Inspection·February 7, 2024

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The facility's (undated) South Hall Shower Sheet documents R323 is to have scheduled showers on Monday, Thursday, and Saturday each week. This same sheet documents, Notify nurse of refusals immediately! Fill out shower sheet for showers, bed baths or refusals! R323's Shower sheet records for the month of January 2024, document R323 received a shower on 1/8/24. No other shower sheets, progress notes or refusal of showers were documented for the entire month of January. R323's Census Report, dated 2/7/24, documents R323 was hospitalized during the month of January from 1/18-1/23/24. This report documents the remainder of the month R323 was in the facility. On 2/7/24 at 12:40 PM, V2 (Director of Nursing) confirmed that there is not documentation to show R28 or R323 received scheduled showers during reviewed months or at minimum, weekly showers. V2 stated, They (staff) are supposed to fill out the shower sheets on scheduled days. The resident would typically complain if they don't get a shower. I know (R323) was out for a while in January. He was in the hospital (from 1/18-1/23/24) but when he came back, he was in isolation and very sick so he could've refused some then, but they should still be filling out a sheet for refusals and charting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145058 If continuation sheet Page 2 of 12 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 02/07/2024 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 interview and record review the facility failed to maintain aseptic technique during wound care for one of one resident (R274) reviewed for wound care in a sample of 42. Residents Affected - Few Findings include: The facility Dressing Change-(Clean/Non-Sterile)-Sample Guidelines, effective 08/2023, documents to wash hands, apply gloves. Remove soiled dressing and place in plastic trash bag. Remove soiled gloves and place in trash bag. Wash hands or if hands are not visibly soiled, and alcohol-based hand gel may be used to decontaminate the hands. If at a point during the dressing change hands become visibly soiled, hands must be washed instead of using hand gel to disinfect. Apply clean gloves. Clean area/wound with solution specified in treatment order. Apply prescribed ointment and/or dressing per doctor order. Follow manufactures recommendations for application of dressing/ointments/creme's/moisturizers, etc In the event more than one wound is present, each wound site is considered a separate treatment. A new pair of non-sterile gloves will be used for the cleansing of each site, as well as disinfecting hands using hand gel between each site. R274's Treatment Administration Record, dated 2/7/24, documents to cleanse R274's buttocks, rectal and gluteal folds with wound cleanser, pat dry and apply silver sulfadiazine cream every shift and as needed. On 2/7/24 at 9:50am, V7, Licensed Practical Nurse, washed her hands and applied gloves. V7 then cleansed R274's left buttock and rectal area with wound cleanser. R274's rectal area had liquid brown stool. V7 then opened the jar of silver sulfadiazine cream jar and put her first finger of her gloved hand into the jar, scooped out the medication. V7 rubbed the medication on R274's buttocks. V7 then removed her gloves and washed her hands. V7 applied clean gloves, then again put her finger into the jar of medicated cream and rubbed it on R274's right buttocks. V7 applied abdominal pads to R274's right and left buttocks, then washed her hands. V7 did not cleanse R274's right buttocks prior to applying the medicated cream. On 2/7/24 at 10:20am, V7 verified she did not perform hand hygiene or change her gloves after cleansing R274's buttocks. V7 stated she should not have put her fingers into the jar of medicated cream. V7 stated hand hygiene should be done when moving from a dirty area to a clean. V7 stated each wound should be cleaned individually. On 2/7/24 at 1:00pm, V2, Director of Nursing, verified R274 was admitted with multiple radiation burns to his buttocks and rectal area. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145058 If continuation sheet Page 3 of 12 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 02/07/2024 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 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 observation, interview and record review, the facility failed to ensure a range of motion program was in place for a resident with functional limitations in range of motion for one of four residents (R64) reviewed for range of motion in the sample of 42. Findings include: The facility's Restorative Nursing Program policy (revised 01/2019) documents the following: A maintenance program is established based on the resident specific needs for the program. A care plan is then initiated. A functional maintenance program may include range of motion provided during routine daily care such as dressing, grooming/hygiene, eating, transfers, etc. Range of Motion programs may include Active Assistive Range of Motion, Active Range of Motion or Passive Range of Motion. R64's Annual Minimum Data Set Assessment (dated [DATE]), Section GG 'Functional Limitation in Range of Motion,' documents R64 has impairment on both sides of her upper and lower extremities. This same section also documents the following: R64 is dependent with toileting hygiene, shower/bathing self, lower body dressing, putting on/taking off footwear; and R64 requires substantial/maximum assistance with upper body dressing and personal hygiene. R64's current care plan documents the following: I am at risk for an ADL (activities of daily living) Self Care Performance Deficit related to: requires extensive assist to total dependence with daily care needs, history of Covid-19 resulting in prolonged hospital stay and critical illness myopathy, other contributing factors include: congestive heart failure, COPD (Chronic Obstructive Pulmonary Disease), morbid obesity, RLS (Restless Leg Syndrome), polyneuropathy, limited ROM (range of motion) of bilateral upper and lower extremities. On [DATE] at 12:50 PM, R64 was sitting in an electric wheelchair in her room operating her cellular phone which was positioned on a cellular phone stand in front of her on a bedside table. Two upper 1/4 bedrails were attached to R64's bed and secured in the upright position. R64 stated she utilizes the bedrails often to reposition herself due to generalized weakness. R64 stated she, nearly died, after having Covid-19 some time ago, I was so weak. I have lost some of the use of my arms and legs. I've gotten some strength back, and hopefully can continue to regain more. I really lost a lot in my hands and fingers. R64 then lifted her right arm up and pointed out all four of her fingers that were maintained in a curved, rigid, claw-like position. R64 stated, I cannot straighten my fingers. They have been like this since I was so sick with Covid-19. R64 stated facility staff currently do not assist her to perform any type of range of motion exercises. R64 stated, I was receiving physical therapy and occupational therapy, but I am not right now. You know how they have to take you off therapy for a few months before they can put you back on. They took me off a little over month or so ago. R64 stated she is required to utilize a sit-to-stand lift to transfer due to her weakness. R64's medical record has no documentation of any type of range of motion program in place. On [DATE] at 11:20 AM, V8 (Minimum Data Set Coordinator/Registered Nurse) confirmed that R64 does not have any type of range of program in place, and stated R64 would benefit from range of motion exercises. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145058 If continuation sheet Page 4 of 12 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 02/07/2024 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 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 ensure a urinary catheter drainage bag was in a privacy bag and secured to prevent contact with the floor for one of one resident (R274) reviewed for urinary catheters in a sample of 42. Findings include: The facility's Urinary Catheter Care policy, dated 08/2023, documents to establish guidelines to reduce the risk of or prevent infections in resident with an indwelling catheter. This form documents the urinary drainage bags and tubing shall be positioned to prevent either from touching the floor directly. May place the drainage bag and excess tubing in a secondary vinyl bag or other similar device to prevent primary contact with floor or other surfaces. On 2/4/24 at 9:45am, R274 was in bed, sleeping. R274's uncovered urinary drainage bag was hanging on the lower aspect of the bed frame, with the drainage bag touching the floor. At 1:20pm, R274's urinary drainage bag remained in the same position. R274's urinary drainage bag was not in a privacy bag. 02/05/24 11:15am, R274's urinary drainage bag was again resting on the floor, uncovered. At 1:15pm, R274 was sitting in a wheelchair, with the urinary drainage bag hanging under the wheelchair, touching the floor and uncovered. On 2/6/24 at 11:45am, R274 was in the dining area. R274's urinary drainage bag was hooked under the wheelchair, with a blue cover over the back of the bag, the bottom of the urinary drainage bag was again touching the floor. On 2/7/24 at 9:40am, R274's urinary drainage bag had a blue privacy cover attached to it, but the bottom of the drainage bag was resting on the floor. On 2/7/24 at 10:20am, V7, Licensed Practical Nurse, verified that R274's urinary drainage bag is not to be touching the floor at all. V7 also stated that the urinary drainage bag is to be in a privacy bag at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145058 If continuation sheet Page 5 of 12 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 02/07/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview and record review, facility staff failed to administer feeding tube flushes as required for one of one resident (R175) reviewed for feeding tubes in a sample of 42. Residents Affected - Few FINDINGS INCLUDE: The facility policy, Medication Administration- Gastrostomy, dated (reviewed) 08/2000 directs staff, (Nurses) may administer medications through a (feeding) tube as allowed, after demonstrating competency. Administer medication: Use liquid preparations whenever possible. If more than one medication is being given at a dosing time, administer each medication separately, flushing the tube with approximately 10 ML (milliliters) of tepid water between medications, or enough to clear the tubing. R175's current Physician Order Sheet includes the following physician Orders: Guaifenesin Oral Liquid 100 MG (milligrams)/5 ML (milliliters) Give 10 ml via feeding tube four times a day; Hydralazine 100 MG Give 1 tablet via feeding tube every 8 hours; Famotidine 20 MG Give 1 tablet via feeding tube every morning and at bedtime; Sennosides Oral Syrup 8.8 MG/5 ML Give 10 ml via feeding tube every morning and at bedtime; Keppra Oral Solution 100 MG/ML Give 10 ml via feeding tube every morning and at bedtime; Valproic Acid Oral Solution 250 MG/5 ML Give 5 ml via feeding tube every morning and at bedtime; Gabapentin Oral Solution 250 MG/5 ML Give 100 mg via feeding tube three times a day; Omeprazole Oral Suspension 2 MG/ML Give 10 ml via feeding tube every morning and at bedtime. On 2/4/2024 at 9:29 A.M., V7/Licensed Practical Nurse (LPN) prepared to administer medications for R175. V7/LPN added Guaifenesin Oral Liquid 10 ml (milliliters) to a plastic cup; crushed one tablet Hydralazine 100 MG and placed it in a plastic cup with tap water, crushed one tablet of Famotidine 20 MG and placed it in a plastic cup; added Sennosides Oral Syrup 8.8 MG/5 ML 10 ml to a plastic cup; added Keppra Oral Solution 100 MG/ML Give 10 ml to a plastic cup; added Valproic Acid Oral Solution 250 MG/5 ML 5 ml to a plastic cup; added Gabapentin Oral Solution 250 MG/5 ML 100 mg to a plastic cup; added Omeprazole Oral Suspension 2 MG/ML 10 ml to another plastic cup and entered R175's room. V7/LPN administered each medication separately without flushing R175's feeding tube with the required 10 ML of water after each medication. On 2/4/2024 at 9:40 A.M., V7/Licensed Practical Nurse confirmed she had not administered the required 10 ML water flush after each medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145058 If continuation sheet Page 6 of 12 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 02/07/2024 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 ongoing communication with the dialysis center and failed to develop a complete comprehensive care plan for one of one resident (R177) reviewed for dialysis, in a sample of 42. Residents Affected - Few FINDINGS INCLUDE: The (undated) facility policy, Care of the Resident Receiving Hemodialysis, directs staff, Monitoring Procedures: Medications as ordered per physician- Notify Nephrologist of changes; Monitor dialysis site (every) shift and (upon) return from Dialysis, for bleeding or redness; Daily weights; Full set vitals per physician order; Lab (Laboratory) monitoring per physician orders; Do not access dialysis site or tamper with dressing without Dialysis Center consent; Follow dietary and fluid restrictions per order- Consult Dietician; Change of conditions to be notified to Dialysis Center/Nephrologist. Communications with Dialysis Center: The (Director of Nurses) will be designee for emergencies for Dialysis Center communication; Facility will use binder for communication forms; Dialysis Communications Sheet will be sent with resident for every treatment and entered in resident chart; Medications held, administered or discontinued will be communicated to Dialysis Center; Variances in weights or vitals will be notified to Dialysis Center. R177's current Physician Order Sheet, dated February 2024 documents that R177 was admitted to the facility on [DATE] and includes the following diagnosis: End Stage Renal Disease. This same form includes the following physician orders: Hemodialysis per physician order; Pre-Dialysis- Obtain V/S (Vital Signs) prior to dialysis treatments on scheduled dialysis days one time a day every Tuesday, Thursday; Post-DialysisObtain V/S (Vital Signs) prior to dialysis treatments on scheduled dialysis days one time a day every Tuesday, Thursday; Check Bruit and Thrill of dialysis fistula every shift; Dialysis - Dialysis Treatments twice weekly at 10 (10:00) A.M., Phone #800-881-5101 Every Tuesday and Thursday via port AV (Arterial Venous) Shunt Access Location: left upper arm; Monitor dialysis catheter for bleeding, s/s (signs and symptoms) infection, warmth, redness every shift. R177's current Care Plan, dated 1/22/2024 includes the following Focus Areas, (R177) needs hemodialysis r/t (related to) renal failure. Also included are the following Interventions/Tasks, Check and change dressing daily at access site. Document: Check for bruit and thrill as ordered and prn (as needed); Do not draw blood or take B/P Blood Pressure) in arm with graft; Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis on Tuesday/Thursday; Monitor/document/report PRN (as needed) any s/sx (signs and symptoms) of infection to access site: Redness, Swelling, warmth or drainage. On 2/4/2024 at 9:50 A.M., R177 was lying on his left side in bed. A bandage was present to R177's upper. left arm. At that time R177 stated, I go to Dialysis two times a week. On 2/7/2024 at 10:26 A.M. V6/Assistant Director of Nurses (ADON) verified R177's electronic medical record did not contain any Dialysis Communication Tools for R177's dialysis treatments. At that time V6/ADON verified the facility policy includes the facility nurse completes a Dialysis Communication Tool prior to a resident leaving for dialysis and gives it to the resident to take to the dialysis appointment, the Dialysis Center nurse completes the form and gives it back to the resident who gives it to the facility nurse upon return to the facility. The facility nurse then scans the form into the resident's electronic medical record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145058 If continuation sheet Page 7 of 12 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 02/07/2024 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 0698 Level of Harm - Minimal harm or potential for actual harm On 2/7/2024 at 10:35 A.M., V7/Licensed Practical Nurse (LPN) stated, I have not seen a Dialysis Communication Tool. I haven't filled one out or sent one with (R177) when he goes to dialysis. On 2/7/2024 at 10:40 A.M., V8/Care Plan Coordinator verified that R177's Care Plan was not complete to address R177's dialysis status. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145058 If continuation sheet Page 8 of 12 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 02/07/2024 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 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 document an appropriate medical indication for the use of an Antipsychotic medication for one resident (R36) and failed to identify and monitor for target behaviors that warrant the use of an Antipsychotic medication for two of three residents (R36 and R39) reviewed for psychotropic medications in the sample of 42. Findings include: The facility's Psychotropic Medication-Gradual Dose Reduction Policy (Revised 02/2018) documents, Purpose: To ensure that residents are not given psychotropic drugs unless psychotropic drug therapy is necessary to treat a specific or suspected condition as per current standards of practice and are prescribed at the lowest dose therapeutic to treat such conditions. 1. R36's current Physician's Orders document the following medication orders: Venlafaxine Oral Capsule Extended Release (Antidepressant) 150 mg (milligrams) give one capsule by mouth in the morning related to Depression; and Aripiprazole Oral Tablet (Antipsychotic) 5 mg give one tablet by mouth in the morning related to anxiety disorder. R36's Consent for Psychotropic Medications (dated 11/17/23) documents R36 takes Aripiprazole for the following: Diagnosis/Indication for Use: Anxiety Disorder. On 02/05/24 at 01:20 PM, R36 was sitting in a chair in her room with her wheelchair nearby. R36 was dressed and groomed, and oral fluids and a call light were within her reach. R36 stated she does have a diagnosis of depression, but feels it is well-controlled at this time. No adverse behaviors were displayed by R36 at this time. On 02/06/24 at 12:15 PM, R36 was sitting in the dining room at the table eating lunch. R36 was conversing with her tablemates, and no adverse behaviors were displayed by R36 during the lunch meal. R36's current care plan has no mention of any target behaviors displayed by R36. R36's Behavior Monitoring and Interventions Report (dated 11/18/23 - 02/06/23) does not document or specify any target behaviors that R36 is being monitored for, and documents zero episodes of any adverse behaviors were displayed by R36 during this time frame. On 02/07/24 at 01:20 PM, V2 (Director of Nursing) stated R36 was admitted to the facility in November 2023 with an order for her antipsychotic, Aripiprazole, and has been taking it as prescribed while residing at the facility. V2 stated the medical indication documented for the use of R36's Aripiprazole is Anxiety, which is not an appropriate indication for the use of an antipsychotic medication. V2 stated R36, has never really displayed any behaviors, and therefore, indicated the facility has not identified any target behaviors to monitor R36 for. V2 stated, We have a generalized behavior sheet, and document any behavior a resident displays even if it hasn't been identified as a target behavior, being the reason for the use of the medication. V2 confirmed that if there are no target behaviors monitored, the facility cannot evaluate the effectiveness of R36's Aripiprazole to determine if a gradual dose reduction is appropriate. V2 then stated R36 is, pretty mellow, and is not a harm to herself or others. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145058 If continuation sheet Page 9 of 12 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 02/07/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 02/07/23 at 02:25 PM, V3 (Registered Nurse/Infection Preventionist) stated that R36, Came to us on her antipsychotic, Aripiprazole. V8 stated R36 has not displayed any behaviors since her admission, so the facility has not identified any target behaviors to monitor. 2. R39's diagnosis list, dated 2/7/2024, documents the following: Dementia without Behavioral Disturbances, Psychotic Episodes, Mood Disorder, and bipolar disorder. R39's Physician Order Sheet, dated 2/1/2024 through 2/29/2024, documents the following: Aripiprazole (Antipsychotic) Oral 15MG (milligram) at bedtime for Bipolar. R39's Behavior Monitoring and Intervention Report, dated 12/1/2023 through 12/26/2023, documents, no behaviors or resident not available. This document does not have any specific behaviors for the use of Aripiprazole 15MG (milligrams) Antipsychotic drug for bipolar disorder. R39's Behavior Monitoring and Intervention Report, dated 1/1/2024 through 1/31/2024, documents, no behaviors or not applicable. This document does not document any specific behaviors for the use of the Antipsychotic Drug-Aripiprazole 15MG (milligram) for bipolar disorder. On 2/5/2024 at 12:05PM R39 was sitting in her wheelchair in the main dining room eating lunch. R39 was calm and quiet. No adverse behaviors noted. On 2/6/2024 at 1:30PM R39 was lying in bed resting and no adverse behaviors observed. On 2/7/2024 at 12:45PM R39 was laying in the bed with eyes closed and no adverse behaviors observed. On 2/7/2024 at 1:15PM V2/DON (Director of Nurses) stated, Yes, I do agree R39's behaviors need to be targeted and specific to her. (R39's) behavior tracking for the past 2 months does not indicate R39 has had any adverse behaviors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145058 If continuation sheet Page 10 of 12 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 02/07/2024 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to offer palatable meals. This failure has the potential to affect 80 residents residing in the facility. Residents Affected - Many Findings include: The facility's Week at a Glance Menu documents lunch for Sunday 2/4/24 is oven fried chicken, baked sweet potato with butter and brown sugar, roasted cauliflower and peach dump cake. Monday 2/5/24 documents lunch is Lasagna, tossed salad/dressing, fruit fluff, garlic bread. Tuesday 2/5/24 is baked turkey crunch, rice pilaf, vegetable medley and bread pudding. On 2/4/24 at 12:15pm, R10 stated he was finished eating. R10 had two pieces of oven fried chicken on his plate. R10 pulled the breading off the chicken and attempted to pull the meat off the bone. R10 stated the chicken was over cooked. The meat R10 pulled off the chicken bone was stringy and very dry. On 2/4/24 at 12:30pm, R16 stated he could not eat his chicken, because it was burnt. R16 had two pieces of chicken on his plate, untouched. R16 ate the rest of the meal. On 2/4/24 at 12:35pm, R18 stated the chicken was over cooked. There were two pieces of chicken untouched on R18's plate. The chicken leg was dark brown with black lines going down each side of it. On 2/4/24 at 12:40pm, R37 had a chicken breast, on her plate, with the skin pulled off. The meat was very dry and stringy. R37 stated all the food is always over cooked and tough. On 2/5/24 at 12:00pm, R10 stated the Lasagna was burnt. R10 did not eat the Lasagna on his plate. The edges of the Lasagna were black, and the noodles appeared to be dry and hard to cut. On 2/5/24 at 12:15pm, R24 stated the Lasagna was burnt, and she could not chew it. On 2/6/24 at 11:30am, a test lunch tray was received. The baked turkey crunch topping was dark brown and hard to chew. The rice and vegetable medley were palatable. At 12:15pm, R10 and R24 again stated the lunch was over cooked. On 2/6/24 at 12:30pm, V10, Certified Nursing Assistant, verified the chicken and the Lasagna were very over cooked. V10 stated most of the residents did not or could not chew it. V10 also verified the turkey bake topping was crunchy and hard for residents to chew. The facility's Long-Term Care Facility Application for Medicare and Medicaid form, dated 2/4/24, documents a census of 80. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145058 If continuation sheet Page 11 of 12 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 02/07/2024 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 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 perform hand hygiene and change gloves during meal service. This has the potential to affect 80 residents residing in the facility. Residents Affected - Many Findings include: The facility's Proper Hand Washing and Glove Use policy, dated 2020, documents that employees will wash hands before and after handling foods, after touching any part of the uniform, face, or hair, and before and after working with an individual resident. Gloves are to be changed any time hand washing would be required. This includes when leaving the kitchen for a break or go to another location in the building; after handling potentially hazardous food; or if gloves become contaminated by touching the face, hair, uniform, or other non-food contact surface, such as door handles and equipment. Staff should be reminded that gloves become contaminated just as hands do and should be changed often. When in doubt, remove gloves and wash hands again. On 02/05/24 at 12:00pm, V4, Dietary Aide/Cook grabbed a plate with her left hand then dished up the Lasagna, then grabbed a bread stick with her gloved hand, put it on the plate. After each plate served V4 would rub her gloved hand down the front of her uniform. V4 did not change her gloves or perform hand hygiene while serving. V4 set a plate on a tray to be served and the bread stick fell off onto the tray. V4 picked it up and put it back onto the plate. On 2/5/24 at 12:20pm, V5, Dietary Manager, verified that V4 is supposed to be using tongs to pick up the breadsticks not her hand. V5 also stated that V4 is to wash her hands and apply clean gloves after touching her uniform and other objects in the kitchen. The facility's Long-Term Care Facility Application for Medicare and Medicaid form, dated 2/4/24, documents a census of 80. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145058 If continuation sheet Page 12 of 12