Health inspection·April 4, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm facility shall consider the resident's life style and personal choices identified through the assessment processes to obtain a picture of his or her individual needs and preferences. Staff shall carry out activities in a manner which assists the resident to maintain and enhance his/her self-esteem and self-worth. Residents Affected - Some Maintaining a resident's dignity should include but is not limited to the following: *Encouraging and assisting residents to dress in their own clothes, rather than hospital- type gowns, and appropriate footwear for the time of day and individual preferences; *Placing labels on each resident's clothing in a way that is inconspicuous and respects his or her dignity (for example, placing labeling on the inside of shoes and clothing or using a color coding system); *Promoting resident independence and dignity while dining, such as avoiding: *Daily use of disposable cutlery and dishware; *Bibs or clothing protectors instead of napkins (except by resident choice); *Staff standing over residents while assisting them to eat; *Staff interacting/conversing only with each other rather than with residents while assisting with meals. Based on observation, interview, and record review the facility failed to honor residents' right to dignity during dining by daily serving of meals on disposable dishware and by standing over residents while providing feeding assistance. This failure affects seven residents (R8, R13, R15, R17, R22, R37, and R61) out of 18 reviewed for dignity on the sample list of 47. Findings Include: 1. On 4/2/24 at 12:10 PM, V3 Dietary Manager stated, We are serving the foam plates due to the dishwasher being broken. The dishwasher has been broken since February (2024), it first started leaking and it got worse, and then it finally quit. The server today started serving on regular plates then realized she intended to use foam plates for everybody. On 4/3/24 at 12:42 PM, R37 stated, I don't like the foam plates. It is too easy to cut through the foam plates with the metal knives, and the foam cups are small at the bottom and large at the top so I am always afraid I am going to tip them over and spill them. It's easy to lose track of time in here but I would say they have been serving the foam plates for about 3 weeks straight or so. On 4/3/24 at 12:44 PM, R13 stated, Foam plates, yeah, the dishwasher must be broken, there's nothing like a regular plate. On 4/3/24 at 12:46 PM, R8 stated, The dishwasher is broken, that's why they are using foam plates. On 4/3/24 at 12:48 PM, R61 stated, The foam plates are easier to get rid of, they just throw them (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145452 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 145452 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at Dwight 300 East Mazon Avenue Dwight, IL 60420 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 0550 away. Level of Harm - Minimal harm or potential for actual harm On 4/3/24 at 12:55 PM, V10 [NAME] stated, We are using the foam plates because the dishwasher is broken. They are supposed to get us a new one. The use of the foam plates has varied but we have been steady using them for about 3 weeks. Nobody wants to stand over the sink and do dishes by hand. Residents Affected - Some On 4/4/24 at 9:45 AM, R15 unprompted, stated, For a couple of months we have been served meals on foam plates. The food gets cold a lot quicker because they can't use the plate warmers on foam plates like they do with regular plates. I hope they fix that dishwasher soon. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145452 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 145452 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at Dwight 300 East Mazon Avenue Dwight, IL 60420 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 - Some 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 maintain safe and comfortable water temperatures in resident hand sinks on the facility's C Hall (300 Hall). This failure affects 14 residents (R5, R10, R11, R13, R26, R31, R33, R38, R46, R52, R57, R58, R59, and R61) out of 18 reviewed for accident hazards on the sample list of 47. Findings Include: On 4/2/24 at 2:15 PM, the water temperature in the hand sink in room [ROOM NUMBER] had a stinging sensation to the hand. The water temperature in this same sink measured 119.4 degrees Fahrenheit (F) with an Illinois Department of Public Health Digital Automatic Calibration thermometer. room [ROOM NUMBER] had a hand sink water temperature of 115.3 F. room [ROOM NUMBER] had a hand sink water temperature measuring 122.3 F. room [ROOM NUMBER] hand sink water temperature measured 114.6 F. On 4/2/24 at 2:28 PM, V5 Maintenance Director, stated, We just got a new water heater and the mixing valve on it is so sensitive, I move it a millimeter and it sends the temperatures way off. V5 continued, Even the 114 (F) is too hot, our standard is to keep it below 110 (F). On 4/3/24 at 2:05 PM, the water temperature in the hand sink in room [ROOM NUMBER] measured 116.9 F. In room [ROOM NUMBER] the hand sink water temperature measured 117.3 F. The water temperature in the hand sink in room [ROOM NUMBER] measured 126.6 F. The water in this hand sink was hot enough to trigger a reflex withdrawal motion when a hand was placed under the water stream. In room [ROOM NUMBER] the water temperature of the hand sink measured 120.7 F, again hot enough to trigger a reflex withdrawal motion. The temperature of the water in the hand sink in room [ROOM NUMBER] measured 117.8 F. The hand sink water temperature in room [ROOM NUMBER] measured 115.7 F. On 4/3/24 at 3:07 PM, V5 Maintenance Director stated, Yesterday I adjusted the mixer valve to turn down the temperature, then I asked my Assistant to check the temperatures first thing this morning and they actually went the wrong way, they went up. We had a plumber out here and he said the mixing valve needs a whole new kit or replaced. On 4/3/24 at 3:10 PM, while observing the mixing valve, V5 stated, I have the valve turned all the way down so right now it should be passing basically 100 percent cold water but it isn't, so I know the temperatures are hot again today. The facility's Resident Roster dated 4/2/24 documents R5, R10, R11, R13, R26, R31, R33, R38, R46, R52, R57, R58, R59, and R61 reside on the facility's 300 Hall (C Hall). R5's Minimum Data Set (MDS) dated [DATE] documents R5 received a score of 2 out of a possible 15 during a Brief Interview for Mental Status (BIMS), rating R5 as severely cognitively impaired. R10's MDS dated [DATE] documents R10 did not have the cognitive capacity to complete a BIMS and received a staff assessment as moderately cognitively impaired with long term memory problems and could not recall the current season. R11's MDS dated [DATE] documents R11 received a score of 11 out of a possible 15 during a BIMS, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145452 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 145452 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at Dwight 300 East Mazon Avenue Dwight, IL 60420 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 rating R11 as moderately cognitively impaired. Level of Harm - Minimal harm or potential for actual harm R13's MDS dated [DATE] documents R13 received a score of 14 out of a possible 15 during a BIMS, rating R13 as cognitively intact. Residents Affected - Some R26's MDS dated [DATE] documents R26 received a score of 5 out of a possible 15 during a BIMS, rating R26 as severely cognitively impaired. R31's MDS dated [DATE] documents R31 received a score of 6 out of a possible 15 during a BIMS, rating R31 with severe cognitive impairment. R33's MDS dated [DATE] documents R33 received a score of 8 out of a possible 15 during a BIMS, rating R33 as moderately cognitively impaired. R38's MDS dated [DATE] documents R38 received a score of 2 out of a possible 15 during a BIMS, rating R38 as severely cognitively impaired. R46's MDS dated [DATE] documents R46 received a score of 10 out of a possible 15 during a BIMS, rating R46 as moderately cognitively impaired. R52's MDS dated [DATE] documents R52 received a score of 6 out of a possible 15 during a BIMS, rating R52 as severely cognitively impaired. R57's MDS dated [DATE] documents R57 received a score of 5 out of a possible 15 during a BIMS, rating R57 as severely cognitively impaired. R58's MDS dated [DATE] documents R58 received a score of 13 out of a possible 15 during a BIMS, rating R58 as cognitively intact. R59's MDS dated [DATE] documents R59 received a score of 6 out of a possible 15 during a BIMS, rating R59 as severely cognitively impaired. R61's MDS dated [DATE] documents R61 received a score of 11 out of a possible 15 during a BIMS, rating R61 as moderately cognitively impaired. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145452 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 145452 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at Dwight 300 East Mazon Avenue Dwight, IL 60420 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 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 provide the services of a clinically qualified director of food and nutrition services. This failure has the potential to affect all 77 residents residing in the facility, with R18 being one exception. Findings Include: On 4/2/24 at 9:44 AM, V5 Dietary Manager stated, I am the Dietary Manager. I started here as the manager in 2019. I have an FSM (Food Service Manager, cooking sanitation certificate) certificate. The FSM took one day to get. It was a one day course of study and take a test. I also have a CFM (Certified Food Manager, cooking sanitation certificate) certificate which is basically the same course of study and take a test that also took one day. V5 continued and confirmed neither of these certificates is similar to a CDM (Certified Dietary Manager), nor CFPP (Certified Food Protection Professional) (nationally certified, 6 months or greater of clinical nutritional study followed by a certification exam). V5 then stated, I am enrolled in the CDM course through the University of North Dakota. This course has a set of 4 books for study and since I have these 2 sanitation certificates, I only have to complete 2 of the books, so I am about halfway through the course. V5 continued, We do have an RD (Registered Dietician) who is here several days per month but is not full time, she works as a consultant. V5 then confirmed she did not meet the state requirements as a Dietetic Service Supervisor (reference Illinois Admin Code 77, Section 300.330, Definitions) by stating, I am not an RD, I haven't graduated from any school or program, I have not completed the CDM course so I don't have the CDM certificate, and I don't have any military service. V5 concluded by stating, We have one resident (R18) who receives feedings through a G-tube (gastrostomy tube) who is NPO (nothing by mouth). On 4/2/24 at 9:44 AM and 11:55 AM, and on 4/3/24 at 12:08 PM through 1:47 PM, V5, Dietary Manager was actively directing and managing the food preparation and food service activities in the facility's kitchen. There were concerns with resident dignity identified during the survey with the daily use of disposable dish wares (reference F550). The facility's Form 802 Resident Matrix dated 4/2/24 documents 77 residents reside in the facility, all of whom, with one exception, R18, consume food prepared from the facility kitchen. This same Form 802 documents R18 receives all nutrition and hydration through a gastrostomy tube and takes nothing by mouth. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145452 If continuation sheet Page 6 of 6