Health inspection·May 29, 2025

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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145774 If continuation sheet Page 2 of 5 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 05/29/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete 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. Event ID: Facility ID: 145774 If continuation sheet Page 3 of 5 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 05/29/2025 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 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. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145774 If continuation sheet Page 4 of 5 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 05/29/2025 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 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145774 If continuation sheet Page 5 of 5