Health inspection·November 1, 2024

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete of the facility, however, the grievances are not resolved and are discussed again month after month. R8 stated the facility does not follow up with resident council members on plans of corrections developed which are intended to resolve the grievance. The facility's Long Term Care Facility Application for Medicare and Medicaid dated 10/29/24 and signed by V1 (Administrator) documents 64 residents currently reside in the facility. Event ID: Facility ID: 145442 If continuation sheet Page 2 of 13 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 145442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Toulon 700 E Main St Toulon, IL 61483 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 ensure a PASARR (Pre-admission Screening and Resident Review) screening was completed for one (R28) of five residents reviewed for PASARR screenings in the sample of 22. Residents Affected - Few Findings Include: The Centers for Medicare and Medicaid Services/CMS National Report: A Review of Preadmission Screening and Resident Review (PASARR) Programs Dated 12/2019 documents: Preadmission Screening and Resident Review (PASARR) is a federal Medicaid requirement that mandates states operate programs designed to: (1) identify individuals who might be admitted to or reside in a nursing facility (NF) who have a serious mental illness (SMI), or an intellectual disability or a related condition (ID/RC); (2) consider both NF and community placements for such individuals and recommend NF placement only if appropriate; and (3) identify the PASARR specific needs that must be met for individuals to thrive, whether in a NF or the community. Facility documentation shows that R28 was admitted to the facility on [DATE] with diagnoses including, Cerebral infarction due to unspecified occlusion or stenosis of basilar artery, generalized anxiety disorder, major depressive disorder, recurrent, moderate. R28's current Medical Record did not include a PASARR screening completed for R28. On 10/31/24 at 10:15am, V1 Administrator stated that R28's PASARR screening was not done; stated that all residents should have a screening prior to admit to nursing facility. V1 stated, We do not have a PASARR for (R28); I looked for one but there is none. On 10/31/24 at 1:00pm, V19 Business Office Manager/BOM stated that (R28) was supposed to be screened before admittance to the facility. At this time V19 BOM stated: (R28) was at the hospital prior to admit; we dropped the ball-the hospital did not screen her and we did not screen her before she was admitted here. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145442 If continuation sheet Page 3 of 13 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 145442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Toulon 700 E Main St Toulon, IL 61483 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 0657 Level of Harm - Minimal harm or potential for actual harm Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on record review, and interview, the facility failed to revise care plans for two residents (R2 and R55) of 16 residents reviewed for Care Plan revisions, in a total sample of 22 residents. Residents Affected - Few FINDINGS INCLUDE: Facility policy, entitled Comprehensive Care Planning, revised 7/20/24, document, b. The Care Plan shall be revised as necessary when the needs/problems and care and services specified in the plan of care no longer reflect those of the resident. R2's Electronic Medical Record (EMR) document R2 was placed on hospice services per physician order dated 7/24/2024 and is still receiving hospice services. R2's Care Plan does not include hospice. R55's EMR document R55 has a stage 2 pressure wound on R55's coccyx with wound care orders dated 10/13/2024. R55's Care Plan was not revised to include R55's stage 2 pressure wound. On 10/31/2024, at 9:27 a.m. and 11:55 a.m., V4/Regional Director of Operations confirmed R2 and R55's Care Plans were not revised, and should have been, to include R2's Hospice services and R55's pressure wound. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145442 If continuation sheet Page 4 of 13 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 145442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Toulon 700 E Main St Toulon, IL 61483 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 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 record review and interview, the facility failed to ensure a Registered Nurse was scheduled for at least eight consecutive hours each day. This failure has the potential to affect all 64 residents living in the facility. Findings include: An undated Nurse Staffing Policy documents, It is the policy of (this facility) to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental and psychosocial well being of each resident. Nurse staffing shall be based upon resident evaluation by the Administrator and Director of Nursing as specified by the Illinois Department of Public Health. The policy continues, A minimum of 25% (percent) of nursing and personal care time shall be provided by licensed nurses, with at least 10% of nursing and personal care time provided by registered nurses. Registered nurses and licensed practical nurses employed by a facility in excess of these requirements may be used to satisfy the remaining 75% of the nursing and personal care time requirements. Review of untitled daily assignment sheets for 10/02/24, 10/09/24 and 10/16/24 document all nurses working during these 24-hour periods are Licensed Practical Nurses. There were no Registered Nurses scheduled on these three days. On 10/30/24 at 11:17 AM, V1/Administrator confirmed there was no registered nurse coverage on 10/02/24, 10/09/24 or 10/16/24. The facility's Long Term Care Facility Application for Medicare and Medicaid, dated 10/29/24 and signed by V1 (Administrator) documents 64 residents currently reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145442 If continuation sheet Page 5 of 13 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 145442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Toulon 700 E Main St Toulon, IL 61483 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on observation, interview and record review the facility failed to provide an appropriate indication for use of antipsychotic medications for two of five residents (R6, R14) reviewed for unnecessary medications in the sample of 21. Findings include: 1. On 12/1/21 R6 had a diagnosis of Unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. On 09/06/24 R6's BIMS/Brief Interview for Mental Status score was 15, indicating R6 is cognitively intact. R6's Care Plan dated 08/21/24 documents behaviors of hoarding and having a history of being paranoid with others including false accusations. R6's 10/17/24 Physician Order Sheet documents an order for Quetiapine (antipsychotic) 50 milligrams to be given with 200 milligram dose totaling 250 milligrams at bedtime related to Unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. On 10/31/24 at 10:51 AM, V4/Director of Operations confirmed R6 has an order for Quetiapine 250 milligrams for Dementia. V4 stated Dementia is not an appropriate diagnosis for Quetiapine. 2. On 07/04/23 R14 was diagnosed with unspecified dementia, unspecified severity, without behavioral disturbance. R14's 09/07/24 Care Plan documents R14 has exhibited in the past a tendency to seek to leave the facility or wander near exits. This is R14's only documented behavior. R14's BIMS dated 09/17/24 documents a score of 15 indicating R14 is cognitively intact. A 06/29/24 order on R14's October 2024 Physician Order Sheet documents, Quetiapine Fumarate oral tablet 50 milligrams. Give one tablet by mouth at bedtime for sleep. On 10/31/24 at 10:51 AM V4 confirmed R14 is ordered Quetiapine for a diagnosis of sleep which is not an appropriate diagnosis for Quetiapine. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145442 If continuation sheet Page 6 of 13 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 145442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Toulon 700 E Main St Toulon, IL 61483 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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to ensure residents were notified that signing an arbitration agreement was not a condition of admission and residents have 30 days to rescind the agreement within 30 days of signing. This failure has the potential to affect all 64 residents in the facility. Residents Affected - Many Findings include: R49's Agreement to Resolve Disputes by Binding Arbitration dated 05/09/23 and R59's Agreement dated 07/06/23 were reviewed. These agreements do not include language which notifies residents that signing the agreement is not a condition of admission and they have the right to refuse. The agreements also do not explicitly grant the resident or their guardian the right to rescind the agreement within 30 calendar days of signing. On 10/31/24 1:45 PM, V4 confirmed the Arbitration Agreements do not contain documentation that signing the agreement is not a condition of admission nor does it say the form can be rescinded within 30 days. The facility's Long Term Care Facility Application for Medicare and Medicaid, dated 10/29/24 and signed by V1 (Administrator) documents 64 residents currently reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145442 If continuation sheet Page 7 of 13 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 145442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Toulon 700 E Main St Toulon, IL 61483 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on interview, observation and record review, the facility failed to ensure the QAA/Quality Assessment and Assurance Committee had the required number of Members; failed to ensure the QAA Committee met at least quarterly; and failed to have reports submitted by Infection Preventionist. This failure has the potential to affect all 64 Residents residing at the facility. Residents Affected - Many Findings Include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Centers for Medicare and Medicaid Services/CMS 671) form dated 10/29/24 documents 64 residents reside in the facility. The facility's Quality Assurance Plan Dated 8/1/17 documents: (Facility) works to continuously improve the way residents are cared for, safety and operations within the facility through the Quality Assurance process. Quality Assurance activities are to be completed continuously and objectively to provide a comprehensive review of the facility's activities. The Quality Assurance Committee will conduct: Quarterly Meetings (at a minimum). On 10/31/24 at 1:45pm, V1 Administrator stated that (V17 Medical Director) and Infection Preventionist would be members of the QAA committee. V1 stated that she has been employed at the facility for seven months and there has been no quarterly QAA meetings since she has been at the facility. V1 stated, This was a lack of education on my part; I was supposed to get training on conducting the meetings; and I have not. Our Medical director (V17 Medical Director) has not attended a meeting; and there is no Infection Preventionist. I got busy doing other things; sometimes, it was just me here. On 10/31/24 at 10:25am, V4 Regional Director of Operations/Licensed Practical Nurse/LPN stated there has been no Infection Preventionist at the facility since January 2024. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145442 If continuation sheet Page 8 of 13 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 145442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Toulon 700 E Main St Toulon, IL 61483 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interview the facility failed to ensure its enhanced barrier precautions policy was followed for two of two residents (R1, R24) reviewed for enhanced barrier precautions in a sample of 22. Residents Affected - Few Findings include: A facility Enhanced Barrier Precaution Policy dated 07/13/23 documents, Purpose: to reduce transmission of multidrug-resistant organisms (MDRO). Enhanced Barrier Precautions (EBP) should be used when contact precautions do not apply, for residents with any of the following: open wounds that require a dressing change, indwelling medical devices, infection or colonized with MDRO. Enhanced Barrier Precautions require use of a gown and gloves during high-contact resident care activities that provide opportunities for the transfer of MDRO's to staff hands and clothing. EBP is primarily intended to use for care that occurs within a resident's room, when high-contact resident care activities are bundled together. 1. R24's October 2024 Physician Order Sheet documents R24 has a supra pubic indwelling catheter and a J-tube (jejunostomy tube). On 10/30/24 at 10:00 AM V3/Registered Nurse entered R24's room to administer medications through R24's J tube. V3 donned gloves, reached across R24's oversized bed with V3's uniform top and pants making contact with R24's blanket. V3 checked R24's J-tube for placement and laid her stethoscope on R24's bed. V3 continued with medication administration and flushes. V3 did not wear a gown, there were no gowns noted in R24's room or in the hallway outside of his room and no gowns noted in R24's trash can. On 10/30/24 at 11:55 AM V5 and V6 Certified Nursing Assistants/CNA's washed their hands and donned gloves prior to performing catheter care for R24. V6 pulled R24's blanket back and removed pillows, then leaned across R24's bed to unfasten his incontinence brief. V6's uniform made contact with R24's blanket. V5 then leaned over R24's bed to perform cares with V5's uniform top touching R24's linens. V5 and V6 did not wear gowns while performing cares for R24. There were no gowns noted in the hallway or in R24's room. There were no gowns noted in R24's trash can. On 10/30/24 at 12:54 PM, V5 and V6 stated they do not know why R24 requires EBP. V5 and V6 stated neither has had education or an in-service on EBP. On 10/30/24 at 12:58 PM V3 stated she has not had training or an in-service on EBP. On 10/30/24 at 1:02 PM V4/Director of Operations stated that he recognizes EBP are not being followed throughout the facility. V4 stated he is aware there are no gowns accessible for staff. V4 stated he cannot provide in-service or education documentation for staff as it has not been done. The facility's Long Term Care Facility Application for Medicare and Medicaid, dated 10/29/24 and signed by V1 (Administrator) documents 64 residents currently reside in the facility. 2. R1's coccyx wound treatment order documents: Cleanse with wound cleanser, pat dry, apply silver alginate dressing and cover with dry island dressing; change daily and prn/as needed every day shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145442 If continuation sheet Page 9 of 13 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 145442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Toulon 700 E Main St Toulon, IL 61483 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 0880 Level of Harm - Minimal harm or potential for actual harm On 10/31/24 at 11:00am, V8 Licensed Practical Nurse/LPN completed wound care treatment for R1's coccyx wound. V8 LPN did not wear enhanced barrier wound activity Personal Protective Equipment/PPE (gown) during wound treatment. V8 LPN stated: I am not required to wear gowns during wound treatment. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145442 If continuation sheet Page 10 of 13 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 145442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Toulon 700 E Main St Toulon, IL 61483 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to develop and implement an Antibiotic Stewardship Program to promote the appropriate use of antibiotics and include a system of monitoring to improve resident outcomes and reduce antibiotic resistance. This failure has the potential to affect all 64 residents residing in the facility. Residents Affected - Many Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid 10/29/24 documents the facility's census of 64 residents. The facility's Antibiotic Stewardship Program policy, dated 12/12/18 states the following: Purpose: To improve the use of antibiotics in healthcare to protect the residents and reduce threat of antibiotic resistance through a set of commitments and actions designed to optimize the treatment of infections while reducing adverse events associated with antibiotic use. R34's Physicians Orders include the following antibiotic order dated 10/18/24: Doxycycline Hyclate Oral Tablet 100 mg (milligrams): Give 100 mg by mouth two times a day for skin wounds until 11/01/2024 16:00/4:00pm for 14 days. R34's MAR (Medication Administration Record) documents Doxycycline 100mg tablets have been administered as ordered. R45's Physicians Orders and MAR (Medication Administration Record) dated 10/27/24 document the following antibiotic order: Clindamycin HCl (Hydrochloride) Oral Capsule 300 MG: Give 300 mg by mouth three times a day for left toe infection. On 10/31/24 at 10:25am V4 Regional Director of Operations stated there has been no Antibiotic Stewardship Program implemented nor monitoring of infections in the facility. V4 also stated there is no Infection Preventionist for the facility nor Infection/Antibiotic logs or an Infection Prevention and Control Program. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145442 If continuation sheet Page 11 of 13 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 145442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Toulon 700 E Main St Toulon, IL 61483 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 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on record review and interview, the facility failed to designate an Infection Preventionist (IP) who is responsible for assessing, developing, implementing, monitoring, and managing the Infection Prevention and Control Program and implement programs and activities to prevent and control infections. This has the potential to affect all 64 residents residing in the facility. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid 10/29/24 documents the facility's census of 64 residents. The facility's Infection Control policy dated 12/7/18 documents the following: It is the policy to do routine and surveillance and monitoring to determine if compliance with infection control practices is maintained. The facility shall employ, at a minimum, a part-time Infection Control Preventionist. R34's medical records document R34 is currently receiving Doxycycline, an antibiotic. Physicians Orders document the following order: Doxycycline Hyclate Oral Tablet 100 mg (milligrams). Give 100 mg by mouth two times a day for skin wounds until 11/01/2024 16:00 for 14 days. R34's Medication Administration Record (MAR) documents Doxycycline 100mg tablets were administered as ordered. R45's MAR documents R45 is currently receiving Clindamycin, an antibiotic, administered as ordered. R45's Physicians Orders documents the following order: Clindamycin HCl (Hydrochloride) Oral Capsule 300 mg: Give 300 mg by mouth three times a day for left toe infection for 10 Days. The facility was unable to provide any documentation or logs identifying infection monitoring and tracking of infections. On 10/30/24 at approximately 2:00pm V1/Administrator stated there is no Infection Preventionist for the facility. On 10/31/24 at 10:25am V4 Regional Director of Operations verified there is no Infection Preventionist currently on staff at the facility and there has not been an Infection Preventionist since January 2024. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145442 If continuation sheet Page 12 of 13 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 145442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Toulon 700 E Main St Toulon, IL 61483 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation and interview, the facility failed to provide influenza vaccine for residents eligible for influenza vaccination during flu season and failed to minimize the risk of acquiring, transmitting and suffering complications from influenza for five of five residents R14, R28, R33, R38, and R45 reviewed for immunizations in the total sample of 22. Residents Affected - Some Findings include: The facility's policy titled Influenza Control Measures dated 10/10/22 documents the following: Influenza Vaccine: 3. Continue to administer the influenza vaccine throughout the influenza season (Upon receipt of the vaccine-March 1). The facility's Infection Control binder includes the IDPH Guidelines for the Prevention and Control of Influenza Outbreaks in Illinois Long Term Care Facilities dated 10/18/21, which documents the following: Long Term Care should implement the following guidelines for vaccinating residents: b. Residents should be vaccinated on an annual basis as soon as influenza vaccine becomes available, unless medically contradicted. R14's Physicians Orders include: May have annual flu vaccine with consent unless contraindicated. R14's medical record documents R14 last received the influenza vaccine on 10/03/23. R28's Physicians Orders May have annual flu vaccine with consent unless contraindicated. R28's medical record documents R28 last received the influenza vaccine on 10/03/23. R33's Physicians Orders document: May have annual flu vaccine with consent unless contraindicated. R33's medical record documents R33 last received the influenza vaccine on 10/03/23. R38's Physicians Orders document: May have annual flu vaccine with consent unless contraindicated. R38's medical record documents R38 last received the influenza vaccine on 10/03/23. R47's Physicians Orders document: May have annual flu vaccine with consent unless contraindicated. R47's medical record documents R47 last received the influenza vaccine on 10/03/23. On 10/31/24 at 12:05pm there were no influenza vaccines present in either of the facility's two Medication Rooms. On 10/31/24 at 10:25am, V4 Regional Director of Operations stated the facility has not provided influenza vaccine for residents or staff and no influenza vaccines have been administered this flu season. V4 stated an outside company is contracted to provide and administer the influenza vaccines for residents and employees and has not done so since flu season began. V4 stated he does not know when the influenza vaccine will be administered. V4 stated the facility does not have any influenza vaccine and the facility has not ordered any influenza vaccine. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145442 If continuation sheet Page 13 of 13