Health inspection·March 21, 2025

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 ensure a PASARR (Pre-admission Screening and Resident Review) Level I screening and/or Level II referral were completed for one (R2) of two residents reviewed for PASARR Screenings in the sample of 22. Residents Affected - Few Findings include: The facility's Preadmission Screening and Annual Resident Review (PASARR) Policy and Procedure dated 3/2024 documents, It is the policy to screen all potential admissions on an individualized basis. As part of the preadmission process, the facility participates in the Preadmission Screening and Resident Review (PASARR) screening process (Level I) for all new and readmissions per requirement to determine if the individual meets the criterion for mental disorder (SMI/SMD (Serious Mental Illness/Serious Mental Disorder)), intellectual disability (ID) or related condition. Based upon the Level I screen, the facility will not admit an individual with a mental disorder or intellectual disability until the Level II screening process has been requested. The facility will coordinate with the State PASARR representative related to the individual needs of the resident as indicated. R2's current diagnoses include: Unspecified Psychosis; Chronic Obstructive Pulmonary Disease(COPD), Alcohol Dependence, Alcoholic Hepatitis, Esophageal varices, Anxiety, Epilepsy, Cirrhosis of Liver. Facility documentation indicated that R2 was admitted to the facility on [DATE]. R2's current Medical Record has no documentation to show that a PASARR screening was completed prior to R2's admit to the facility. On 3/20/25 at 11:40 AM, V5 Minimum Data Set/MDS/Care Plan Coordinator stated that the facility got new owners on 11/1/24 and she does not know where the resident charts from the previous owners of the facility were located; V5 stated that she was unable to locate a Level I screening that should have been done for R2 prior to his admit to the facility. At this same time, V5 stated: There should also have been a Level II screening referral for (R2) as well for his Psychosis diagnosis. I will try to follow up with the (agency) to see if they (Level I and Level II Screenings) were done and have copies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145774 If continuation sheet Page 2 of 11 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 03/21/2025 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the Facility failed to provide activity of daily living/ADL assistance for hygiene/scheduled baths for one dependent resident (R4) of 16 resident's reviewed for Activity of Daily Living assistance in a sample of 22. Residents Affected - Few Findings include: The Facility Bathing, Shower and Tub Bath Policy, revised 10/2024, documents: To ensure the residents cleanliness to maintain proper hygiene and dignity; shower, tub bath or bed/sponge bath will be offered according to resident's preference, no less than once per week or according to the resident's preferred frequency and as needed or requested; and shower chair or bed, towels and wash cloths, body wash, shampoo, deodorant/antiperspirant, lotion and other toiletry items as requested by resident and residents clothing. R4's current Care Plan documents: (R4) requires staff assistant for Activities of Daily Living/ADL for bathing and grooming; assure resident that staff is plentiful and available for assist at any time;.maintain consistent routine to insure compliance and avoid confusion; monitor for changes in condition ADL assist level; has an ADL self-care performance deficit related to Hemiplegia/Hemiparesis following a stroke (Cerebral Vascular Accident) affecting right dominate side; requires the assist of two staff members with bathing/showering and dressing; and requires one assist with personal hygiene and oral care. The Facility Resident Shower Schedule, undated, does not document a scheduled shower day or time for R4's (Room number) shower. On 3/19/25 at 11:00 am, V4 (Corporate Regional Nurse Consultant) could not provide R4's Shower/Abnormal Skin Reports in the entirety for the period of 12/15/25 through 3/19/25. V4 did provide R4's Shower/Abnormal Skin Sheets that were dated 1/9/25, 1/13/25, 1/20/25, 1/23/25, 1/27/25, 1/30/25, 2/14/25, 2/18/25, 2/21/25 and 2/25/25. All Shower/Abnormal Skin Reports document that R4 received a bed bath, and no showers were documented. On 3/18/25 at 11:30 AM, R4 was lying in bed, hair unkempt and appeared to be oily/greasy. R4 stated, I never get a shower, all they do is just wash me up while I am in bed. They wash my hair with a sponge that they just swipe it about three or four times across my crown. I know that I am a big lady, but I would like to actually get up out of bed and into the shower. I have not gotten a real shower since before Christmas. On 3/19/25 at 1:02 PM, R4 was lying in bed talking to V4 (Corporate Regional Nurse Consultant) and stated to V4 I have not had a shower since before Christmas. They just give me bed baths and I want to get in a shower. On 3/19/25 at 11:01 AM, V4 (Corporate Regional Nurse Consultant) stated, I cannot find all of (R4's) Shower records. I am not going to lie to you, but when I looked up (R4's) bathing ADL (Activity of Daily Living) in our computer program it looks like (R4's) showers were scheduled for midnight so they documented that she was always refusing them, so (R4) never got any showers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145774 If continuation sheet Page 3 of 11 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 03/21/2025 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to have orders for a BiPAP/Bilevel Positive Airway Pressure machine and failed to label and change oxygen and nebulizers per their policy and orders for three (R30, R191, and R192) of five residents reviewed for oxygen in a sample of 22. Residents Affected - Few Findings include: Facility Oxygen and Respiratory Equipment- Change/Cleaning, copyright 2025, documents The hand held nebulizer should be changed weekly and PRN (as needed). A clean plastic bag with a zip loc or draw string will be provided with each new set up and will be marked with the date the set up was changed. Nasal cannulas are to be changed once a week and PRN. A clean plastic bag with a zip loc or draw string will be provided to store the cannula when it is not in use. It will be dated with the date the tubing was changed. On 3/21/25 at 11:11 AM, V19 RN/Registered Nurse stated Night shift nurses are responsible for changing oxygen tubing and humidifiers out. We assist residents with cleaning their CPAP (Continuous Positive Airway Pressure)/BIPAP or make sure they are on at night and off in the morning, and document that on the MAR/Medication Administration Record or TAR/Treatment Administration Record, or the CNAs/Certified Nurse Aides document in their tasks. The oxygen and nebulizer tubings are changed weekly on night shift and should be labeled with the date they were changed. 1. R30's current orders for March 2025 document Oxygen at 3L (liters) via nasal cannula continuous with an order date of 1/29/2025. Change Oxygen tubing cloth/plastic holding bag every night shift every Wednesday with an order date of 1/29/2025. Change 02 (oxygen) and Nebulizer Tubing weekly every night shift every Wednesday. On 3/18/25 at 11:30 AM, R30 was in her room with oxygen on via nasal cannula at three liters. R30 also had a nebulizer machine with tubing not in a bag that she stated she uses four times a day. Oxygen tubing was dated February 2025 and nebulizer tubing had no date. 2. On 3/20/25 at 1:50 PM, R191 had a BiPAP machine and distilled water in his room. At that same time, R191 stated he uses his BiPAP every night. R191's medical record has no orders for his BiPAP machine. 3. On 3/19/25 at 11:34 AM, R192 had distilled water and a CPAP at the bedside, nebulizer machine and tubing not in a bag, and oxygen was on at 4L via nasal cannula. The nebulizer and oxygen tubing had no dates. At that same time, R192 stated she uses her oxygen and nebulizer daily, and her CPAP at night. R192's current orders for March 2025 document O2/Oxygen via nasal prongs at 4L with an order date of 1/9/25. Change oxygen tubing and humidifier bottle weekly and PRN at bedtime every Sunday with an order date of 1/9/25. R192's orders for March 2025 had orders for her CPAP and nebulizer treatments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145774 If continuation sheet Page 4 of 11 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 03/21/2025 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 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 interview and record review, the facility failed to have a Registered Nurse/RN for eight hours a day seven days a week. This has the potential to affect all 46 residents in the facility. Residents Affected - Many Findings include: Facility Assessment, updated 3/1/25, documents Average daily census of 40. Facility resources needed to provide competent support and care for our resident population every day and during emergencies. Staff type; Nursing Services RN-1 on day shift. State PBJ/Payroll Based Journal Staffing Data Report, Quarter (October 1 - December 31, 2024) documents no RN hours on the following dates: 11/01 (FR/Friday); 11/02 (SA/Saturday); 11/03 (SU/Sunday); 11/09 (SA); 11/10 (SU); 11/16 (SA); 11/17 (SU); 11/23 (SA); 11/24 (SU); 11/30 (SA); 12/01 (SU); 12/07 (SA); 12/08 (SU); 12/14 (SA); 12/15 (SU); 12/21 (SA); 12/22 (SU); 12/25 (WE/Wednesday); 12/28 (SA); and 12/29 (SU). Facility daily staffing sheets for January thru March 2025 reviewed with no RN coverage for 1/11, 1/12, 1/25, 1/26, 2/8, 2/9, 2/22, 2/23, 3/8 and 3/9/25. V2 DON confirmed no RN coverage on those dates. Facility CNA/Nurse listing, undated, documents ten nurses are employed by the facility where two (V2 DON and V19 RN) are RN's and the rest are LPN's/Licensed Practical Nurses. On 3/18/25 at 10:45 AM, V1 Administrator stated the current facility took over the Nursing Home November 1, 2024. On 3/21/25 at 11:00 AM, V2 DON/Director of Nursing stated the following: We have three opening for nurses; no RN's thru agency available; LPN's cover the weekend shifts that V19 RN doesn't work; and we only have one RN on staff and she works every other weekend. At that same time, V2 verified she does not come in on the weekends to cover the RN coverage openings. The Department of Health and Human Services Centers for Medicaid and Medicare Services, Form 671-Long-Term Care Facility Application for Medicare and Medicaid, dated 3/18/2025, documents 46 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145774 If continuation sheet Page 5 of 11 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 03/21/2025 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview, and record review, the facility failed to post the required staffing information on a daily basis and failed to have the total number of actual hours worked for licensed and unlicensed nursing staff. This has the potential to affect all 46 residents in the facility. Residents Affected - Many Findings include: On 3/19/25 at 11:07 AM and 3/21/25 at 11:00 AM, the front entrance door had staffing posted dated 3/15/25 and the staffing sheet did not have the total hours worked filled in for the 3/15/25 posted staffing with a census of 46. On 3/21/25 at 11:00 AM, V2 DON/Director of Nursing verified the posting for staffing was not updated and was dated 3/15/25 and should have the total hours worked filled in. At that same time, V2 stated The night nurse is responsible for posting the staffing for the next day. The Department of Health and Human Services Centers for Medicaid and Medicare Services, Form 671-Long-Term Care Facility Application for Medicare and Medicaid, dated 3/18/2025, documents 46 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145774 If continuation sheet Page 6 of 11 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 03/21/2025 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 0801 Level of Harm - Minimal harm or potential for actual harm Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, interview and record review, the facility failed to have a Certified Dietary Manager/CDM and failed to have certified staff. This has the potential to affect all 46 residents in the facility. Residents Affected - Many Findings include: Facility Dietary Aid job description, copyright 2025, documents The dietary aid is responsible for aiding all food functions as directed/instructed and in accordance with established food policies and procedures. Essential Duties and Responsibilities: Ensure food is prepared in accordance with sanitary regulations. Facility Dietary Manager/DM job description, copyright 2025, documents The Dietary Manager is responsible for partnering with the Dietician to plan, organize, develop, and direct the overall operation of the Dietary Department in accordance with current federal, state, and local standards, guidelines and regulations governing our facility, to assure that quality nutritional services are provided on a daily basis and that the Dietary Department is maintained in a clean, safe, and sanitary manner. Must possess Food Service Sanitation Manager Certification. Facility Cook job description, copyright 2025, documents The [NAME] is responsible for food preparation in accordance with current applicable federal, state, and local standards, guidelines and regulations, with our established policies and procedures, to assure that quality food services is provided at all times. Must have Illinois Food Service Sanitation certification. Dining Menu Week at a Glance, copyright 2025, documents for week four 3/18/25 (Tuesday) lunch of the following: Ground Beef Stroganoff Over Noodles, Soft Chopped Sauteed Fresh Zucchini, Bread/Margarine, Soft Chopped Canned Chilled Fruit, and Beverage. Facility Dietary Schedule, March 2025, documents the following: V6 DM worked 3/2-3/4; 3/8, 3/12, 3/14, 3/17 and 3/20/25 as a cook, afternoon or morning aid, and DM; V10 [NAME] worked 3/1, 3/2, 3/4-3/7, 3/10-3/13, 3/15, 3/16, 3/18-3/20/25 as the morning cook; V11 [NAME] 3/9/25 as the afternoon aid; V12 [NAME] worked 3/3-3/5; 3/8-3/11; 3/13, 3/14, 3/17-3/19/25 as the morning cook, and morning aid; V13 [NAME] worked 3/1-3/4, 3/7, 3/10, 3/11, 3/13, 3/15, 3/16, 3/18/25 as the afternoon cook, and afternoon aid; V14 DA worked 3/1-3/3, 3/6-3/8, 3/15, 3/16/25 as the morning aid; V15 DA 3/3/25 as the afternoon aid; and V16 DA worked 3/3/1, 3/2, 3/5-3/7, 3/9, 3/10, 3/12, 3/14-3/17, and 3/19/25 as the afternoon aid. During this survey from 3/18/25-3/21/25, the facility was unable to provide a CDM certificate and staff food handler certificates. On 3/18/25 at 11:00 AM, V6 DM/Dietary Manager stated I don't have my CDM certificate; I have been here since November 2024 working as the DM; my food handler certificate expired the beginning of this month (March 2025); and I cannot find any of my staff food handler certificates and my staff does not have a copy or able to obtain their food handler certificates. At that same time, V10 [NAME] and V12 Dietary Aid were observed during a meal delivery service where V10 scooped the food onto plates for the residents, and V12 put the drinks and supplements on the trays and handed to the staff outside of the kitchen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145774 If continuation sheet Page 7 of 11 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 03/21/2025 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 0801 V6 DM Serv Safe Certification documents Date of Expiration 3/2/25. Level of Harm - Minimal harm or potential for actual harm Facility Food Protection Manager (Sanitation 8 hour course for cooks), undated, documents the following: V6 [NAME] expiration date 3/2/25; and V10-V13 all Cooks had no certification. Residents Affected - Many Facility Food Handlers Certificate (dietary aides), undated, documents the following: V14-V16 all dietary aides had no certification. The Department of Health and Human Services Centers for Medicaid and Medicare Services, Form 671-Long-Term Care Facility Application for Medicare and Medicaid, dated 3/18/2025, documents 46 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145774 If continuation sheet Page 8 of 11 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 03/21/2025 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 0802 Level of Harm - Minimal harm or potential for actual harm Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and record review, the facility failed to have sufficient staff during the meal service. This has the potential to affect all 46 residents in the facility. Residents Affected - Many Findings include: Facility Assessment, updated 3/1/25, documents Average daily census of 40. Facility resources needed to provide competent support and care for our resident population every day and during emergencies. Staff type: Food and Nutrition Services (Director, support staff, Registered Dietician). Facility Dietary Aid job description, copyright 2025, documents The dietary aid is responsible for aiding all food functions. Facility Dietary Manager job description, copyright 2025, documents The Dietary Manager is responsible to assure that quality nutritional services are provided on a daily basis. Facility Cook job description, copyright 2025, documents The [NAME] is responsible to assure that quality food services is provided at all times. Facility Meal times and locations, undated, documents 7:30 AM small and main dining room; 11:30 AM small and main dining room; and 5:30 PM small and mail dining room. On 3/18/25 at 11:00 AM during a meal service, staff filled meal carts for residents that eat their meals in their room and left the dining room to serve residents down the hallways which left no staff to serve the residents who were seated in the dining room. On 3/18/25 at 11:00 AM, V6 Dietary Manager/DM stated We serve room trays first and there is quite a lot of them. The staff delivers the food down the hallways and the residents in the dining room have to wait for their food because there is not enough staff to serve the residents in the dining room. I have one person help deliver trays from the dietary department. During the resident council meeting on 03/19/25 at 10:00 AM, all five residents (R13, R3, R36, R31, and R33) in attendance stated We have to wait for our meals in the dining room because their is not enough staff; they serve the room trays first and the staff is busy doing that; they tried serving the dining room first but that didn't work either; they don't have enough staff for meals; and they need to find a solution. The Department of Health and Human Services Centers for Medicaid and Medicare Services, Form 671-Long-Term Care Facility Application for Medicare and Medicaid, dated 3/18/2025, documents 46 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145774 If continuation sheet Page 9 of 11 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 03/21/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 have a delivery, use-by date, or expiration date for Zucchini and loaves of bread. This has the potential to affect all 46 residents in the facility. Findings include: Facility Food and Supplies: Storage, copyright 2025, documents All foods will be covered, labeled, and dated. If there is no expiration date on the package or container, a use-by date must be written on the product. On 3/18/25 at 11:00 AM during the kitchen tour with V6 DM/Dietary Manager a bag of frozen zucchini had no date on it when received, use-by date, or expiration date; and multiple loaves of bread did not have a received, use-by date, or expiration date on them. At that same time V6 DM stated I thought the bread had a date on them, but I don't see one, and that bag of zucchini was taken out of the box today. I am on staff all the time to make sure they are dating when we get our deliveries and when they are opened. The Department of Health and Human Services Centers for Medicaid and Medicare Services, Form 671-Long-Term Care Facility Application for Medicare and Medicaid, dated 3/18/2025, documents 46 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145774 If continuation sheet Page 10 of 11 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 03/21/2025 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 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide specialized rehab services after an order for one (R191) of one resident reviewed for Rehab Services in a sample of 22. Residents Affected - Few Findings include: R191's hospital Physical Therapy notes, dated 3/4/25, documents Decline in functional mobility, poor functional mobility, and deconditioning. Discharge disposition: Nursing home for continued therapy. Frequency: 1-2 times/day on Monday through Friday. Duration: 2 weeks. Treatment plan to include the following: Gait training; mobility/transfers/strength/ROM (Range of Motion); education; family training; and balance activities. R191's medical record documents an admission date of 3/5/2025 (Wednesday), and a medical diagnosis of Polymyalgia Rheumatica and Congestive Heart Failure/CHF. R191's current care plan for March 2025 documents The resident is at risk for falls related to impaired mobility. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Pt evaluate and treat as ordered or PRN/as needed. R191's progress note, dated 3/5/2025 2:56 PM, documents Resident arrived in a wheelchair from the hospital with admitting diagnosis of Muscle Weakness (Generalized). R191's nursing note, dated 3/6/25 at 12:50 PM, documents Needs assist with transfers and ADL's/Activities of Daily Living. R191's physician orders, dated 3/6/25, documents the following: OT (Occupation Therapy)/PT (Physical Therapy)/ST (Speech Therapy) may evaluate and treat as indicated. R191 Physical Therapy evaluation and plan of treatment notes, document a start of care date 3/14/25. On 3/21/25 at 10:00 AM, R191 was in the hallway with physical therapy and a gaitbelt with a wheeled walker. At that same time R191 was alert and oriented and stated the following: I am getting therapy for my legs; I didn't get it for two weeks and I was about to leave; I started therapy this week; I was really disappointed I didn't start right away and I was going to go home and walk down the road with my wife if they didn't get therapy started; and I am not sure why it didn't start right away because that is why I am here to get therapy and go home with my wife. On 3/21/25 at 11:05 AM, V20 PTA/Physical Therapy Aid stated (R191) got therapy 3/17, 3/18, 3/20, and 3/21/25 for 55 minutes. He was evaluated last Friday on 3/14/25. We have a COTA/Certified Occupational Therapy Aid here 2-3 days a week and PTA here five days a week. I have six residents I give PT to for about 3.5 hours a day here. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145774 If continuation sheet Page 11 of 11