Inspection·September 5, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some possible 15, indicating severe cognitive impairment.The same MDS documents R4 has had no delusions or hallucinations, and no behavior directed towards self or others, during the seven day lookback period.R5's MDS dated [DATE] documents R5's BIMS score of 14 out of a possible 15, indicating no cognitive impairment.R5's same MDS documents R5 has had no delusions or hallucinations, and has had no behaviors directed towards self or others during the seven day lookback period.The Facility Reported Incident (FRI) of 8/17/25/2601814 documents: Resident to Resident Physical Assault. The same FRI report documents the following: On 8/17/25 R2 was sitting in front of the menu board making it difficult for residents to exit the dining room. (R5) told (R4) to move out of the way and then (R4) swatted at (R5) making contact with (R5's) arm.The facility's Illinois Department of Public Health Initial Report dated 8/17/25 and corresponding Final Abuse Investigation Report, Resident to Resident Physical dated 8/21/25 documents the following conclusion: 1. Based on the results of the investigation, the facility has found the following: a. Resident (R4) was observed sitting in front of the menu board after the Sunday afternoon church service. b. Resident (R5) believed (R4) was blocking the hallway and told her (R4) to move. c. Resident (R4) reached out and made contact with (R5's) arm in response to being told to move.On 9/02/25 at 2:50 pm V10, Social Service Designee/Dementia Unit stated V10 completed the psychosocial assessments on R4 and R5 after the resident-to-resident altercation. V10 stated on 8/17/25, R4 had hit R5 with a book.On 9/5/25 at 11:07 am (R5) stated (R4) is always out to get me. She is always making snide remarks and thinks people are talking about her. I just stay clear of her. The day we were coming out of church, I was talking to (V26, R20's Family Member). (R4) was stopped in front of us. I told (V26) to tell her (R4) to get out of our way. (R4) backed her wheelchair up. She (R4) raised her arm up and swung so fast, I couldn't block her. She (R4) hit me (R5) across the chest and my arm with her bible. It was a black, heavy book. (V28, Activity Assistant) immediately moved (R4) out of the way and went down the hall. I was fine physically. It only hurt a minute. It did not stay red long. She isn't that strong, just mean.(chest and arm). I was just (expletive) it happened is all. I (R5) stay clear of her (R4) as much as possible. I have not had anything like that happen again.On 9/5/25 at 10:58 am V28, Activity Assistant stated I was talking to a(unidentified family member) right after the church activity. I heard (R5) say to (R4) 'Do not hit me'. I turned around immediately and could see (R4's) pull back her hand real fast. I went over immediately and separated them. I did not actually see her hit (R5). (R5) said she did, though. (R5) said she asked (R4) to move because she was blocking the residents trying to leave the activity. I could see (R4) was holding up traffic coming out of church service. I took (R4) to the nurse's station for close observation. I told (V29, Licensed Practical Nurse) the nurse. She called the Administrator ( V1, Abuse Prevention Coordinator) and went to do a did skin check on (R5). I know (R20)'s (V26, Family Member) was pushing (R20's) wheelchair and saw the altercation too. (R5) is alert and oriented. She can tell you exactly what happened. (R4) is mostly confused. She can carry on a conversation but as far as recollecting anything, I am sure she can't. (R4) has a lot of paranoia. She often tells other people, including (R5) to quit talking about her. Other than brief remarks, I have never seen either of them get physical. That day was a first, and I believe (R4) did hit (R5).On 9/5/25 at 12:05 pm V1, Administrator/Abuse prevention Coordinator reviewed R4 and R5 abuse allegation investigation documented above and confirmed R4 intentional hit R5 with a book.3.) R11's Minimum data Set (MDS) dated [DATE] documents R11's Brief Interview of Mental Status (BIMS) score as 00 (Zero) out of 15, indicating severe cognitive impairment.R11's same MDS documents the following: R11 has had no hallucinated or delusions.The same MDS documents R11 has had physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) that occurred (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145732 If continuation sheet Page 2 of 9 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 09/05/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4-6 days of seven the look back period, R11 has had verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) that occurred 4-6 days of seven the look back period, and other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) that occurred 4-6 days of seven the look back period.R11 same MDS R11 has had behaviors of 'rejecting evaluation or care' that occurred 4-6 days of seven the look back period and has had behavior of wandering that occurred 4-6 days of seven the look back period.R12's MDS dated [DATE] documents R12's BIMS score as 04 (four) out of a possible 15, indicating severe cognitive impairment.R12's same MDS documents: R12 has had no delusions or hallucinations and has had no physical behaviors, .R12 same MDS documents R12 has had verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) that occurred one to three days in the lookback period of 7 days, and other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) that occurred 4-6 days in the lookback period of seven days.The Facility Reported Incident (FRI) of 7/02/25/2601326 documents: Resident to Resident Physical Assault. The same FRI report documents the following: On 7/2/25 (R12) attempted to help (R11) with (R12's) Bingo card. (R11) then pushed (R12's) hands away from the Bingo card and then (R11) made contact with (R12's) forehead with the Bingo card.The facility's Illinois Department of Public Health Initial Report dated 7/02/25 and corresponding Final Abuse Investigation Report, Resident to Resident Physical dated 7/07/25 documents the following conclusion:1. Based on the results of the investigation, the facility has found the following: a. Residents (R12) and (R11) were seated side by side during the Bingo activity. b. Resident (R11) was observed moving Resident (R12's) hands from her Bingo card and then made contact (R12's) head using the Bingo card. c. Resident (R12) does not recall the alleged occurrence. d. Resident (R11) does not recall the alleged occurrence.On 9/3/25 at 12:00 pm V21, Activity Assistant / Legacy Dementia Unit stated V21 was present and observed (R11) haul off and hit (R12) in the head with the bingo card. It was deliberate. He (R12) is always trying to help other residents with something. (R11) can get agitated with a flip a switch. We are careful with making sure she is not setting to close to anyone. That day during Bingo, (R12) went over to (R11). He invaded her space, and she let him know, she didn't' not want his help. It was a second or two later she (R11) hit him (R12) in the head. It was not an accident by any stretch of the imagination. It stunned (R12) but did not leave a mark. I was right there, and could not prevent the altercation. Knowing (R11), I was immediately going to separate them to prevent it. I just was not fast enough. I separated them right after the fact. I told the nurse what happened and was present when she called ( V1, Administrator/ Abuse Prevention Coordinator).On 9/5/25 at 12:05 pm V1, Administrator/Abuse prevention Coordinator reviewed R11 and R12's abuse allegation investigation documented above and confirmed R11 intentional hit R12 on the head with a bingo card. 4.) R9's Minimum data Set ( MDS) dated [DATE] documents the following: R9's Brief Interview of Mental Status (BIMS) score of three of a possible 15, indicating severe cognitive impairment. R9's same MDS documents R9 has had no delusions, hallucinations or behaviors directed towards self or others.R13's MDS dated [DATE] document R13's BIMS score of nine out of a possible 15, indicating moderate cognitive impairment.R13's same MDS documents R13 has had no hallucinations, no delusions no behaviors of any type, during the seven day look back period.The Facility Reported Incident (FRI) of 6/18/25/2594972 documents: Resident to Resident Physical Assault. The same FRI report (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145732 If continuation sheet Page 3 of 9 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 09/05/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some documents the following: On 6/18/25 (R9) tossed a fork on the floor. (R13) then propelled self (herself) over to retrieve the fork from the floor. (R9) told (R13) to go away and get out of there. (R9) then reached out and made contact with (R13's) arm.The facility's Illinois Department of Public Health Initial Report dated 6/18/25 and corresponding Final Abuse Investigation Report, Resident to Resident Physical dated 6/24/25 documents the following conclusion: 1. Based on the results of the investigation, the facility has found the following: a. Resident (R9) was observed tossing a fork on the floor. b. Resident (R13) was observed retrieving the fork from the floor and telling Resident (R9) to go away'' and get out of here. c. Resident (R9) was then observed reaching out and contacting Resident (R13) arm. d. Resident (R13) does not recall the alleged occurrence. e. Resident (R9) does not recall the alleged occurrence. On 9/5/25 at 10:45 m V27, Certified Nursing Assistant (CNA) stated It was a couple months ago. I witnessed (R9) throw a fork on the floor. (R13) wheeled her wheelchair over to picked it up. (R9) grabbed her wrist. She screamed and said it hurt at the time. After a few minutes, she had forgotten about it . The nurse (unidentified) did a skin assessment and there was nothing there. It was on a weekend or second shift. We separated the residents. We reported immediately, after we made sure the residents were safe. We told (V2, Director of Nursing/DON) because (V1, Administrator/Abuse prevention Coordinator) was not here. The (V2,DON) reported to (V1,Administrator/Abuse Prevention Coordinator). (R9) was anxious before and after that. We did a one on one with him the rest of the shift.On 9/5/25 at 12:05 pm V1, Administrator/Abuse prevention Coordinator reviewed R9 and R13's abuse allegation investigation documented above and confirmed R9 intentional made contact with R13's arm.The facility policy Abuse prevention and Reporting-Illinois dated 09/2024 documents the following: Guidelines:This facility affirms the right of our residents to be free from abuse, neglect, exploitation,misappropriation of property, deprivation of goods and services by staff or mistreatment. This facilitytherefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment ofresidents. In order to do so, the facility has attempted to establish a resident sensitive and residentsecure environment. The purpose of this policy is to assure that the facility is doing all that is within itscontrol to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivationof goods and services by staff and mistreatment of residents.The same policy documents:Definitions: Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain and/or maintain physical, mental, and psychosocial well-being. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish. The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. An example of a deliberate (willful) action would be a cognitively impaired resident who strikes out at a resident within his/her each, as opposed to a resident with a neurological disease who has involuntary movements (e.g., muscle spasms, twitching, jerking, writhing movements) and his/her body movements impact a resident who is nearby. Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment The same policy documents: Resident-to-Resident Abuse (any type): A resident-to-resident altercation should be reviewed as a potential situation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145732 If continuation sheet Page 4 of 9 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 09/05/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm of abuse. Not all resident-to resident altercations result in abuse. For example, infrequent arguments or disagreements that occur during the course of normal social interactions (e.g., dinner table discussions) would not necessarily constitute abuse but should be investigated to make this determination. Resident-to-resident altercations that include any willful action that results in physical injury, mental anguish or pain must be reported in accordance with regulations. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145732 If continuation sheet Page 5 of 9 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 09/05/2025 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 0641 Ensure each resident receives an accurate assessment. 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 accurately encode minimum data sets for antipsychotic medications and falls, and failed to complete the correct minimum data set for a discharged resident. These failures affect two residents (R6 and R1) out of thirteen reviewed for minimum data sets on a sample list of 25.Findings include: 1. R6's Physician Order Sheet dated [DATE] documents R6 has a physician order to receive the antipsychotic medication Quetiapine in a dose of 100 milligrams daily, an order initiated on [DATE], the day of R6's admission to the facility. R6's Medication Administration Record dated for [DATE] documents R6 received this antipsychotic medication as ordered. R6's admission Minimum Data Set, dated [DATE] section N0450 documents R6 did not receive antipsychotic medications since admission to the facility. This section, when coded as affirmative, serves as a prompt for further questions about required dosage reduction attempts On [DATE] at 3:40 PM, V16, Minimum Data Set Coordinator, stated she was aware R6 takes Quetiapine and must have been in a hurry to make a mistake coding the wrong section at the bottom of the page for R6. V16 further stated she would need to submit a correction for R6's Minimum Data Set. 2. R6's Nursing Progress Note dated [DATE] at 9:30 PM documents R6 was found on the floor of her own room at 9:00 PM stating she had fallen off of the bed, hit her shoulder, was complaining of right shoulder pain, and stating needed to go to the hospital. This note further documents R6 left the facility with emergency medical technicians to go to the hospital at 9:22 PM. R6's Nursing Progress Note dated [DATE] at 2:58 AM documents R6 had returned to the facility from the hospital with a diagnosis of a right humerus fracture which was immobilized. R6's Care Plan for a focus area of ADL (activities of daily living) self-care deficit dated as initiated [DATE] documents R6's right shoulder fracture as a contributing factor. The facility's Fall Investigation Report dated as initiated [DATE] with an initial report to IDPH [DATE] and final report dated [DATE], includes R6's Nursing Progress Notes from [DATE] and [DATE], R6's Care Plan revisions, and x-ray reports documenting a displaced fractured right humerus. R6's admission Minimum Data Set, dated [DATE] section J1800 and J1900 documents R6 had experienced 1 fall with an injury that was not a major injury since her admission to the facility. Section J1900 clarifies injuries not considered major include skin tears, abrasions and bruises, while major injuries include fractures. On [DATE] at 3:40 PM, V16, Minimum Data Set Coordinator, stated when she coded the section for R6's falls she had obtained her information from the facility's risk management section of the electronic medical records which listed R6's injuries as swelling and edema and had no further revisions. V16 clarified she was aware R6 went to the hospital but missed the part about a fracture. V16 further stated she had missed a lot of things on the Minimum Data Set for R6 and would need to submit a correction. 3. R1's Minimum Data Set, dated [DATE] for Death in Facility documents R1 expired on [DATE] in the facility. R1's State of Illinois Certificate of Death certified [DATE] documents R1 expired [DATE] at 9:40 PM at (local hospital). On [DATE] at 11:58 AM and 1:10 PM, V16, Minimum Data Set Coordinator, stated R1 was discharged to the hospital but was never admitted to the hospital and so R1 was still considered to be a resident of the facility when he expired, and that was why V16 completed a ‘Death in Facility' assessment. At 1:40 PM, V16 referenced the Centers for Medicare and Medicaid Services Long Term Care Facility Resident Assessment Instrument 3.0 Users Manual dated from [DATE] (current Minimum Data Set manual) which documents (page 31) The Death in Facility assessment must be encoded when a resident dies in the facility or while on a leave of absence. This same manual (page 35) defines a leave of absence to include, IF the resident was in a hospital for observation for less than 24 hours, AND the hospital does not admit the resident. This same manual (page 32) documents a Discharge Minimum Data Set must be completed If a Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145732 If continuation sheet Page 6 of 9 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 09/05/2025 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete resident has a hospital observation period for greater than 24 hours, regardless if the hospital admits the resident. R1's Nursing Progress Note dated [DATE] documents R1 was sent to the emergency room at 12:45 PM on this date. At 2:50 PM on this same date, R6's Nursing Progress Note documents a facility nurse received an update from the hospital that R1 was pending an admission to an ICU (intensive care unit) bed. On [DATE] at 1:40 PM, V16 agreed from 12:45 PM on [DATE] until 9:40 PM on [DATE] was something like 32 hours, more than the 24 hours referenced in the Minimum Data Set manual. V16 stated the appropriate Minimum Data Set to complete for R1 would have been a Discharge with Return Anticipated and she would need to submit a corrected Minimum Data Set for R1. Event ID: Facility ID: 145732 If continuation sheet Page 7 of 9 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 09/05/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review the facility failed repeatedly to maintain complete and accurate medical records for two of 14 residents (R2 and R14) reviewed for accuracy of medical records on the sample list of 25.Findings include: 1.) R2's Physician Order Sheet dated 9/1/25 documents the following diagnosis and medication order: Ativan (name brand), ( antianxiety- Lorazepam) Oral Tablet 0.5 MG (Milligrams), Give 0.5 mg by mouth (PO) every 8 (eight) hours as needed (prn) for anxiety/agitation related to Anxiety Disorder, Unspecified for 14 months (inaccurate duration, exceeds the 14 day limit for prn anti-anxiety medication). Start date 07/29/25, end date of 9/26/26 (two-thousand twenty-six). R2 ‘s Consent dated 7/29/25, is incomplete, as it does not document the duration of time for Lorazepam 0.5 mg by mouth (PO) every 8 (eight) hours as needed (prn) for anxiety. R2's (Private Company) Psychiatry Note dated 8/22/25 documents the following: Type of Visit: Follow-up Visit :Chief Complaint: Per staff, patient exhibits agitation, aggression, and behavioral changes. The same (Private Company) Psychiatry Note documents the following a current medication list with no changes to the physician ordered Ativan ordered 7/29/25. R2's current medication list documents the same error in the duration of Ativan prn which exceeds the 14 days. The note documents R2's Ativan PRN (as needed ) order as follows: Lorazepam 0.5 mg PO q (every) 8 hrs (hours) PRN X (times )14 days, end dated 9/29/26 (two-thousand twenty-six). The documented Ativan order has the correct 14 day duration, but also documents inaccurately, the end date which is incongruent with the end date of a 14 month duration. R2's electronic Medication Administration Record (MAR) dated 9/1/25- 9/30/25 continued unrevised, with the same 7/29/25 Ativan PRN order that should have been replaced or discontinued on 8/11/25, after the 14-day required limit. R2's MAR dated 8/1/25 – 8/31/25 documents R2 was administered one dose of Ativan 0.5 mg on 8/29/25, (18 days after R2's Ativan was due to be revised or discontinued on 8/11/15). On 9/3/25 at 2:35 pm V2, Director of Nursing (DON) confirmed R2's electronic medical records. V2, DON stated R2's Physician Ordered for Ativan 'was a transcription error and should have been caught before the order went unrevised for the additional 23 days. V2 then clarified the order should not have exceeded 14 days. The documented 14 months was triggered in error. This error resulted in the wrong duration of 14 months documented throughout R2's chart ( included above) and R2's Ativan 0.5 mg dose being administered on 8/29/25, when the Ativan should have been discontinued or revised on 8/11/25. The facility policy “ Psychotropic Medication- Gradual Dosage Reduction” dated 04/2025 documents the following: “Purpose: To ensure that residents are not given psychotropic drugs unless psychotropic drug therapy is necessary to treat a specific or suspected: condition as per current standards of practice and are-prescribed at the lowest therapeutic dose to treat such conditions. The plan to alternatives to psychotropic medication and/or use of psychotropic shall be incorporated into the care plan with suitable goals and approaches. This will be initiated by the resident's needs/ problems, goals and approaches as it relates to the use of psychotropic drug use.” (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145732 If continuation sheet Page 8 of 9 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 09/05/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The same policy Psychotropic Medication- Gradual Dosage Reduction document: PRN (as needed) Psychotropics: “PRN hypnotic, antianxiety or antidepressant medications shall not be used beyond 14 days unless the prescribing practitioner indicates the clinical rationale for extended use and the expected duration for PRN use of the medication. The duration of use should not extend beyond 6 (six) months unless re-evaluated by the attending physician or prescribing practitioner and clinical rationale is provided.” 2. R14's Hospital Progress Notes dated for 8/9/25 through 8/25/25 documents R14 had experienced a urinary tract infection from the multi-drug resistant bacteria Klebsiella. These progress notes document R14 was simultaneously experiencing sepsis and a bacterial infection of his left knee hardware, all treated with the intravenous antibiotics Cefepime and Ceftriaxone. R14's Hospital Discharge Orders dated 6/26/25 document R14 was to continue the intravenous antibiotic Ceftriaxone daily beginning on 8/27/25, the day after R14's return to the facility as R14 had received a dose for 8/26/25 at the hospital. R14's Medication Administration Record dated for August 2025 does not document administration of Ceftriaxone to R14 on 8/27/25, 8/28/25, and 8/29/25. This lack of administration was noted as blank spaces where the administering nurse should place their initials when the medication was administered. On 9/3/25 at 9:40 AM, V2, Director of Nursing, stated he was the administering nurse as the intravenous medications are administered by a Registered Nurse. V2 stated he did administer the intravenous antibiotic and did not go into R14's record to document the administration. R14's Medication Administration Record dated for September 2025 did not document the administration of R14's intravenous antibiotic Ceftriaxone for 9/3/25, leaving R14's antibiotic administrations undocumented for a total of 4 out of 7 days between 8/27/25 through 9/3/25. On 9/5/25 at 1:45 PM, V2 again stated he had administered R14's intravenous antibiotic on 9/3/25 and had not gone into R14's record to document the administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145732 If continuation sheet Page 9 of 9