Health inspection·February 11, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The facility's Final Report, dated 9/19/24, documents the following: R24 was interviewed and voiced he was sweeping in the dining hall and R20 tried to take his broom and then came up behind him and put his arms around his head/ear. R24 reported he had an abrasion to the right ear from R20 putting his arms around him. V9, Licensed Practical Nurse, LPN, stated she came to the dining hall after being alerted of an alleged altercation between R20 and R24 and saw R20 with his hands and arms around R24's neck and face. V9 stated she separated the two residents and observed an abrasion to R24's right side of his face below his ear and provided first aid. Intervention: R24 enjoys sweeping and will sweep while staff are present. Staff will encourage R20 to leave the dining room during clean up. Care plans were reviewed and adjusted as needed. The facility's Final Report, dated 12/13/24, documents the following: V8, AD (Activity Director), stated she heard someone say stop and when she turned around, she saw spilled coffee and R24 put his arm up as if to block the coffee, then R20 hit R24 in the left forearm. V8 stated she separated the two residents. R24 stated he does not know why R20 did this, he did not do anything to R20. Intervention: R20 will be seen by psychiatry services on 12/24/24. Review and revise care plans accordingly. R20's Progress Note, dated 12/29/24 at 5:27 PM, documents the following: Writer observed resident (R20) ramming his wheelchair into the back of another resident's (R36) wheelchair in the dining area. R36 asked resident (R20) to stop, and resident (R20) became aggressive and grabbed her (R36) arm and attempted to yank/pull her arm away from her. Female resident (R36) began to scream in pain and yell at R20. At this time, writer came into the dining area and separated both residents. Writer assessed female resident (R36) and found no injuries. Offered analgesic, which she declined. Call placed to administrator to notify of incident. The facility's Final Report to the State Agency, dated 1/3/25, documents the following: V4, LPN (Licensed Practical Nurse), stated R36 said to R20 Grandpa, don't bump my chair. R20 then grabbed R36's arm. R36 stated she didn't know why R20 did this, he was bumping into her wheelchair, so she asked him to stop, when she said that, he grabbed her upper left arm and then staff came to help and took R20 out of the dining room. No injuries noted. Intervention: R20 was redirected by staff from the dining room after displaying behaviors, review, and update care plan accordingly. On 2/6/25 at 12:31 PM V7, Social Services Director, (SSD), stated R20 has agitation due to his Dementia. V7 stated R2 becomes agitated when it is louder than he would like, when someone bumps into him or his wheelchair or when he feels like he is being yelled at. V7 stated in response, he will intentionally bump into the other person or grab them, trying to get them. V7 stated as an intervention she will try to talk with R20 or if he is having a rough day, try and find out why and R20 likes hot chocolate so they will offer that to him. The Abuse Prevention and Reporting Policy, dated 11/2016, documents the facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services or mistreatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145136 If continuation sheet Page 2 of 7 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 145136 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Auburn 304 Maple Avenue Auburn, IL 62615 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 provide surgical site care on 1 of 3 residents (R257), reviewed for quality of care in the sample of 34. Residents Affected - Few Findings include: On 2/5/25 at 1:00 PM R257's left hip dressing, undated, was observed with the outer layer of the dressing torn away, exposing gray layer of dressing. R257's Face Sheet, undated, documents R257's medical diagnoses includes Orthopedic Aftercare, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Hypertension, Hyperlipidemia, Hypothyroidism, Congestive Heart Failure and Chronic Kidney Disease. R257's Care Plan, dated 1/24/25, documents R257 is at risk for skin impairment with interventions to monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs/symptoms of infection, maceration etc. to MD (Medical Doctor). R257's admission Assessment, dated 1/24/25, documents R257 is cognitively intact, alert to person, place, time, and situation. Left trochanter (hip) Incision line well-approximated with 24 staples. No redness or drainage noted. Measures 18 cm in length. R257's Physician Order, dated 1/24/25, documents to schedule a follow up appointment with the Orthopedic Surgeon 2 weeks from surgery. R257's Hospital Discharge Plan, dated 1/24/25. documents discharge wound instructions: treatment: do not submerge incision in water. Do not apply ointments, creams, or lotions. R257's Wound Rounds Assessment History, dated 1/27/25, documents R257 has surgical site to left hip measuring 22 cm (centimeters) x 5 cm and unable to determine if infection is present. R257's Wound Rounds Assessment Details Report, dated 2/4/25, documents R257 has dressing to left hip surgical site with light amount of serosanguinous drainage present and unable to determine if signs of infection present, measuring 22 cm x 5 cm, unable to remove dressing at this time. R257's Nursing Note, dated 2/5/25 at 1:29 PM, documents the following Writer phoned (Orthopedic Surgeon) to inquire about when follow up appointment was scheduled for. It is scheduled for 02/06/2025 at 1400. Writer also inquired to the nursing staff re: dressing & drainage. Informed that dressing pad was almost completely saturated with exudate. Writer asked if MD would like for dressing to be changed before appointment or wait until tomorrow. Nurse stated that if dressing is leaking, staff may change the dressing before the appointment. On 02/05/25 at 1:00 PM R257 stated the facility has not done anything with her left hip dressing or surgical incision. On 2/5/25 at 11:10 AM V3, ADON (Assistant Director of Nurses) stated R257 has follow up appointment with the Orthopedic Surgeon on 2/6/25 at 2:00 PM On 2/5/25 at 11:34 AM V3, ADON stated R257's Orthopedic Doctor monitors R257's left hip surgical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145136 If continuation sheet Page 3 of 7 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 145136 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Auburn 304 Maple Avenue Auburn, IL 62615 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 incision and bandage. Level of Harm - Minimal harm or potential for actual harm On 2/5/25 at 1:32 PM V3, ADON stated she has not seen R257's left hip surgical incision and does not know what it looks like. When asked about physician orders for R257's left hip surgical incision, V3, ADON stated the facility has orders from R257's hospital discharge regarding the incision. V3, ADON stated it is normal standard practice not to remove a surgical dressing, when the resident has their follow up orthopedic appointment the dressing will be removed. Residents Affected - Few On 2/5/25 at 1:58 PM V13, RN (Registered Nurse) at Orthopedic Doctor's Office stated the physician expects the facility to be checking the resident's surgical incision and site for any signs and symptoms of infection. V13 stated if a patient is discharged to a facility after surgery, the physician will have the facility check and take care of the patient's surgical wound and dressing. V13 stated R257's physician notes documents to have the surgical dressing remain clean, dry, and intact until follow up appointment and may reinforce and change as needed. V13 stated the facility should be checking R257's surgical dressing every shift, monitoring for any signs and symptoms of infection. V13 stated if R257's dressing is saturated and does not get changed, then the surgical site could get infected. V13, stated the facility contacted the physician's office on 2/5/25 reporting R257's dressing was saturated and soiled. V13 stated the facility was informed they can change R257's dressing due to it being saturated. V13 denied any other documented phone calls from the facility regarding R257's surgical incision and dressing. On 2/5/25 at 2:30 PM V3, ADON asked if she would be changing R257's left hip dressing and V3, ADON stated she would not be changing the hip dressing because it was not leaking. V3, ADON stated the physician's office stated the facility could change the dressing if it was saturated or leaking. On 2/5/25 at 1:28 PM V2, DON (Director of Nurses) stated when a resident is admitted to the facility following a surgery, she expects the resident to have orders documented regarding surgical incisions and care to be provided. The Facility's Skin Condition Assessment & Monitoring Non-Pressure Policy, revised 6/2018, document's purpose: to establish guidelines for assessing, monitoring and documenting the presence of non-pressure skin conditions and assuring interventions are implemented. Dressings which are applied to incisions shall include the date of the licensed who performed the procedure. Dressing will be checked daily for placement, cleanliness and signs and symptoms of infection. A licensed nurse shall observe condition of wound incision daily or with dressing changes as ordered. Observations such as drainage, dehiscence, redness, swelling or pain will be documented in the nurse's notes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145136 If continuation sheet Page 4 of 7 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 145136 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Auburn 304 Maple Avenue Auburn, IL 62615 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to have a system in place to monitor and track, infections in the facility for 5 of 5 (R3, R8, R47, R30, and R22) residents reviewed for antibiotic stewardship/ Infection control in a sample of 34. Residents Affected - Some Findings include: 1. R3's Physician order sheet dated 8/19/2024 documents Fosfomycin Tromethamine Oral Packet 3 gram (GM). Give 3 gram by mouth one time only for Urinary Tract Infection (UTI) for one day. R3's Medication Administration Sheets (MARS) dated 8/1/2024 - 8/31/2024 documents Fosfomycin Tromethamine Oral Packet 3 GM. Give 3 gram by mouth one time only for Urinary Tract Infection for one day. Date of administration 8/19/2024. Facility's infection control log dated 8/19/2024 documents Fosfomycin, Urinary Tract Infection. No organism documented. R3's Nursing Notes dated 8/19/2024 at 1:40PM documents daughter called requesting R3 be placed on an antibiotic for UTI. Nurse Practitioner, NP, notified and ordered Fosfomycin 3 GM by mouth times one. Daughter called back and made aware. 2. R8's Physician order sheet dated 12/20/2024 documents Amoxicillin Oral Capsule 500 MG (Amoxicillin). Give one capsule by mouth in the morning for cellulitis for 30 Days. R8's Physician order sheet dated 1/25/2025 documents Amoxicillin Oral Capsule 500 MG (Amoxicillin). Give one capsule by mouth one time a day for preventative cellulitis. R8's Medication Administration Sheets (MARS) dated 12/1/2024-12/31/2024 documents Amoxicillin Oral Capsule 500 MG. Give one capsule by mouth in the morning for cellulitis for 30 Days Start Date-12/21/2024 at 6:00AM. Dose administered 12/21/2024-12-31-2024. R8's Medication Administration Sheets (MARS) dated 1/1/2025-1/31/2025 documents Amoxicillin Oral Capsule 500 MG. Give one capsule by mouth in the morning for cellulitis for 30 days. Start Date-12/21/2024 at 6:00AM. Dose administered 1/1/2025-1/19/2025. Facility's Infection Control Log dated 12/20/2024 documents for R8: Ceftriaxone, Bacterial, Cellulitis. Facility's Infection Control Log dated 1/27/2025 documents for R8: Amoxicillin. Infection unknown. R8's Nurse's Notes dated 12/21/2024 at 8:53PM document continue on intravenous Ceftriaxone and by mouth Amoxicillin for cellulitis to left lower extremity with no adverse reactions noted. Fluids encouraged and taken well. PICC line in place to right upper arm with no signs or symptoms of infection noted. No redness, edema, or warmth noted to left lower extremity. Voices no complaints of pain. R8's Nurse's Notes dated 1/25/2025 at 2:15PM documents Call received from Nurse Practitioner, NP at Infectious Disease. R8 is to start Amoxicillin 500 MG daily. Antibiotic will have no stop date. This is a preventative medication to help prevent cellulitis from returning. NP gave OK to start (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145136 If continuation sheet Page 5 of 7 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 145136 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Auburn 304 Maple Avenue Auburn, IL 62615 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 medication in the AM. Level of Harm - Minimal harm or potential for actual harm 3. R47's Physician Order Sheet dated 1/25/2025 documents Cephalexin (Keflex) capsule. Give 500 MG by mouth two times a day for UTI for 5 days. Residents Affected - Some R47's Medication Administration Sheets dated 1/25/2025 Cephalexin (Keflex) capsule. Give 500 mg by mouth two times a day for UTI for 5 Days. Start Date-01/25/2025 at 4:00PM. Doses administered 1/25/2025-1/30/2025. R47's Nursing Note dated 1/25/2025 at 3:45PM documents Physician here in building. Aware of urinalysis being obtained but lab being unable to pick urine up until Monday. R47's urine is cloudy and has sediment. Orders received to start Keflex 500 MG by mouth twice daily for 5 days for possible UTI. First dose obtained from back up for R47. Facility Infection Control log dated 1/24/2025 documents for R47: Acyclovir, Bacterial, UTI. 4. R22's order sheet dated 1/2/2025 documents Levofloxacin Oral Tablet 500 MG (Levofloxacin). Give one tablet by mouth one time a day for Cellulitis until 01/12/2025 11:59PM. R22's Medication Administration Sheets dated 1/1/2025-1/31/2025 documents Levofloxacin Oral Tablet 500 MG(Levofloxacin). Give one tablet by mouth one time a day for Cellulitis until 1/12/202523:59-Start Date 1/02/2025 4:00PM. Doses administered 1/2/2025-1/12/2025. R22's Nursing Notes dated 1/2/2025 at 5:40AM documents R22 has redness, slight swelling to left lower extremity, warmth noted, pain noted. Physician notified. New orders given for antibiotic. Will continue to monitor. Facility infection control log dated 1/2/2025 documents for R22: levofloxacin, bacterial skin infection. 5. R30's Physician Order Sheets dated 11/22/2024 documents Sulfamethoxazole-Trimethoprim Oral Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim). Give one tablet by mouth every morning and at bedtime for prophylactic until 11/29/2024 11:59PM. R30's Medication Administration Sheets dated 11/1/2024-11/30/2024 documents Sulfamethoxazole-Trimethoprim Oral Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) Give one tablet by mouth every morning and at bedtime for prophylactic until11/29/2024 at 11:59PM. Start Date 11/22/2024 at 8:00AM. Doses administered 11/22/2024-11/29/2024. R30's Nursing Notes dated 11/22/2024 at 12:45PM documents R30 returned via facility transport from OCI. New order received for Bactrim DS one tablet by mouth twice daily times seven days for prophylactic use. Soft care on left arm. May remove for hygiene. Complaints of pain to bilateral arms. Will continue to monitor. Facility infection control log dated 11/26/2024 documents for R30: Sulfamethoxazole. Bacterial cellulitis. On 2/6/2025 at 10:00AM V2, Director of Nursing, DON, stated We have a computer program that we track and trend with. If a resident comes into the facility on an antibiotic but no culture, we have to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145136 If continuation sheet Page 6 of 7 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 145136 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Auburn 304 Maple Avenue Auburn, IL 62615 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 try to get it. Level of Harm - Minimal harm or potential for actual harm Facility policy dated 2025 states The facility is dedicated to implementing an Antibiotic/Antimicrobial Stewardship program to reduce the unnecessary use of antibiotics. This program help ensure that our residents get the right antibiotics at the right tie for the right duration and can improve individual patient outcomes prevent deaths from resistant infections, slow antibiotic resistance, decrease Clostridium difficile infections, and reduce healthcare costs. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145136 If continuation sheet Page 7 of 7