Health inspection·December 12, 2024

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete On 12/9/24 at 10:02 am, V3 (Social Service Director) stated, I just started working here on 11/18/24, and we have not had an Activity Director for at least over a week. The last I knew, was that she just up and quit. I have not seen hardly any activities going on in here for the Residents. I just found out that they are assigning me to the Activity Director position as well, so I guess I will be doing both jobs. On 12/12/24 at 11:10 am, V1 (Administrator in Training/AIT) verified that the Facility did not have an Activity Director or full time Activity Assistant, and stated, (V10/Former Activity Director) had just started recently, then just up and quit over a week ago, and we have not had anyone in that position. Event ID: Facility ID: 145774 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 145774 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Havana 609 North Harpham Street Havana, IL 62644 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the Facility failed to initiate resident specific fall interventions for one of four Residents (R1) reviewed for falls in a sample of four. This failure resulted in R1 requiring laceration treatment and radiography testing, on two separate occasions, at the local hospital Emergency Department. Findings including: Facility Fall Prevention Program Policy, revised 5/2022, documents: to assure the safety of all Residents in the Facility when possible; the program will include measures which determine the individual needs of each Resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary; methods to identity risk factors and identify Resident's at Risk; use and implementation of professional standards of practice; addresses each fall; interventions are changed with each fall, as appropriate; preventative measures; and Accident/Incident Reports involving falls will be reviewed by the Interdisciplinary Team to ensure appropriate care and services were provided and determine possible safety interventions. R1's Incident Report Form to the local State Agency, dated 9/23/24, documents R1 was found on the floor after a self-transfer, with a cut on the skull/bleeding and R1 was sent to the local hospital for treatment of the skull laceration (three staples to head). The Report Form documents a fall intervention of staff in-service and R1 was educated on fall prevention and assessed for a new wheelchair. R1's Physician Order Sheet, dated 12/10/24, documents R1's diagnoses including Pneumonia, Dysphagia, Traumatic Brain Injury, Seizures, Bipolar Disorder, Muscle Wasting and Atrophy, Lack of Coordination, Abnormal Gait and Mobility. R1's diet order of Regular texture thin consistency and pleasure feedings was discontinued on 12/3/24 and a new order, on 12/10/24, for Regular, pureed texture and nectar liquids. R1's Minimum Data Set/MDS, dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of moderate/severe cognitive impairment (0/15). The MDS Functional Abilities documents upper and lower limited range of motion and requires substantial/maximal assistance with activities of daily living. R1's current Care Plan documents: that R1 is at risk for decreased mobility, impaired mobility related to a history of weakness; has a history of falls; impaired cognitive function related to Traumatic Brain Injury/TBI and unable to answer BIMS questionnaire; communication problem; mood fluctuations related to TBI and Bipolar diagnosis; and has risk factors that require monitoring and intervention to reduce potential for self-injury related to TBI, unsteady gait and fall history. The Care Plan does not document specific Resident fall interventions for the individual falls for R1. R1's AIM for Wellness Event Record, dated 9/16/24, documents R1's 9/16/24 at 8:15 pm, fall out of the wheelchair onto the floor, while trying to open bathroom door to empty urinal. R1 sustained a hematoma and abrasion to the Right Forehead (2.5 centimeter/cm in length and superficial depth). No intervention is documented. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145774 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 145774 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Havana 609 North Harpham Street Havana, IL 62644 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm R1's AIM for Wellness Event Record, dated 9/23/24, documents R1's 9/23/24 at 1:00 pm, unwitnessed fall with head injury and (R1) states (R1) was putting (R1) to bed and fell, hitting (R1's) head on (R1's) end side table. R1 was transferred to the local Hospital Emergency Department for treatment of a scalp laceration (7.0 by 0.1 centimeter/cm) and the fall intervention was to not applicable (NA) to be determined (TBD). Residents Affected - Few R1's AIM for Wellness Event Record, dated 10/5/24, documents R1's 10/5/24 at 3:00 am, fall in room from bed and the intervention was to re-educate (R1) on importance of using call light when assistance is needed. R1's AIM for Wellness Event Record, dated 10/10/24 at 3:15 pm, documents R1's 10/10/24 at 3:15 pm, fall when transferring from the wheelchair to the bed and R1 sustained a laceration to the forehead. R1 was transferred to the local Hospital Emergency Department for treatment of the forehead laceration (2.0 cm by 1.0 cm) and the intervention was to remind (R1) to ask for assistance with transfers. R1's local Hospital Discharge Disposition, dated 9/23/24, documents R1 sustained a minor closed head injury and superficial laceration, requiring staples to the scalp after a fall/tripping. The Disposition documents staple removal in ten days. R1's local Hospital Discharge Disposition, dated 10/10/24, documents R1 was treated for a superficial laceration to the Forehead after a fall from a chair on the same level by slipping. On 12/10/24 at 9:55 am, attempts to interview R1 were unsuccessful. R1 was unable to communicate. R1 was sitting in the middle of R1's room, in a wheelchair, leaning to the right side and drool/saliva on mouth. R1 did not have a call light within reach. On 12/11/24 at 10:44 am, R1 was in R1's room and R1 did not have a call light within reach. On 12/10/24 at 10::00 am, R5 (Resident Council President/R1's Roommate) stated, He (R1) has fallen many times and a lot lately. I am not sure what exactly they are doing to help him, because look at him, he definitely needs their help with everything. He just keeps getting up on his own. On 12/11/24 at 9:50 am, V3 (Assistant Director of Nursing/ADON) stated, (R1) is pretty much nonverbal and has had falls with injury that required (R1) to go to the hospital. I know that (R1) had some lacerations from the falls and also had to have a Comminuted Tomography (CT scan), but that was negative. I do not think that all the fall interventions have been appropriate for (R1). I completely understand that the interventions we have been using are not working. On 12/11/24 at 9:50 am, V2 (Director of Nursing/DON) stated, (R1) does have a brain injury and is impulsive. (R1's) communication is also impaired. On 9/16/24 the intervention for (R1) was to encourage (R1) to use the call light. On the 9/23/24 fall, the intervention was to stay in common area and remind (R1) to use the call light. On the 10/10/24 fall, the intervention was to remind (R1) to ask for assistance to transfer and for (R1) to stay in sight. I can see that these interventions are not appropriate for (R1). (R1) does continue to be impulsive and continues to fall and injury himself. We will start looking at the interventions for our falls a little more now and make them more appropriate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145774 If continuation sheet Page 4 of 4