Health inspection·December 8, 2023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 12/05/23 at 11:18 AM R43 had an accumulation of facial hairs. R43 said he had not been shaved in two months. R43 said he wanted to be shaved and no one asked him if he wanted a shave. On 12/06/23 at 10:13 AM R43 continued to have facial hairs. R43 stated he had not had a shower or bed bath this week. R43 said his normal shower/bed bath days are Monday and Thursday and he did not receive his bed bath on Monday. R43 said sometimes they miss my bed bath days. Residents Affected - Some On 12/07/23 (Thursday) at 1:50 PM V12 (CNA/Certified Nursing Assistant) said she was unaware of R43 needing a shave. V12 said she did not give R43 a bed bath or shower today. V12 stated all residents should be showered or a bed bath given two times per week. V12 said that residents should get their hair washed, get nail care, and be shaved on their shower/bed bath days. V12 said her responsibilities are assisting residents with shaving, showering, and nail care. R43's face sheet showed R43 had diagnoses of Guillain-Barre Syndrome, essential hypertension, hypothyroidism, gastro-esophageal reflux disease without esophagitis, chronic obstructive pulmonary disease, atrial fibrillation, vitamin deficiency, constipation, major depressive disorder, abdominal aortic aneurysm without rupture, and diseases of the nervous system and sense organs. R43's MDS dated [DATE] showed R43 was cognitively intact. The same MDS showed R43 was dependent upon staff for showering/bathing and required substantial/moderate assistance from staff for personal hygiene. R43's care plan revised on 06/01/23 showed R43 required assistance from two staff members with bathing/showering. 3. On 12/05/23 at 12:01 PM R68 had an accumulation of facial hairs and said he wanted to be shaved. R68's right and left-hand fingernails had a dark colored substance underneath. On 12/06/23 at 10:00 AM R68 continued to have an accumulation of facial hairs and a dark colored substance underneath his fingernails. R68 said he had not had a shower this week. On 12/07/23 at 1:50 PM V12 (CNA/Certified Nursing Assistant) said she was unaware of R68 needing a shave and having a dark colored substance underneath his fingernails. V12 said she did not give R68 a bed bath or shower this week. On 12/07/23 at 2:10 PM V2 (DON/Director of Nursing) said it is expected that all residents have two showers per week, along with shaving and nail care. V2 said it is expected that CNA's assist the residents with all ADL's (Activities of Daily Living), or setup help if the residents require supervision. R68's face sheet showed R68 had diagnoses of diabetes mellitus, acute kidney failure, essential hypertension, heart failure, peripheral vascular disease, lack of coordination, unsteadiness on feet, abnormal posture, local infection of skin and tissue, and anemia. R68's MDS dated [DATE] showed R68 was cognitively intact. The same MDS showed R68 required supervision/touching assistance with personal hygiene. R68's care plan dated 09/18/23 showed R68 required assistance from one staff for bathing/showering and personal hygiene. The same care plan said, check nail length, trim, and clean on bath day and as necessary. 6. On 12/5/23 at 11:30 AM, R56 was observed with jagged fingernails with a brown substance underneath them. When asked if the facility staff trims his nails, R56 replied, It's never come up. R56's MDS (Minimum Data Set) dated 10/19/23 shows he requires supervision for personal hygiene. R56's Care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145623 If continuation sheet Page 2 of 18 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 145623 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Morris 1095 Twilight Drive Morris, IL 60450 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Plan dated 11/7/23 says R56 has an ADL (Activities of Daily Living) self-care performance deficit related to disease process. Interventions state, Check nail length and trim and clean on bath day and as necessary. The facility's policy titled, Nail Care last approved 8/2023 states, Guideline: 1. Observe condition of resident nails during each time of bathing. Note cleanliness, length, uneven edges, hypertrophied nails .5. Trim . fingernails in an oval fashion avoiding tissue after bathing or when needed . 4. On 12/06/23 at 11:11 AM, R38 was observed with long jagged nails with brown substances under the nails and flakes of skin on his shirt. R38's nose and face was observed dry with flaky skin. R38 said the last time he had his nails cut was a couple of weeks ago. R38 said he has asked staff to cut his nails, but nobody would do it. R38's electronic health record showed that he is a [AGE] year old male admitted to the facility with diagnoses including scoliosis, anemia, pressure ulcer stage 4 left lower back, and edema. R38's 10/23/23 MDS (Minimum Data Set) showed that R38's mental status is cognitively intact. R38's 8/7/23 MDS section GG showed that for shower/bath, R38 needs substantial/maximal assistance. R38's 10/30/23 care plan for ADL (Activities of Daily Living) showed self-care deficit. resident requires 1 assist with personal hygiene, check nail length and trim and clean on bath day as necessary. 5. On 12/05/23 at 10:57 AM, R64 was observed with his nails long and jagged and with brown substances under them. R64 said that he has asked the staff to cut his nails, but they will not cut them. R64's electronic health record showed that he is an [AGE] year old male admitted to the facility on [DATE] with diagnoses including dementia, anxiety disorder, chronic respiratory failure, & chronic kidney disease. R64's 7/24/23 MDS (Minimum Data Set) section GG showed that he needs supervision for shower/bath. R64's 6/8/23 care plan showed resident has an ADL (Activities in Daily Living) self-care performance deficit related to Dementia . BATHING/SHOWERING: The resident requires assist of (1) staff member with bathing/showering. PERSONAL HYGIENE: The resident requires set up assistance with personal hygiene and oral care. Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. On 12/07/23 at 1:27 PM, V2 DON (Director of Nursing) said that resident should not have long jagged nails with brown substances under the nails because of infection control and safety for themselves and others. V2 said that if a resident asks to have them clipped and cleaned, the staff should do it. V2 said that staff should be cutting and cleaning the residents' nails when they shower them. At 1:45 PM, V2 DON (Director of Nursing) said that staff should apply lotion to skin for skin integrity and dignity. Based on observation, interview and record review the facility failed to ensure residents receive regular bathing, grooming and assistance with activities of daily living. This failure applies to 6 residents. (R18, R38, R43, R56, R64 and R68) in the sample of 31 residents reviewed for assistance with activities of daily living. The findings include: 1. On 12/05/23 at 11:13 AM at the nursing station R18 was sitting in a dirty high back recliner. The seat, the back and the arms of the chair have a thick dark substance with some loose debris. R18 has no left eye and dry skin can be seen inside of the socket. R18 had many growths of skin on his face. One lesion was bleeding slowly with blood crusting and sticking to his overgrowth of facial hair. R18 had jagged nails with black debris under the nails. R18's clothing had dried food debris on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145623 If continuation sheet Page 3 of 18 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 145623 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Morris 1095 Twilight Drive Morris, IL 60450 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the shirt and the pants. R18 had an odor. R18's hair is oily and has a white scaly substance on the scalp. R18 does not answer any questions. When staff was asked who was caring for him, they said they would get the staff to get him cleaned up. On 12/6/23 at 10:00 AM, R18 was in dining area and his nails were still not cut and were dirty. R18 still had not been shaved. V8 RN stated, the staff should have cut and cleaned R18's nails after his shower last night. They should have shaved him as well. On 12/6/23 at 11:00am, per telephone, a family interview showed that they felt the facility could be doing more to help R18 with his care. The family stated they come every 3 weeks and were able to help but always have to ask staff to clean him up. R18's current care plan showed that staff are to perform all bathing, shaving and cutting nails. R18 also needs assistance with eating. The current policy for bathing, grooming and personal care states that the caregivers are to follow the care plan and report to nursing if the resident refuses care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145623 If continuation sheet Page 4 of 18 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 145623 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Morris 1095 Twilight Drive Morris, IL 60450 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 Based on observations, interviews and record reviews, the facility failed to assist in the application of ordered braces. The facility failed to assist with clothing changes. This applies to one resident (R26) reviewed for brace use in a sample of 31. Residents Affected - Few The findings include: On 12/05/23 at 11:15 AM, R26 stated she has neck, left shoulder and right leg pain. R26 stated she was told by V2 DON (Director of Nursing) and V19 CNA (Certified Nursing Assistant) she is a standby assist, and she can do things for herself. R26 stated she often does not receive staff assistance with showering or application of her brace and sling. R26 stated because she is overweight and has chronic pain, she is unable to put her sling and brace on without staff assistance. R26 stated sometimes wearing the sling makes her feel more comfortable. R26 stated when she has to walk around without the brace, she has more pain. On 12/06/23 at 9:46 AM, R26 was observed walking without her shoes, braces, or arm sling. R26 had the same clothes on from the previous day. R26 stated she had been walking around since 8:30 AM. On 12/06/23 at 10:34 AM, V16 CNA (Certified Nursing Assistant) stated R26 had been up since 8 or 8:30 AM. V16 stated she will assist R26 to apply the sling, brace and shoes upon request. V16 stated there was no order for the arm sling or leg braces. On 12/06/23 at 4:10 PM, V18 PT (Physical Therapist) stated R26 had an MRI (Magnetic Resonance Imaging) of her ankle that showed a sprain a month ago. On 12/07/23 at 9:29 AM, R26 again was observed not wearing any braces or shoes, and R26 wore the same clothes she had on 12/5/23 and 12/6/23. R26 stated she had not seen her CNA and did not know who was assigned to her. On 12/07/23 at 9:37 AM, V8 LPN (Licensed Practical Nurse) stated V19 was R26's CNA and should put her braces on before she is up and walking around. Not wearing the brace may cause her to have more discomfort. V8 stated staff should assist her even if she is standby assist. On 12/07/23 at 10:32 AM, V19(CNA) stated R26 will come and find her to ask for assistance and V19 does not ask R26 if she needs assistance. V19 stated R26 is able to wash herself and change her own clothes between shower days. On 12/07/23 at 3:06 PM, V2 DON (Director of Nursing) stated if R26 asks for assistance, the staff should help her. R26 should wear the ankle brace when she is out of bed. V2 stated there is no documentation of R26 refusing to wear her brace. V2 stated R26 reported to her that staff have refused to help her apply her sling, brace, and shoes. V2 stated she has told R26 she is capable of doing things herself. Review of R26's medical record shows Physician Orders to assist resident with applying shoes and socks every morning and removal at bedtime. Assist resident with putting on brace every am and off every pm. Please assist with daily foot care, washing her feet and applying lotion as resident has difficulty applying to herself. Right ankle - one time a day for pain apply brace to ankle. Right ankle - one time a day for pain remove brace. Right knee brace to be worn during all weight bearing activities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145623 If continuation sheet Page 5 of 18 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 145623 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Morris 1095 Twilight Drive Morris, IL 60450 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 Review of R26's MDS (Minimum Data Set) shows she is cognitively intact. R26's care plan states activities of daily living self-care performance deficit related to Myalgia, Fibromyalgia, affective mood disorder, chronic pain, and morbid obesity. R26 has Osteoarthritis. Review of outpatient physician progress notes show ongoing treatment of right ankle sprain and upper extremity pain. Physician instruction noted to assist resident with foot care, brace, socks, and shoes. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145623 If continuation sheet Page 6 of 18 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 145623 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Morris 1095 Twilight Drive Morris, IL 60450 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor residents at risk for weight loss, offer nutritional supplements as ordered by the physician in order to prevent additional weight loss, and offer food substitutes for meals/snacks that were refused to prevent unplanned weight loss and maintain resident nutritional status. This failure resulted in R40 experiencing a 29.29% weight loss within 4 months of admission. This applies to 2 residents (R40 and R43) reviewed for weight loss in a sample of 31. Residents Affected - Few The findings include: 1. R40's MDS (Minimum Data Set) dated 11/14/23 shows her cognition is intact. On 12/5/23 at 12:18 PM, R40 said, I have lost about 60 pounds since August. R40 said the facility was giving her mighty shake supplements, but she had not received one in almost a week. R40's lunch tray was then delivered in the presence of surveyor, and it did not have any supplement on it. On 12/6/23 at 12:30 PM, V22 (R40's spouse) said R40 lost 20 pounds in the last month. R40's Face sheet shows an admission date of 8/8/23. The facility's Weights and Vitals Summary report shows R40's weight has been measured 4 times between the dates of 8/8/23 and 12/7/23. R40's admission weight on 8/8/23 was 198 pounds. R40's next weight recorded on 9/6/23 was 184.6 pounds, showing a 6.77% weight loss in 1 month. R40's weight was not recorded in the month of October. R40's next weight measured on 11/3/23 was 159.4 pounds, showing a 13.65% weight loss in 2 months. R40's next weight measured on 12/4/23 was 139.8 pounds, showing a 12.3% weight loss in 1 month. R40 lost 58.2 pounds since her admission four months earlier, showing a 29.39% total weight loss. R40's POS (Physician Order Sheet) shows an order dated 11/14/23 for weekly weight to be done every Wednesday for 4 weeks because of weight loss. R40's MAR (Medication Administration Record) shows weekly weights were not completed on Wednesday 11/15/23, Wednesday 11/22/23, Wednesday 11/29/23, or Wednesday 12/6/23. Nurse documentation on 11/22/23 shows weight not obtained and nurse documentation on 11/29/23 states to be done. On 12/7/23 at 12:54 PM, V2 (DON/Director of Nursing) said she is aware of R40's weight loss. V2 said there was no documentation of R40 refusing to be weighed in October. V2 said the nurse documented on 11/15/23 that R40 refused to be weighed, but on 11/22/23, 11/29/23, and 12/6/23 R40's weights were not obtained, and refusals were not documented. V2 said she thinks the doctor needs to do a medical work up on R40 to determine why she is losing weight. On 12/7/23 at 2:18 PM, V11 (Dietician) said R40's intakes are not very good and sometimes V22 (R40's spouse) brings her food to eat, but it is not enough to regain the weight she has lost. V11 said R40 was supposed to be getting weighed weekly in November, but the facility has been having issues with obtaining weekly weights. V11 said that residents are supposed to get weekly weights for the first 4 weeks after admission, but the facility has not been compliant. V11 said she does not know why R40 has not been getting weighed as ordered because R40 does not refuse to be weighed. V11 said when a resident has significant weight loss, V11 notifies the facility Administrator, Assistant Administrator, DON, and Dietary Manager by email and then it is the facility's responsibility to notify the physician. On 12/7/23 at 1:27 PM, V10 (R40's physician) said a 60-pound weight loss in 4 months is a lot. V10 said he was not personally notified of R40's weight loss. R40's Care Plan dated 11/20/23 shows R40 is at increased nutritional risk related to Anemia, Chronic Obstructive Pulmonary Disease, and Hypertension. Interventions include monitor monthly weights or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145623 If continuation sheet Page 7 of 18 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 145623 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Morris 1095 Twilight Drive Morris, IL 60450 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 - Actual harm Residents Affected - Few per facility protocol and report significant changes to the physician and power of attorney. An additional Care Plan focus (initiated during this survey on 12/5/23) states R40 has an unplanned/unexpected significant weight loss and interventions include monitor weights per facility protocol. The facility's undated policy titled, Weight Assessment and Intervention states, Guideline: Weights are monitored monthly or more often as recommended by the interdisciplinary care team. The goal is to ensure adequate parameters of nutritional status are maintained by preventing unintentional weight loss .Procedure: 1. Nursing staff will record the resident weight upon admission and once a week for four weeks thereafter to establish a base weight and stability of weights. If no weight concerns are noted, the resident's weight will be recorded monthly thereafter or as indicated by the interdisciplinary care team .4. Any weight change of 5% or more since the previous weight assessment shall be re-taken to confirm. If the weight is verified, nursing will notify the appropriate designated individuals such as the physician, registered dietician, dining services manager, or other members of the interdisciplinary team .6. The threshold for significant unplanned and undesired weight loss shall be based on the following criteria: 1 month interval-significant loss 5%-severe loss greater than 5%, 3 month interval-significant loss 7.5%-severe loss greater than 7.5%, 6 month interval-significant loss 10%-severe loss greater than 10% .Analysis:1. Assessment information will be analyzed by the interdisciplinary team and conclusions shall be made .2. The physician along with the interdisciplinary team will identify conditions and medications that may be causing anorexia, weight loss, or an increased risk of weight loss . 2. On 12/05/23 at 11:18 AM R43 stated he does not like the food the facility offers. On 12/07/23 at 10:20 AM R43's breakfast tray was observed. R43 consumed 25% of scrambled eggs and 100% of nonfat yogurt. R43 said, the meals are not good here and I have lost weight since being here because of the food. R43 said he does not receive any nutritional supplement drinks from the facility. R43 said he asked for Ensure Plus nutritional drink because he likes the taste of it but was told the facility does not carry that in stock. R43 said they offered him the house stock nutritional drink. R43 said he does not like the house stock and does not drink it. R43 said the nurses offer the house stock nutritional drink to him once a week and he refuses it. R43 said no other alternatives for nutritional supplements were offered to him. R43's face sheet showed R43 was admitted to the facility on [DATE] with diagnoses of Guillain-Barre Syndrome, essential hypertension, hypothyroidism, gastro-esophageal reflux disease without esophagitis, chronic obstructive pulmonary disease, atrial fibrillation, vitamin deficiency, constipation, major depressive disorder, abdominal aortic aneurysm without rupture, and diseases of the nervous system and sense organs. R43's MDS dated [DATE] showed R43 was cognitively intact. The same MDS showed R43's most current weight was 171 pounds. R43's care plan dated 05/24/23 showed R3 is at increased nutritional risk and to offer alternatives at mealtimes when appropriate, monthly weights, and to report significant weight changes to the MD (Medical Doctor) and POA (Power of Attorney). Per the weight summary, R43's admission weight on 05/15/23 was 183.9 pounds. No recorded weight for the month of June. On 07/10/23 R43's weight was 185.3, on 08/08/23 R43's weight was 175.0 (-5.56%), on 09/07/23 R43's weight was 170.6 (-2.51%), no recorded weights for October and November, and on 12/04/23 R43's was 170.4. The dietary assessment dated [DATE] showed R43 had a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. The same assessment stated R43 was not on a prescribed weight loss program. R43's weight change progress note dated 09/15/23 showed R43 was triggered for significant weight loss for two months and weight continues to trend down. The same note stated resident reports not liking food very much at the facility. Resident with additional Ensure supplement in place three times per day, however, resident states he has not been receiving supplements. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145623 If continuation sheet Page 8 of 18 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 145623 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Morris 1095 Twilight Drive Morris, IL 60450 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 - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 12/07/23 at 2:10 PM V2 said she was aware of R43's insidious weight loss. V2 said she was not aware of R43 not liking the house stock nutritional drink. V2 said no alternative supplement was offered to R43 since he does not like the house stock nutritional drink. V2 said it is expected that when residents refuse supplements, the dietitian is notified for alternatives. V2 said the dietitian was not notified for any alternative supplements. Event ID: Facility ID: 145623 If continuation sheet Page 9 of 18 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 145623 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Morris 1095 Twilight Drive Morris, IL 60450 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 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 interviews and record reviews, the facility failed to have a full time RN (Registered Nurse) as the facility's DON (Director of Nursing). Residents Affected - Many This affects all 81 residents at the facility reviewed for staffing. The 12/5/23 CMS-671 form showed 81 residents live in the building. On 12/07/23 at 4:24 PM, V2 DON said, I am an LPN (Licensed Practical Nurse) full time. I am the only DON. V2 said the facility knew that the DON is supposed to be an RN. V2 said that she has been the DON since July of 2023. V2 said that I have been the DON and V21 (Operations Consultant), the administrator at that time, told me he knew that the DON needs to be an RN, but he put me in the position anyway. On 12/07/23 at 4:13 PM, V1 (Administrator) said he did not know if V2 was an RN or not. The facility's Lookup Detail View from Illinois Department of Financial and Professional Regulation showed V2 as an LPN in active status, effective 1/9/23, and expiration date of 1/31/25. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145623 If continuation sheet Page 10 of 18 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 145623 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Morris 1095 Twilight Drive Morris, IL 60450 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On [DATE] at 11:19 AM, two bottles of Fluticasone propionate 50 mcg nasal spray (nasal steroid used to decrease inflammation in nose) were observed on R62's bedside table. On [DATE] at 9:38 AM, V2 DON (Director of Nursing) said that the medications should not be at bed side. V1 said medication should only be in residents' rooms if they are locked in a box and if they have an order for them. V2 said this could cause the resident to take the wrong dose, or at the wrong time, or another resident could take the medication. The facility's Medication Storage Policy dated 3/2024 showed the facility should ensure that the residents' medications and biologics storage areas are locked. Based on observation, interview, and record review, the facility failed to store active medications safely and discard outdated medications. This applies to 3 of 5 residents (R7, R15, and R62) reviewed for medication storage in a sample of 31. The findings include: 1. On [DATE] at 9:47 AM, the cart that housed R7's medications was checked with V13 LPN (Licensed Practical Nurse). A Tiotropium Bromide 18 MCG (Microgram) inhaler prescribed for R7 expired 10/ 2023. A blister pack of Lorazepam 0.5 MG (Milligrams) prescribed for R6 had one blister opened and retaped. A blister pack of Tramadol 50mg prescribed for R7 had three blisters opened two were retaped. On [DATE] at 10:05 AM, the the cart that housed R15's medications was checked with V13 LPN. A medicine cup filled with pills was observed. V13 stated they were morning medications for R15. The medication cup was not labeled with contents or R15's name. A blister pack of Lorazepam 0.5 MG prescribed for R15 had one pill that had been opened and retaped. On [DATE] at 10:21 AM, the long-term medication room was reviewed with V13 LPN. Four bags of Daptomycin 500 MG in 100 ML (Milliliters) of NACL (Sodium Chloride) observed in the refrigerator had an expiration date of [DATE]. On [DATE] at 3:06 PM, V2 DON (Director of Nursing) stated outdated medications should be discarded. Outdated medications are not as effective. If a medication was discontinued and the resident is no longer taking it, the medication should be discarded for safety reasons. If controlled medication bingo cards (blister packs) are compromised, the medications should be wasted with two nurses and the count corrected. Staff should not be taping the back of the card because we can't be sure if it is the original medication or if it has been switched out. The facility policy Medication Storge dated 8/2023 states the facility should ensure that: (1) medications and biologicals that have an expired date on the label; (2) have been retained longer than the recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the supplier. The facility should ensure that the medications and biologicals for each resident are stored in the containers in which they are originally received. The facility should not administer / provide bedside (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145623 If continuation sheet Page 11 of 18 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 145623 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Morris 1095 Twilight Drive Morris, IL 60450 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 0761 Level of Harm - Minimal harm or potential for actual harm medications or biologicals without a physician / prescriber order and approval by the interdisciplinary care team and facility administration. The facility should store bedside medications or biologicals in a locked compartment within the residents room. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145623 If continuation sheet Page 12 of 18 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 145623 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Morris 1095 Twilight Drive Morris, IL 60450 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 12/6/23 at 1:13pm the last resident plate was made. The next plate was made for testing temperatures. The last tray made was followed and once delivered to the resident the temperatures of the test tray were as follows: Residents Affected - Few Chicken breast =120 degrees Fahrenheit. Texture rubbery and dry. Mashed potatoes= 132 degrees Fahrenheit. Mechanical soft chicken difficult to measure but was somewhat warm. The texture was soft and dry and lacked flavor. The mixed vegetables= 110 Fahrenheit. Not well seasoned and bland. All temperature were taken by V15 (Food Service Director) with a calibrated stick thermometer and V3 (Cook) and Corporate staff in attendance. 3. On 12/5/23 at 1:02 PM, R185, who was alert and oriented, said The lunch sucked. It tasted like dog food. It was goulash or something, and the pears had no taste to them at all. On 12/07/23 at 1:27 PM V2 DON (Director of Nursing) said that food should taste good so the residents will want to eat, because if they don't eat, they can develop pressure sores, lose weight, and can even cause death. R185's electronic health record showed that R185 is a [AGE] year old male admitted to the facility on [DATE]th, 2023, with diagnoses including atrial fibrillation, chronic obstructive pulmonary disease, and acute kidney failure. A review of the last year of Resident Council meeting notes showed: On 1/4/23 cold food, tough meats, and mushy tater tots. On 2/1/23 cold food, menus not being posted, and grilled sandwiches not fully cooked. On 4/5/23 vegetables over cooked. On 5/3/23 food served cold. On 6/7/23 food to spicy, and hard bread served. On 7/5/23 cold food, menus not matching meals served, running out of sweetener, and out of bananas. On 8/2/23 cold food, and tickets not matching meals served. On 9/6/23 cold food and need more sweetener on meal cart. On 10/4/23 pasta over cooked, potatoes under cooked, and soggy vegetables. Based on observation, interview and record review the facility failed to prepare foods to residents' liking. This applies to 3 residents (R40, R77, and R185) out of 32 residents reviewed for meal satisfaction. 1. On 12/5/23 at 12:18 PM, R40 said she can't stand the food. R40 said the French fries are cold and hash browns are limp and cold. R40's POS (Physician Order Sheet) shows she is on a no added salt diet. R40's MDS (Minimum Data Set) dated 11/14/23 shows her cognition is intact. R40's Care Plan dated 11/20/23 shows R40 is at increased nutritional risk related to anemia and hypertension. Interventions include, prepare and serve diet as ordered. 2. On 12/5/23 at 12:31 PM, R77 said the food is a concern, she can't eat it and it is always cold. R77's POS shows she is on a no added salt diet. R77's Care Plan dated 11/21/23 shows R77 is at an increased nutritional risk related to malnutrition. Interventions include, Prepare and serve diet as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145623 If continuation sheet Page 13 of 18 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 145623 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Morris 1095 Twilight Drive Morris, IL 60450 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 0804 ordered. Level of Harm - Minimal harm or potential for actual harm On 12/7/23 at 12:54 PM, V2 (DON/Director of Nursing) said residents have complained to her about food temperature and taste. V2 said she does not think any changes have been made in regard to resident food complaints. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145623 If continuation sheet Page 14 of 18 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 145623 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Morris 1095 Twilight Drive Morris, IL 60450 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review the facility failed to serve food in a sanitary manner. This applies to all 81 residents reviewed for sanitary food storage and preparation. Residents Affected - Many The findings include: The 12/5/23 CMS-671 form showed 81 residents live in the facility. 12/05/23 09:45AM V4, [NAME] and V3 FSD (Food Service Director) were in the kitchen area preparing lunch. A large garbage can was next to food prep table and the steam table and open to air. A multitude of refuse was piled high with a pair of bags and gloves with a blood like substance dripping off. A cleaning rag and a cellular phone was on top of the food prep table across from the stove. There was a large buildup of scale (beige debris) in steam table wells. Water has particles floating in it. Overall, the food preparation area has debris on the floor and under the steam table and several carts. The log for sanitizing sink is not consistently filled out. The log for food temps not done since 12/3/23. General floor is dirty. Shelves under steam table dirty. A large beef roast was on the prep table area near garbage. The roast was covered in thin plastic wrap and not on a tray. A large log of hamburger meat is sitting in a sink filled with water. No running water. The sink has food particles floating in the water and in the sink next to it was a dirty food processor with lots of food particles in the bottom. On 12/5/23 at 10:00am the refrigerator had a gallon bag of stew meat with bloody fluid on middle rack with no tray under the bag and over a box of frozen franks. There was no date on the bag of stew meat indicating when it was put in the bag. There were 5 crates of milk stored on the floor. Next to the milk on a wire shelf were 2 bags open to air of lettuce with another bag of sliced red cabbage in the bag of lettuce. No date on the bags as to when they were opened. In the freezer was an open bag of 5 omelets and bag of chicken breasts also open to air. There were no dates on these bags as when they were opened. On 12/5/23 at 11:50am V4 (Cook) was setting up steam table. The garbage can is again open next to food line and food prep area. At 12:05pm V4 dumped the water from the noodles in the sink and put the noodles in the steam table pan already in the well. Then V4 added 7 #8 scoops (4-5 ounces each) of ground beef to noodles. V4 then poured approximately 22- two-ounce scoops of brown gravy over the meat and noodle mixture. There was no cooking on the stove or checking the temperatures. On 12/5/23 at 12:40 pm V4 was running out of carrots. V14 (Food Service Worker) was observed with a container of corn in a square dish microwaving it. After approximately 5 minutes V4 took the container and put the corn in the well. V4 started plating the new foods without checking the temperature of the foods. When asked if V4 checked the temp V4 stated, I forgot Temperature taken by V4 was 150 degrees Fahrenheit with stick thermometer. V4 then took the corn back out of the well to reheat in the oven. On 12/6/23 at 9:45am V15, [NAME] was in the kitchen area, the temperature, recipe and menu logs were on the food prep area and were very soiled with debris and stains. The garbage can is right next to the food prep table and steam table without a lid on top. There were 2 empty plastic bags with a label of mashed potatoes without a date. There were approximately 5 trays of chicken breast. V15 said that they were only partially cooked, and he would be putting them back into the oven again. A (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145623 If continuation sheet Page 15 of 18 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 145623 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Morris 1095 Twilight Drive Morris, IL 60450 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many large steel bowl had approximately 8 chicken breast that were frozen just sitting on the counter next to the sink that had soiled dishes in it. Staff was not able to say why the chicken breast was there or when they were pulled out of the freezer. On 12/6/23 at 12:23pm during meal service at the steam table, V15 was touching chicken breasts and vegetables frequently with his gloved hand. V15 also was touching his apron and shirt. V15 then pulled a hamburger patty out of the steam well with his gloved fingers and then placed the patty onto a bun. V15 then put a chicken breast back into the well after it was on a plate. No changing of gloves or handwashing at this time. The facility policy that is not dated showed that prior to serving meals temperatures would be taken of hot and cold foods. The temperature would be recorded. Food that are frozen should be thawed in refrigerated units or under potable water with sufficient water velocity to float and agitate loose food particles away from the food product. The policy showed that foods thawed and cooked in the microwave need to be brought to a temperature 25 degrees above the specified requirement for the food product. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145623 If continuation sheet Page 16 of 18 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 145623 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Morris 1095 Twilight Drive Morris, IL 60450 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 12/05/23 at 10:54 AM, the temperature log for R47's personal refrigerator did not have a temperature documented for 12/2/23. Inside of the refrigerator there were sandwiches, chips, and pop. Residents Affected - Some 5. On 12/05/23 at 10:57 AM, the temperature log for R64's personal refrigerator did not have a temperature documented for 12/2/23. Inside the refrigerator was milk, pudding, and jello. On 12/07/23 at 1:59 PM, R64's temperature log was missing off R64's refrigerator. V2 DON (Director of Nursing) said she doesn't know where the temperature log went and she would check with maintenance to see if they had it. 6. On 12/05/23 at 11:56 AM, an unopened and expired carton of Premier Protein Strawberries and Cream, dated 11/19/2023, was observed on R184's dresser. On 12/07/23 at 1:27 PM, V2 DON (Director of Nursing) said that staff should be taking the temperatures of the refrigerators and recording them on the temperature logs on the residents' personal refrigerators. 2. On 12/05/23 at 11:00 AM, R52's personal refrigerator temperature long was not completed on 12/2/23. An open fourteen-ounce package of smoked sausage was in the fridge that expired on 10/25/23. 3. On 12/05/23 at 11:15 AM, R26's refrigerator was observed with a bowl that appeared to be macaroni salad. The macaroni salad was not labeled and did not have an expiration date. A plate of food containing carrots, mashed/chunk potatoes, and a roll was incompletely covered with plastic wrap and was not dated. A brown box of hard biscuits was dated 11/30/23. A bowl identified by R26 as chili mac soup was not labeled or dated. Based on observation, interview, and record review, the facility failed to maintain temperature logs and label food items in residents' personal refrigerators and failed to discard outdated food items. This applies to 6 of 6 residents (R24, R26, R47, R52, R64 and R184) reviewed for personal food storage. The findings include: 1. On 12/05/23 at 11:03 AM inside of R24's refrigerator, there were eight half pint cartons of expired milk. The dates of expiration ranged from 10/30/23 (over a month earlier) through 11/21/23. A meat sandwich dated 11/19/23 and one low fat yogurt with best by date of 12/18/22 was inside of the refrigerator. Two small cups containing pickles and mayo were in the refrigerator without a date. On 12/06/23 at 09:45 AM R24 said the only thing in the refrigerator is milk, pop and ice cream. R24 said she cleans the refrigerator out every couple of weeks. R24 said the CNAs (Certified Nursing Assistant) working on the unit check the refrigerator daily for old and expired foods. On 12/06/23 at 09:56 AM V2 (DON/Director of Nursing) observed the expired eight half pint cartons of milk, the meat sandwich, and low-fat yogurt inside of the refrigerator. V2 said housekeeping is responsible for cleaning the refrigerators and checking for expired/ non-dated foods daily. V2 said I see it not being done. V2 said residents could become sick from eating or drinking expired foods/liquids. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145623 If continuation sheet Page 17 of 18 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 145623 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Morris 1095 Twilight Drive Morris, IL 60450 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 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete R24's faces sheet showed R24 had diagnoses of dementia, protein-calorie malnutrition, alcohol dependence with alcohol induced persisting dementia, alcoholic cirrhosis of liver without ascites, essential hypertension, edema, generalized anxiety disorder, major depressive disorder, and age related nuclear bilateral cataracts. R24's MDS dated [DATE] showed R24 was cognitively intact. The facility's policy titled Food-Resident Pantry- Safe Storage policy (last approved 11/2023) showed- that to ensure that residents food items are stored in a manner that is sanitary and safe for consumption and to prevent contamination and spoilage *other staff such as housekeeping will be assigned to cleaning resident's personal refrigerators and documenting refrigerators temperatures. *All residents foods and beverages, including alcoholic beverages shall be labeled with the residents name and dated. *Food items, condiments and liquids that are in the original containers shall follow the expiration date on the container. *Foods which are outdated or are not labeled and dated shall be discarded daily when cleaning. *Food items, condiments, and liquids that are not in the original container shall be discarded three days after the date labeled on the container. Event ID: Facility ID: 145623 If continuation sheet Page 18 of 18