Inspection·April 10, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some their hallway or in their rooms so she can wash her hands or her face in the morning and that she was not given or offered a warm wet washcloth to wash her hands and face. On 4/8/2025 at 8:30 AM, R3's hot water in her bathroom was cold to touch after running several minutes. R3's MDS, dated [DATE], documented that her cognition was intact, but bathing and showering was marked not applicable. R3's Care plan, undated, documented that she required an assist of 1 for bathing and showering. 4. On 4/8/2025 at 11:00 AM, R5 stated that she has hot water, but the other hall hasn't had any for a week or 2 and she would not want to be without hot water to wash her face and hands. R5's MDS, dated [DATE], documented that her cognition was intact and that she was dependent upon staff for bathing and showers. On 4/7/2025 at 10:20 AM, V1, Administrator stated that yes, the water heater went out on the south hallway and that the new on was ordered and it would have been put in last week, but the company sent them the wrong one because theirs is propane. On 4/7/2025 at 10:40 AM, the south hall's shower room hot water was cold to touch when ran for several minutes. On 4/9/2025 at 11:00 AM V7, Certified Nurse's Aide, CNA, stated that when the water heater was out no residents missed their showers because they were using the other shower room. She also stated that it was hard with making sure the residents had hot water to wash their hands and faces but they used the water basins. V7 stated that she used the bathroom up front to wash her hands. On 4/9/2025 at 11:05 AM, V8, CNA, stated that they brought the residents off that hall down to the other shower room when that one was out. V8 stated that she washed her hands in the kitchen or the bathroom up front and that she had a stack of rags in a plastic bin with hot water and she would hand them out. On 4/9/2025 at 11:10 AM, V9, CNA, stated that they brought the residents down to the other shower room to give them their showers. V9 stated that she would go and get warm water and wash cloths and pass them out to the residents who needed them in the morning. V9 stated that she used cold water to wash her hands. On 4/8/2025 at 3:40 PM, V1, Administrator, stated that she was unsure of the date as to when the hot water heater went out but did not think it was on 3/24/2025 when shown the work order. V1 stated that the pilot light kept going out of it and they thought they could replace the part but they ended up having to replace the whole thing and then they were sent the wrong water heater and that was why it took so long. V1 also stated that they thought about having a cooler with hot water and wash cloths in it to pass out to the residents but was told it was an infection control issue. On 4/9/2025, at 10:55 AM, V3, Maintenance Director, stated that around 3/24/25, was when the pilot light kept going out. He was having to light it every morning and it may have lasted a few days before having to re light it. V3 stated that they figured out they needed a whole new water heater. A (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145136 If continuation sheet Page 2 of 6 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 04/10/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some new one was ordered, then they got it and realized it was propane and they needed the other one that was not. Resident council meeting minutes, dated 4/3/2025, documented, (V3, Maintenance Director) laundry, and housekeeping supervisor was at the meeting. He talked about the new hot water heater and discussed any maintenance and laundry questions Maintenance work order, dated 3/24/2025, documented, South has no hot water. Residents' Rights for People in Long-Term Care Facilities, dated 11/2018, documented, Your facility must be safe, clean, comfortable and homelike. The facility's room roster, dated 4/7/25, documented that there were 21 residents on the south wing which included the following residents: R1, R2, R3, R7, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R23, R24, R25, and R26. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145136 If continuation sheet Page 3 of 6 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 04/10/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview and record review, the facility failed to maintain a hot water heater to supply hot water to residents for 16 days for 21 of 21 resident (R1, R2, R3, R7, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R23, R24, R25, R26) reviewed for Physical Environment in a sample of 26. Findings include: 1. On 4/7/2025 at 10:30 AM, R1 stated that the hot water heater was still out on his hallway, and it's been a week since he got his last shower. R1 stated that he doesn't have hot water to wash his hands or face in the morning or after he uses the toilet. R1 also stated that was not provided nor offered a warm wet washcloth to clean his face or hands. On 4/7/2025 at 10:30 AM, R1's bathroom faucet was turned on and after a few minutes, the hot water was still cold. 2. On 4/7/2025 at 11:50 AM, R2's hot water from her bathroom faucet was cold to touch after running it several minutes. On 4/7/2025 at 1:15 PM, R2 stated that they have to take her down to the other hallway to get a shower because the water heater on their hall has been out for the past 3 weeks. R2 stated she has been unable to wash her hands and face because there was no hot water and that she was not given a warm wet washcloth to wash her hands and face. 3. On 4/8/2025 at 8:30 AM, R3 stated that it is frustrating that there has been no hot water on their hallway or in their rooms so she can wash her hands or her face in the morning and that she was not given or offered a warm wet washcloth to wash her hands and face. On 4/8/2025 at 8:30 AM, R3's hot water in her bathroom was cold to touch after running several minutes. On 4/7/2025 at 10:20 AM, V1, Administrator stated that yes, the water heater went out on the south hallway and that the new on was ordered and it would have been put in last week, but the company sent them the wrong one because theirs is propane. On 4/7/2025 at 10:40 AM, the south hall's shower room hot water was cold to touch when ran for several minutes. On 4/9/2025 at 11:00 AM V7, CNA, stated that when the water heater was out. V7 stated that it was hard with making sure the residents had hot water to wash their hands and faces but they used the water basins. V7 stated that she used the bathroom up front to wash her hands. On 4/9/2025 at 11:05 AM, V8, CNA, stated that they brought the residents off that hall down to the other shower room when that one was out. V8 stated that she washed her hands in the kitchen or the bathroom up front and that she had a stack of rags in a plastic bin with hot water and she would hand them out. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145136 If continuation sheet Page 4 of 6 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 04/10/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 4/9/2025 at 11:10 AM, V9, CNA, stated that they brought the residents down to the other shower room to give them their showers. V9 stated that she would go and get warm water and wash cloths and pass them out to the residents who needed them in the morning. V9 stated that she used cold water to wash her hands. On 4/8/2025 at 3:40 PM, V1, Administrator, stated that she was unsure of the date as to when the hot water heater went out but did not think it was on 3/24/2025 when shown the work order. V1 stated that the pilot light kept going out of it and they thought they could replace the part but they ended up having to replace the whole thing and then they were sent the wrong water heater and that was why it took so long. V1 also stated that they thought about having a cooler with hot water and wash cloths in it to pass out to the residents but was told it was an infection control issue. On 4/9/2025, at 10:55 AM, V3, Maintenance Director, stated that around 3/24/25, was when the pilot light kept going out. He was having to light it every morning and it may have lasted a few days before having to re light it. V3 stated that they figured out they needed a whole new water heater. A new one was ordered, then they got it and realized it was propane and they needed the other one that was not. Maintenance work order, dated 3/24/2025, documented, South has no hot water. Electronic mail between V11, Director of Plant Operations, to V10, Purchasing Officer, dated 3/26/2025, V11 documented, We are indeed (sic) of a water to replace the current one that has a cracked tank . Electronic mail between V10, Purchasing Officer and V11, Director of Plant Operations, dated 3/27/2025, documented, (V11) we are quoting out and will keep you posted here. Electronic mail between V10, Purchasing Officer to V14, Regional Director of Operations, dated 3/28/2025, documented, (V14) can you please advise if this is approved: 74-gallon BT-80 75, 100 BTU Commercial Gas Water Heater (NG). Electronic mail between V14, Regional Director of Operations, and V10, Purchasing Officer, dated 3/31/2025, documented, Approved. Electronic mail between V10, Purchasing Officer and V12, Regional Maintenance Director, dated 3/31/2025 at 2:26 pm, documented, This has been ordered, looks like its back ordered, will keep an eye on the ETA, please let me know if would like us to make any changes: Arriving Thu, May 01- Tue, Jun 03. Electronic mail between V12, Regional Maintenance Director to V10, Purchasing Officer dated 3/31/2025 at 2:37 pm, documented, We'll need something prior to those dates. we currently have a shower room/laundry that has no hot water. Electronic mail between V10, Purchasing Officer to V12, Regional Maintenance Director and V11, Director of Plant Operations, dated 4/2/2025 at 7:40 AM, (V12 and V11) please confirm if this option will work for the facility. Electronic mail between V14, Regional Director of Operations to V10, Purchasing Officer, dated 4/2/2025 at 9:22 AM, documented, Approved. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145136 If continuation sheet Page 5 of 6 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 04/10/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 4/8/2025 at 1:45 PM, V3, Maintenance Director, stated that the new hot water heater is in, and they now have hot water for that hallway. The facility's room roster, dated 4/7/25, documented that there were 21 residents on the south wing which included R1, R2, R3, R7, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R23, R24, R25, and R26. On 4/9/2025 at 3:25 PM, V1, Administrator, stated that EWSP, stands for emergency water supply process and since the facility did not lose water, they did not follow that process. V1 stated that she does not think the facility has a policy about when the hot water heater goes out. The facility's Emergency Operations Plan, undated, documented, The ESWP will vary from facility to facility, but with an ESWP will assist to ensure that patient and staff standard of care will be maintained during a water emergency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145136 If continuation sheet Page 6 of 6