Health inspection·May 29, 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 maintain a sanitary and orderly environment for Residents by failing to stock disposable hand towels and/or cloth hand towels/wash clothes in Resident restrooms for nine of nine Residents (R2, R3, R4, R7, R8, R9, R10, R11 and R12) and maintain clean and orderly Resident restrooms for two Residents (R1 and R7) of nine reviewed for clean and homelike environment in a sample of 12. Findings include: The Facility Resident Rights for People in Long-Term Care Facilities, revised 11/2018, documents: the Facility must provide services to keep your physical and mental health at the highest practical levels; and must be safe, clean, comfortable, and homelike. The Facility Housekeeper Job Description, revised 7/2024, documents: the primary purpose is to perform day-to-day activities of the Housekeeping Department in accordance with federal, state and local standards, guidelines and regulations; to ensure the Facility is maintained in a clean, safe and comfortable manner; and to coordinate housekeeping services with nursing services when performing routine cleaning assignments in Resident living and/or residential areas. The Facility Assessment, dated 3/1/2025, documents the Facility must ensure that staff members are educated and trained on the rights of the Resident and the responsibilities of a Facility to properly care for its Residents; Infection Control competencies for hand-hygiene and standard universal precautions; and the physical environment needs include body cleansing products. The Facility Supply Purchase Orders, dated 5/1/25 through 5/27/25, were reviewed and document one entry on 5/27/25 for two cases of roll towels. a) On 5/27/25 at 9:00 am, R1's bathroom commode interior toilet bowl was moderately black tinged with black debris exposed through the porcelain bowl. On 5/27/25 at 9:01 am, R1 stated, My toilet bowl has been like that for quite a while. It's like all the paint at the bottom of the bowl is scraped off and the porcelain is off, but it looks dirty. I do not think they have ever tried to replace it or fix it. b) On 5/27/25 at 8:39 am and 5/28/25 at 1:56 pm, R2's and R9's shared adjoining restroom paper towel dispenser was empty, did not have disposable paper towels or did not have clean wash cloths/hand towels. Page 1 of 5 145774 145774 05/29/2025 Arcadia Care Havana 609 North Harpham Street Havana, IL 62644

F 0584 On 5/27/25 at 8:39 am, R2 stated, I have not had any paper towels to dry my hands off for quite a few days. Level of Harm - Minimal harm or potential for actual harm On 5/28/25 at 1:57 pm, R9 stated, I have been here for six days, and I have not had any paper towels in the bathroom since I have been here. I do not even have any towels to dry my hands, so I just wipe my hands on my clothes. Residents Affected - Some c) On 5/27/25 at 8:52 am and 5/28/25 at 2:07 pm, R3's (Resident Council President) restroom paper towel dispenser was empty, did not have disposable paper towels or did not have clean wash cloths/hand towels. R3's restroom had a moderate area of yellow colored wet substance (urine) on the floor base of the commode and debris on the floor. On 5/27/25 at 8:52 am, R3 (Resident Council President) stated, I do not have any towels in by bathroom to clean my hands, they ran out. d) On 5/27/25 at 9:13 am, R8's restroom paper towel dispenser was empty, did not have disposable paper towels or did not have clean wash cloths/hand towels. On 5/27/25 at 9:14 am, R8 stated, They run out of towels in the bathroom all the time. I just do not use anything to dry my hands, I just shake them. e) On 5/27/25 at 8:26 am, R4's restroom paper towel dispenser was empty, did not have disposable paper towels or did not have clean wash cloths/hand towels. On 5/27/25 at 8:27 am, R4 stated, There are no hand towels in the bathroom. Sometimes I have to ask for them, now they have not filled them for a couple of days. f) On 5/27/25 at 9:08 am, R7's restroom paper towel dispenser was empty, did not have disposable paper towels or did not have clean wash cloths/hand towels. R7's bathroom commode had an attached raised plastic seat riser. The bottom side rim of the seat riser (closest to the water in the commode bowl) was entirely black tinged on the rim and the seat riser, toilet tank and surrounding commode had a substantial amount of splattered brown/black debris. On 5/27/25 at 9:08 am, R7 stated, I ran out of bathroom towels, and they have not put any in for a couple days. I am not sure what that black stuff on that white toilet riser is, it looks like black mold, and it never cleans off. g) On 5/17/25 at 9:50 am, R10's restroom paper towel dispenser was empty, did not have disposable paper towels or did not have clean wash cloths/hand towels. R10 was not available for interview. h) On 5/28/25 at 8:40 am, R11 and R12's restroom paper towel dispenser was empty, did not have disposable paper towels or did not have clean wash clothes/hand towels. On 5/28/25 at 8:49 am, V8 (Housekeeping) was pushing a housekeeping supply cart down the hallway, and V8's cart did not have any disposable paper towels. V8 stated, I do not have any paper towels. On 5/27/28 at 10:30 am, the Facility main supply closet did not have disposable paper towels in stock. V7 (Housekeeping/Maintenance/Laundry Supervisor) stated, We do not currently have any paper towels, our shipment should be coming in within the next day or so. I do know that some of the rooms are 145774 Page 2 of 5 145774 05/29/2025 Arcadia Care Havana 609 North Harpham Street Havana, IL 62644

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some out of paper towels, but they probably did not get changed since it was the Memorial Day holiday weekend. V7 verified that the Facility did not have paper towels in stock to re-stock the Resident restrooms. On 5/28/25 at 11:00 am, V1 (Administrator) stated, I just sent (V8) to buy more disposable towels at the local discount store until our shipment gets in. I was never made aware that we did not have any paper towels until now, and that so many Residents were without them. (V8) has only been here for about two months and has to oversee three departments, so (V8) is still learning how to order supplies. 145774 Page 3 of 5 145774 05/29/2025 Arcadia Care Havana 609 North Harpham Street Havana, IL 62644

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the Facility failed to follow Physician Orders to apply bilateral lower extremity compression stockings and provide basic activity of daily living nail care for one of five Residents (R2) reviewed for cares in a sample of 12. Residents Affected - Few Findings include: The Facility Resident Rights for People in Long-Term Care Facilities, revised 11/2018, documents: must treat you with dignity and respect and care for Residents in a manner that promotes quality of life; provide equal access to quality of care regardless of diagnosis or condition; provide services to keep physical and mental health at highest practical levels; and receive services included in plan of care. The Facility's Certified Nursing Assistant/CNA Job Description, revised 7/2023, documents: to provide Resident of this Facility with nursing and personal care and to safeguard the health, safety and welfare of all Residents of the Facility in accordance with policies and procedures and applicable laws and regulations; carry out assignments for Resident care including bathing and grooming; and responsible for well-being and nursing care of all Residents assigned to unit; attend nursing department and care plan meetings; attend in-service educational classes and on-the-job training programs. R2's current Physician Order Sheet/POS, documents R2 admitted to the facility on [DATE] and R2's diagnoses included Chronic Kidney Disease Stage Two, Osteoarthritis, Aneurysm, Repeated Falls, Muscle Disorder, Abnormal Gait and Mobility, Lack of Coordination Anemia, Zoster, Major Depressive Disorder and Dementia. The POS documents an order dated 5/14/25, for compression stockings to be on in the morning and off at night for Edema (bilateral lower extremities). R2's Care Plan documents: an Activity of Daily Living self-care performance that requires staff assistance with personal hygiene and bathing; check nail length and trim and clean on bath day and as necessary; and to report any changes to the nurse. R2's Care Plan does not document a care area for R2's physician order for bilateral lower extremity compression stockings. R2's Medical Record documents R2's shower dates of 5/13/25, 5/19/25, 5/22/25 and 5/26/25. The Shower Sheets do not document that R2's fingernails were cleaned or trimmed. R2's Minimum Data Set/MDS, dated [DATE], documents that R2 requires substantial/maximal assistance with personal hygiene. On 5/27/25 (8:39 am, 9:47 am, and 1:40 pm) and 5/28/25 (8:43 am and 1:56 pm), R2's legs were swollen with moderate pitting Edema and R2 did not have compression stockings on bilateral lower extremities. R2's fingernail tips were long and had a moderate amount of black dry debris under each nail tip. On 5/27/25 at 8:39 am, R2 stated, They do not put on my stockings but they are suppose to, so my legs get swollen. No one has cleaned my nails, I like them long but they need cleaned. On 5/28/25 at 1:56 pm, V1 (Administrator) verified that R2's fingernail tips had a moderate amount of debris under each nail tip. V1 stated, I will make sure that (R2's) fingernails get cleaned up. 145774 Page 4 of 5 145774 05/29/2025 Arcadia Care Havana 609 North Harpham Street Havana, IL 62644

F 0684 Nails are supposed to be cleaned on shower days. (R2) just had a shower on Monday (5/26/25) and they should have been cleaned then. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 145774 Page 5 of 5