Inspection·May 31, 2024

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 perform PASARR (Preadmission Screening and Annual Resident Review) Level I or Level II screenings for two (R10 and R55) of three residents reviewed for PASARR's in the sample of 43. Residents Affected - Few Findings include: The facility's Preadmission Screening and Annual Resident Review (PASARR) policy and procedure, dated 3/2024, documents Procedure: 1. admission and readmission a. The facility will participate in or complete the Level I screen for all potential admission regardless of payer source to determine if the individual meets the criterion of mental disorder SMI/SMD (Sever Mental Illness/Severe Mental Disorder), intellectual disability (ID) or related condition. b. Based upon the Level I screen, if an individual is determined to meet the above criterion, the facility will refer the potential admission to the State PASARR representative for the Level II screening process. c. Upon completion of the Level II screen, the facility will review the screen recommendations and determine the facility's ability to provide the specialized services outlined. The facility's Action Summary of resident payer source, documents R10 and R55. 1. The Face Sheet for R10, documents R10 was admitted to the facility on [DATE] with the following diagnoses: Major Depressive Disorder, Psychosis, Bipolar Disorder, Dementia with Behavioral Disturbance. R10's EHR (Electronic Health Record) does not include a PASARR Level I screening or a PASARR Level II having been completed. 2. The Face Sheet for R55, documents R55 admitted to the facility on [DATE] with the following diagnoses: Major Depressive Disorder, Post-Traumatic Stress Disorder, Vascular Dementia, and Anxiety Disorder. R55's EHR (Electronic Health Record) does not include a PASARR Level I screening or a PASARR Level II having been completed. On 5/29/24 at 2:00 pm, V10 (Social Service Director) stated the facility does not do PASARR screenings or level II's for the (specified payor source) residents because the (specified payor source) is paying their bills and V10 does not have any PASARR screenings for R10 or R55. On 5/31/24 at 11:45 am, V1 (Administrator) confirmed all residents admitting to the facility are required to have a PASARR Level I screening completed and a Level II if needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145062 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 145062 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at Streator 1525 East Main Street Streator, IL 61364 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on observation, interview, and record review the facility failed to revise comprehensive care plans to reflect resident condition and cares for 3 (R45, R53 and R58) of 22 residents reviewed for care planning in the sample of 43. Findings include: The facility's Skin Condition Assessment and Monitoring - Pressure and Non-Pressure dated 11/2023, documents the following: The resident's care plan will be revised as appropriate, to reflect altercation of skin integrity, approaches, and goals for care. The facility's Comprehensive Care Plan policy and procedure, dated 11/2023, documents The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving. On 5/31/24 at 11:50 am, V2 (Director of Nursing/DON) and V1 (Administrator) confirmed Resident Care Plans are to be revised and updated to reflect resident condition and cares as they come up. 1. The Face Sheet for R53 includes the following diagnoses: Neurocognitive Disorder with Lewy Bodies, Dementia with Mood Disorder, Cerebral Ischemia, Major Depressive Disorder, Psychophysiological Insomnia, Anxiety Disorder, Parkinson's Disease, Chronic Obstructive Pulmonary Disease, Spinal Stenosis, Psychosis, Dementia, and Cognitive Communication deficit. On 5/28/24 at 10:00 am, R53 was noted lying in a low bed with a dry steri-strip to the bridge of his nose and dried skin tears to R53's left second toe and right elbow. The current Order Summary Report for R53 documents the following Physician Orders as dated: 5/14/24 Monitor right elbow, open to air, every shift until healed. 5/14/24 Monitor area to left second toe, open to air, every shift daily until healed. 5/22/24 Monitor steri-strips to skin tears on bridge of nose. Replace as needed every shift. The Comprehensive Incident Fall Assessments for R53, dated 5/22/24, 5/6/24, 4/2/24, 2/5/23, 2/2/24, 1/18/24, 12/6/23 and 9/10/23 document R53's falls, investigation, and interventions. The current Care Plan for R53 does not include the root cause analysis interventions for R53's falls on 9/10/23, 12/6/23, 2/2/24, 2/5/24, and 5/22/24 that were added to prevent R53 from further falls. This same Care Plan does not include R53 wounds, treatments or monitoring of R53's right 2nd toe, bridge of nose, and right elbow. 2. The Face Sheet for R58 includes the following diagnoses: Chronic Congestive Heart Failure, Chronic Peripheral Venous Insufficiency, Atrial Fibrillation, Acidosis, Cognitive Communication Deficit, Stage 3 Chronic Kidney Disease, Generalized Edema, Disorder of the skin and Subcutaneous Tissue, Morbid Obesity, Disorder of Kidney and Ureter, Atrial Flutter, and Lymphedema. On 5/28/24 at 9:50 am, a sign was posted on the wall of R58's room that stated R58 is on a 1500 ml (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145062 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 145062 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at Streator 1525 East Main Street Streator, IL 61364 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 (milliliter) fluid restriction. Level of Harm - Minimal harm or potential for actual harm On 5/28/24 at 9:54 am, R58 stated I am supposed to be on a 1500 ml fluid restriction because of my heart. I am not supposed to drink a lot. I drink what they bring me. My family brings stuff for me sometimes. Residents Affected - Few On 5/28/24 at 10:26 am, R58 was sitting up in a wheelchair complaining of butt crack pain when he sits up too long and skin irritation and stinging to his groin area. On 5/30/24 at 10:03 am, R58 was lying in bed on his right side with buttocks and coccyx areas bright red and moist with flaky layers of skin missing from various areas. R58 stated he sweats a lot, had skin problems at home, and a nurse had to come and do a treatment. On 5/30/24 at 10:05 am, V11 (Licensed Practical Nurse/LPN) stated the facility Wound Nurse believes this is a fungal issue due moisture of R58 sweating and the treatment ordered has not helped and is going to have the wound doctor assess R58's buttock area. On 5/29/24 at 2:45 pm, V12 (Registered Nurse/RN) stated R58 is non-compliant with his fluid restriction and R58's family and doctor are aware. R58's family brings in bottles of stuff for R58 to drink. R58 has been educated as to why his fluids are being restricted but he does not care and does what he wants. V12 RN stated, I try to make sure that I document when he is non-compliant. The Progress Note for R58, dated 5/6/24, 5/16/24 and 5/23/24 document skin wounds to R58's rectal crease and coccyx as MASD (moisture-associated skin damage). The current Order Summary for R58, documents the following dated Physician Orders: 5/11/24 Zinc oxide cream to both right and left buttocks every shift and every two hours as needed; 5/11/24 Cleanse perineal area and abdominal fold, pat dry, apply zinc cream every shift and as needed for gaulding; 5/11/24 Clean open area to rectal crease, pat dry, and apply zinc barrier cream every shift until healed; and 4/17/24 Weekly skin assessment every evening shift every Wednesday. The current Order Summary Report for R58, documents a Physician Order as: 4/1/24 Monitor Intake: Fluid restriction 1500 ml every shift related to Chronic Systolic CHF (Congestive Heart Failure). This same Care Plan does not document R58's non-compliance with the fluid restriction or the need to educate R58 and R58's family. The current Care Plan for R58, documents I am at risk for a skin impairment related to aging, disease process, decreased mobility, and Diabetes. This Care Plan does not include R58's current skin concerns, monitoring, or care. This same Care Plan does not include R58's Fluid Restriction or monitoring. 3. R45's Wound Evaluation and Management Summary, dated 5/23/2024, documents the following: R45 has a wound to mid right upper back and left coccyx. R45's Skin-other skin condition report, dated 4/11/2024, documents R45 has an area to left gluteal fold and an area on right upper mid back. R45's care plan, dated 3/13/2024, documents R45 has an actual skin impairment to the left gluteal fold and right upper mid back. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145062 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 145062 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at Streator 1525 East Main Street Streator, IL 61364 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm On 5/30/2024 at 2:30PM V7 (Wound Nurse) stated, R45 does not have a wound to the left gluteal fold. The area R45 has is on the left coccyx. I need to write out the correct sites on the care plan and I will fill out telephone orders with the correct sites for the physician to sign. This will correct everything else. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145062 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 145062 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at Streator 1525 East Main Street Streator, IL 61364 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview and record review, the facility failed to maintain water temperatures in a range to prevent scalding burns, for one of four residents (R1) reviewed for accidents/supervision, in a sample of 43. Findings include: The facility policy, Bathing- Shower and Tub dated 03/2024 directs staff, Purpose: To ensure resident's cleanliness to maintain proper hygiene and dignity. Turn on water and ensure that water is at a comfortable and safe temperature. Temperature should be 100- 110 degrees Fahrenheit. On 5/28/24 at 10:28 A.M., R1 was at the sink in (R1's) room washing her hands. At that time R1 stated, Be careful when you wash your hands, the water gets very, very hot. At that time an observation of the water coming from the sink in R1's room was very hot to the touch. On 5/29/24 at 9:26 A.M., The water temperature at the sink in (R1's) room was very hot to the touch. At that time a request for V9 (Maintenance Director) to check the water temperature with a thermometer was made. At 9:43 A.M., a check of the water temperature in (R1's) room with V9 documents the temperature at 113 degrees. At that time V9 stated, What's the temperatures for the water supposed to be? Should I turn them back? That water felt pretty hot. It could burn a resident or staff member. On 5/29/24 at 10:20 A.M., a review of the facility Hot Water Log Temperatures provided by V9 document resident room water temperatures from 9/7/23 until 5/24/24 range between 115-124 degrees on the facility 200 hall. At that time, V9 confirmed the hot water temperatures in the resident rooms on 200 hall was too hot and needed to be turned back to prevent scalding burns. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145062 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 145062 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at Streator 1525 East Main Street Streator, IL 61364 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 prepare food in a sanitary manner/environment for all residents residing in the facility. This failure has the potential to affect all 91 residents residing in the facility. Findings include: The Long-Term Care Facility Application for Medicare and Medicaid, form CMS (Central Management Services) 671, dated 5/28/24, documents there are currently 91 residents residing in the facility. The Facility Dietary Cleaning Schedule Policy, revised 9/2023, documents: there will be a written, comprehensive cleaning schedule posted and monitored to maintain the cleanliness and sanitation of the food service department; the Food Service Manager is responsible for developing a cleaning schedule for the Department and he/she will monitor the compliance and overall cleanliness and sanitation of the department; the cleaning schedule will include each piece of equipment, specific position assigned to complete the task, frequency of cleaning (i.e., after each use, daily, weekly) and the method and agents to be used for cleaning will be written for each task; and a cleaning schedule will be posted and employees will initial and date tasks when completed. On 5/28/24 at 9:35 am, the Facility top oven, of the dual oven system, was not working and the working bottom oven had a moderate amount of built-up dried debris/food on the oven handles, a moderate amount of yellow/brown/black grease build up on the bottom of the oven, and debris/food on the bottom of the oven and handles. The exterior door and door handle, on the bottom oven, had a moderate amount of dried debris/food. On 5/28/24 at 9:35 am, two knife storage wall mounts had a moderate amount of debris/dust on the interior and exterior base of the storage unit. On 5/30/24 at 11:24 am, the Facility top oven, of the dual oven system, was not working and the working bottom oven had a moderate amount of built-up dried debris/food on the oven handles, a moderate amount of yellow/brown/black grease build up on the bottom of the oven, and debris/food on the bottom of the oven and handles. On 5/30/24 at 11:24 am, two knife storage wall mounts had a moderate amount of debris/dust on the interior and exterior base of the storage unit. The exterior door and door handle, on the bottom oven, had a moderate amount of dried debris/food. On 5/28/24 and 5/30/24, Facility Cleaning Schedules could not be provided by the Facility. On 05/29/24 at 9:30 am, V6 (Laundry Aide), without hair protection/hair net, walked into the kitchen, past the unprepared food (raw/frozen vegetables) on the preparation table and retrieved soiled dish towels and Resident clothing protectors, and walked out of the kitchen, past the food preparation table, to exit the Kitchen. On 5/28/24 at 9:40 am, V5 (Dietary Cook) stated, The top oven does not work, we had it fixed a week ago, but now it is broken again, so we only use the bottom oven. These (ovens and knife wall mount) have not been cleaned in a long while. We have not had a cleaning schedule in the past, but we are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145062 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 145062 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at Streator 1525 East Main Street Streator, IL 61364 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 supposed to be starting a new cleaning schedule. All staff that enter the Kitchen should be wearing a hair net. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145062 If continuation sheet Page 8 of 8