Health inspection·December 17, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on interview and record review, the facility failed to notify the physician of a new pressure ulcer and nausea/stomach pain for two residents (R5, R247) of two residents reviewed for reporting changes in status in the sample list of 25. Findings include: 1.) R5's Care Plan dated 12/6/24, documents R5 is high risk for Pressure Ulcers due to Osteoarthritis, Weakness, and Incontinence. This same Care Plan documents if open skin is assessed, report to the doctor and responsible party. R5's Nursing Notes by V14 (Registered Nurse) dated 12/8/24 at 4:00 AM, documents open area noted to right coccyx, barrier applied and covered bony prominence with (an absorbent foam dressing). No further documentation is in the nursing notes about the area. On 12/15/24 at 2:29 PM, V3 (Resident Care Coordinator/Licensed Practical Nurse), stated V3 did not know about an open area on R5, and nothing was reported and V3 was not even aware of any orders being documented. V3 stated V14 should have filled out a new skin sheet and notified the doctor and whoever was on call. 2.) R247's undated diagnoses list documents R247's diagnoses as: wound infection of left lower extremity related to tibia/fibula fracture and open distal left tibia/fibula fracture status post open reduction and internal fixation (ORIF). R247's Nursing Notes dated 12/13/24 at 8:00 PM, document: resident complaining of nausea and stomachache, nurse faxed primary care provider on change and will continue to monitor. There is no further documentation regarding nausea being addressed. On 12/16/24 at 11:40 AM, V2 (Director of Nursing) stated the nurse should have called the doctor or on-call nurse to get an order. The facility's Notification for Change in Resident Condition or Status Policy dated Revised 12/7/17, documents the facility staff shall promptly notify the Administrator, Director of Nursing, Physician, Health Care Power of Attorney of changes in the resident's status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 2 of 16 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 12/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of Farmer City 404 Brookview Drive Farmer City, IL 61842 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility to ensure the least restrictive restraint was used for the least amount of time for one resident (R8) of one resident reviewed for restraints in a sample list of 25. Residents Affected - Few Findings Include: The facility's Physical Restraint/Enabler policy revised 7/24/18 states Policy: To allow residents to be free of physical restraints which are not required to treat medical symptoms or as a therapeutic intervention. Physical restraints shall not be used for the purpose of discipline or convenience. It is recognized that there may be emergency situations in which restraints may be required. Under the heading Procedures the policy also states Place physical restraint problem on the resident's Care Plan. The Care Plan must address the duration, type, and circumstances under which the restraint can be used. After initial documentation, all physical restraints require quarterly documentation regarding the type of physical restraint used, resident's response to the physical restraint, and if any reduction plan has been attempted. Initiate Restraint Elimination/Reductions Program ninety days after application. R8's Physician's Order Sheet (POS) for December 1, 2024 to December 31, 2024 included the following diagnoses: Dementia, Anxiety, Depression, Coronary Artery Disease, Atrial Fibrillation, and Pelvic Tilt. R8's MDS (Minimum Data Set) dated 11/22/24 documents R8 as severely cognitively impaired with two restraints under chair that prevents rising and two restraints under other restraints. R8's Care plan updated 6/5/24 documents (R8) Least restrictive measure to ensure safety include use of device that limits movement and accessibility (meets definition of physical restraint). Device in place: Self-releasing safety belt and busy tray while up in wheelchair. (R8) has unsafe sitting balance and leans forward and sideways in (R8's) wheelchair. (R8) attempts to pick up off the floor making safety an issue. R8's reclining seat and back wheelchair with bilateral trunk supports is not addressed in the Care Plan. On 12/16/24 at 11:00AM R8 was observed being transferred to reclining seat lifted wheelchair with bilateral trunk supports in place by V11 (Certified Nursing Assistant/CNA) and V12 (CNA). A sling type mechanical lift was being utilized. R8 was placed in the wheelchair with the seat lifted and the back reclined. The bilateral trunk supports were placed on either side of R8. A seat belt was fastened across R8's lap. A rigid tray was put in place extending outward from R8's waist. When asked if R8 could stand, V11 stated not very well anymore. But (R8) can wiggle forward and fall that is why her (family member) insists we have the seat belt and the tray on when (R8) is up. V12 nodded in agreement stating (R8) can't stand, but she can get out of this chair without the belt and tray. (R8) has fallen that way before and gotten a couple of big lumps on (R8's) head. (R8's) husband had us add the lap tray because (R8) was fiddling with the buckle on the safety belt. R8's Physical Enabler/Restraint Use/Reduction Evaluation last updated 11/22/24 does not include the lap tray, the reclining raised seat wheelchair, or the trunk supports. On 12/17/24 at 12:00PM V2 (Director of Nursing) verified R8 is Care Planned for restraints and only (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 3 of 16 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 12/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of Farmer City 404 Brookview Drive Farmer City, IL 61842 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 the seat belt has been assessed. V2 stated V2 believes these are not restraints but are for positioning. Level of Harm - Minimal harm or potential for actual harm On 12/17/24 at 2:00PM V1 (Administrator) stated (R8's) husband insists (R8) have these (devices) and I don't think they are restraints. When asked why they are coded on the MDS as restraints V1 indicated V1 did not know. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 4 of 16 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 12/17/2024 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to consistently maintain good personal and oral hygiene for one of three residents (R26) reviewed for Activities of Daily Living on the sample list of 25. Residents Affected - Few Findings Include: The facility A.M. Care policy dated 3/20/23 documents A.M. Care will be given to all residents daily. Nursing assistants are responsible for providing daily A.M. care to all residents which includes providing oral hygiene including the brushing of teeth, washing of the face, underarms, and perineal areas, applying deodorant, dressing in clean clothing, and providing nail care. R26's Physician Order Sheet dated December 2024 documents R26 is diagnosed with Epileptic Syndrome with Seizures and Mild Neurocognitive Disorder. R26's Minimum Data Set, dated [DATE] documents R26 is cognitively intact and is totally dependent on staff for oral care, bathing, dressing, and requires maximal assistance with personal hygiene. R26's Care Plan Summary dated 10/25/24 documents R26 has a self-care deficit and needs assist to complete Activities of Daily Living. The same care plan documents R26 has his own teeth and is to be set up and assisted with oral care. Staff are to provide hygiene and grooming per Resident's preference. Staff should provide care for R26's fingernails on shower days and as needed. On 12/15/24 at 10:06 AM R26 stated staff never offer to set him up to brush his teeth, wash his face, put on deodorant, or clean up his beard. He gets a shower on occasion but sometimes he will refuse because they come so early in the morning, and it is freezing cold. R26 stated they don't offer another time or come back later- he just doesn't get one that week. R26 stated he needs help to take care of himself. On 12/15/24 at 10:06 AM R26's hair appeared dirty and greasy. R26's nails were long and dark, dirt like substance was under his fingernails. R26's beard had food debris throughout it. R26's white shirt was stained with multiple yellow stains up around his neck and chest. R26's face appeared unwashed, and he had dry skin flaking off. R26's teeth and gums appeared coated with debris. On 12/15/24 at 11:48 AM V2 (Director of Nursing) confirmed R26 does refuse showers sometimes and should be getting showers at least once per week and per his preference. V2 confirmed R26 needs new unstained clothing. V2 confirmed staff should be offering assistance with and encouraging morning care which would include face washing, brushing of teeth, combing hair, and cleaning hands and nails. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 5 of 16 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 12/17/2024 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. Based on observation, interview, and record review, the facility failed to maintain infection control standards for catheter irrigation for one resident (R2) of one resident reviewed for catheter care in the sample list of 25. Findings include: R2's undated diagnoses report documents R2's diagnoses as: Spastic Quadriplegic Cerebral Palsy, other Obstructive and Reflex Uropathy, Atrophy of Kidney (terminal), Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, and personal history of Urinary Tract Infections. R2's Medication Administration Record (MAR) dated 12/1/24 through 12/31/24, documents and order to flush (indwelling) catheter twice a day with 10 cubic centimeters (cc) of normal saline. On 12/16/24 at 1:05 PM, V15 (Licensed Practical Nurse) performed irrigation of R2's indwelling catheter. V15 did not wash V15's hands before the procedure. V15 pulled the catheter apart from the drainage tubing to do the irrigation and did not wipe off the catheter before administering the flush or before connecting the catheter back to the drainage tubing. On 12/16/24 at 1:12 PM, V15 stated she did not wash her hands before the task and stated oh yeah when asked about cleaning off the catheter after taking it apart and putting it back together. The facility's Irrigation of Indwelling Catheter dated Reviewed 03/2018, documents pull the privacy curtains and close the door to the resident's room, wash your hands, cleanse the connection site between the drainage tubing and the catheter with antiseptic wipes, and reconnect the tubing to the catheter using aseptic technique. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 6 of 16 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 12/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of Farmer City 404 Brookview Drive Farmer City, IL 61842 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to change, date and store oxygen tubing and humidifier bottles in a sanitary manner for two of two residents (R3, R14) reviewed for respiratory care in the sample list of 25. Residents Affected - Few Findings Include: 1. R3's Medical Diagnoses list dated December 2024 documents R3 is diagnosed with Congestive Heart Failure and Atrial Fibrillation. R3's Physician Order Sheet (POS) dated December 2024 documents R3 is prescribed oxygen at two liters per nasal cannula continuously. Nursing is to change oxygen tubing weekly. On 12/15/24 at 10:43 AM R3's oxygen tubing was laying on the ground. The nasal cannula was attached to the concentrator which was running at two liters per minute. The humidifier bottle was empty and both tubing and humidifier bottle were undated. Humidifier bottle was a refillable bottle and appeared to have white dried residue on the bottom of the container. 2. R14's Medical Diagnoses list dated December 2024 documents R14 is diagnosed with Chronic Obstructive Pulmonary Disease. R14's Physician Order Sheet (POS) dated December 2024 documents R14 is prescribed oxygen at two liters per nasal cannula and nursing should change oxygen tubing and water weekly. On 12/16/24 at 12:37 PM R14's oxygen tubing was hanging over the oxygen concentrator with the nasal cannula touching the floor. On 12/16/24 at 3:35 PM V2 (Director of Nurses) confirmed staff should be storing oxygen tubing in plastic bags, refilling humidifier bottles when needed and should be changing tubing and humidifier bottles at least weekly, dating when changed and documenting in the Treatment Administration Record (TAR). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 7 of 16 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 12/17/2024 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 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide Trauma Informed Care for one resident (R27) of one resident reviewed for Post Traumatic Stress Disorder in a sample of 25. Residents Affected - Few Findings Include: The facility's Trauma Informed Care Policy dated [DATE] states Purpose: To ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. The third bullet point under Types of trauma survivors is Survivors of abuse. This policy also states If a resident is determined to have suffered a traumatic event, the SSD (Social Service Director) will discuss with the resident or the resident's representative regarding potential triggers that may cause re-traumatization and interventions or preferences that eliminate or decrease triggers that may cause re-traumatization. The IDT (Interdisciplinary team) will develop a resident centered Care Plan that will identify the stressors, triggers, clinical manifestations, and interventions to mitigate against Re-traumatization. IDT will monitor the resident's response and adjustment to placement through collaboration and communication and input from the resident or the resident's representative. The trauma informed Care Plan will be updated and revised on an ongoing basis. R27's Physician's Order Sheet (POS) for [DATE] to [DATE] includes the following diagnoses: Type II Diabetes, Late Onset Alzheimer's without Behavioral Disturbance, Generalized anxiety Disorder, Post Traumatic Stress Disorder (PTSD). R27's Behavioral Health assessment dated [DATE] documents History of PTSD secondary to decades of Spousal abuse and Generalized Anxiety Disorder with Alzheimer's Dementia. (R27's) abusive spouse is deceased now and (R27) receives visits from one of (R27's) two sons. Visits are generally pleasant and positive interactions. Patient has high anxiety and repeatedly feels (R27) is not doing 'the right thing' and that 'I'm always wrong' and questions self often throughout the day, even with simple tasks like using the toilet. On [DATE] at 9:00AM R27 was observed in the front common area sitting in a wheelchair picking at a cardboard box on the table in front of her. (R27) appears anxious stating I don't know where I need to go or if I need to lay down. I'm tired. (R27's) voice is tremulous. No staff are observed to attempt to redirect (R27) or intervene to assist (R27). R27's Care Plan revised [DATE] does not include interventions to implement related to R27's PTSD. On [DATE] at 11:40AM V19 (Social Service Director) stated (R27) had been abused by (R27's) spouse for years. V19 verified the IDT was aware of R27's diagnosis of PTSD and should have a care plan in place to address this. On [DATE] at 12:00PM V2 (Director of Nursing) verified R27 has a diagnosis of PTSD and does not but should have a care plan in place with interventions to address identified triggers for PTSD. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 8 of 16 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 12/17/2024 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. Based on observation, interview, and record review the facility failed to maintain safe and secure bed rail for one of one resident (R14) reviewed for bed rails on the sample list of 25. Findings Include: R14's Medical Diagnoses list dated December 2024 documents R14 is diagnosed with History of Falling, Mixed Alzheimer's Vascular Dementia with Behavioral Disturbances, Insomnia, Anxiety, Psychotic Disorder, Bipolar Disorder with Psychotic Features, Attention Concentration Deficit, and Chronic Obstructive Pulmonary Disease. R14's Physician Order Sheet (POS) dated December 2024 documents R14 is prescribed the use of a right 1/2 side transfer bar for physical function of bed mobility. On 12/15/24 at 10:30 AM R14's side rail was extremely loose and moved from side to side and front and back leaving a big gap between the bed mattress and side rail. On 12/16/24 at 3:10 PM V16 (Maintenance Director) moved R14's bed rail and stated yes this is very loose and this needs tightened. V16 confirmed R14 has behaviors and can get aggressive and shake the bed rail and is at risk for falls. On 12/16/24 at 3:15 PM V16 (Maintenance Director) stated he does not routinely check bed rails unless they are new or a resident moves rooms or beds. V16 stated he would expect the staff working with her daily to notify him if a bed rail is loose or needs fixed. On 12/17/24 at 10:30 AM V1 (Administrator) confirmed R14 does need her bed rail checked often because she will shake the rail when upset and is a safety concern due to cognition, behaviors, and falls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 9 of 16 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 12/17/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to properly dispose of a medication for one of six residents (R197) reviewed for medication administration in a sample of 25. Findings include: The facility's Drug release/Destruction Policy revised [DATE] states Discontinued medications or medications belonging to discharged residents should be destroyed as soon as practical and within seven days of resident discharge or drug discontinuation. On [DATE] at 11:00AM V2 (Director of Nursing) accompanied surveyor to review the medication room for the facility. During review of the medication refrigerator a zip lock package of Bisacodyl Suppositories were observed in the refrigerator with (R197's) name on the label. V2 stated (R197) expired on [DATE] and those should have been disposed of. On [DATE] at 9:30AM V2 verified it is the facility's policy to destroy or if appropriate return to the resident all medications upon discharge. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 10 of 16 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 12/17/2024 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to administer medications as ordered to keep the medication error rate below five percent (5%). There were three medication errors out of 25 opportunities resulting in a 12% error rate. This failure affected one resident (R19) of six residents reviewed for medications on the sample list of 25. Residents Affected - Few Findings Include: The facility's Medication Administration policy revised 11/18/17 states Medications must be prepared and administered within one hour of the designated time or as ordered. (i.e. Medication time is 9:00AM the medication can be administered as early as 8:00AM or as late as 10:00AM.) Medication is ordered Daily then medication can be given during the day at residents preference. R19's Medication Administration Record for December 2024 lists the following current physician's orders for medications scheduled at 8:00AM. 1. MiraLAX 17 Grams in 8 ounces water Daily 2. Aspirin 325 milligrams (mg) daily 3. Gabapentin 600 mg Three times Daily 4. Multiple vitamin 1 daily 5. Tiotropium Bromide 3% 1 spray in each nostril Daily 6. Tylenol 650 mg Three times Daily 7. Tramadol 650 mg Twice Daily. On 12/16/24 at 9:20AM V9 (Registered Nurse) was observed to administer all seven of these medications. Although the facility policy stipulates medications ordered daily can be given during the day at the resident's preference R19's Tramadol, Tylenol, and Gabapentin were not administered within one hour of the designated time. On 12/16/24 at 12:00 V2 (Director of Nursing) verified the acceptable window for medication administration is one hour before and one hour following the ordered time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 11 of 16 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 12/17/2024 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 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide dental services for one of two residents (R26) reviewed for Dental Services on the sample list of 25. Residents Affected - Few Findings Include: R26's Physician Order Sheet (POS) dated December 2024 documents R26 is diagnosed with Epileptic Syndrome with Seizures and Mild Neurocognitive Disorder. The same POS documents an order for dental services to be provided as needed. R26's Care Plan Summary dated 10/25/24 does not address R26's need for dental services and broken teeth. R26's Minimum Data Set (MDS) dated [DATE] documents R26 is cognitively intact. On 12/15/24 at 10:06 AM R26 stated staff never offer to set him up or assist him with brushing his teeth. R26 stated he has had multiple teeth break off and has not seen a dentist since he has been in the facility. R26 stated although he does not have tooth pain currently, the broken teeth do affect how and what he can eat. R26 stated there are things he enjoys that he can't eat anymore due to his broken teeth. On 12/15/24 at 10:06 AM R26's teeth and gums appeared coated with debris. R26 had broken teeth. On 12/16/24 at 10:20 AM V2 (Director of Nursing) stated the facility does not have a dental service that provides regular cleanings and check-ups in the facility. V2 stated a couple residents see a dentist regularly but she does not know if R26 has ever seen a dentist for regular cleanings or to address acute concerns since being admitted to the facility. V2 confirmed residents should get regular dental care, cleanings, and checkups and R26 should get his broken teeth addressed and if he would like dentures, R26 should be able to get that process started. On 2/17/24 at 10:30 AM V1 (Administrator) confirmed the facility does not currently contract with or provide dental services for resident check-ups, cleaning, and broken teeth on a regular and routine basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 12 of 16 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 12/17/2024 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide and/or assist the resident in arranging dental services for a resident with broken dentures for one resident (R24) of two residents reviewed for dental issues in a sample list of 25. Residents Affected - Few Findings Include: R24's Care Plan dated 4/19/24 Documents R24 requires oral/dental health maintenance related to (R24) is edentulous. Coordinate arrangements for dental care and transportation as needed/as ordered. On 12/15/24 at 10:00AM V20 (R24's family member) stated (R24) hasn't got any dentures. They were broken at the nursing home (R24) was in before (R24) came to (the facility). I have asked for (R24) to be taken to the dentist over and over to get some new teeth. I have even spoken to the administrator, but they just grind (R24's) food. (R24) does not like the ground food. R24's Physician's Order Sheet (POS) for December 1, 2024 through December 31,2024 documents R24 was admitted to the facility on [DATE]. On 12/16/24 at 11:00AM V2 (Director of Nursing) stated (R24) should have had arrangements made to see a dentist by this time. (R24) has been at (the facility) for several years. V2 denied knowledge the facility has arrangements with a dental service to provide care for residents at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 13 of 16 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 12/17/2024 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 0801 Level of Harm - Potential for minimal harm Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, interview, and record review, the facility failed to provide the services of a qualified director of food and nutrition services. This failure affects all 44 residents residing in the facility. Residents Affected - Many Findings Include: On 12/15/24 at 9:15 AM V1 (Administrator) stated the facility has not had a qualified Dietary Manager since the last one quit. The facility hired V17 (Dietary Manager) who is starting work on 12/16/24 and would work on getting V17 trained and qualified. On 12/16/24 at 11:45 AM V17 was actively supervising and directing the meal service for lunch. The facility's Centers for Medicare and Medicaid Services Long Term Care Facility Application for Medicare and Medicaid dated 12/16/24 documents 44 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 14 of 16 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 12/17/2024 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. Based on observation, interview, and record review, the facility failed to monitor walk-in refrigerator and freezer temperatures and failed to prevent food contamination by storing utensils in bulk food containers. These failures have the potential to affect all 44 residents residing in the facility. Findings Include: The facility's Storage policy dated October 2020 documents Food should be stored at the proper temperature and utensils or tools should not be left in food containers. The facility's Equipment Temperatures policy dated September 2008 documents all refrigerators and freezers shall be monitored regularly to ensure that they are working properly and to correct any mechanical difficulties quickly to prevent food spoilage. The temperatures should be recorded on the corresponding Temperature Charts. On 12/15/24 at 8:30 AM there were scoops and spoons observed in multiple multi-use food containers. A plastic scoop was inside the thickener container with the handle of the scoop in direct contact with the powder. A plastic scoop was inside the oatmeal container with the handle of the scoop in direct contact with the oats. A metal spoon was inside the brown sugar container with the handle in direct contact and partially covered with brown sugar. A metal spoon was inside the hot cocoa container with the handle in direct contact with the powder. On 12/15/24 the Freezer Temperature Log for December 2024 was only filled out on 12/2/24 for the morning shift and from 12/4-12/8, and 12/11-12/12/24 on the evening shift. On 12/15/24 the Walk-in Refrigerator Temperature Log for December 2024 was only filled out on 12/2/24 for the morning shift and from 12/4-12/8, and 12/11-12/12/24 on the evening shift. On 12/16/24 at 3:28 PM V17 (Dietary Manager) confirmed the dietary staff should be completing temperature logs for the walk-in refrigerator and freezers twice per day. V17 also confirmed staff should not be storing scoops or spoons in containers of food products. The facility's Centers for Medicare and Medicaid Services Long Term Care Facility Application for Medicare and Medicaid dated 12/16/24 documents 44 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 15 of 16 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 12/17/2024 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Based on interview and record review, the facility failed to have a communication process in place with the Hospice service provider and failed to have an up to date Hospice Plan of Care for one (R36) of one residents reviewed for Hospice Services on the sample list of 25. Findings include: R36's Face Sheet (current) documents the following diagnoses: Generalized Anxiety Disorder, Dementia, and Alzheimer's Disease. R36's Medical Record did not contain a Hospice Plan of Care. The Hospice service provider communication binder does not contain any nursing entries by V18 Hospice Registered Nurse (RN) for R36. On 12/17/24 at 8:35am, V3 Resident Care Coordinator stated V18 Hospice RN would write any new orders/changes directly on the Physician Order Sheet and flag the chart. V3 stated V18's only means of communication to the nursing staff of any resident order changes and/or changes in care was to reposition the page in R36's chart. V3 stated the chart would then be placed back on the shelf or left on the nurses station. V3 stated V18 does not write any communication in the communication binder or make nursing staff aware of these changes. V3 stated V18 should be documenting in the Hospice communication binder any visits and pertinent information pertaining to R36 including changes in status, care, and orders. The Nursing Facility Hospice Services Agreement with R36's Hospice Provider (dated 10/28/24) documents the following: Coordination of Services. Hospice shall: Designate a member of the interdisciplinary group responsible for each Resident. The designated interdisciplinary group member is responsible for providing overall coordination of the hospice care of the Resident with Facility representatives and communicating with Facility representatives and other health care providers participating in the provision of care for the terminal illness and related conditions and other conditions to ensure quality of care for the patient and family. Provide the Facility with the following information: the most recent Hospice Plan of care specific to each Resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146104 If continuation sheet Page 16 of 16