Inspection·December 1, 2022

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure a resident had access to a call light for one resident (R36) out of 17 residents reviewed for call lights in a sample of 25. Residents Affected - Few Findings include: The facility's Call Light policy dated 8/1/05, document Procedure: 7. Make certain call light is within resident's reach before leaving the room. On 11/29/22 at 10:45 AM, R36 observed lying in bed with no call light in reach. R36 stated, I don't know where my call light is. I had it before I took my shower, but I haven't seen it since I got back a few minutes ago. On 11/29/22 at 10:49 AM, V10, Licensed Practical Nurse (LPN) observed going into R36's room and searching for R36's call light. V10, LPN, found R36's call light behind his bed and stated, Oh, here it is. It must have fell. As V10, LPN, attempted to put R36's call light on his bed, she was unable to place it on R36's bed and stated, It won't reach. Why won't it reach? Oh, I see! It's tangled up with the fan cord. That's why it won't reach. V10, LPN, untangled the call light and placed it back on R36's bed. V10, LPN, stated, He does need his call light because he knows when he has to use the bathroom and requires assistance. On 11/30/22 at 12:04 PM V6, Care Plan Coordinator (CPC) stated (R36) is mostly continent of his bladder and he has the cognition to use his call light to ask for assistance to use the bathroom. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145058 If continuation sheet Page 2 of 8 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 145058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at Chillicothe 1028 Hillcrest Drive Chillicothe, IL 61523 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure staff maintained and protected a resident's privacy while providing perineal care for one resident (R52) of 17 residents reviewed for privacy in a sample of 25. Residents Affected - Few Findings Include: The Illinois Ombudsman Program Resident Rights, dated 11/2018, documents, Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life; and Your medical and personal care are private. Facility staff must respect your privacy when you are being examined or given care. The facility's Resident Dignity Policy, Reviewed 9/2011, documents: All residents have the right to have their privacy maintained irrespective of their functional and cognitive status. Staff will respect this right in the following ways: 4. Close drapes, privacy curtains and room doors as necessary to maintain privacy. The facility's Perineal Care Policy and Procedure, Revised 11/2016, documents: Resident privacy will be maintained while perineal care is being provided. R52's Minimum Data Set (MDS) dated [DATE], documents R52 has a BIMS (Brief Interview of Mental Status) score of 11. (MDS indicates that on a scale of 0 - 15, 13 to 15 cognitively intact and 8 to 12 moderate impairment). R52's current Care Plan documents I (R52) am alert and can make my needs known. On 11/30/22 at 12:40pm, V11 Registered Nurse (RN) and V12 Certified Nursing Assistant (CNA) entered R52's room to provide and/or assist with peri care and wound treatment. R52's room also housed two other residents. Neither V11 nor V12 pulled R52's privacy curtain around her when providing cares to R52. V12 stated, I forgot; usually do pull the curtains for privacy. On 12/1/22 at 10:20 am, V2 Director of Nursing (DON) stated, It is expected that when staff are going to provide cares for residents, the resident's privacy curtain should be around the resident with any kind of cares including treatments and peri care; and make sure the door to the resident's room is closed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145058 If continuation sheet Page 3 of 8 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 145058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at Chillicothe 1028 Hillcrest Drive Chillicothe, IL 61523 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to ensure a resident's catheter bag and tubing were not laying on the floor for one resident (R44) out of three residents reviewed for catheters in a sample of 25. Residents Affected - Few Findings include: R44's physician order sheet dated 11/1/22 through 11/30/22 documents R44 as having an indwelling catheter. On 11/29/22 at 12:27 PM, R44 observed lying in bed with catheter bag and tubing laying on the floor. On 11/29/22 at 12:29 PM, V2, Director of Nursing (DON) stated, The bag and tubing aren't supposed to be on the floor. I'll have to figure out how to hang it from the bed since (R44) has a low air loss mattress and low bed. What probably happened is the CNA (Certified Nursing Assistant) hung the bag on the side of the bed, but when she lowered the bed, the bag hit the floor and popped off the bed. On 12/1/22 at 09:24 AM, V2, DON, stated, We don't have a policy telling the staff not to let the tubing or catheter bag touch the floor. It's just common sense that it's not supposed to. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145058 If continuation sheet Page 4 of 8 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 145058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at Chillicothe 1028 Hillcrest Drive Chillicothe, IL 61523 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 ensure a licensed nurse administered oxygen for one resident (R6) out of one resident reviewed for oxygen therapy in a sample of 25. Residents Affected - Few Findings include: The facility's Oxygen Administration policy revised 5/1/17 documents Oxygen is administered by an LPN (Licensed Practical Nurse) or RN (Registered Nurse) per physician orders. (Other staff may not regulate, start or discontinue oxygen.) R6's physician order sheet dated 11/1/22/ through 11/30/22 documents Oxygen (O2) at two - three liters per minute (L/M) to keep SpO2 (oxygen saturation) 91% or greater. On 11/29/22 at 01:40 PM V9, Certified Nursing Assistant (CNA) transferred resident, took oxygen tubing off the oxygen concentrator, hooked it to the portable oxygen tank hanging from R6's wheelchair and turned the oxygen to 2 L/M. V9, CNA verified she turned the oxygen to 2 L/M and stated Yeah, I just turned it to two liters because I know that's what she's on. On 12/1/22 at 09:00 AM, V2, Director of Nursing (DON) stated The CNAs aren't supposed to be administering oxygen. I did an in-service letting everyone know that only the nurses are supposed to be the ones administering the oxygen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145058 If continuation sheet Page 5 of 8 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 145058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at Chillicothe 1028 Hillcrest Drive Chillicothe, IL 61523 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on observation, interview and record review, the facility failed to ensure a resident's identity was verified prior to administering medication to one resident (R68) out of one resident reviewed for competent nursing staff in a sample of 25. Finding Include: The facility's pharmacy Medication Pass Tips policy dated 1/2017 documents Prior to preparing medication, verify the resident's identity. Verify the drug against the eMAR (Electronic Medication Administration Record). The facility's resident roster by room dated 11/29/22 documents R36 and R68 are roommates. R68's medical record documents R68 as cognitively intact. R68's medical record dated 11/15/22 documents R68 arrived back from the hospital at 9:12 AM. R68's physician order sheet (POS) dated 11/1/22 through 11/30/22 documents Benefiber Powder (Wheat Dextrin) Give two tablespoons by mouth three times a day for constipation. Give at 6:00 AM, 10:00 AM and 4:00 PM. Tramadol Tablet 50 milligrams. Give one tablet by mouth three times a day for pain. Give at 8:00 AM, 2:00 PM and 8:00 PM. R68's narcotic medication administration record dated 11/15/22 documents one Tramadol was taken from the medication bubble pack at 8:00 PM. R68's eMAR dated 11/15/22 documents R68 received his Benefiber at 10:00 AM and 4:00 PM. R36's POS documents Lactulose Solution 10 grams (GM)/15 milliliters (ML). Give 15 ML by mouth four times a day R36's eMAR dated 11/1/22 through 11/30/22 documents Lactulose Solution 10 GM/15ML. Give 15 ml by mouth four times a day at 8:00 AM, 12:00 PM, 5:00 PM and 8:00 PM. 11/15/22 8:00 PM administered. On 11/29/22 at 10:39 AM, R68 stated, About two weeks ago I was given the wrong medication. The nurse gave me my roommate's (R36) medication. She said she thought I was still in the hospital and thought I was (R36). About two weeks ago I was sent to the hospital but came back the morning of the 15th (11/15). I was sitting in my room and (R36) was out of the room. The nurse came in and handed me a cup of medication that I put in my mouth and then handed me a cup that I thought was water. When I took a drink, I immediately spit everything out and said This isn't water. These aren't my pills. I spit everything all over the place. The nurse then asked, Aren't you (R36)? I said No, I'm (R68). She said, 'I thought you were in the hospital.' I told her I had been back from the hospital for about 12 hours. So, she left and came back with a new set of pills that were mine and I took those. No, the nurse never asked me my name, she just came in and handed me pills. She kept saying 'The computer says your still in the hospital.' I told her I've been back for the last 12 hours. On 11/29/22 at 11:00 AM, V10, Licensed Practical Nurse (LPN) verified R68 is cognitively intact and stated, I would say he's definitely able to recall something that happened two weeks ago. He was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145058 If continuation sheet Page 6 of 8 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 145058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at Chillicothe 1028 Hillcrest Drive Chillicothe, IL 61523 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few very accurate on his timeframe of when he went to the hospital and how long he had been back. He got back around 9:00 AM on 11/15, so yeah, he'd been back for about 12 hours. On 11/29/22 at 12:54 PM V7, Registered Nurse (RN) stated, I went into (R68)'s room and gave him his medication and handed him his water. He put all the medication in his mouth and when he started drinking the water, he spit everything out and said, 'These aren't my pills!', but I told him they were his. I had to go re-pull all his medication and give them a second time. What happened was that I didn't mix his Benefiber up correctly and that's why he spit everything out thinking they weren't his. Yes, I had to throw away all the pills and pull all his medications a second time. On 11/29/22 at 1:15 PM, V2, Director of Nursing (DON) reviewed R68's narcotic tracking sheet dated 11/15/22 for Tramadol and stated, I see what you're saying. If (V7, RN) had to pull his 8:00 PM medications twice, then we would see Tramadol signed out twice, but it's not. She only signed it out once at 8:00 PM. On 11/29/22 at 2:05 PM, R68 stated, The liquid the nurse gave me was not my Benefiber mix. I take that thing three times a day, so I know what it is. What she gave me was a thick syrupy liquid. I immediately spit it out because I don't take anything like that. After I spit it out, it was very sticky. I also know it wasn't my Benefiber drink because I don't get that at bedtime. On 11/29/22 at 2:05 PM, R36 stated, What (R68) is describing sounds just like what I take at bedtime. On 11/29/22 at 2:10 PM Director of Nursing (DON), stated, The Benefiber we use comes in a packet that mixes with water. It's clear and it's not thick or sticky. On 12/1/22 at 8:54 AM, V8, RN, observed pulling a brown bottle out of the medication cart and identifying it as R36's Lactulose medication and stating, I'm not sure if you can see, but it's a thick syrupy like liquid. It's sticky. 12/1/22 09:00 AM V2, DON, verified V7, RN should have verified R68's identity prior to giving him medication and stated, I don't think we have a medication administration policy or procedure that tells the nurse to identify the resident prior to administering medication. As nurses, we all know we have to identify the resident before giving them medication, especially since she (V7, RN) was an agency nurse new to the building and didn't know the residents. on 12/1/22 at 11:30 AM, V2, DON, stated, We didn't do a medication error report because (R68) never actually swallowed the wrong medication. He was able to spit them out. We banned (V7, RN) from returning to the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145058 If continuation sheet Page 7 of 8 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 145058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at Chillicothe 1028 Hillcrest Drive Chillicothe, IL 61523 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 ensure open food products stored in the facility freezer were labeled and dated. This failure has the potential to transmit food borne illness to all 67 residents residing in the facility. Findings include: The facility's Food Labeling and Dating policy dated 2/22 documents, The following procedures are to be used for proper food labeling. 1) Proper food labeling includes: name of product, date stored and in some cases, the time of the day. 2) The food must be labeled and dated if it is removed from its original container. 3) Leftover foods placed in a container must be cooled down properly, labeled and dated. On 11/29/22 at 09:22 AM, during a walkthrough of the kitchen freezer, two undated and unlabeled clear bags of food were observed sitting on the storage racks. Also observed was an open undated bag sitting in a cardboard box labeled as blueberries. The blueberries were not sealed and open to the freezer. On 11/29/22 at 09:23 AM, V5, Dietary Manager, stated, The clear bags are French fries and hash browns (tater tots). They should have a date written on the bag. The blueberries should not be open like this and it's supposed to also have a date. V5, Dietary Manager observed grabbing the bag of blueberries and closing the bag to seal the contents. CMS (Center for Medicare and Medicaid Service) form 672 signed by V6, Care Plan Coordinator, and dated 11/29/22 documents 67 residents residing in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145058 If continuation sheet Page 8 of 8