Health inspection·September 5, 2025

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 interview and record review the facility failed obtain physician ordered weekly weights for one resident of three residents (R1) reviewed for weights in a sample of 15. Findings Include:The facility's Significant Weight Gain or Loss Policy dated 02/2025 documents, All residents will be weighed monthly unless physician order indicates differently.R1's physician's orders, dated 9/5/25, document weekly weights were ordered to begin for R1 on 6/23/25. R1 also has orders to receive the following medications for the diagnosis of congestive heart failure: Torsemide 20mg (milligrams) by mouth daily, Diltiazem 300mg by mouth daily, Metoprolol Succinate ER 50mg by mouth daily, and Aldactone 12.5mg by mouth.On 9/3/25 at 11:17 AM, R1 stated she has not been getting weighed because the machine used to weigh her has been broken.R1's Weight and Vitals Summary dated 9/3/25 documents from 6/23/25 to 8/17/25 weights were only obtained on the following dates: 6/23/25 (419.8 pounds), 7/1/25 (416 pounds), and 7/7/25 (415 pounds).On 9/3/25 at 9:38 AM, V1 (Administrator) verified the facility has three mechanical lifts, and the mechanical lift with the scale attached has not been functioning since 7/10/25.On 9/3/25 at 11:15 AM, V2 (Director of Nursing) confirmed R1 had not been weighed from 7/8/25 through 9/3/25. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145319 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 145319 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at El Paso 555 East Clay El Paso, IL 61738 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 - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to implement new interventions after falls and failed to complete a thorough post fall assessment for three of three residents (R2, R4 and R5.) reviewed for falls in a sample of 15. Findings include: 1. R2's medical record documents that R2 was admitted on [DATE] with diagnosis to include but not limited to unspecified dementia, moderate without behavioral disturbance, cerebral infarction and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R2's documentation Un-witnessed fall dated 8/13/25 filled out by V2 (Director of Nursing) documents resident self-transferred from toilet resulting fall. Resident lying on left side of shower room floor. R2's documentation Un-witnessed fall dated 8/13/25 filled out by V2 (DON) documents under Mental status that resident was disoriented, but wnl (within normal limits) for this resident, oriented to person and oriented to situation were marked. The areas of resident did call for help, resident was able to call for help and call light was within reach were not marked.R2's documentation ~Un-witnessed fall dated 8/13/25 filled out by V2 (DON) has a documentation area marked Predisposing Physiological Factors that had Weakness/Fainted, Forgets to use call light and fragile skin marked. The same area had resident was standing, resident was lying, resident was sitting areas available and none were marked. R2's Unwitnessed fall dated 8/13/25 filled out by V2 (DON) Predisposing Physiological Factors documentation area also had antihistamine use as an area available and it was not marked. R2's Physician Order Sheet dated August 2025 documents R2 receives Hydroxyzine (antihistamine) 10 mg (milligrams) every 8 hours as needed. The facility could not provide Medication Administration Record for August to include any use of this antihistamine for review. R2's Unwitnessed fall dated 8/13/25 filled out by V2 (DON) Predisposing Physiological Factors documentation had Anti-hypertensive use as an area available and it was not marked. R2's Physician Order Sheet dated August 2025 documents that R2 receives Metoprolol (anti-hypertensive) Tartrate 50 mg twice daily.R2's Un-witnessed fall dated 8/13/25 filled out by V2 (DON) Predisposing Physiological Factors documentation had an Anti-depressant use are available to be marked. R2's Physician Order Sheet dated August 2025 documents R2 receives Sertraline (anti-depressant) 25 mg daily. Throughout the survey R2 was wearing glasses and did not answer questions appropriately. R2's Un-witnessed fall dated 8/13/25 filled out by V2 (DON) Predisposing Physiological Factors documentation had areas for impaired vision, wears glasses, was wearing glasses. None of these areas were marked. R2's Un-witnessed fall dated 8/13/25 filled out by V2 (DON) Predisposing Physiological Factors documentation had an area for restorative programs that was not marked. R2's current Care plan dated 3/24/25 documents R2 is on a restorative ambulation program, restorative dressing and grooming program dated 7/20/25, and Restorative AROM (Active Range of Motion) program dated 7/20/25.R2's Un-witnessed fall dated 8/13/25 filled out by V2 (DON) had Predisposing Situation Factors as listed Increased agitation, other, recent room change, side rails up, using cane, using wheeled walker, none, change in sleep patterns, recently sleeping less than usual, combative, restless, wandering, recent LOA (leave of absence ) with family, other recent fall, padded rails, Geri sleeves, other (describe), large groups, reaching, restrained, staff approach, using walker, wanderer, resistive to care, recent over sleeping, agitated at the time of fall, hallucinations at time of fall, sundowns, recent blood draw, combative with care and previous skin tears or bruises. None of these areas were marked. R2's Nurse's Notes dated 8/14/25 at 4:00 PM document that the IDT (Interdisciplinary Team) met to discuss R2's fall and the new intervention to implement was Anticipate resident's toileting needs. Offer assistance to toilet before and after each meal. R2's current care plan implemented 08/01/2025 and last updated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145319 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 145319 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at El Paso 555 East Clay El Paso, IL 61738 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 - Minimal harm or potential for actual harm Residents Affected - Few 8/14/25 documents R2 is at risk for falls related to confusion, gait/balance problems, self-ambulating to restroom, fracture of right hip and acute pain right hip. Interventions for R2's fall risk document anticipate and meet the resident's needs dated 8/1/25 and anticipate and offer assistance with needs with toileting throughout the night. On 9/5/25 at 12:45 PM V6 (Care Plan Coordinator) confirmed R2 already had an intervention in place on her fall plan to anticipate her needs and to anticipate her toileting needs. V6 stated, That isn't very different. 2. R4's Medical Record documents that she was admitted on [DATE] with diagnosis to include but not limited to unspecified dementia, anxiety and fracture in thoracic spine. R4's Un-witnessed fall dated 6/14/25 filled out by V18 (LPN) documents on 6/14/25 at 5:00 AM R4 was found on the floor at the foot of opposite bed. R4's Un-witnessed fall dated 6/14/25 filled out by V18 has a Mental Status section had area marked that documented disoriented, but wnl (within normal limits) for this resident. The Mental Status section also had sections for resident was able to call for help, resident did call for help and call light was within reach that were not marked.R4's Un-witnessed fall dated 6/14/25 filled out by V18 had Predisposing Physiological Factors that only had wears glasses marked. The form did not have Osteoporosis marked. R4's Physician Order Sheet dated June 2025 documents a diagnosis of age related osteoporosis. The form did not have Discomfort/Pain marked. R4's Physician Order Sheet dated June 2025 documents Gabapentin 1000 mg (milligrams) twice daily (an anticonvulsant medication used to treat seizures and nerve pain) for spinal stenosis and Hydrocodone-Acetaminophen (narcotic) 5-325 mg every 4 hours as needed for pain. The form did not have Anti-hypertensive use marked. R4's Physician Order Sheet for June 2025 documents Metoprolol Tartrate (Anti-hypertensive) 25 mg twice daily for hypertension.R4's Un-witnessed fall dated 6/14/25 filled out by V18 had Predisposing Situation Factors listed as active exit seeker, ambulating with assist, behavior symptoms, during transfer, increased agitation, other, admitted within last 72 hours, ambulating without assist, dislikes roommate, improper footwear, large groups and reaching. None of these areas were marked. R4's Un-witnessed all dated 6/14/25 filled out by V18 had Predisposing Situations Factors listed as recent room changes, side rails up, using cane, using wheeled walker, none, change in sleep patterns, recently sleeping less than usual, combative, restless, wandering, recent LOA (leave of absence) with family, other recent fall, padded rails, geri sleeves, other (describe), restrained, staff approach, using walker, wanderer, resistive to care, recent over sleeping, agitated at the time of the fall, hallucinations at the time of the fall, sundown, recent IV use, recent blood draw, long fingernails, combative with care and previous skin tears or bruises. None of the predisposing situations factors were assessed/marked. R4's current Care Plan initiated 8/7/25 last updated on 8/11/25 documents, Floor bed (42 inch) with floor mats of equal height obtained. Ensure bed in lowest position to floor and bed mat at bedside while in bed to establish a larger safe space for resident while in bed. On 8/3/25 at 10:30 AM V6 stated that the bed listed on the care plan is a floor bed that sits directly on the floor. V6 confirmed that R4 had a regular bed with a floor mat that was slid underneath the bed. The resident was not in the bed during the observation. V6 stated, I don't know why that isn't a floor bed in her room. R4's Nurse's Notes dated 6/17/25 at 10:24 AM document that the IDT (Interdisciplinary Team) determined the root cause of R4's fall on 6/14/25 was that R4 attempted to self-transfer with no assistance. The new intervention to be put in place was to encourage resident to participate in activities when restless. R4's current Care Plan initiated 8/7/25 last updated 8/11/25 documents that R4 is at risk for falls related to impaired gait and stability, unaware of safety needs, poor judgement, daily use of pain and psychotropic medications and attempts to self-transfer from bed. R4's intervention dated 8/7/25 documents, encourage the resident to participate in activities that promote exercise, physical activity for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145319 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 145319 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at El Paso 555 East Clay El Paso, IL 61738 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 - Minimal harm or potential for actual harm Residents Affected - Few strengthening and improved mobility. On 8/3/25 at 10:30 AM V6 (Care Plan Coordinator) stated, encouraging people who fall to do activities is pretty standard, they need to build up strength and they are less likely to try to self-transfer if they are out amongst a group of people. V6 stated she didn't know where the intervention of encouraging R4 to participate in activities came from, a fall or a high risk for falling. 3. R5's Medical Record documents that she was admitted on [DATE] with diagnosis to include but not limited to Alzheimer's Disease, abnormalities of gait and mobility and osteoporosis. R5's Un-witnessed fall dated 5/16/25 filled out by V18 (LPN) documents that R5 was found on the floor sitting on her bottom next to her bed. R5's Un-witnessed fall dated 5/16/25 filled out by V18 had an area labeled mental status that oriented to person was marked. The areas available for resident did call for help, resident was able to call for help, and call light was within reach were not assessed/marked. R5's Un-witnessed fall dated 5/16/25 filled out by V18 had a section Predisposing Environmental Factors with the following areas listed ; clutter, fall alarm, noise, other (describe), poor lighting, uneven floor, none, bedspread or blanket, cords, resident to resident contact, crowding, furniture, other, pets, rugs/carpeting, wet floor, slick floor, clothing or shoes, other personal items, and there was already a safety intervention in place. None of these areas were assessed/marked.R5's Un-witnessed fall dated 5/16/25 filled out by V18 had a section Predisposing physiological factors with the following areas listed: confused, drowsy, gait imbalance, impaired memory, new/signs of infection, recent change in cognition, recent illness, current UTI (Urinary Tract Infection), functional loss, hypotensive, incontinent, other, recent change in medications/new medications and sedated. None of these area were assessed/marked. R5's Un-witnessed fall dated 5/16/25 filled out by V18 (RN) had a section Predisposing Physiological Factors with Forgets to use call light marked. Restorative Programs was not marked. R4's current care plan dated 1/31/25 documents that R4 is on a restorative dressing/grooming program and also a restorative walking program. R5's Un-witnessed fall dated 5/16/25 filled out by V18 had a section Predisposing Situation Factors with areas listed as: active exit seeker, ambulating with assist, behavior symptoms, during transfer, increased agitation, admitted within last 72 hours, ambulating without assist, dislike roommate, improper footwear and large groups. No areas were assessed/marked. R5's Un-witnessed fall dated 5/16/25 filled out by V18 had Predisposing Situation Factors with areas listed as: other, recent room change, side rails up, using cane, using wheeled walker, none, change in sleep patterns, recently sleeping less than usual, combative, restless, wandering, recent LOA (Leave of absence) with family, other recent fall, padded rails, geri sleeves, other (describe) reaching, restrained, staff approach, using walker, wanderer, resistive to care, recent over sleeping, agitated at time of fall, hallucination at time of fall, sundown, recent IV use, recent blood draw, long fingernails, combative with care, previous skin tears or bruises. None of these areas were assessed/marked. On 9/5/25 at 9:30 AM V2 (Director of Nursing) stated, All of these blank areas area addressed with a different assessment (72 hour monitoring). V2 was unable to provide a 72 hour monitoring form or any assessment that documented the predisposing physiological and environmental factors for R2, R4 or R5 throughout the survey. The Facility's Fall Prevention Program policy dated 5/2022 documents the purpose of the policy is to assure the safety of all residents in the facility, when possible. the program will include measure 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 Program will monitor the program to assure ongoing effectiveness. The fall Prevention Program includes the following components: methods to identify risk factors, methods to identify residents at risk immediate change in interventions that were successful documentation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145319 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 145319 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at El Paso 555 East Clay El Paso, IL 61738 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 - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete requirements Care plan incorporates identification of all risk/issue, addresses each fall, interventions are changed with each fall, as appropriate, preventative measures.The Facility's Fall Prevention Program documents 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. A fall risk assessment will be performed at least quarterly and with each significant change in mental or functional condition and after any fall incident. Event ID: Facility ID: 145319 If continuation sheet Page 6 of 6