Inspection·August 21, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete hallway.On 8/18/25 at 2:07 PM V7/Housekeeping Supervisor confirmed at this time room [ROOM NUMBER]'s floor remained sticky with scattered debris, room [ROOM NUMBER]'s floor had small stains throughout the floor with a large brown sticky stain remaining underneath the bed and another large-yellowish brown stain slightly underneath the side table, room [ROOM NUMBER]'s floor remained scattered with crumbs, debris, and a red stain by the bed, room [ROOM NUMBER] had thick black marks on the floor and the floor remained sticky, room [ROOM NUMBER] remained sicky with scattered debris throughout room, and A Hall (long and short) remained with scattered stains. V7 stated, This past weekend we only had one housekeeper and one laundry aide for the entire building. I was here on Saturday, but we can't get everything done. Every other weekend is like that. On the weekend with one housekeeper, they will typically clean the dining room out from breakfast and lunch, clean the nurse's station, take out the trash from the rooms, clean the bathrooms, and do spot checks. During the week we typically schedule one laundry aide and two housekeepers, as well as me. One housekeeper will take A hall and one will take B hall. I assist with doing the small dining room, offices, and running the floor machine throughout the facility. We had a call in today, so we had one laundry, one housekeeper, and then me. I did spot checks today on B hall but couldn't get to everything. I still have a little more to do in some of the rooms.On 8/18/25 at 9:18 AM R1 stated housekeeping misses his room a lot for cleaning and states he does not believe housekeeping did much to his room over the weekend.On 8/18/25 at 2:14 PM R8 stated, My trash has not been taken out of my room since last Friday and no one has cleaned my room since then. They are always short on housekeepers, and I get tired of my room not getting cleaned. I tell them all the time and then no one comes back to speak to me about it. I don't like when my room gets that dirty.On 8/19/25 at 1:45 PM, R3 was sitting on his bed in his room. R3's room had a very strong urine odor. R3 stated housekeeping often does not come in and clean his room because they do not have enough help.On 8/19/25 at 11:46 AM V13/LPN (Licensed Practical Nurse) stated housekeeping is terrible and they do not do the job correct.On 8/19/25 at 11:56 AM, V14/CNA (Certified Nursing Assistant) stated the facility is dirty and they only have one housekeeper on each side of the facility per day and they cannot get to it all.On 8/19/25 at 12:40 PM V19/CNA stated that the facility is often not clean and stated there is only one housekeeper that cleans one time a day and is not able to get all the cleaning done. On 8/19/25 at 12:11 PM V15/Human Resource Director provided the hours worked per department for housekeeping and laundry for the dates 8/15, 8/16, 8/17, and 8/18/25. On 8/15/25 there were a total of 22 hours worked in housekeeping and laundry, 8/16/25 a total of 23 hours worked in housekeeping and laundry, 8/17/25 a total of 15 hours worked in housekeeping and laundry, and 8/18/25 a total of 23 hours worked in housekeeping and laundry. V15 stated at this time they use the calculation of 0.45 x (times) the census to determine how many housekeeping/laundry/and maintenance staff to schedule. V15 verified at this time 37.8 hours per day should have been staffed for 8/15, 8/16, 8/17, and 8/18 and were not.On 8/19/25 at 1:55 PM V1/Administrator in Training stated We (the facility) have 37.8 hours per day for housekeeping/laundry/maintenance. We currently are not meeting that. Event ID: Facility ID: 145248 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 145248 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Morton 190 East Queenwood Road Morton, IL 61550 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to promptly provide medical care for a resident promptly after a decline in condition for one of five residents (R2) reviewed for change in condition in a sample of nine. Findings include:The facility's Hospice Services, dated 10/2024, documents Guidelines: the facility shall honor the advance directives and care alternatives residents may desire when terminally ill and to afford residents with care that allows for dignity and comfort during the end stage of their lives. 2. The resident's advanced directives will be honored in all aspects of Hospice services. 9. Facility licensed personnel will be responsible to notify the Hospice Service Coordinator in the event of a change in the Hospice residence condition and prior to transfer of resident to another facility including an acute hospital.R2's admission Record, dated [DATE], documents R2 admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Presence of Cardiac Pacemaker, Major Depressive Disorder, and Alzheimer's Disease. R2's current Census record documents R2 admitted to hospice on [DATE]. R2's IDPH (Illinois Department of Public Health) Uniform POLST (Practitioner Order for Life-Sustaining Treatment) form revised [DATE] documents R2 is a full code and to attempt CPR (Cardiopulmonary Resuscitation). This further documents R2 selected full treatment with primary goal of attempting to prevent cardiac arrest by using all indicated treatments. Utilize intubation, mechanical ventilation, and all other treatments as indicted. R2's Progress Note, dated [DATE] at 5:15 AM and signed by V22/Agency LPN (Licensed Practical Nurse), documents (R2) exhibiting [NAME] strokes breathing pattern. BP (Blood Pressure) 63/54, R (Respirations) 22, SPO2 (Saturation of Peripheral Oxygen) 84% (percent) on 2 L (liters) oxygen via NC (nasal cannula) continuous. Temperature 98.3. P (Pulse) 144. Generalized mottling noted. (Hospice) contacted. Spoke with (V23/Hospice Registered Nurse/RN) updated on (R2's) condition and signs and symptoms. (R2) remains full code at this time. (Hospice) is contacting appointed guardian on call phone number for clarification. (R2) continues medications for comfort. Hygienic cares performed and positioned for comfort.R2's Client Coordination Note, dated [DATE] at 5:22 AM and signed by V23/Hospice RN) documents V23 received a call from the facility that R2 had a change in condition with an elevated heart rate of 140 that was weak, R2's blood pressure was 60/30, and oxygen saturation reading was 84% despite oxygen therapy. V23 further documents she made facility aware that R2 remains a Full Code at this time and that V5/R2's Guardian did not feel that R2's medical record contained enough documentation to change R2's code status the last time they spoke. V23 made facility aware she would make some calls for guidance and call the facility back with updates. R2's Client Coordination Note, dated [DATE] at 5:50 AM and signed by V23/Hospice RN, documents V23 contacted V24/R2's on call Guardian and received guidance that nothing can be done to change R2's Code Status until the following day. V24 advised V23 that the facility should follow protocol for a resident with a declining condition that is a Full Code. V23 documents that V23 contacted the facility with this guidance and was told V23 would receive a call back after facility determines what they are required to do. R2‘s Progress Note, dated [DATE] at 6:04 AM and signed by V22/Agency LPN, documents Received return call from (V23/Hospice RN) with (Hospice.) Made aware (Hospice) spoke with on call guardian and made aware No attorney available over the weekend. (R2) to remain full code until further notice. (V23) scheduled (Hospice) visit with (R2) today. (R2) remains resting quietly with eyes closed. Comfort medications continue. Will continue to monitor.R2's Client Coordination Note, dated [DATE] at 8:05 AM and signed by V23/Hospice RN, documents that after multiple attempts to contact the facility nurse V23 spoke to V11/LPN who stated the nurse from the previous shift did not pass along R2's Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145248 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 145248 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Morton 190 East Queenwood Road Morton, IL 61550 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few condition change or that V11 was to follow up with V23. This note further documents that V23 made V11 aware that R2 is a Full Code and R2's code status could not be changed until the following day, V23 requested that V11 contact V1/Administrator in Training (Prior Director of Nursing) for guidance as they should follow R2's current code status. V23 documents that V11 stated she would contact V1 and then call V23 back with an update. R2's Client Coordination Note, dated [DATE] at 10:00 AM and signed by V23/Hospice RN, documents V23 called the facility back and spoke with V11 who stated she has a call out to V1 and if she has not heard anything by the time V11 is done passing medications for the morning V11 will call again. V11 stated she will call V23 if she hears anything.R2's Progress Note, dated [DATE] at 5:22 PM and signed by V10/LPN documents This nurse spoke with (V23/Hospice RN) and contacted (V1/Administrator in Training) for approval to send (R2) to the emergency room. This nurse wasn't able to obtain a BP and (R2) had a low oxygen saturation. (R2) remained on 3 L of O2 (oxygen) until EMT (Emergency Medical Technicians) arrived. (R2) was sent to the emergency room via emergency medical transport. (V23) was made aware (R2) had been sent and stated to this nurse she (V23) would contact the guardian and keep the facility updated on (R2's) status.R2's Client Coordination Note, dated [DATE] at 11:15 AM and signed by V23/Hospice RN, documents V23 received a call from V11 who stated that R2 was being sent to the local hospital by ambulance.On [DATE] at 3:24 PM V5/R2's Guardian stated, The facility should have sent (R2) to the hospital right away if he was actively dying. I was never able to sign the DNR (Do Not Resuscitate) based on the information provided from the (Hospice) company prior to (R2) having to go to the hospital. I was upset when I found out the facility waited approximately five and a half hours before they sent (R2) out to the hospital since (R2) was still a Full Code. On [DATE] at 4:15 PM V23/Hospice RN stated, I thought it was an extreme amount of time to wait to send (R2) to the hospital on [DATE] since he was a full code. The facility contacted me at approximately 5:20 AM and stated (R2) was actively dying. I advised the facility to treat (R2) as they would with any resident who was a full code. The nurse that contacted me stated she was going to get ahold of the charge nurse before sending (R2) out to the hospital to see what they wanted to do. I never heard anything back from that nurse, so I called the facility back around 6:00 AM and spoke to the nurse again and let them know what (V24/R2's On Call Guardian) had stated. That nurse stated they were still waiting to speak to the charge nurse because they felt like since he was on hospice they shouldn't send him to the emergency room. I then called back around 8:00 AM and spoke to a different nurse on duty. I then explained again I would advise them to send (R2) out to emergency room. They stated they could hardly get a BP on (R2) and that (R2) had begun to mottle. The staff nurse continually told me they were going to wait for the charge nurse to let them know what to do. I let the facility know that would be on them, that (R2) is a full code and should be treated as such. Around 11:00 AM the facility called me and stated they were transferring (R2) to the hospital.On [DATE] at 12:27 PM V10/LPN stated I was not aware of (R2's) condition until (V23/Hospice RN) called the facility. I spoke to (V23) around 8:00 AM regarding the status of (R2). I told (V23) I would have to notify (V1/Administrator in Training) to see if they wanted me to send (R2) out to the hospital, since that is our facility's protocol. We (facility staff) have been told we have to let management know before sending someone out to the hospital to ensure it is ok since (R2) was hospice. I assessed (R2) and could hardly get a BP reading and you could tell (R2) was actively dying. I didn't know what to do since (R2) was on hospice, but still a full code. I believe I messaged (V1) around 8:30 AM because she was off that day. I did not hear back from (V1) until approximately 10:30 AM to send (R2) to the hospital. I did not get (R2) sent to the (local hospital) until around 11:00 AM. Between 8:00 AM and 10:30 AM (V23) kept calling to see where we were with sending (R2) out to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145248 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 145248 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Morton 190 East Queenwood Road Morton, IL 61550 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete hospital because (V23) stated we should be sending (R2) since (R2) is still a full code. I kept telling (V23) I was waiting to hear back from (V1) to see what to do. To be honest I am a brand-new nurse and wasn't sure what to do. I did not document the time correctly in the progress notes. I accidently put 5:22 PM but it was technically around 11:00 AM when I sent (R2) out to the hospital.On [DATE] at 2:37 PM V1/Administrator in Training stated she was the prior Director of Nursing when R2 was sent out to the hospital on [DATE]. V1 stated, If any resident, including residents on hospice, are a full code and are actively dying staff should notify the physician and send the resident out to the hospital immediately. There is no rule at the facility that staff must get a hold of the Director of Nursing first. (R2) should have been sent out immediately when (R2) was experiencing a change in condition and was actively dying. V1 verified five and a half hours was too long to wait to send R2 out to the hospital on [DATE]. Event ID: Facility ID: 145248 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 145248 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Morton 190 East Queenwood Road Morton, IL 61550 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 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Actual harm Residents Affected - Some Based on interview and record review, the facility failed to ensure sufficient nursing staff were available to meet the needs of residents. This failure has the potential to affect all 85 residents residing in the facility.Findings include:The facility's Call Light policy revised 1/2022 documents resident call lights will be answered in a timely manner. All staff should assist in answering call lights. Nursing Staff members shall go into the resident's room to respond to call system and promptly cancel the call light when the room is entered. Bathroom lights should be viewed as emergencies and immediate attention will be given. Requests shall be responded to in a professional and courteous manner. The Facility Assessment (reviewed 8/16/2024) documents the following: Staffing Plan: The facility's plan to ensure sufficient staff to meet the needs of the residents at any given time is based on the staffing calculator, which takes into consideration the facility census and acuity levels impacting staffing needs.The facility's Resident Roster dated 8/18/25 documents 85 residents reside in the facility. On 8/18/25 at 2:34 PM V3(Ombudsman) stated it was mentioned in resident council on 8/7/25 that it was taking staff long periods of time to answer residents call lights and to be taken to the bathroom. On 8/19/25 at 1:55 PM V17 (Activity Director) stated she is responsible for resident council and typing the resident council concerns. V17 stated, I have not been documenting the concerns voiced in resident council on the resident council minutes. I was instructed not to from past administration. Usually if residents voice concerns, I go to the department head responsible for the department they are complaining about and let them know the concerns. Nothing gets documented. I believe it was brought up in the last resident council meeting that call lights have not been answered timely.On 8/19/25 at 11:40 AM, V12 (Licensed Practical Nurse) stated staffing is an issue because staff call in often. V12 stated when staff call in for their shift, we must make do with the staff we have which causes longer wait times for the residents. On 8/19/25 at 11:46 AM, V13 (Licensed Practical Nurse) stated staffing is an issue at the facility and Certified Nursing Assistants (CNAs) are understaffed. Residents will often complain that their call lights are not being answered timely because we don't have enough staff. On 8/19/25 at 11:56 AM, V14 (Certified Nursing Assistant) stated residents often experience long wait times and staff struggle to respond promptly due to limited coverage.On 8/19/25 at 12:40 PM, V19 (Certified Nursing Assistant) stated that the facility is often not clean, and the staff often work short which makes for longer wait times for residents. V19 stated the residents will complain often that they are not getting the help they need. On 8/18/25 at 9:18 AM R1 states from 2pm-10pm he has had to wait 3 hours before when he had turned on his call light. R1 stated, I hate sitting in my poop waiting for someone to change me. The staff rarely get to my call light timely on nights. I wait at least 30 minutes every night sometimes more for my call light to be answered. They don't have enough staff.On 8/19/25 at 1:45 PM, R3 stated his call light is frequently ignored, with wait times exceeding one hour, and expressed concern about insufficient staffing.The facility Concern Form dated 8/7/25 documents R8 expressed in Resident Council that R8 is having issues with her call light being answered in a timely manner, and staff state that R8 needs to wait. This form further documents R8 has had to wait for two hours for toileting assistance. On 8/20/25 at 12:35 PM, R8 stated that she often waits a long time for toileting assistance. R8 stated she requires a mechanical lift to be transferred to the toilet and staff will tell R8 that it takes too long to toilet her, so R8 often urinates and poops in her adult brief. R8 stated she has had to wait for hours in a soiled adult brief for staff to come and change her. The facility's Daily Assignment Sheet dated 8/9/25 documents the total Nursing Staff hours were 190 hours for the day. V21 (Regional Director of Operations) documented on Daily Assignment Sheet the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145248 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 145248 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Morton 190 East Queenwood Road Morton, IL 61550 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 0725 Level of Harm - Actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete was short 33 Nursing hours for 8/9/25 based on Facility Assessment staffing calculations. The facility's Daily Assignment Sheet dated 8/10/25 documents the total Nursing Staff hours were 185 hours for the day. V21 documented on Daily Assignment Sheet the facility was short 38.5 Nursing hours for 8/10/25 based on Facility Assessment staffing calculations. The facility's Daily Assignment Sheet dated 8/16/25 documents the total Nursing Staff hours were 176.9 hours for the day. V21 documented on Daily Assignment Sheet the facility was short 47.1 Nursing hours for 8/16/25 based on Facility Assessment staffing calculations. The facility's Daily Assignment Sheet dated 8/17/25 documents the total Nursing Staff hours were 177.5 hours for the day. V21 documented on Daily Assignment Sheet the facility was short 41.5 Nursing hours for 8/17/25 based on Facility Assessment staffing calculations. On 8/20/25 at 11:56 AM, V21 (Regional Director of Operations) confirmed staffing shortages on the above dates based on minimum staffing calculations. Event ID: Facility ID: 145248 If continuation sheet Page 7 of 7