Inspection·August 26, 2025

F 0644 screening. Level of Harm - Minimal harm or potential for actual harm The facility's Preadmission Screening and Annual Resident Review (PASARR) Policy dated 10/2024 documents the following: The facility will refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or related condition for a level II review upon a significant change in status assessment to the State PASARR representative. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145389 If continuation sheet Page 2 of 8 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 145389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Watseka 715 East Raymond Road Watseka, IL 60970 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to reweigh a resident (R3) for a documented significant weight gain, failed to accurately document meal intakes and provide nutritional supplementation as ordered for a nutritionally high-risk resident (R61), and failed to obtain weekly weights as ordered for two (R3 and R61) of four residents reviewed for nutrition in the sample list of 29.1. R61's Face Sheet dated 8/26/25 documents R61 has a diagnosis of Protein-Calorie Malnutrition. Residents Affected - Few R61's Dietary Note dated 7/14/25 documents R61 has significant weight lost noted times six months and continue to monitor weights and intakes. Further documents R61 is on multiple supplements including fortified ice cream daily and nutritional shake three times a day. R61's Care Plan (current) documents R61 is at nutritional risk with interventions including monitoring weights/meal intakes and providing supplements as ordered. Further documents to alert nurse/dietician if not consuming supplements on a routine basis and alert dietician if consumption (food) is poor for more than 48 hours. R61's weighed 89.7 pounds (lbs) on 7/18/25 and weighed 84.5 lbs on 8/22/25 which is a -5.8% Loss. R61's Physician Order Sheet (current) documents the following orders: Fortified ice cream with dinner, nutritional shake three times a day for weight management, and weekly weights on Friday. R61's Weight Summary does not document any weights for R61 on 8/8/25 or 8/15/25. R61's Medication Administration Record does not document any weights for R61 on 8/8/25 and 8/15/25. R61's Meal Intakes dated 7/28/25 through 8/26/25 documents R61 consumed less than 50% of meals on 22 occasions. R61's Electronic Medical Record does not document V11 Dietitian being alerted of R61's poor meal intakes. On 8/24/25 at 12:20pm, R61 was in the dining room for lunch. R61 had two empty bags of a cheese flavored puffed corn snack, a hot dog, flavored water, and a soft drink on table in front of R61. There was no nutritional shake supplement present with R61's lunch meal. On 8/25/25 at 12:23pm, R61 was in the dining room for lunch. R61 had a bowl with mashed potatoes and ground meatballs, a soft drink, flavored water, and an empty bag of cheese flavored puffed corn snack on the table. There was no nutritional shake supplement present with R61's lunch meal. On 8/25/25 at 12:25pm, V7 Staffing Coordinator was assisting with meal tray service. V7 stated nutritional supplements are given at mealtimes if on the residents' meal ticket. R61's Lunch meal ticket documents R61 is to receive a nutritional shake. On 8/25/25 at 12:27pm, a nutritional shake was opened and placed on the table in front of R61 by staff. R61 was not advised of what was set on the table. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145389 If continuation sheet Page 3 of 8 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 145389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Watseka 715 East Raymond Road Watseka, IL 60970 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 8/25/25 at 1:01pm, R61 was still in the dining room with a full plate of cut up hot dog on the table. R61's mashed potatoes and ground meatballs were not consumed. R61's nutritional shake was still full on the table. On 8/25/25 at 1:22pm, R61 was no longer in the dining room. R61's full plate of hot dog and nutritional shake remained untouched. On 8/26/25 at 8:52am, V11 Dietitian stated staff should be encouraging R61 to eat. V11 stated staff should be accurately documenting resident meal intakes. V11 stated this is very important with nutritionally high-risk residents [R61] as V11 monitors those intakes. On 8/26/25 at 10:36am, V2 Director of Nursing stated staff are expected to accurately document resident meal intakes and obtain weights as ordered. The facility's Significant Weight Gain or Loss Policy dated 2/2025 documents the following: To ensure that insidious/significant weight gain or loss will be identified so that the nutritional needs can be evaluated and appropriate intervention provided. Dietary/Nursing team will obtain weights from nursing and reweighs will be determined after review. All residents will be weighed monthly unless physician order indicates differently. 2. R3's diagnoses undated diagnoses list documents R3's diagnoses as: Cerebral Atherosclerosis, encounter for Palliative Care, unspecified Dementia, unspecified severity, with other Behavioral Disturbances, unspecified abnormalities of Gait and Mobility, unsteadiness on feet, and Schizoaffective Disorder, Bipolar type. R3's Care Plan dated 5/1/25, documents R3 has a significant weight loss due to disease process, poor appetite, and on hospice care. R3's Weight assessment dated [DATE], documents to monitor weights weekly. R3's Weight Summary documents weights as: 7/2/25 – 174.2 pounds and 8/1/25 – 235.0 pounds. No weekly weights are documented in R3's medical record. On 8/25/25 at 11:15 AM, V2 Director of Nursing (DON) stated the expectation is that the staff will immediately reweigh the resident and report it to the nurse and the nurse should document it in the resident's chart. On 8/26/25 at 12:19 PM, V14 Certified Nursing Assistant (CNA) stated on 8/1/25, V14 weighed R3 and entered the weight in R3's medical record. V14 stated someone (cannot remember who it was) told V14 to push the wheelchair option in R3's medical record and the weight would appear correctly. V14 stated V14 did see the weight difference in R3's medical record but thought it would change. V14 stated the facility policy states to report this to the nurse. V14 is aware of re-weighing a resident immediately if there is a weight discrepancy. There is no documentation in R3's medical record of R3 being reweighed and no documentation as to what follow-up was completed. The facility's Obtaining Resident Weight Policy dated Next Review 2/2025, documents to assure resident does not have additional items on when weighing residents and assure no additional items are in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145389 If continuation sheet Page 4 of 8 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 145389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Watseka 715 East Raymond Road Watseka, IL 60970 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 0692 the chair or on the chair and subtract the wheelchair weight from the total, including foot pedals. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145389 If continuation sheet Page 5 of 8 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 145389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Watseka 715 East Raymond Road Watseka, IL 60970 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to provide sufficient Registered Nursing (RN) hours on nine of forty-four days reviewed for RN staffing. This failure has the potential to affect all 61 residents in the facility. Findings include:The Facility Nursing Daily Schedule dated July 12,2025 through August 24, 2025, documents on 7/12/25, 7/13/25, 7/22/25, 7/23/25, 7/30/25, 8/6/25, 8/14/25, 8/20/25 and 8/24/25, the facility scheduled zero (0) hours of RN coverage for a 24-hour period. On 8/25/25 at 12:30pm, V2 Director of Nursing (DON) and V5 Regional Director of Operations confirmed the hours listed on the facility nursing daily schedule were correct and the facility failed to have RN coverage on 7/12/25, 7/13/25, 7/22/25, 7/23/25, 7/30/25, 8/6/25, 8/14/25, 8/20/25 and 8/24/25The Facility Resident Midnight Census dated 8/24/25 documents 61 residents reside in the facility. Event ID: Facility ID: 145389 If continuation sheet Page 6 of 8 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 145389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Watseka 715 East Raymond Road Watseka, IL 60970 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to administer medications according to physician's orders for one (R6) of three residents reviewed for medication administration in the sample list of 29. This failure resulted in five medication errors out of 25 opportunities, resulting in a 20% medication error rate.On 8/24/25 at 9:33am, V3 Licensed Practical Nurse (LPN) administered the following medications to R6: Fluticasone-Salmeterol (Advair) Inhaler 100-50 micrograms (mcg) 1 puff, Loratadine 10 milligrams (mg), Famotidine 40mg, Folic Acid 800mcg, Furosemide 40mg, Gabapentin 300mg, Losartan Potassium 50mg, Oxybutynin ER 10mg, Psyllium Husk Powder 1 tablespoon in water, Sennosides-Docusate Sodium (Senna) 8.6-50mg, and Oxycodone 5mg.R6's Physician Order Sheet (POS) dated 8/25/25 documents the following orders: Fluticasone-Salmeterol (Advair) Inhaler 100-50 micrograms (mcg) 1 puff inhaled to be given twice a day, Loratadine 10 milligrams (mg) daily, Famotidine 40mg daily, Folic Acid 1mg daily, Duloxetine 60mg daily, Furosemide 40mg twice a day, Gabapentin 300mg three times a day, Losartan Potassium 50mg twice a day, Oxybutynin ER 10mg daily, Psyllium Husk Powder 1 tablespoon in water twice a day, Sennosides-Docusate Sodium (Senna) 8.6-50mg twice a day, Oxycodone 5mg every four hours as needed, Carvedilol 25mg twice a day, and Fluticasone 50mcg nasal spray-1 spray alternating nostrils in the morning.R6's August Medication Administration Record (MAR) documents the following medications were not given to R6 on 8/24/25 at 9:33am: Carvedilol 25mg, Fluticasone 50mcg nasal spray, and Duloxetine 60mg. This same record documents the above medications are to be administered to R6 during the liberalized (Lib) A or B medication pass. This same record documents entries for Fluticasone-Salmeterol (Advair) Inhaler 100-50 mcg/act 1 puff inhaled to be given twice a day Lib B and Lib D and duplicates the entry for the same Fluticasone-Salmeterol order to be given Lib A and Lib L. R6's Fluticasone-Salmeterol 100-50mcg/act order summary documents the following: Give 1 puff by mouth two times a day for COPD (Chronic Obstructive Pulmonary Disease) AND give 1 puff by mouth two times a day for COPD. Further documents there were two medication routines inputted into R6's POS for this medication on 5/20/25 by V3 LPN. These routines document this medication to be administered liberalized twice a day which duplicated to four times a day on R6's MAR. A Physician's Order note dated 5/21/25 documents the following: This order is outside of the recommended dose or frequency. Fluticasone-Salmeterol 100-50 mcg/act Aerosol Powder, breath activated give 1 puff by mouth two times a day for COPD AND give 1 puff by mouth two times a day for COPD. The dosing regimen of 1 puff 4 times per day exceeds the usual dosing regimen of 1 puff 2 times per day. The frequency of 4 times per day exceeds the usual frequency of 2 times per day.There is no documentation in R6's Electronic Medical Record documenting any follow up to the 5/21/25 Physician's Order note.There is no documentation in R6's EMR on 8/24/25 regarding R6 not receiving R6's Carvedilol, Fluticasone, and Duloxetine or the prescribing physician/pharmacy being notified. On 8/26/25 at 10:36am, V2 Director of Nursing stated staff should pull medications from back up pharmacy stock if available. V2 stated if the medication is not in stock, nurses should notify the provider and pharmacy. V2 stated if the medication is not given for any reason, it should be documented in the EMR and on the MAR.The facility's Medication Administration Policy dated 10/2024 documents the following: Medications must be administered in accordance with a physician's order-the right resident, right medication, right dosage, right route, and right time. Documentation of medication administration is recorded on the Medication Administration Record (MAR) and includes the date, time, and initials of the licensed nurse who administered the medication. If a medication error occurs, the licensed nurse will immediately notify the attending physician, describe the error and resident's response in the Nurse's notes, complete an Incident Report, identify the error on the 24-Hour Report, and monitor the resident's status. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145389 If continuation sheet Page 7 of 8 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 145389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Watseka 715 East Raymond Road Watseka, IL 60970 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, interview and record review, the facility failed to ensure the director of food services met the regulatory qualifications. The current Dietary manager was not a certified dietary manager, certified food service manager, or credentialed as required. This failure effects all 61 residents.Findings include:On 8/24/25, 8/25/25 and 8/26/25, V6 (Dietary Manager) was actively supervising dietary operations in the facility kitchen during resident meal preparations. V6 reported being the full-time manager of the facility food service and reported not being a clinically qualified Certified Dietary Manager or having the equivalent training. The Resident Census and Conditions of Residents report dated 8/24/25 documents 61 residents reside in the facility.Facility Assessment Tool documents: Facility Resources Needed to Provide Competent Support and Care for our resident Population Every Day and During Emergencies. Position Dietitian or other clinically qualified nutrition professional to serve as the director of food and nutrition services. 1 Full Time Food Service Manager. Event ID: Facility ID: 145389 If continuation sheet Page 8 of 8