45's inattention at meals. On 11/9/23 at 2:24PM V2 (Director of Nursing/DON) confirmed R45's Care Plan should address the weight loss and R45's inattention during meals. 2.) The facility's Monthly Weight Grid dated November 2022-October 2023 documents R26 weighed 134 pounds (lbs.) in February and March, 129 lbs. in May, 122 lbs. in June (8.96% since March and 5.43% loss in 1 month), 120 lbs. in August, and 118 lbs. in September (11.94% loss in 6 months). R26's Minimum Data Set (MDS) dated [DATE] documents R26 has severe cognitive impairment, requires limited assistance of one staff person for eating, and has had a significant weight loss within the past month or six months. R26's November 2023 Physician Order Summary documents an order initiated on 9/21/23 for (nutritional supplement) 90 milliliter (ml) three times daily. R26's June 2023 Medication Administration Record (MAR) documents (nutritional supplement) 60 ml three times daily was initiated on 6/26/23. R26's Care Plan dated 7/5/22 documents R26 is at risk for altered nutritional status and/or weight loss and has not been updated to address R26's significant weight loss and interventions after 7/5/22. On 11/6/23 at 2:33 PM V3 (Assistant Director of Nursing) confirmed R26's care plan has not been updated to include R26's significant weight loss and nutritional interventions. V3 stated the facility does not have an MDS/Care Plan Coordinator as of 11/1/23, and both V2 (Director of Nursing) and V3 have been trying to update/complete care plans. The facility's Policy Comprehensive Care Plans revised 7/20/22 states The Comprehensive Care Plan (CCP) shall be developed within seven day of the completion of the RAI. a. The CCP shall be reviewed after each Annual, Significant Change, and Quarterly MDS and revised as necessary to reflect the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 17 of 38 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 11/13/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm resident's current medical, nursing and mental and psychosocial needs as identified by the IDT (Intradisciplinary Team) b. The Care Plan shall be revised as necessary when the needs, problems and care and services specified in the plan of care no longer reflect those of the resident. c. The IDT may determine a Comprehensive revision of the Plan of Care may warrant a Significant Change MDS (Minimum Data Set). Documentation of such a decision shall be contained in the resident's record. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 18 of 38 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 11/13/2023 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide Restorative Nursing Programs for one resident (R24) of one resident reviewed for positioning and mobility in a sample list of 33 residents. Findings Include: R24's Physician's Order Sheet (POS) for November includes the following diagnoses: Cerebral Infarct, Emphysema, Chronic Kidney Disease Stage III, Malignant Neoplasm of the Spinal Cord, Type II Diabetes, and Depression. On 11/6/23 at 11:00AM R24 stated After I finished therapy, they were supposed to start Restorative programs, but I don't get them. R24's Minimum Data Set (MDS) dated [DATE] documents R24 is to receive Passive Range of Motion, Active Assisted Range of Motion, Bed Mobility, Transfer, dressing, and grooming restorative programs. On 11/08/23 at 9:09 AM V2 (Director of Nursing/DON) stated the CNAs (Certified Nursing Assistants) are supposed to do restorative programs. We did have a Restorative Aide, but she quit a little while ago. They should be documented in the CNA book. R24's October and November 2023 restorative CNA documentation includes zero minutes of restorative programs. On 11/08/23 at 9:15 AM V33 (CNA) stated, We try to do the restorative programs, but with the number of aides we have it isn't always possible. A policy for restorative Nursing programs was requested numerous times over the course of the survey. No policy was provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 19 of 38 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 11/13/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete a fall risk assessment and thoroughly investigate falls for one (R28) of four residents reviewed for accidents in a sample list of 33 residents. Findings include: On 11/05/23 at 10:54 AM V11 (R28's Spouse) stated R28 admitted to the facility after a fall at home with a hip fracture that required surgical repair. V11 stated R28 fell at the facility a few days after admission. R28's Minimum Data Set (MDS) dated [DATE] documents R28 has severe cognitive impairment, requires extensive assistance of one staff person for transfers, bed mobility, dressing and toileting, and requires staff assistance to stabilize balance during transitions and walking. R28's November 2023 Physician Order Summary documents R28 has diagnoses of Dementia and Closed Fracture of Neck of Left Femur. R28's medical record does not contain a completed Fall Risk Assessment or a comprehensive care plan to address fall risk, history of falls, or interventions to prevent falls. R28's baseline care plan dated 9/25/23 does not identify fall risk, history of falls, or fall interventions. R28's 9/28/23 Fall Investigation documents at 7:20 PM R28 fell, R28's fall was unwitnessed and R28 was found on the floor of the women's restroom near the nurse's station. The investigation documents R28 was last seen sitting on the toilet 3 minutes prior to the fall and R28 said that R28 was attempting to pull up R28's pants when R28 fell. This investigation documents R28 was sent to the emergency room and diagnosed with a NONSTEMI (non-ST elevated myocardial infarction), and the new intervention was that R28 was admitted for treatment and possible stent placement. V8 (Certified Nursing Assistant's/CNA) written interview dated 9/28/23 documents V8 transferred R28 onto the toilet, gave R28 the call light, and stepped outside the bathroom to allow for privacy. An unidentified resident was yelling in the front dining room so V8 left R28 and went to assist the other unidentified resident onto the toilet. V36 (CNA) then came and told V8 that R28 was on the floor. R28's 10/7/23 Fall Investigation documents R28 had an unwitnessed fall at 6:25 AM. R28 was last observed at 6:05 AM sleeping and R28 stated R28 was attempting to go to the bathroom when R28 fell. There is no documentation as to the last time R28 was toileted or provided incontinence care. The root cause of the fall is R28 did not use a call light and attempted to transfer without assistance. The post fall intervention was a low bed and fall mat. R28's 10/17/23 Fall Investigation documents R28 had an unwitnessed fall at 7:45 PM and R28 was last seen lying in bed 15 minutes prior to the fall. There is no documentation as to the last time that R28 was toileted or provided incontinence care. The root cause is R28 attempted to ambulate without assistance or device and R28's bedroom furniture was rearranged as the post fall intervention. R28's 10/20/23 Fall Investigation documents R28 had an unwitnessed fall at 11:15 AM and R28 was last seen sitting in R28's wheelchair 15 minutes prior to the fall. There is no documentation of when R28 was last toileted or provided incontinence care prior to the fall. The root cause of the fall was R28 attempted to stand up out of wheelchair without assistance or device and a pressure alarm was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 20 of 38 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 11/13/2023 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 0689 implemented as a post fall intervention. Level of Harm - Minimal harm or potential for actual harm On 11/07/23 at 3:37 PM V2 (Director of Nursing) stated the facility uses a fall risk assessment tool that is completed upon admission and quarterly. V2 reviewed R28's chart and was unable to locate a completed Fall Risk Assessment. V2 stated the former MDS/Care Plan Coordinator was responsible for completing the Fall Risk Assessments. V2 reviewed R28's baseline care plan and confirmed it does not address fall risk or interventions and confirmed R28 does not have a comprehensive care plan to address falls. V2 stated R28 requires assistance of one staff person for toileting and R28 fell on 9/28/23 after V8 (CNA) transferred R28 onto the toilet in the employee bathroom. V2 stated V8 left R28 on the toilet because another resident was in the dining room walking without a walker. V2 stated V2 told V8 that V8 should have stayed with R28 and yelled for staff while staying with R28 in the bathroom. V2 confirmed R28's October falls were unwitnessed and confirmed the investigations do not document when R28 was last toileted or provided incontinence care prior to the falls. Residents Affected - Few The facility's policy Fall Prevention revised 11/10/19 states Policy: To provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. Responsibility: All Staff. 1. Conduct fall assessments on the day of admission, quarterly, and with changes in condition. 2. Identify on admission the resident's risk for falls. 3. Assessment of fall risk will be completed by the admission nurse at the time of admission. Appropriate interventions will be implemented for residents determined to be at high risk at the time of admission for up to 72 hours. This policy also states If residents with a high-risk code are observed up or getting up, help must be summoned or assistance must be provided to the resident. This policy also states A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. 6. The unit nurse will place documentation of the circumstances of the fall in the nurse's notes or on a AIMS for wellness form along with any new interventions deemed to be appropriate at the time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 21 of 38 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 11/13/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to correctly perform incontinence care for one (R6) of four residents reviewed for Urinary Tract Infections in the sample list of 33. Findings include: The facility's Perineal Cleansing policy dates as revised 9/21/10 documents for female perineal cleansing use long strokes from the most anterior down to the base of the labia (front to back motion), turn resident onto side and wash peri-anal area from the base of the labia up over the buttocks (front to back motion). On 11/05/23 at 11:30 AM R6 stated R6 has been in the hospital three to four times within the last year, including a few times for Urinary Tract Infections (UTIs). R6 stated R6 is incontinent, and staff provide R6's incontinence cares. R6's Minimum Data Set, dated [DATE] documents R6 has a Brief Interview for Mental Status score of 12 (the higher end of moderate cognitive impairment), R6 requires extensive assistance of one staff person for toileting, and R6 is frequently incontinent of bowel and bladder. R6's Urine Culture reported on 9/1/23 documents Escherichia Coli (E. Coli) (a bacteria present in the colon/stool) greater than 100,000 colony forming units per milliliters (cfu/ml), indicating an infection. R6's Urine Culture reported on 9/15/23 documents E. Coli 70-99,000 CFU/ml. On 11/6/23 at 3:18 PM V19 and V18 (Certified Nursing Assistants/CNAs) entered R6's room to provide incontinence cares. R6's brief was wet with urine. During R6's incontinence care V19 cleansed R6's frontal perineal area, turned R6 onto R6's side, and wiped R6's buttocks moving from R6's rectum to R6's labia twice with disposable wipes. On 11/6/23 at 3:28 PM V19 stated V19 has received training on incontinence care and UTI prevention. V19 stated we are supposed to wipe front to back to prevent infection. V19 confirmed during R6's incontinence cares V19 wiped from back to front, buttocks to labia. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 22 of 38 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 11/13/2023 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 0692 Provide enough food/fluids to maintain a resident's health. 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 report significant weight loss to the resident representative and physician, timely implement nutritional recommendations, and record amount of intake for nutritional supplements for one (R26) of two residents reviewed for nutrition in the sample list of 33. Residents Affected - Few Findings include: The facility's Resident Weight Monitoring policy revised March 2019 documents significant weight changes of 5% or more in one month, 7.5% or more in 3 months, and 10% or more in six months will be reported to the resident, resident representative, and physician. This policy documents the dietitian will make recommendations for nutritional interventions and nursing will convey the recommendations to the physician to obtain orders. The facility's Monthly Weight Grid dated November 2022-October 2023 documents R26 weighed 134 pounds (lbs.) in February and March, 129 lbs. in May, 122 lbs. in June (8.96% since March and 5.43% loss in 1 month), 120 lbs. in August, and 118 lbs. in September (11.94% loss in 6 months). R26's Minimum Data Set, dated [DATE] documents R26 has severe cognitive impairment, requires limited assistance of one staff person for eating, and has had a significant weight loss within the past month or six months. R26's Care Plan dated 7/5/22 documents R26 is at risk for altered nutritional status and/or weight loss and has not been updated to address R26's significant weight loss. R26's Progress Note dated 6/9/23 recorded by V20 (Registered Dietitian) documents R26 has a Body Mass Index (BMI) 19 (low), significant weight loss of 7 lbs./5.4% in one month and 12 lbs./9.1% loss in 3 months. V20 recommended to start (nutritional supplement) 60 milliliters three times daily. R26's Progress Note dated 9/15/23 recorded by V20 documents R26 triggered for 11.9% weight loss in the last six months and V20 recommended to increase (nutritional supplement) to 90 ml three times daily. R26's November 2023 Physician Order Summary documents an order initiated on 9/21/23 for (nutritional supplement) 90 ml three times daily (six days after V20's recommendation). R26's June 2023 Medication Administration Record (MAR) documents (nutritional supplement) 60 ml three times daily was initiated on 6/14/23 (5 days after V20's recommendation). R26's June 2023-September 2023 MARs do not document supplement intake amounts. On 11/06/23 at 2:33 PM V3 (Assistant Director of Nursing) stated V3 is responsible for notifying the physician and resident representative of weight loss and would refer to the facility's policy for reporting weight loss to the physician and representative. V3 stated R26 had COVID-19 and had lost weight. V3 stated V20 sends V20's recommendations to V3 via electronic mail. V3 prints the recommendations and gives them to V24 (Nurse Practitioner) for approval. V3 stated on 9/15/23 V20 recommended increasing the nutritional supplement to 90 ml three times daily, and confirmed this recommendation was not implemented until 9/21/23. V3 stated V24 may not have been in the facility 9/18/23 and therefore V24 didn't sign an order for the recommendation. V3 stated on 6/9/23 V20 recommended changing R26's diet to regular and initiating (nutritional supplement). V3 confirmed R26's medical record does not contain any nursing notes after May 2023 and no documentation that R26's Family (V15) and physician were notified of R26's significant weight loss. At 3:42 PM V3 stated nutritional supplements are recorded on the MAR. V3 confirmed the consumed amount of nutritional supplements are not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 23 of 38 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 11/13/2023 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 0692 documented on R26's MAR and should be. Level of Harm - Minimal harm or potential for actual harm On 11/7/23 at 11:06 AM V20 stated V20 visits the facility monthly and creates a generated report that is emailed to V3, V1 and the Dietary Manager. V20 stated the facility has had issues with not having a Dietary Manager so V3 has been following up on V20's recommendations. V20 stated V20 submits her report on the same day as V20's visits, which is usually Friday. V20 stated V20 expects V20's recommendations to be implemented by the following Monday or Tuesday. V20 stated supplement intakes should be recorded to determine how much is consumed. V20 stated V20 would recommend something else if the resident is not consuming the supplement. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 24 of 38 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 11/13/2023 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to identify the risk for entrapment for one (R11) of one resident reviewed for bed rails in a sample list of 33 residents. Findings Include: R11's Physician's Order Sheet (POS) for November 2023 includes the following diagnoses: Parkinson's Disease, Depression, Anxiety and Chronic Fatigue Syndrome. R11's Minimum Data Set, dated [DATE] documents R11 is cognitively intact and requires staff assistance or is dependent on staff for Activities of Daily Living (ADL's). On 11/05/23 at 11:55 AM R11 was lying in her bed. There is a 1/2 length side rail in place to both sides of R11's bed. On the end of the rail toward R11's legs there is a gap in the rail approximately 5 by 10. R11 is very thin, and her left foot is against the rail. When comparing R11's foot with the rail it could easily fit into the gap. On 11/06/23 at 2:32 PM V21 (Maintenance Director) stated that is a 10 gap and I see that (R11) could get an arm or leg caught in that. I will change that out today. The facility's policy Determining for use of bed rails/Transfer Bars dated 5/12/17 states Zone assessments for the enablers will be conducted at the time they are placed on the bed and at least annually. The facility's Siderail Zone Assessment for R11 (Not dated) states Zone 1-Within the rail gap circular cross section less than 4 3/4 in diameter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 25 of 38 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 11/13/2023 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 0712 Ensure that the resident and his/her doctor meet face-to-face at all required visits. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to provide physician visits at least every 60 days alternating with an advanced practice nurse for three of four residents (R11, R15,R45) reviewed for physician's visits in the sample list of 33. Residents Affected - Few Findings Include: The facility's Policy Physician's Services (not dated) documents After the first 90 days a resident must be seen by a physician at least every 60 days. The physician may schedule alternate visits by a Physician's Assistant or a Nurse Practitioner. 1. R11's Nurse Practitioner Progress note dated 8/31/23 documents R11 has been a resident since 2015. V24 (Nurse Practitioner) documented assessments for R11 on 8/31/23. There is no documentation to indicate a physician has evaluated R11 in July, August, September, or October 2023. There is no documentation to indicate R11 has been assessed by a physician so far in November 2023. 2. R15's Face Sheet documents R15 has been a resident since 5/24/23. V24 (Nurse Practitioner) documented assessments for R15 on 9/18/23, and 10/5/23. There is no documentation to indicate a physician has evaluated R15 in July, August, September, or October 2023. There is no documentation to indicate R15 has been assessed by a physician so far in November 2023. 3. R45's Face Sheet documents R45 has been a resident since 4/4/23. V24 documented assessments for R45 on 8/24/23, 9/11/23 and 10/26/23. There is no documentation to indicate a physician has evaluated R45 in July, August, September, or October 2023. There is no documentation to indicate R45 has been assessed by a physician so far in November 2023. On 11/9/23 at 2:00PM V1 (Administrator) stated, We did have a little trouble getting physician's notes in June and July. We hired V39 (Medical Director) in August 2023 and we are in the process of getting the physician's visits caught up. I'm sorry to say I can't locate physician's notes for (R11, R15, R45) since July. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 26 of 38 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 11/13/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on observation, interview, and record review the facility failed to track targeted behaviors for one (R15) of five residents reviewed for psychotropic medications in a sample list of 33 residents. Findings Include: R15's Physician's Order Sheet (POS) for November 2023 includes the following diagnoses: Mixed Alzheimer's Disease, Vascular Dementia with behavioral disturbances, Anxiety, and Major Depression. This POS also documents current physician's orders for the following psychotropic medications: 1. Alprazolam (antianxiety) 0.25 milligrams (MG) in the AM and 0.5 mg at Bedtime. 2. Quetiapine (antipsychotic) 12.5 mg every morning. 3. Buspar (Antianxiety) 15 mg twice daily. 3. Remeron (antidepressant) 7.5 mg at bedtime. 4. Melatonin (sleep aide) 10 mg at bedtime. The only behavior tracking sheet documented for R15 is for November 2023 and the sheet is blank. On 11/8/23 V1 (Administrator) stated We are aware our psychotropic medication documentation and care plans are not complete. We lost the Care Plan Coordinator recently and we found that the documentation was not what it should be. The facility's Psychotropic Medication Policy revised 6/17/22 states, 4. Initiate a Psychotropic Medication Quarterly Evaluation within 14 days of admission for those residents currently receiving psychotropic medication. 5. Psychotropic medication shall not be prescribed or administered without the informed consent of the resident, the resident's guardian, or other authorized representative. 7. Any resident receiving such medication shall have a psychiatric diagnoses or documented evidence of maladaptive behavior, which can be considered harmful to themselves or others, destructive to property, or if emotional problems exist which cause the resident frightful distress. 8. The behavioral tracking sheet of the facility will be implemented to ensure behaviors are being monitored. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 27 of 38 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 11/13/2023 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to administer insulin per orders, have parameters for notifying the physician of blood glucose results, and coordinate times for glucose monitoring and insulin administration. These failures resulted in significant medication errors for one (R28) of five residents reviewed for medications in the sample list of 33. Residents Affected - Few Findings include: R28's October 2023 Physician Order Summary (POS) documents R28 has Type 1 Diabetes Mellitus. This POS documents an order dated 10/23/23 for Novolog (insulin) 5 units subcutaneous with meals (8:00 AM, 12:00 PM, and 4:00 PM). R28's November 2023 POS includes the following orders: Novolog give three times daily (8:00 AM, 11:00 AM, and 4:00 PM) per sliding scale, for blood glucose 161-220 give 1 unit, 221-280 give 2 units, 281-340 give 3 units, 341-400 give 4 units, and greater than 400 give 5 units. Notify the physician for blood glucose levels greater than 400, implemented on 11/6/23. R28's blood glucose checks are ordered at 6:00 AM, 11:00 AM, 4:00 PM, and 8:00 PM. There is no documentation that prior to 11/6/23 R28 had ordered parameters for notifying the physician of blood glucose results. R28's November 2023 Medication Administration Record (MAR) documents the following: On 11/2/23 at 6:00 AM R28's blood glucose was 433 and Novolog 4 units was given (not 5 units as ordered per sliding scale). On 11/2/23 at 11:00 AM R28's blood sugar was 540 and Novolog 3 units was given (not 5 units as ordered per sliding scale). On 11/2/23 at 4:00 PM R28's blood glucose was hi. This MAR does not document R28's blood glucose was rechecked at that time, or that Novolog insulin per sliding scale parameters was administered as ordered. R28's 8:00 PM blood glucose on 11/2/23 was 516. R28's Nursing Note dated 11/2/23 at 5:30 AM documents R28's blood glucose was 433 and was rechecked with a result of 448. Novolog 4 units was given (not 5 units as ordered). V24 (Nurse Practitioner) was called, but V24 did not answer. There are no documented additional attempts to notify V24 or that V39 (Physician) was notified of R28's blood glucose results after 11/2/23 at 5:30 AM until 11/2/23 at 7:30 PM. R28's Nursing Note dated 11/2/23 at 7:30 PM documents R28's blood glucose was 516, it was rechecked with a result of 587. The Nurse Practitioner was notified and gave orders to give (Novolog) 7 units, Basaglar (insulin) 10 units, give protein/carbohydrate snack, recheck blood glucose level in one hour, call if results are greater than 500, and recheck blood glucose again at midnight. On 11/08/23 at 10:10 AM V2 (Director of Nursing) and V3 (Assistant Director of Nursing) reviewed R28's chart and confirmed R28's Novolog sliding scale order includes to give 5 units for a blood glucose greater than 400. V3 stated 5 units should have been given on 11/2/23 at 8 am, not 4 units, and the nurse (V40 Registered Nurse) should have notified V39 (Physician) since it was before 9:00 AM. V3 stated we contact V24 (Nurse Practitioner) if it is after 9:00 AM. V3 confirmed there is no documentation of follow up with V24 or V39 after 11/2/23 at 5:30 AM until 11/2/23 at 7:30 PM. V3 stated V40 is an agency nurse and it was V40's first night working in the facility. At 10:26 AM V3 stated we have always checked blood glucose at 6:00 AM since the resident will be fasting at that time. V3 stated the Novolog per sliding scale is given at 8:00 AM and is based on the 6:00 AM blood glucose results. On 11/13/23 at 11:20 AM V3 confirmed R28's blood glucose result is recorded as 540 on 11/2/23 at 11:00 AM. V3 stated a high reading is anything over 599, since the blood glucose meter only gives a numerical result up to 599. V3 stated prior to 11/6/23 R28 did not have ordered blood glucose parameters for when to notify V24 or V39. V3 stated on 11/6/23 we added the order to notify for blood glucose over 400. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 28 of 38 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 11/13/2023 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The facility's Medication Administration policy revised on 11/18/17 documents medications should be administered within one hour before or after the designated time, verify the seven rights of administration including the right dose, and record the date/time/drug/dose/route on the MAR. The facility's Notification for Change in Resident Condition or Status revised 12/7/17 documents the nurse will notify the attending or on-call physician when there is a change in condition including when signs/symptoms are unrelieved by previously prescribed measures. This policy includes notifying the physician of abnormal laboratory results and when there is a need to alter the resident's medical treatment significantly. This policy documents to record information regarding changes in the resident's condition in the resident's medical record. Event ID: Facility ID: 146104 If continuation sheet Page 29 of 38 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 11/13/2023 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 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 observation, interview and record review, the facility failed to have sufficient dietary staff to timely serve meals. This failure has the potential to affect all 44 residents who reside at the facility. Findings Include: On 11/5/23 at 10:31 AM, R24 stated the facility food/meals are always served late. On 11/6/23 at 11:22 AM, V12 (Cook) and V13 (Dietary Aide) were the only two staff working in the kitchen preparing food for lunch. On 11/6/23 at 12:06 PM, V12 served the first meal tray and stated, lunch is supposed to be served at 11:30 am however, it is hard because of only having two people in the kitchen. V12 explained there is always only two staff in the kitchen, a cook, and the aide and that the facility really needs an extra person. V12 also stated that V12 is taking over as Dietary Manager and as soon as V12 can find someone to take V12's spot as the cook. On 11/6/23 at 12:19 PM, V12 had to stop serving lunch trays to make gravy to put onto R23's mashed potatoes stating, I can't serve potatoes without gravy, and V12 had not prepared the gravy yet. Serving was halted until 12:24 PM. On 11/6/23 at 12:40 PM, the last lunch tray was served. The Facility assessment dated [DATE] documents the facility will have a full time Dietary Manager, and two food/nutrition service staff on first shift. The facility Matrix for Providers dated 11/5/23 documents 44 residents reside at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 30 of 38 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 11/13/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure proper food storage, cleanliness of the kitchen and prevent potential food contamination by not ensuring facial hair was covered while preparing and serving food. This failure has the potential to affect all 44 residents who reside at the facility. Findings Include: The facility Kitchen Sanitation Policy dated October 2020 documents the Food Service Manager will monitor sanitation of the Dietary Department on a daily basis. The Dietary Sanitation QA (Quality Assurance) Review shall be used as a tool to monitor compliance with sanitation standards and identify which areas need corrective action. The Food Service Manager will develop a cleaning schedule for the department and ensure that dietary employees complete cleaning tasks as scheduled. The Food Service Manager shall provide cleaning instructions for each area and piece of equipment in the kitchen and specify which chemical and personal protective equipment should be used for each task. The Dietary Sanitation QA Review Sheet dated October 2020 includes areas of evaluation that includes but is not limited to: hair nets being worn by everyone entering the kitchen, including facial hair coverings, ensure food and non-food contact surfaces are easily cleanable including shelves and cart and that they are clean, all food is covered and containers are labeled with contents, dated when opened and dated when to discard, food is stored in airtight containers and labeled if not in original container, ceilings and walls are clean, a cleaning schedule is posted/followed and that staff are knowledgeable about cleaning schedule and duties. 1. On 11/6/23 between 2:00 -2:15 PM, the Dietary Storage Room, which is also the Dietary Manager's Office had a gallon jug of Apple Cider Vinegar with less than 1/4 left in it that was undated and the lid was not closed/sealed. At this time, V12 (Cook/Dietary Manager) stated the lid should be closed and it should have been dated when it was opened. There was also an opened bag of [NAME] powder, undated and unsealed sitting in a plastic container without a lid, on the storage rack. V12 stated, We (facility) don't have lids for the container, it has been like that. Also on the storage rack was an open bag of rice crispy cereal dated 9/21/23 that was not sealed, an open/unsealed bag of cinnamon streusel coffee cake mix dated 11/1/23 that was half used, a bag of complete buttermilk pancake mix dated 11/5/23 that was open and not sealed, two large bags of pasta opened, unsealed and undated. In the kitchen, the prep table had two pull-down built-in cabinets, one with a large tub of flour and the other with a large tub of sugar, neither were covered with lids, the lids were off the tubs and sitting in the cabinet. The facility Food Safety Policy dated April 2017 documents food or beverages should be labeled and dated to monitor for food safety. The facility Storage Policy dated October 2020 documents all food shall be stored on shelves in areas that provide the best preservation. When using only a part of a product, the remaining product should be in the original package or an airtight container and be dated and labeled. 2. On 11/6/23 at 11:22 AM, the back of the stove has food splatters up the back of it, including on the pots that are sitting on the shelf above the stove top. The shelf has a yellow substance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 31 of 38 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 11/13/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many hanging from the shelf on the right side. Under the counter by the sink and dishwasher, there are dark brown streaks running down the wall. There are brownish colored food splatters all over the wall behind the steam table, from the table extending approximately 3 feet up the wall. On the shelf under the steam table/prep area where the cups are stored, there are circular in shape white rings appearing to be calcium/lime build up. On the bottom shelf of the steam table/prep area where the napkins and cup lids are stored, there is white colored food/drink splatter. The milk machine has white substance splatters covering the front of it. The mixer cart, parked next to the milk machine, has dried white splatters on the top, middle, and bottom shelf. On 11/6/23 at 12:19 PM, V12 stated the kitchen floors are cleaned daily but the facility does not really have a cleaning schedule they go by. V12 stated, the walls haven't been cleaned since (V12) has been here that (V12) is aware of, and V12 has worked at the facility for one year. V12 explained cleaning the kitchen is just hard with only two of us and no dietary manager. On 11/6/23 at 2:10 PM, the ice maker, in the kitchen, had yellowish brown residue streaking down the side of the ice maker and a buildup of a white substance on the front/door of the machine. On 11/6/23 at 2:15 PM, V1 (Administrator) stated V1 has not seen a cleaning schedule for the kitchen but knows that about one month ago, the wall behind the steam table was cleaned. On 11/7/23 at 1:48 PM, the shelf above the stove continues to have yellowish dried food hanging from the right side, the pots on the shelf continue to have food splatters on it, as does the back of the stove, the same as yesterday (11/6/23). Dried brown food splatter remains on the wall behind the steam table, as do the dark brown streaks on wall by the dishwasher and sink. The facility Cleaning Schedule Policy dated October 2014 documents the facility will have a system for determining frequency of cleaning and to document the completion of a particular cleaning task. 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 should be divided into categories that must be completed daily, weekly, and monthly and each position in the Dietary Department is assigned certain cleaning tasks to be completed at a particular frequency. 3. On 11/6/23 at 12:06 PM, V13 (Dietary Aide), who has a bushy full beard approximately three inches in length, was placing drinks and pears on the trays. V13 did not have a cover over V13's beard. At this time, V13 stated V13 was told V13 didn't need to wear a beard cover if V13's beard was less than one inch. V13 was asked if V13 thought V13's beard was less than one inch and V13 responded, V13 will go get a cover. The facility's untitled procedure guide dated October 2016 documents hair net or appropriate hair coverings, including facial hair covering, will be used while involved in food production and clean-up activities. The facility Matrix for Providers dated 11/5/23 documents 44 residents reside at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 32 of 38 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 11/13/2023 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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to give residents and their representatives an option of not signing an arbitration agreement as a condition of admission. This failure has the potential to affect all 44 residents who reside at the facility. Residents Affected - Many Findings include: R28's Agreement to Resolve Disputes by Binding Arbitration dated 9/25/23 was signed by V11 (R28's Spouse) and V4 (Social Service Director/SSD). On 11/6/23 at 10:07 AM, V11 stated upon R28's admission to the facility, V11 does not recall anybody giving V11 the option to not sign the arbitration agreement. V11 explained V11 was just given several papers and was told where V11 needed to sign. On 11/7/23 at 2:33 PM, V4 stated everybody is required to sign it therefore, V4 does not give residents or resident representative's an option. On 11/7/23 at 2:49 PM, V5 (Business Office Manager) checked the computer system for Arbitration Agreements and stated all residents that reside at the facility have a signed Arbitration Agreement. At this time, V1 (Administrator), stated residents and/or resident representatives should be given the option to not sign the agreement so if V4 isn't doing that, V4 needs re-educated. The facility Matrix for Providers dated 11/5/23 documents 44 residents reside at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 33 of 38 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 11/13/2023 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to have timely quarterly Quality Assurance (QA) meetings. This failure has the potential to affect all 44 residents residing in the facility. Residents Affected - Many Findings include: The facility's Quality Assurance meeting sign in sheets for the last year were requested and were provided by V1 (Administrator). The facility had documented meetings on 1/23/23, 6/5/23, 8/15/23, and 10/25/23. The QA Meeting sign in sheet dated 1/23/23 documents the facility reviewed information from the months of October 2022, November 2022, and December 2022. There is no documented QA meeting sign in sheet for April 2023. The QA Meeting sign in sheet dated 6/5/23 documents the facility reviewed information from the months of January, February, and March 2023. The QA Meeting sign in sheet dated 8/15/23 documents the facility reviewed information from the months of April, May, and June 2023. On 11/6/23 at 4:10 PM V1 stated we did not have a meeting in April 2023 and the January-March information was reviewed at the June 2023 meeting. V1 stated as long as we have meetings that review information from each quarter we are in compliance. V1 confirmed the facility does not have quarterly QA meetings based on the time frame of every 3 months per calendar year. V1 stated the April meeting had to be rescheduled due to a change in Medical Directors. V1 confirmed the August 2023 meeting reviewed information from April-June 2023. The facility's CMS (Centers for Medicare & Medicaid Services) Form 802 dated 11/5/23, provided by V1 documents 44 residents reside in the facility. The facility's QAPI (Quality Insurance Performance Improvement) Plan dated as reviewed 7/20/23 documents: At a minimum on a quarterly basis, data will be collected and reported to the QAPI Committee from the following areas: -Input from caregivers, residents, families, and others -Adverse events -Performance indicators -Survey findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 34 of 38 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 11/13/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement their Infection Control Surveillance and Monitoring Policy by failing to thoroughly complete infection control logs, analyze the data, identify trends, and implement the appropriate isolation precautions for shingles. This failure has the potential to affect all 44 residents who reside at the facility. Residents Affected - Many Findings Include: The facility Infection Control Surveillance and Monitoring Policy dated 3/10/22 documents the facility will do routine surveillance and monitoring of the facility to determine if compliance with work practices. Monitoring of the day-to-day operation of the Infection Control Program will be conducted by the DON (Director of Nursing). Included in these duties are investigation and implementation of controls to prevent infections in the facility, determine and direct the correct procedures necessary for the prevention of infections (this should be done on an individual basis, applying the concepts of isolation per infection), and follows up on documentation of and reporting of infection to physicians through direct and random inspections of the clinical record with respect to isolation techniques instituted and followed. The Infection Control Log shall be updated on a daily basis in order to analyze data and identify trends that would indicate the need for additional controls to prevent any further spread of an infection. Maintaining records of surveillance and monitoring will be the DON and/or Administrator and shall reflect: the conditions associated with each incident of mucous membrane or parenteral exposure to blood/body fluids; and an evaluation of those conditions and a description of any corrective measures taken to prevent a recurrence or similar exposure. 1. R27's Progress Notes dated 10/30/23 document R27 has red blisters/spotty redness down R27's neck and right side of chest. R27's October 2023 Physician Order Sheet documents R27 was started on Acyclovir (Antiviral) 400 mg (milligrams) TID (Three times a day) for 5 days. R35's November 2023 Physician Order Sheet documents an order for Nitrofurantoin (Antibiotic) 100 mg daily as prophylaxis, received on 7/31/23. The facility's July - October 2023 Infection Control Logs do not document that R35 is receiving Antibiotics. The October 2023 Infection Control Log also does not document R27's Antiviral. The facility also did not provide any infection surveillance or data analysis for infections in October 2023. On 11/8/23 at 10:58 AM, V3 ADON/IP (Assistant Director of Nursing/Infection Preventionist) stated R27's Antiviral is not on the October 2023 Infection Control Log because the log is not completed. V3 also stated V3 has not done any infection surveillance or data analysis because the Infection Control Log isn't completed. V3 explained that V3 does not put any prophylactic antibiotics on the infection control log, including R35's. V3 confirmed that any infection control monitoring, surveillance, and data analysis would not be accurate due to all infections and antibiotic/antiviral usages not being monitored. V3 stated V3 has been in the IP (Infection Preventionist) role since June/July 2023. 2. R27's Progress Notes dated 10/30/23 document R27 has red blisters/spotty redness down R27's neck and right side of chest. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 35 of 38 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 11/13/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm R27's October 2023 Physician Order Sheet documents an order dated 10/30/23 to start Acyclovir (Antiviral) 400 mg (milligrams) TID (Three times a day) for 5 days and to place R27 in contact isolation. R27's November 2023 Physician Order Sheet documents an order dated 11/3/23 to start Acyclovir 400 mg TID for 2 days along with an order on 11/6/23 to discontinue isolation. Residents Affected - Many R27's Care Plan dated 10/30/23 documents R27 has Shingles, Blisters/Rash present to the right shoulder and neck. On 11/7/23 at 3:47 PM, V3 ADON/IP (Assistant Director of Nursing/Infection Preventionist) stated R27 was being treated for suspected shingles and was placed on contact isolation only and was not on droplet/airborne isolation. On 11/8/23 at 9:40 AM, V22 (Certified Nursing Assistant/CNA) stated R27 was recently on contact isolation for shingles. V22 stated R27's rash/blisters were never covered with a dressing and were only covered by what R27's clothing would cover, which was not the entire area as it was on R27's chest and up on R27's neck. The CDC (Centers for Disease Control and Prevention) Guidance for Preventing Varicella-Zoster Virus Transmission from Herpes Zoster in Healthcare Settings dated 5/10/23 documents for Immunocompetent residents, the localized lesions should be completely covered, and the resident should be on airborne and contact precautions until the lesions are dry and scabbed. The facility Matrix for Providers dated 11/5/23 documents 44 residents reside at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 36 of 38 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 11/13/2023 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement their antibiotic stewardship program. This failure has the potential to affect all 44 residents who reside at the facility. Residents Affected - Many Findings Include: The facility Antibiotic Stewardship Program dated 11/1/17 documents this program is used to improve the use of antibiotics in healthcare to protect residents and reduce the threat of antibiotic resistance through a set of commitments and actions designed to optimize the treatment of infections while reducing adverse events associated with antibiotic use. This will be accomplished utilizing the Core Elements: Leadership Commitment (demonstrates support and commitment for safe and appropriate antibiotic use), Accountability (identify physicians, nursing and pharmacy leads responsible for promoting and overseeing antibiotic stewardship activities), Drug Expertise (establish access to consultant pharmacists or other individuals with experience or training in antibiotic stewardship), Action (implement at least one policy or practice to improve antibiotic use), Tracking (monitor at least one process measure of antibiotic use and at least one outcome from antibiotic use), Reporting (Provide regular feedback on antibiotic use and resistance to prescribing clinicians, nursing staff and other relevant staff), and education (provide resources to clinicians, nursing staff, residents and families about antibiotic resistance and opportunities for improving antibiotics). R35's November 2023 Physician Order Sheet documents an order received on 7/31/23 for Nitrofurantoin (Antibiotic) 100 mg (milligrams) daily as prophylaxis. On 11/7/23 at 12:54 PM, V3 ADON/IP (Assistant Director of Nursing/Infection Preventionist) stated V3 does not use any kind of assessment tool to ensure or determine the appropriateness for use of the ordered antibiotic. V3 also stated V3 does not have any clinically documented rational for continued use of prophylactic antibiotic use for R35. V3 also stated V3 has not followed up with any medical providers regarding R35's antibiotic use or provided antibiotic stewardship education to them. On 11/8/23 at 10:58 AM, V3 was not able to provide any assessments for the documented use of antibiotics for any documented infections from June 2023 - November 2023 stating the facility really doesn't do any antibiotic stewardship to make sure the ordered antibiotic is appropriate or not. At this time, V3 also stated a lot of times, when a resident is started on antibiotics outside of the facility, the facility is not able to get the culture results from the hospital therefore the facility has no way to check to ensure the residents are on the appropriate antibiotic. The facility Matrix for Providers dated 11/5/23 documents 44 residents reside at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 37 of 38 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 11/13/2023 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to provide pneumococcal vaccinations per resident/resident representative request for two of five residents (R27, R31) reviewed for vaccinations on the sample list of 33. Residents Affected - Few Findings Include: 1.) R27's Consent for vaccinations dated 12/28/22 documents R27 wishes to have the PPSV23 (Pneumococcal Polysaccharide Vaccination) and/or PCV13 (Pneumococcal Conjugate Vaccination), whichever vaccination R27 is able to receive. R27's medical record does not document that R27 has historically received a Pneumococcal vaccination or that the facility administered the PPSV23 or PCV13 vaccination as requested. 2.) R31's Consent for vaccinations dated 8/12/22 documents R31 wishes to have the PPSV23 and/or PCV13, whichever vaccination R31 is able to receive. R31's medical record does not document that R31 has historically received a Pneumococcal vaccination or that the facility administered the PPSV23 or PCV13 vaccination as requested. On 11/8/23 at 9:31 AM, V2 (Director of Nursing) stated Pneumonia Vaccination requests are only obtained upon admission, and that is why R31 does not have a more recent consent. V2 also stated that V2 is not able to follow the vaccination guide/table so V2 is unsure what type of Pneumococcal vaccination R27 and R31 need therefore the requested Pneumococcal vaccination has not been given. V2 explained that V2 has asked V24 (Nurse Practitioner) to find out which vaccination R27 and R31 need but that V24 has not gotten back to V2 with the information. The facility Immunization of Residents Policy dated 4/21/22 documents the facility will offer immunizations and vaccinations that aid in the prevention of infectious diseases unless medically contraindicated or otherwise ordered by the resident's attending physician or the facility's medical director. Explain to the resident, resident's guardian, or the resident's Durable Power of Attorney of Health Care, at the time of admission and at the start of the recognized mass immunization period, the importance of vaccination against common illnesses such as pneumonia and influenza. Assess all newly admitted residents' Pneumococcal and influenza vaccination status upon admission and record last known immunization on the resident's Immunization Record. Offer the PCV13, PCV15 (Pneumococcal Conjugate Vaccination), PCV20 (Pneumococcal Conjugate Vaccination) or PPSV23 as indicated utilizing the Pneumonia Vaccination Timing Guidelines, unless contraindicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 38 of 38