Health inspection·May 20, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview, and record review the facility failed to provide the necessary linen supplies for 97(R2, R3, R8-R103) of 103 residents reviewed for linen supplies from a total sample list of 103 residents reviewed. Findings include: The facility provided grievance dated 3/3/25 documents that resident council complained that whites have been taking too long to come back from the laundry. The response was documented that the delay was due to the elevator not functioning. The facility provided grievance dated 5/5/25 documents that resident council continued to complain that there were no wash cloths or towels for morning care. On 5/19/25 at 2:30PM the west linen room did not contain any washcloths or towels. On 5/19/25 at 2:35PM, the laundry room contained one dryer that appeared to have towels drying in it. V9 CNA (Certified Nurses Assistant) confirmed that no other washcloths or towels could be located in the laundry room. On 5/19/25 at 2:45PM the east linen room contained 6 towels and no washcloths or bed pads. On 5/19/25 at 2:20PM, V12 (CNA) stated that there are never towels and washcloths available for the second shift cares. On 5/19/25 at 2:30AM, V9 (CNA) stated that the facility is usually short of washcloths and towels 2 of 7 day shifts per week and that When we don't have towels and washcloths, we have to use wet paper towels on the resident's faces and bodies. On 5/19/25 at 2:50, V11 (CNA) stated that the facility is short of washcloths and towels every day of the week on the second shift and that she has had to use wet toilet paper to clean residents. On 5/19/25 at 2:55PM, V1 (Administrator) stated that there should always be towels and washcloths available for resident use and that it is not acceptable to use wet paper towels or toilet paper for washing and cleansing. On 5/20/25 at 9:00AM, V13 (Housekeeping Supervisor) stated that she had more towels and washcloths in the basement but no one knew where they were located. I'm having a meeting with my staff tomorrow Page 1 of 4 145732 145732 05/20/2025 Arc at Normal 509 North Adelaide Normal, IL 61761

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 145732 Page 2 of 4 145732 05/20/2025 Arc at Normal 509 North Adelaide Normal, IL 61761

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. 145732 Page 3 of 4 145732 05/20/2025 Arc at Normal 509 North Adelaide Normal, IL 61761

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 145732 Page 4 of 4