Inspection·May 16, 2024

F 0690 said his catheter hurts. Dark, cloudy, yellow urine noted. Afebrile. Wife (V7) present and aware. Writer will notify MD (doctor) at this time. Level of Harm - Actual harm Residents Affected - Few R3's Nurse's Note, dated 4/5/2024 9:01 PM, documents, Health Status Note Text: (V6, R3's Physician) is aware of dark, cloudy, yellow urine and gave orders: UA (urinalysis), CBC (complete blood count), CMP (Comprehensive Metabolic Panel). R3 is aware and said he will tell his wife. Documentation from V8's Urology Office regarding communication to the facility documents 04/10/24 01:22pm, Patient has UTI. Bactrim DS Q (every)12 hrs. (hours) x 7 days. Change catheter in 5 days. 4/10/2024 at 2:58 PM Left message to return call back to office. R3's Nurse's Note, dated 4/12/2024 at 12:11PM, documents, Nurses Note Narrative: This nurse placed a call to AHA (lab) and inquired on the final results from UA was completed on 4/7/24. Associate told this nurse they were awaiting a call back from staff to see if we wanted them to complete the work up on the urine. This nurse told them absolutely and we were under the impression it was already being done due to the partial saying C+S (culture and sensitivity) to follow. Final results should be available tomorrow 4/13/24 and will need to be faxed to (V8, physician) office at (office number). R3's Urinalysis Lab Results, dated 4/13/2024, documents the specimen was collected on 4/7/2024 at 5:00 AM, Lab received 4/8/2024 at 7:20 PM and reported to the facility on 4/13/2024. The Report documented R3 had a urinary tract infection. Documentation from V8's Urology Office regarding communication to the facility documents, 4/16/2024 at 10:07 AM Left message to return call back to office. 4/17/2024 at 11:37 AM Left message to return call back to office, 3rd attempt. 4/18/2024 at 11:16 AM (Facility) on the line to speak with the nurse. He is a resident there. They are calling about UA results. Documentation continued 4/18/2024 at 7:13 PM Patient has UTI. Bactrim-DS Q12'hrs x 10 days., Change Foley catheter in 5 days. 4/19/2023 at 8:43 AM nurse has been made aware. Medication sent to pharmacy. R3's Nurse's Note, dated 4/19/2024 9:30 AM, documents, Order Note Text: The order you have entered Bactrim DS Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) Give 1 tablet by mouth every 12 hours for bacterial infection for 10 Days Has triggered the following drug protocol alerts/warning(s): Drug to Drug Interaction The system has identified a possible drug interaction with the following orders: Losartan Potassium Oral Tablet 25 MG Give 25 mg by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Severity: Moderate Interaction: Coadministration of angiotensin II receptor antagonists and trimethoprim may increase the risk of hyperkalemia especially in the elderly. R3's Physician Order Sheet, not dated, documents 4/19/2024 Bactrim DS Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) Give 1 tablet by mouth every 12 hours for bacterial infection for 10 Days. R3'S Medication Record (MAR), dated April 2024, documents R3 received the 1st dose of Bactrim on 4/19/2024 at 8PM. R3's Progress Note, dated 4/20/24 at 12:39 AM, documents INFECTION TYPE: Type or Infection: Urinary Tract infection urine. The Note documents TREATMENT/ ORDERS: (R3) is receiving Bactrim DS Tablet 800-160 MG,1 tablet by mouth every 12 Hours. changed foley. R3's Change in Condition Evaluation, dated 4/23/2024, documents R3 was experiencing a change in condition. R3's had abnormal vital signs, decrease food intake/inability to eat, urinary incontinence (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145160 If continuation sheet Page 2 of 4 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 145160 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care on the Hill 555 West Carpenter Springfield, IL 62702 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 - Actual harm Residents Affected - Few new or worsening, BP (blood pressure)114/62, P (pulse) 62, R (respirations) 16, T (temperature) 98.7, O2 Sat RA (room air) 94% obtained on 4/23/2024 at 11:14 AM. R3 had increase confusion, general weakness and need more assistance with ADLs, decline in ability to dress, eat and transfer. R3 had decreased urine output, poor urine flow with foley changed several times, frequent urinary issues. Pain to back, musculoskeletal, persistent back pain not responding to existing or progressive orders with no new abnormal neurological signs. Progressive or more frequent pain. R3's (Local Hospital) emergency room (ER) Notes, dated 4/23/2024, documents, Pt (Patient) arrives via EMS (Emergency Medical Service) from (facility) with reports of abnormal lab results of hgb (hemoglobin) of 7.7 drawn on 4/8/24. Pt also complains of lower abdominal pain. Pt has foley catheter in place. Hx (history) of UTI's. Pt BP found to be 80's/40's for EMS (Emergency Medical Services). Pt Aox4. Patient is a [AGE] year-old male with past medical history of CAD (Coronary Artery Disease) status post CABG (Coronary Artery Bypass Graft) and PCI (percutaneous coronary intervention), pacemaker implantation for second-degree AV block, CKD (chronic kidney disease) stage III baseline of 1.6, A-fib previously on Xarelto held for GI bleeding, thalassemia, COPD not on home oxygen, chronic Foley presented to the ER with suprapubic pain, weakness and decreased oral intake, found to have AKI (acute kidney injury), oliguric, likely prerenal/ATN (acute tubular necrosis) with metabolic acidosis, severe anemia with hemoglobin of 5 without any active signs of bleeding, lactic acidosis, elevated lipase with CT (computed tomography) scan showing acute Interstitial pancreatitis, hypoglycemia, sepsis secondary urinary tract infection versus pneumonia, received 2 L (Liters) of IV (intravenous) fluid along with 2 units of blood In the ER following which was started on pressers and ICU (Intensive Care Unit) was consulted. R3's Nurse's Notes, dated 4/23/2024 11:29 PM, documents, Narrative: resident admitted to (Local Hospital) in cardiac ICU (intensive care) with dx (diagnosis) septic shock. On 5/1/2024 at 12:54 PM V4, Licensed Practical Nurse, LPN, stated since admission R3 has been in poor health. V4 stated R3 had multiple physicians. V4 stated R3 was receiving cancer treatments and had urinary issues. V4 stated R3 had a catheter and frequent urinary tract infections (UTI). V4 stated R3 was seeing V8, Urologist, for his urinary problems. V4 stated she works 3 to 4 days a week. V4 stated she is not sure when the urinalysis results came back. V4 stated when she got the results, she faxed them to V8's office. V4 stated she was off for a couple of days after. V4 stated when she noticed there hadn't been a response, she called V8's office and left a message with the receptionist needing an order for R3's UTI. V4 stated she did not speak with V8 or his nurse. V4 stated it is difficult to speak to and has never spoken directly to V8 or his nurse. V4 stated she has only spoken to the receptionist. V4 stated R3's urine always fluctuates. V4 stated sometimes it's clear and sometimes it dark. V4 stated R3 doesn't drink well and only takes sips. V4 stated R3 always have pain. V4 stated R3 is more worried about the bone pain. V4 stated she sent R3 out to the hospital on the 23rd. V4 stated R3 was pale, weak, talking in a whisper. V4 stated she has sent R3 to the hospital in the past and this is how he gets. V4 stated R3 was different than his normal. On 4/2/2025 AT 8:24 AM V8, Urologist, stated he is seeing R3. V8 stated he saw R3 on 3/27/2024 and performed a cystoscopy. V8 stated at time he felt R3 was poorly cared for and R3's bladder was loaded with debris. V8 stated at time he ordered Bactrim, monthly catheter change, irrigation for 5 days and as needed after. V8 stated he did receive the urinalysis results but not the culture. V8 stated from 4/10/2024 to 4/19/2024 his office made several attempts to contact the facility without success to give order for antibiotic therapy, catheter irrigations and catheter change at the next doctor's visit. V8 stated after several attempts over several days he reached out to the nurse practitioner. V8 stated he was informed on 4/23/2024 R3 had started antibiotic on the 19th and had a catheter (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145160 If continuation sheet Page 3 of 4 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 145160 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care on the Hill 555 West Carpenter Springfield, IL 62702 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 - Actual harm Residents Affected - Few change at the facility. V8 stated R3 having a delay in antibiotic therapy, the change in catheter prior to 5 days of therapy caused R3's current septic condition. V8 stated the purpose in the catheter being changed in his office was so the antibiotic had time to treat, and the irrigations would flush the debris out. V8 stated this reduce and prevents the risk for the infection to become systemic. V8 stated he feels when the catheter was changed, prior to treatment, this caused the infection to become systemic. On 5/6/2024 at 1:50 PM V11, CNA, stated she provides care to R3. V11 stated she is normally assigned to R3. V11 stated R3 had a catheter. V11 stated there were only small amounts in bag. V11 stated R3 would take small sips of drinks. V11 stated she encouraged R3 to eat and drink more but he would not. V11 stated V7 was here visiting every day. V11 stated V7 was nice and did not complain to her about anything with R3. V11 stated both R3 and V7 were very nice. On 5/6/2024 at 1:56 PM V3, Assistant Director of Nursing, stated she was aware of R3 having the urinalysis. V3 stated she noticed there were no results posted as 4/12/2024. V3 stated she contacted the lab to find out if they faxed the results. V3 stated she was informed the lab and had spoken with a nurse at the facility and was awaiting a return call for ok for culture. V3 stated at time she gave the ok for the culture. V3 stated she did not receive the culture results. V3 stated she left for vacation on the following day. On 5/8/2024 at 3:20 PM V12, Client Service from Laboratory, stated R3's urinalysis was faxed to the facility on 4/10/2024. V12 stated the facility also has access to the Emed lab website and can retrieve the results from there as well. On 5/16/2024 at 9:30 AM V3 stated a urinalysis takes 24 hours to return. V3 stated if there is a culture the culture can take up to 48 hours. V3 stated it is the nurse who is assigned responsibility to follow through with this process and checking for results. V3 stated once the resident receives the antibiotic the nurses document an infection note. On 5/16/2024 V1, Administrator, stated the only Change in Condition policy was Physician-Family Notification- Change in Condition policy. V1 stated she looked, and this was the only one. The facility's Physician-Family Notification- Change in Condition policy, dated 11-13-18, documents Purpose: To ensure medical care problems are communicated to the attending physician or authorized designee and family/responsible party in a timely, efficient, and effective manner. Guidelines: The facility will inform the resident; consult with the resident's physician or authorized designee such as Nurse Practitioner; and if known, notify the resident's legal representative or an interested family member when there is: (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); Life-threatening conditions are such things as a heart attack or stroke. Clinical complications are such things as development of a stage II pressure sore, onset or recurrent periods of delirium, recurrent urinary tract infection, or onset of depression. (C) A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); A need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences (e.g., an adverse drug reaction), or commence a new form of treatment to deal with a problem (e.g., the use of any medical procedure, or therapy has not been used on resident before). (D) A decision to transfer or discharge the resident from the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145160 If continuation sheet Page 4 of 4