Inspection·October 17, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few stated, I don't know, I don't know why I'm doing this. Resident assessed in place, cleansed and dressed skin tear, lifted to bed, discussed with MD. Skin tear: right elbow. Resident lethargic post fall. Wheelchair bound. Staff documented resident was taken to hospital. No intervention documented on fall report to prevent future falls. R7's Nursing Note, dated 10/6/2025 at 8:25 AM documents Resident returned from ED visit. Dx of Hypokalemia. IV fluids 500 ml (milliliters) administered at ED. R7's Hospital Discharge Paperwork, dated 10/6/2025 documents R7 received IV fluids and a narcotic pain medication, hydrocodone/acetaminophen. R7's Electronic Medical Record (EMR) dated 10/5/2025 and 10/6/2025 no documentation fall interventions or precautions to prevent falls were implemented upon admission to the facility on 9/30/2025 or after these two falls.On 10/10/2025 at 10:35 AM V2, Director of Nurse (DON) stated when residents are initially admitted to the facility, they don't really know the resident other than what the hospital medical discharge paperwork documents. V2 stated if a resident had a history of falls, and the facility staff were aware of that there should be interventions documented on the resident's baseline care plan and admission assessment. All residents have low bed and are orientated to their call light to ask for assistance from staff when needed. V2 stated staff ensure residents always have proper footwear on, their call light within reach and are orientated to the facility. The Facility's Fall Prevention Program, revised 5/2022 purpose: to assure the safety of the residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Guidelines: The Fall Prevention Program includes the following components: methods to identify risk factors, methods to identify residents at risk, educate resident and to fall prevention program at the time of admission, throughout residents stay and when changes occur, assessment time frame, use and implementation of professional standards of practice, immediate change in interventions that were successful, notifications of physician, communication with direct care staff members, documentation requirements, adherence to manufacturer's recommendation in use of alarm and medical devices and special care equipment. Care plan incorporates: identification of all risk/issue, addresses each fall, interventions are changed with each fall, as appropriate, preventative measures. Periodic quality assurance audit activities of records relating to falls that exhibit adherence to facility policies and implementation of the plan of care. Standards: A Fall Risk Assessment will be performed by a licensed nurse at the time of admission. The assessment tool will incorporate current clinical practice guidelines. The admitting nurse as assigned CNA are responsible for initiating safety precautions at time of admission. All assigned nursing personnel are responsible for ensuring ongoing precautions are put in place and consistently maintained. Accident/Incident Reports involving falls will be reviewed by the Interdisciplinary Team to ensure appropriate care and services were provided and determine possible safety interventions. The Director of Nursing or designee is responsible for monitoring the Fall Prevention Program, including further staff education programs, purchase of additional equipment, or other appropriate environmental altercations. In addition, Director of Nursing is responsible for information the Administrator of program analysis. Fall/safety interventions may include but are not limited to: monitor gait, balance and fatigue with ambulation if applicable, foot wear will be monitored to ensure the resident has proper fitting shoes and/or footwear is non-skid, the resident will be reminded as needed to call for assistance before attempting to ambulate, residents at risk of falling will be assisted with toileting needs as identified during the assessment process and as addressed on the plan of care, nursing personnel will be informed of residents who are at risk of falling, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145160 If continuation sheet Page 2 of 3 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 10/17/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the fall risk interventions will be identified on the care plan, dim lighting may be left on in resident's room at night, call lights will be answered promptly, residents will be observed approximately every two hours to ensure the resident is safely positioned in the bed or a chair and provide care as assigned in accordance with the plan of care, the residents personal possessions will be maintained within reach when possible, these items include tissues, water, drinking glass and phone. Event ID: Facility ID: 145160 If continuation sheet Page 3 of 3