Inspection·May 20, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm to address these issues. No, I'm not surprised that they didn't have enough towels and washcloths, I had heard rumblings. The facility census indicates the following residents reside on the impacted wings, R2, R3, R8-R103. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145732 If continuation sheet Page 2 of 4 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 145732 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at Normal 509 North Adelaide Normal, IL 61761 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow physician orders for one (R1) of three residents reviewed for physician orders from a total sample list of 103 residents. This failure resulted in R1 being hospitalized with high ammonia levels that could have resulted in permanent harm. Residents Affected - Few Findings include: R1's undated diagnosis sheet includes the following diagnoses: unspecified convulsions, alcohol dependence with alcohol-induced persisting dementia, fracture of right acetabulum, fracture of rib, malnutrition, fracture of anterior wall of right acetabulum, traumatic subarachnoid hemorrhage with loss of consciousness, and diabetes. The facility provided admission/discharge report documents that R1 was admitted to the facility on [DATE]. R1's hospital discharge orders dated 2/21/25 document medications to be continued including: Lactulose 10 gram/15 milliliter (ML) oral solution. Take 30 ML by mouth three times daily. R1's physician orders for February 2025 do not include an order for Lactulose. R1's February 2025 Medication Administration Record does not document that Lactulose was administered. R1's progress notes document on 2/22/25 that R1's mental status is alert and oriented to person, place, time, and situation. R1's progress notes document on 2/23/25 that R1's family member was concerned because R1 was not responding appropriately/like himself and seems extremely weak. R1 was unable to hold his head up and confusion was noted. R1's family member requested that R1 be sent to the emergency department for evaluation and treatment. R1's hospital records dated 2/23/25-3/3/25 document that R1 was admitted to the hospital with Hepatic Encephalopathy with hyperammonemia secondary to not receiving Lactulose at the facility. While hospitalized , R1 received Lactulose in various amounts to bring the ammonia level down with the result of improving mentation. On admission to the hospital on 2/23/25, R1's ammonia level was documented as 116 with significant confusion and decreased to 82 on 3/1/25 with lactulose administration resulting in improved mentation and the recommendation to continue lactulose for ammonia management. On 5/19/25 at 10:30AM, V3 RN (Registered Nurse) stated that she recalled having a conversation with R1's family member regarding not providing R1 Lactulose in the facility and that it was missed because of a system issue with the way that they look at discharge records and that they didn't look at the paper discharge records for R1. The staff are supposed to look at the paper discharge that comes with the resident, as well as the electronic discharge paperwork. On 5/19/25 at 1:10PM, V8 Nurse Practitioner stated that it was her expectation that the facility completed medication reconciliation with the discharge paperwork that comes with the resident from the hospital as soon as the resident arrives at the facility to ensure that nothing has changed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145732 If continuation sheet Page 3 of 4 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 145732 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at Normal 509 North Adelaide Normal, IL 61761 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 - Actual harm On 5/19/25 at 1:16PM, V7 Discharging Medical Doctor stated that R1 was mentally altered from the ammonia and it could have resulted in a coma. The family and patient told me that (R1) had not received his Lactulose in the facility and this certainly could have permanently harmed him. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145732 If continuation sheet Page 4 of 4