Health inspection·August 11, 2025

F 0569 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to refund unused resident funds to a resident's representative within 30 days of the resident's death for one of three residents (R1) reviewed for resident funds in the sample of three.Findings include:The Illinois Department on Aging Centers for Medicare and Medicaid Understating Your Financial Rights Guidelines dated 7/12/21 document, Your financial rights: The nursing home must return funds with a final statement to the person or court handling your estate within 30 days after your death. R1's Hospital Record documents:R1 was transferred to the hospital from the facility on 6/21/25 and passed away while in the hospital on 6/23/25.R1's Resident Statement Landscape dated 11/5/24 through 6/12/25 documents R1 had 60.00 dollars each month deposited by SSA (Social Security Administration) into the facility's trust fund account for R1's personal use. R1's Resident Statement Landscape dated 8/1/25 documents R1 had 420.00 personal dollars left in the facility's trust fund account that R1 had not spent or used since 11/5/24.On 8/6/25 at 8:45 AM V7 (R1's Power of Attorney) stated, I have been asking since 7/8/25 for the facility to refund (R1's) remaining funds. The facility has yet to refund the funds, and I feel like I am getting the run around.On 8/8/25 at 11:30 AM V15 (Regional Director of Operations) stated, The facility does not have a policy on when remaining trust funds are distributed to the residents' representatives, however we (the facility) follow CMS (Centers for Medicare and Medicaid Services) guidelines. (V7/R1's Power of Attorney) should have received (R1's) remaining 420.00 dollars left in the facility's trust fund within 30 days after (R1's) death (6/23/25). The facility has not sent out the 420.00 dollars yet. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145774 If continuation sheet Page 2 of 19 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 08/11/2025 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 0572 Give residents a notice of rights, rules, services and charges. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to promptly provide a copy of the updated admission agreement/contract to all residents and/or residents' representatives upon change of facility ownership. These failures have the potential to affect all 34 residents residing within the facility upon change of ownership on 11/1/24.Findings include:The facility's Daily Census Report dated 11/1/24 documents 34 residents residing within the facility on 11/1/24. The Business Office Manager policy dated 7/2023 documents Business Office Manager Job Description Summary: The primary purpose of the Business Office Manager is to assist in the day-to-day accounting functions of the facility in accordance with current acceptable accounting and cost reimbursement principles relating to nursing facility operations, and as may be directed by the Administrator, Director of Finance, or Accountant. Ensure that resident admission contracts are signed and appropriately filed.V5's (Prior Business Office Manager's) Performance Improvement Plan dated 4/28/25 documents V5 was responsible for doing admission contracts with the residents and residents' representatives and was not doing the admission contracts within 24-48 hours of the residents' admission. On 8/9/25 at 8:30 AM V1 (Administrator) provided a list of all residents residing within the facility upon change of ownership on 11/1/24 with the date of when the admission contract was provided to the residents or residents' representatives. According to this list, none of the 34 residents residing within the facility on 11/1/24 received the facility's admissions agreement within 30 days.On 8/6/25 at 1:38 PM V8 (R3's Guardian) stated, I did not sign (R3's) admission contract until months after (the facility) took ownership.On 8/7/25 at 11:30 AM V1 (Administrator) verified none of the residents' admission contracts were signed or given to the residents or residents' representatives immediately, or within 30 days, upon the facility taking over ownership on 11/1/24. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145774 If continuation sheet Page 3 of 19 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 08/11/2025 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 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to protect R2 and R3 from financial exploitation from their guardians, after the facility was made aware, for two of three residents (R2 and R3) reviewed for misappropriation of funds in the sample of three. These failures resulted in V11 (R2's Guardian) continuing to have access to R2's accounts after the facility was made aware on 1/29/25 of potential exploitation of R2's funds of 3,755.00, subjecting R2 to 11,542.00 more dollars of representative social security monetary fraud/exploitation after 1/29/25, R2 expressing feelings of anger and fear of displacement to another facility with no alternate plan, and R2 being provided with a past due bill indicating R2 may be subjected to a notice of involuntary discharge, and V8 (R3's Guardian) continuing to access R3's accounts after the facility was made aware on 4/29/25 of potential exploitation of R3's funds of 1,993.00, subjecting R3 to 12,284.00 more dollars of representative monetary fraud/exploitation after 4/29/25.These failures resulted in an Immediate Jeopardy.While the immediacy was removed on 8/8/25, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring. Findings include:The Abuse Prevention and Reporting policy dated 9/2024 documents Guidelines: The 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 facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by: Identifying occurrences and patterns of potential mistreatment; Immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property; Implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation misappropriation of property and mistreatment, and making the necessary changes to prevent future occurrences; Filing accurate and timely investigative reports. 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, the goods of 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. Exploitation means taking advantage of a resident for a personal gain through the use of manipulation, intimidation, threats or coercion. Misappropriation of Resident property means the deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a residence belongings or money without the residents sent. Misappropriation of a residence property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a residence belongings or money without the resident's consent.The facility's admission Contract Between Resident and Facility documents A. Definitions 3. Reasonable Party is an individual who has control and/or access to Resident's funds and or assets. The Responsible Party who executes this Agreement agrees to act on Resident's behalf and agrees to cause payment of fees and charges incurred by or on Resident's behalf from Resident's funds, assets or estate. The Responsible Party agrees to provide an accounting of Resident's Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145774 If continuation sheet Page 4 of 19 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 08/11/2025 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 0602 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few funds, assets and estate upon request including providing documentation to verify accounts. Failure to cause payment or fees and charges incurred by or on Resident's behalf from Resident's funds, assets or estate shall constitute a failure to exercise due care and will subject the Responsible Party to personal liability for the charges incurred by Resident. The Responsible Party may act in more than one capacity and agree to other applicable terms and conditions of this Agreement. The Responsible Party, if any, must also agree to and comply with Attachment B: Income and Personal Resource Statement. 4. Resident Representative is the individual who has the legal authority to make decisions on the Resident's behalf regarding healthcare. By signing this Contract as the Residents Representative, the individual represents that he/she has the legal authority to make health care decisions on behalf of the Resident. The Resident Representative agrees to provide the Facility a copy of all documentation relating to his/her status as the legal decision maker (e.g., (example) healthcare power of attorney, letters, or guardianship) 5. Representative Payee A person(s) who execute this Contract as the Representatives Payee will receive social security benefit for and on behalf of the Resident, which benefits are assets of the Resident. The Representative Payee is hereby authorized and requested by the Resident, immediately upon receipt to pay all such amounts due the Facility. The Representative Payee further agrees to notify the Facility upon registration, removal, or appointment of a new Representative Payee. d. Transfer of Assets. The Resident shall not transfer or dispose any beneficial interest in his assets while a resident at the Facility that would in any way affect Residents ability to pay for services at the Facility. Failure of the Resident's Representative and/or Responsible Party to properly allocate the Resident's funds and assets for the payment of the Resident's care may constitute abuse and/or financial exploitation.1. R2's admission Record documents R2 is an [AGE] year-old that was admitted to the facility on [DATE] with the diagnoses of Obsessive Compulsive Disorder and Generalized Anxiety Disorder.R2's MDS (Minimum Data Set) assessment dated [DATE] documents R2 is cognitively intact.R2's admission Contract between R2 and the facility was signed on 2/3/25.R2's current Care Plan documents R2 and R2's responsible party are in favor of long-term placement and have expressed a desire to remain at (the facility) for permanent placement, No discharge/transfer potential at this time. This same Care Plan documents R2 displays signs and symptoms of depression and anxiety.R2's Past Due [NAME] Dated 1-29-25 and signed by V6 (Prior Business Office Manager) documents, This letter is to inform you (R2) that you have an outstanding balance at (the facility) in the amount of 3,755.00 dollars. Statement is enclosed. All payments are due by the fifth of the month. If you should have questions, please feel free to call me at [PHONE NUMBER]. Note: Please note if payment is not received in full within 30 days (the facility) may take further action, including but not limited to issuing a Notice of Involuntary Transfer or Discharge.R2's Past Due Statement Dated 8/1/25 and sent to R2 and V11 (R2's Guardian) documents, Amount Due: 15,297.00 dollars. The balance is due upon receipt. If the balance is not paid in 30 days, an Involuntary Transfer and Discharge Notice may be issued.R2's Bank Statement dated 1/1/25 through 1/31/25 document V11 as Guardian of this account. This same Bank Statement documents 2,167.00 dollars were deposited during this timeframe into R2's account ending in (5990) and 1,800.00 dollars were debited during this timeframe and transferred to another bank account, (ending in 2428) that is not associated with R2. The first date noted that a transfer was made to the account not associated with R2 (ending in 2428) was on 1/6/25 in the amount of 155.00 dollars.R2's Bank Statement dated 2/1/25 through 2/28/25 documents 2,167.00 dollars were deposited during this timeframe into R2's account ending in (5990) and 460.00 dollars were debited during this timeframe and transferred to another bank account, (ending in 2428) that is not associated with R2.R2's Bank Statement dated 3/1/25 through 3/31/25 documents 2,167.00 dollars (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145774 If continuation sheet Page 5 of 19 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 08/11/2025 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 0602 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few were deposited during this timeframe into R2's account ending in (5990) and 1,500.00 dollars were debited during this timeframe and transferred to another bank account, (ending in 2428) that is not associated with R2.R2's Bank Statement dated 4/1/25 through 4/30/25 documents 2,253.00 dollars were deposited during this timeframe into R2's account ending in (5990) and 2,175.00 dollars were debited during this timeframe and transferred to another bank account, (ending in 2428) that is not associated with R2.R2's Bank Statement dated 5/1/25 through 5/31/25 documents 2,322.00 dollars were deposited during this timeframe into R2's account ending in (5990) and 2,145.00 dollars were debited during this timeframe and transferred to another bank account, (ending in 2428) that is not associated with R2.R2's Bank Statement dated 6/1/25 through 6/30/25 documents 2,329.00 dollars were deposited during this timeframe into R2's account ending in (5990) and 2,348.00 dollars were debited during this timeframe and transferred to another bank account, (ending in 2428) that is not associated with R2.R2's Final Abuse Investigation Report dated 8/1/25 documents, Original Allegation: Exploitation of funds. On 7/30/25 V1 (Administrator) was notified by the Business Office Manager (V3) and Regional Financial Coordinator (V5) were gathering financial information for (R2's) Medicaid application. During review of financial documents, concerns were noticed that (R2's) social security income was being deposited into (R2's) personal bank account, but then immediately transferred to a different/unknown bank account that (R2) claims to have no access to. Conclusion and Action Taken: Based on the results of the investigation the facility found the following: a. (V3/Business Office Manager) and (V5/Regional Financial Coordinator) noted discrepancies on (R2's) banking documents. B. Facility abuse coordinator contacted local authorities with concerns related to potential financial exploitation. 3. Facility is working with legal and State Office of Guardianship to address change of guardian due to concerns of not being able to contact them and concerns about monetary misappropriation.R2's Local Police Department Report dated 7/30/25 and signed by V16 (Local Police Officer) documents, I (V16) received a call from (V1/Administrator). (V1) advises some of her employees noticed that (R2's) bank accounts appear to have fraudulent activity. (V1) advised (R2's) Medicaid checks are coming in, but it appears the money is then moved to another account.On 8/6/25 at 11:02 AM V6 (Prior Business Office Manager) stated, While I was working at the facility I was doing human resources, admission contracts, and business office manager. I started on 12/1/24 and was terminated on 6/12/25. I had three jobs and could not keep up. (V11/R2's Guardian) was (R2's) rep (representative) payee and received (R2's) social security checks. (V11) was responsible for paying (R2's) bill at the facility. I suspected sometime around January 2025 that (R2's Guardian/V11) was stealing (R2's) money because (V11) wasn't paying (R2's) bill. Sometime in March 2025 (R2) reported to me that she felt like (V11) was stealing (R2's) money and using the money. (R2) was really upset because she could not even buy herself a new pair of shoes. (R2) told me she was wanting new shoes and (V11) couldn't get (R2) new shoes because (R2) did not have any money. I did not have time to do anything about (V11) not paying (R2's) bills.On 8/6/25 at 11:30 AM V3 (Business Office Manager) stated, (R2's) Medicaid recertification was due months ago and the facility asked for an extension. When I had to get (R2's) Medicaid Recertification documents submitted I had to ask for (R2's) bank statements. When I requested (R2's) bank statements I noticed (R2's) social security income was being transferred to another account that did not belong to (R2). I suspected (V11) was stealing (R2's) social security funds as (V11) was (R2's) only person that had access to (R2's) funds and was the payee for (R2's) social security. Also, (V11) had not been paying (R2's) bill since January 2025.On 8/6/25 at 11:43 AM V14 (Local Bank Bookkeeper) stated, The only person that has access to (R2's) online electronic banking number ending in 5990 that I am aware of is (V11). All the funds taken out of (R2's) account have been transferred (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145774 If continuation sheet Page 6 of 19 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 08/11/2025 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 0602 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few electronically, using online banking, to an account ending in 2428. Legally I cannot tell you who's account ends in 2428, but what I can tell you is (V11) is the only one that has access to (R2's) account that would be able to make those transfers.On 8/6/25 at 1:55 PM R2 was sitting in the dining room. R2 stated, I told (V6/Prior Business Office Manager) around March (2025) that I needed a new pair of shoes and asked my sister (V11) to get me some shoes and (V11/R2's Guardian) told me I didn't have any money to get shoes. I told (V6) that I thought (V11) might be stealing my money since (V11) is on my bank accounts and I couldn't even get a pair of shoes. (V6) told me she thought (V11) might be stealing my money too because my stay at the nursing home was not being paid for by (V11). No one has gotten back to me until about two weeks ago when (V3/Business Office Manager) asked me if it was okay for the facility to get a copy of my bank statements and said they suspect (V11) might be taking my funds. I gave them the okay to get my bank statements because I am scared I will not get to live here, and this is the only place I have ever lived. I do not want to leave here due to (V11) not paying my bills.On 8/7/25 at 10:10 AM V12 (CNA/Certified Nursing Assistant) stated, I have worked here three years. (R2) never has money to buy clothes, snacks, or shoes. We (facility staff) try to buy (R2) things she needs. (R2) has reported to me clear back since 2022 that her sister (V11) takes her social security check and is stealing (R2's) money. (R2) has been very upset and tells me she is mad and feels like (V11) does not care about her. (R2) told me around four or five months ago that (V6) knows, and she thinks (V6) is finally going to do something about it.On 8/7/25 at 10:20 AM V4 (Prior Administrator) stated, I know we (the facility) thought (V11) was spending (R2's) social security and the facility was not getting paid. When I was at the facility the financials were a hot mess. (R2) would say that (V11) was not turning over (R2's) money.On 8/7/25 at 10:45 AM V13 (CNA) stated, I know (R2) gets upset and tells me (V11) keeps her money and won't let (R2) buy anything. (R2) does not get the clothes or shoes she needs.On 8/7/25 at 11:30 AM V1 (Administrator) verified V6 (Prior Business Office Manager) should have tried to protect R2's funds from being exploited by V11 when V6 first became aware (January 2025).On 8/9/25 at 9:10 AM V1 (Administrator) verified the first electronic transfer out of R2's checking account made to another account ending in 2428, that was not associated with R2, was on 1/6/25 in the amount 155.00 dollars.2. R3's admission Record documents R3 is a [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Hemiplegia and Hemiparesis following a Cerebral Infarction, Bipolar Disorder, Vascular Dementia, Aphasia, Schizoaffective Disorder, and Depression. This same admission Record documents V8 is R3's Guardian and Responsible Party.R3's MDS assessment dated [DATE] documents R3 is cognitively impaired.R3's admission Contract between R3 and the facility was signed on 2/19/25.R3's current Care Plan documents R3 has an appointed Legal Representative/Guardian as evidenced by a court order and R3's Guardian (V8) will advocate and discuss best interest of R3 when in question of decision maker. This same Care Plan documents R3 has expressed a desire to remain at (the facility) for permanent placement and R3 has episodes of depression as evidenced by mood triggers.R3's Statement dated 1-1-25 documents, Amount Due: 4,238.00 dollars. The balance is due upon receipt. If the balance is not paid in 30 days, an Involuntary Transfer and Discharge Notice may be issued.R3's Past Due [NAME] Dated 4-29-25 and signed by V6 (Prior Business Office Manager) documents, This letter is to inform you (R3) that you have an outstanding balance at (the facility) in the amount of 1,993.00 dollars. Statement is enclosed. All payments are due by the fifth of the month. If you should have questions, please feel free to call me at [PHONE NUMBER]. Note: Please note if payment is not received in full within 30 days (the facility) may take further action, including but not limited to issuing a Notice of Involuntary Transfer or Discharge.R3's Past Due [NAME] Dated 7-29-25 and signed by V5 (Regional Financial Coordinator) documents, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145774 If continuation sheet Page 7 of 19 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 08/11/2025 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 0602 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few This letter is to inform you (R3) that you have an outstanding balance at (the facility) in the amount of 14,277.00 dollars. Statement is enclosed. All payments are due by the fifth of the month. If you should have questions, please feel free to call me at [PHONE NUMBER]. Note: Please note if payment is not received in full within 30 days (the facility) may take further action, including but not limited to issuing a Notice of Involuntary Transfer or Discharge.R3's Banking Statements dated 12/5/24 through 6/3/25 document R3 as the primary bank account holder of the account number ending in 7125, and V8 was listed on the account as R3's Guardian. These same Bank Account Statements document 1,354.00 dollars were being deposited monthly into R3's account number ending in 7125 from R3's long-term disability, and 2,191.00 dollars were being deposited monthly into R3's account number ending in 7125 from the Social Security Administration. These Banking Statements document none of R3's 1,354.00 dollars deposited by R3's long term disability have been surrendered to (the facility) and also document multiple charges have been taken out of R3's account for purchases to grocery stores, gas stations, department stores, fast food restaurants, cannabis dispensary's, car dealerships, online retailers, and car dealerships, and multiple payments to credit card accounts were made during this time.R3's Final Abuse Investigation dated 7/7/25 documents, Original Allegation: Exploitation of funds. On 7/2/25 (V1/Administrator) was notified by (V3/Business Office Manager) and (V5/Regional Financial Coordinator). (V3) and (V5) were gathering financial information for (R3's) Medicaid application. During review of (R3's) financial documents, concerns were noticed that (V8/R3's Guardian) was spending (R3's) private income on personal use items and this was brought to the attention of the facility's Abuse Coordinator (V1). Based on the facts of the investigation the facility has found the following: (V3) and (V5) noted discrepancies on (R3's) banking documents. (V1) contacted local authorities with concern related to potential financial exploitation.R3's Local Police Department Report dated 7/2/25 and signed by V16 (Local Police Officer) documents, On 7/2/25, (V16) was on duty for the (local) police department. I was contacted by (V1/Administrator). (V1) advises that they have a resident (R3) that they believe has fraudulent activity to their bank account. (V1) advised that the resident is (R3). (V1) advises (R3's) brother (V8) is (R3's) stated approved Guardian. (V1) stated that she observed transactions from (R3's) account for oil changes, groceries, and the cannabis dispensary that were made by (V8). (V1) advised (R3's) income comes from SSI (Supplemental Security Income) and Disability and believed the case with be Social Security/Medicaid Fraud.On 8/6/25 at 11:02 AM V6 (Prior Business Office Manager) stated, While I was working at the facility, (V8/R3's Guardian) stopped paying the entire amount for (R3's) bill to the facility. (V8) was the representative payee for (R3's) social security check. I sent several of (R3's) overdue bills to (R3) and (V8) from January 2025 to June 2025. I was supposed to do (R3's) Medicaid recertification sometime around March 2025 and noticed (R3) was also getting a disability check from prior employment. (V8) had never been turning the disability check money over. I recall (R3's) disability check being over 1,000.00 dollars per month. I stuck the information in (R3's) file and never got time to deal with (V8) not paying the facility. I figured (V8) was spending (R3's) money. I never reported this to the administrator. On 8/6/25 at 11:30 AM V3 (Business Office Manager) stated, (R3's) Medicaid recertification was due months ago and the facility asked for an extension. When I had to get (R3's) Medicaid Recertification documents submitted I had to ask for (R3's) bank statements and noticed (R3's) private income was being used by (V8/R3's Guardian) on personal use items and not for (R3). I also noticed (R3) was getting a long-term disability check that was not being turned over to the facility and the facility was not getting the entire payment for (R3's) stay.On 8/6/25 at 1:38 PM V8 (R3's Guardian) stated, (R3) has been getting a check from long-term disability for years. The facility has always been aware. In (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145774 If continuation sheet Page 8 of 19 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 08/11/2025 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 0602 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete fact, back in March (V6/Prior Business Office Manager) told me to keep it and not worry about it, and the facility would never find out about it. I have been using the check to come and see (R3) and take (R3) out to dinner. V8 also confirmed he has been using R3's long-term care disability checks to buy V8 and his family personal items, to pay taxes, and to pay personal credit card accounts.On 8/7/25 at 11:30 AM V1 (Administrator) verified V6 (Prior Business Office Manager) should have tried to protect R3's funds from being exploited by V8 when V6 first became aware (March 2025).The Immediate Jeopardy started on 1/29/25 when V5 (Prior Business Office Manager) first suspected V11 (R2's guardian) was exploiting R2's funds and failed to protect R2 from further exploitation. V1 (Administrator) and V15 (Regional Director of Operations/RDO) were notified of the Immediate Jeopardy on 8/8/25 at 8:10 AM.On 8/9/25 and 8/11/25 this surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy:1.On 8/8/25 V3 (Business Office Manager) and V5 (Regional Financial Coordinator) completed a 100 percent audit of all resident trust funds to ensure all residents' accounts were paid up to date and all discrepancies were immediately investigated.2.On 8/8/25 V15 (RDO) educated V1 on the facility's abuse policy regarding immediately reporting and investigating abuse.3.On 8/8/25 V1 (Administrator) and V17 (MDS Coordinator) in-serviced all staff regarding the facility's abuse policy and procedures.4.On 8/8/25 V1 held a QA (Quality Assurance) meeting with the Inter-Disciplinary Team to ensure compliance with Abuse and Misappropriation of resident funds.5.On 8/8/25 V1 provided all families with a copy of the facility's Abuse Policy by certified mail.6.On 8/8/25 V18 (Activity Director) in-serviced all residents regarding the facility's abuse policy and procedures.7.On 7/31/25 V1 notified the Social Security Administration and R2's social security funds were suspended.8.On 8/8/25 V1 notified the Social Security Administration and R3's social security funds were suspended.9. On 8/8/25 V1 contacted The Guardian Life Insurance Company of America to ask for R3's long term disability check to be sent directly to R3 in care of (the facility) due to exploitation of finances by (V8/R3's Guardian).10. R2 no longer requires a Guardian, and the facility is currently working with R2 to appoint R2 a power of attorney in the event R2 is no longer able to make her own healthcare decisions. 11.On 8/8/25 V1 contacted the facility's legal department and Office of State Guardianship to file a petition to change R3's Guardian. 12. On 8/8/25 V3 (Business Office Manager) sent all residents and residents' representative current financial statements by certified mail.13. On 8/8/25 V3 (Business Office Manager) reported all discrepancies of residents' payments not being made to V1, and V1 reported all discrepancies of resident payments not being made to the local police and state agency.Completion Date: 8/8/25. Event ID: Facility ID: 145774 If continuation sheet Page 9 of 19 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 08/11/2025 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 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to report allegations of exploitation of funds from residents' guardians immediately to the state agencies, local police, and Administrator, once the facility was made aware, for two of three residents (R2 and R3) reviewed for misappropriation of funds in the sample of three. These failures resulted in R2 and R3's guardians exploiting their monetary funds, even after the facility was made aware, and the Administrator, local police, State agency, Office of Inspector General, and Social Security Office not being made aware. As a result, R2 and R3's money situation worsened, resulting in R2 expressing feelings of anger and fear of displacement without an alternate plan, R2 being unable to purchase personal care items, and R3 being provided with a past due bill indicating R3 may be subjected to a notice of involuntary discharge without an alternate plan.These failures resulted in an Immediate Jeopardy.While the immediacy was removed on 8/8/25, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring. Findings include:The Abuse Prevention and Reporting policy dated 9/2024 documents, The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. Exploitation means taking advantage of a resident for a personal gain through the use of manipulation, intimidation, threats or coercion. Misappropriation of Resident property means the deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a residence belongings or money without the residents sent. Misappropriation of a residence property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a residence belongings or money without the resident's consent. Reporting Requirements and Identification of Allegations: employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, or to an immediate supervisor who must then immediately report it to the administrator. In the absence of the administrator, reporting can be made to an individual who has been designated to act as administrator in the administrator's absence. Reports should be documented, and record kept of the documentation. Supervisors shall immediately inform the administrator or person designated to act as administrator and the administrator's absence of all reports of incidents, allegations or suspicion of potential abuse, neglect exploitation mistreatment or misappropriation of resident property. Any allegation of abuse or incident that results in serious bodily injury will be reported to the Department of Public Health immediately, but not more than two hours after the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours. The resident's physician and representative, if necessary, shall be notified of any incident or allegation of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property. External Reporting Initial Reporting of Allegations: When an allegation of abuse, exploitation, neglect, mistreatment, or misappropriation of resident property has occurred, the resident's representative and the Department of Public Health's regional office shall be informed by telephone or fax. Public health shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property has been reported and is being investigated. Informing Local Law Enforcement. The facility shall also contact local law enforcement authorities (i.e. (example) telephoning 911 when available) in the following situations: When there is a reasonable suspicion that a crime has been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145774 If continuation sheet Page 10 of 19 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 08/11/2025 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 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few committed in the facility by a person other than a resident. If there is a reasonable suspicion that a crime has been committed that results in serious bodily harm, a report shall be made to local law enforcement immediately and Department of Public Health notified within 2 (two) hours. If there is a reasonable suspicion that a crime has been committed that is not listed above and does not involve serious bodily injury, then a report to local law enforcement and Department of Public Health as soon as possible but within 24 hours of when the suspicion was formed. The resident or residence representative will also be informed of the report of an occurrence of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property and that an investigation is being conducted.The Business Office Manager policy dated 7/2023 documents, Essential Duties and Responsibilities: Monitor and collect accounts receivable. Report delinquent accounts to the Accountant/Director of Finance/Administrator.R2's admission Record documents R2 is an [AGE] year-old that was admitted to the facility on [DATE] with the diagnoses of Obsessive Compulsive Disorder and Generalized Anxiety Disorder.R2's current Care Plan documents R2 and R2's responsible party are in favor of long-term placement and have expressed a desire to remain at (the facility) for permanent placement, No discharge/transfer potential at this time. This same Care Plan documents R2 displays signs and symptoms of depression and anxiety.R2's Past Due [NAME] Dated 1-29-25 and signed by V6 (Prior Business Office Manager) documents, This letter is to inform you (R2) that you have an outstanding balance at (the facility) in the amount of 3,755.00 dollars. Statement is enclosed. All payments are due by the fifth of the month. If you should have questions, please feel free to call me at [PHONE NUMBER]. Note: Please note if payment is not received in full within 30 days (the facility) may take further action, including but not limited to issuing a Notice of Involuntary Transfer or Discharge.R2's Past Due Statement Dated 8/1/25 and sent to R2 and V11 (R2's Guardian) documents, Amount Due: 15,297.00 dollars. The balance is due upon receipt. If the balance is not paid in 30 days, an Involuntary Transfer and Discharge Notice may be issued.R2's Banking Statement dated 1/1/25 through 1/31/25 documents R2's primary checking account has V11 listed as Guardian of the account. This statements document 2,167.00 dollars were deposited during this timeframe into R2's account ending in (5990) and 1,800.00 dollars were debited during this timeframe and transferred to another bank account, (ending in 2428) that is not associated with R2. The first date noted that a transfer was made to the account not associated with R2 (ending in 2428) was on 1/6/25 in the amount of 155.00 dollars.R2's Bank Statement dated 2/1/25 through 2/28/25 documents 2,167.00 dollars were deposited during this timeframe into R2's account ending in (5990) and 460.00 dollars were debited during this timeframe and transferred to another bank account, (ending in 2428) that is not associated with R2.R2's Bank Statement dated 3/1/25 through 3/31/25 documents 2,167.00 dollars were deposited during this timeframe into R2's account ending in (5990) and 1,500.00 dollars were debited during this timeframe and transferred to another bank account, (ending in 2428) that is not associated with R2.R2's Bank Statement dated 4/1/25 through 4/30/25 documents 2,253.00 dollars were deposited during this timeframe into R2's account ending in (5990) and 2,175.00 dollars were debited during this timeframe and transferred to another bank account, (ending in 2428) that is not associated with R2.R2's Bank Statement dated 5/1/25 through 5/31/25 documents 2,322.00 dollars were deposited during this timeframe into R2's account ending in (5990) and 2,145.00 dollars were debited during this timeframe and transferred to another bank account, (ending in 2428) that is not associated with R2.R2's Bank Statement dated 6/1/25 through 6/30/25 documents 2,329.00 dollars were deposited during this timeframe into R2's account ending in (5990) and 2,348.00 dollars were debited during this timeframe and transferred to another bank account, (ending in 2428) that is not associated with R2.R2's Final Abuse Investigation Report dated 8/1/25 documents, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145774 If continuation sheet Page 11 of 19 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 08/11/2025 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 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Original Allegation: Exploitation of funds. On 7/30/25 V1 (Administrator) was notified by the Business Office Manager (V3) and Regional Financial Coordinator (V5) were gathering financial information for (R2's) Medicaid application. During review of financial documents, concerns were noticed that (R2's) social security income was being deposited into (R2's) personal bank account, but then immediately transferred to a different/unknown bank account that (R2) claims to have no access to. Conclusion and Action Taken: Based on the results of the investigation the facility found the following: a. (V3/Business Office Manager) and (V5/Regional Financial Coordinator) noted discrepancies on (R2's) banking documents. B. Facility abuse coordinator contacted local authorities with concerns related to potential financial exploitation. 3. Facility is working with legal and State Office of Guardianship to address change of guardian due to concerns of not being able to contact them and concerns about monetary misappropriation.R2's Local Police Department Report dated 7/30/25 and signed by V16 (Local Police Officer) documents, I (V16) received a call from (V1/Administrator). (V1) advises some of her employees notice that (R2's) bank accounts appear to have fraudulent activity. (V1) advised (R2's) Medicaid checks are coming in, but it appears the money is then moved to another account.On 8/6/25 at 11:02 AM V6 (Prior Business Office Manager) stated, While I was working at the facility I suspected (R2's Guardian/V11) was stealing (R2's) money because (V11) wasn't paying (R2's) bill starting sometime around January 2025. Sometime in March 2025 I (R2) reported to me that she felt like (V11) was stealing (R2's) money and using the money. I did not report this to (V4/Prior Administrator) or V1 (Administrator). I was so busy with everything I did not get time to report.On 8/6/25 at 1:55 PM R2 was sitting in the dining room. R2 stated, I told (V6/Prior Business Office Manager) around March (2025) that I needed a new pair of shoes and asked my sister (V11) to get me some shoes and (V11/R2's Guardian) told me I didn't have any money to get shoes. I told (V6) that I thought (V11) might be stealing my money since (V11) is on my bank accounts and I couldn't even get a pair of shoes. (V6) told me she thought (V11) might be stealing my money too because my stay at the nursing home was not being paid for by (V11). No one has gotten back to me until about two weeks ago when (V3/Business Office Manager) asked me if it was okay for the facility to get a copy of my bank statements and said they suspect (V11) might be taking my funds. I gave them the okay to get my bank statements because I am scared I will not get to live here, and this is the only place I have ever lived. I do not want to leave here due to (V11) not paying my bills.On 8/7/25 at 10:10 AM V12 (CNA/Certified Nursing Assistant) stated, (R2) has reported to me clear back since 2022 that her sister (V11) takes her social security check and is stealing (R2's) money. (R2) has been very upset and tells me she is mad and feels like (V11) does not care about her. (R2) told me around four or five months ago that (V6) knows, and she thinks (V6) is finally going to do something about it. I know (V4/Prior Administrator) was aware.On 8/7/25 at 10:20 AM V4 (Prior Administrator) stated, I know we (the facility) thought (V11) was spending (R2's) social security and the facility was not getting paid. When I was at the facility the financials were a hot mess. (R2) would say that (V11) was not turning over (R2's) money. V4 verified she never reported the suspicion of V11 exploiting R2's social security money to any state agencies or the local police.On 8/7/25 at 11:30 AM V1 (Administrator) verified V6 (Prior Business Office Manager) should have reported the suspicion that V11 was exploiting R2's social security money when V6 first became aware in January 2025. V1 confirmed she was not made aware, and the state agencies and local police were not made aware until V3 (Current Business Office Manager) reported the allegation to V1 on 7/30/25. On 8/9/25 at 9:10 AM V1 (Administrator) verified the first electronic transfer out of R2's checking account made to another account ending in 2428, that was not associated with R2, was on 1/6/25 in the amount 155.00 dollars.2. R3's admission Record documents R3 is a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145774 If continuation sheet Page 12 of 19 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 08/11/2025 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 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Hemiplegia and Hemiparesis following a Cerebral Infarction, Bipolar Disorder, Vascular Dementia, Aphasia, Schizoaffective Disorder, and Depression. This same admission Record documents V8 is R3's Guardian and Responsible Party.R3's MDS assessment dated [DATE] documents R3 is cognitively impaired.R3's current Care Plan documents R3 has an appointed Legal Representative/Guardian as evidenced by a court order and R3's Guardian (V8) will advocate and discuss best interest of R3 when in question of decision maker. This same Care Plan documents R3 has expressed a desire to remain at (the facility) for permanent placement and R3 has episodes of depression as evidenced by mood triggers.R3's Statement dated 1-1-25 documents, Amount Due: 4,238.00 dollars. The balance is due upon receipt. If the balance is not paid in 30 days, an Involuntary Transfer and Discharge Notice may be issued.R3's Past Due [NAME] Dated 4-29-25 and signed by V6 (Prior Business Office Manager) documents, This letter is to inform you (R3) that you have an outstanding balance at (the facility) in the amount of 1,993.00 dollars. Statement is enclosed. All payments are due by the fifth of the month. If you should have questions, please feel free to call me at [PHONE NUMBER]. Note: Please note if payment is not received in full within 30 days (the facility) may take further action, including but not limited to issuing a Notice of Involuntary Transfer or Discharge.R3's Past Due [NAME] Dated 7-29-25 and signed by V5 (Regional Financial Coordinator) documents, This letter is to inform you (R3) that you have an outstanding balance at (the facility) in the amount of 14,277.00 dollars. Statement is enclosed. All payments are due by the fifth of the month. If you should have questions, please feel free to call me at [PHONE NUMBER]. Note: Please note if payment is not received in full within 30 days (the facility) may take further action, including but not limited to issuing a Notice of Involuntary Transfer or Discharge.R3's Banking Statements dated 12/5/24 through 6/3/25 document R3 as the primary bank account holder of the account number ending in 7125, and V8 was listed on the account as R3's Guardian. These same Bank Account Statements document 1,354.00 dollars were being deposited monthly into R3's account number ending in 7125 from R3's long-term disability, and 2,191.00 dollars were being deposited monthly into R3's account number ending in 7125 from the Social Security Administration. These Banking Statements document none of R3's 1,354.00 dollars deposited by R3's long term disability have been surrendered to (the facility) and also document multiple charges have been taken out of R3's account for purchases to grocery stores, gas stations, department stores, fast food restaurants, cannabis dispensary's, car dealerships, online retailers, and car dealerships, and multiple payments to credit card accounts were made during this time.R3's Final Abuse Investigation dated 7/7/25 documents, Original Allegation: Exploitation of funds. On 7/2/25 (V1/Administrator) was notified by (V3/Business Office Manager) and (V5/Regional Financial Coordinator). (V3) and (V5) were gathering financial information for (R3's) Medicaid application. During review of (R3's) financial documents, concerns were noticed that (V8/R3's Guardian) was spending (R3's) private income on personal use items and this was brought to the attention of the facility's Abuse Coordinator (V1). Based on the facts of the investigation the facility has found the following: (V3) and (V5) noted discrepancies on (R3's) banking documents. (V1) contacted local authorities with concern related to potential financial exploitation.R3's Local Police Department Report dated 7/2/25 and signed by V16 (Local Police Officer) documents, On 7/2/25, (V16) was on duty for the (local) police department. I was contacted by (V1/Administrator). (V1) advises that they have a resident (R3) that they believe has fraudulent activity to their bank account. (V1) advised that the resident is (R3). (V1) advises (R3's) brother (V8) is (R3's) stated approved Guardian. (V1) stated that she observed transactions from (R3's) account for oil changes, groceries, and the cannabis dispensary that were made by (V8). (V1) advised (R3's) income comes from SSI (Supplemental (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145774 If continuation sheet Page 13 of 19 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 08/11/2025 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 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Security Income) and Disability and believed the case with be Social Security/Medicaid Fraud.On 8/6/25 at 11:02 AM V6 (Prior Business Office Manager) stated, While I was working at the facility, (V8/R3's Guardian) stopped paying the entire amount for (R3's) bill to the facility. (V8) was the representative payee for (R3's) social security check. I was supposed to do (R3's) Medicaid recertification sometime around March 2025 and noticed (R3) was also getting a disability check from prior employment. (V8) had never been turning the disability check money over. I recall (R3's) disability check being over 1,000.00 dollars per month. I stuck the information in (R3's) file and never got time to deal with (V8) not paying the facility. I figured (V8) was spending (R3's) money. I never reported this to the administrator. On 8/6/25 at 1:38 PM V8 (R3's Guardian) stated, (R3) has been getting a check from long-term disability for years. The facility has always been aware. In fact, back in March (V6/Prior Business Office Manager) told me to keep it and not worry about it, and the facility would never find out about it. I have been using the check to come and see (R3) and take (R3) out to dinner. V8 also confirmed he has been using R3's long-term care disability checks to buy V8 and his family personal items, to pay taxes, and to pay personal credit card accounts.On 8/7/25 at 10:20 AM V4 (Prior Administrator) stated, (V6/Prior Business Office Manager) never reported anything to me while I worked at the facility about (V8) taking (R3's) funds and not paying (R3's) bill.On 8/7/25 at 11:30 AM V1 (Administrator) verified V6 (Prior Business Office Manager) never made V1 aware of V6's suspicion that V8 was exploiting R3's funds. V1 verified V6 should have reported the suspicion that V8 was exploiting R3's funds when V6 first became aware in March 2025. V1 confirmed she was not made aware, and the state agencies and local police were not made aware until V3 (Current Business Office Manager) reported the allegation to V1 on 7/2/25. The Immediate Jeopardy started on 1/29/25 when V5 (Prior Business Office Manager) first suspected V11 (R2's guardian) was exploiting R2's funds and failed to report this to the Administrator, therefore the local police and state agencies were not notified immediately upon suspicion. V1 (Administrator) and V15 (Regional Director of Operations/RDO) were notified of the Immediate Jeopardy on 8/8/25 at 8:10 AM. On 8/9/25 this surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1.On 8/8/25 V3 (Business Office Manager) and V5 (Regional Financial Coordinator) completed a 100 percent audit of all resident trust funds to ensure all residents' accounts were paid up to date and all discrepancies were immediately investigated.2.On 8/8/25 V15 (RDO) educated V1 on the facility's abuse policy regarding immediately reporting abuse.3.On 8/8/25 V1 (Administrator) and V17 (MDS Coordinator) in-serviced all staff regarding the facility's abuse policy and procedures.4. On 8/8/25 V1 held a QA (Quality Assurance) meeting with the Inter-Disciplinary Team to ensure compliance with reporting Abuse and Misappropriation of resident funds.5.On 7/31/25 V1 notified the Social Security Administration and R2's social security funds were suspended.6.On 8/8/25 V1 notified the Social Security Administration and R3's social security funds were suspended.7. On 8/8/25 V1 contacted The Guardian Life Insurance Company of America to ask for R3's long term disability check to be sent directly to R3 in care of (the facility) due to exploitation of finances by (V8/R3's Guardian).8. On 8/8/25 V3 (Business Office Manager) reported all discrepancies of residents' payments not being made to V1, and V1 reported all discrepancies of resident payments not being made to the local police and state agency.Completion Date: 8/8/25. Event ID: Facility ID: 145774 If continuation sheet Page 14 of 19 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 08/11/2025 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 0610 Respond appropriately to all alleged violations. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to protect residents from exploitation of funds from their guardians, once the facility suspected misappropriation of funds, and failed to immediately initiate an investigation of an allegation of misappropriation of funds for two of three residents (R2 and R3) reviewed for misappropriation of funds in the sample of three. These failures resulted in funds from R2's social security funds being transferred out of R2's checking account monthly into another account not associated with R2, even after the facility was made aware and no interviews, no bank record reviews, and no referrals sent to the state agencies. As a result, R2's money situation worsened, resulting in R2 expressing feelings of anger and fear of displacement to another facility, R2 being unable to purchase personal care items, and resulted in R3's monthly pension funds and social security funds being exploited by R3's guardian (V8) after the facility was made aware, and no bank record reviews, no interviews, and no referrals send to the state agencies, As a result, R3's money situation worsening, and R3 being provided with a past due bill indicating R3 may be subjected to a notice of involuntary discharge. These failures resulted in an Immediate Jeopardy.While the immediacy was removed on 8/8/25, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring. Findings include: The Abuse Prevention and Reporting policy dated 9/2024 documents, The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. Exploitation means taking advantage of a resident for a personal gain through the use of manipulation, intimidation, threats or coercion. Misappropriation of Resident property means the deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a residence belongings or money without the residents sent. Misappropriation of a residence property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a residence belongings or money without the resident's consent. Protection of Residents The facility will take steps to prevent potential abuse while the investigation is underway. Residents who allegedly abused another resident shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his for her safety, as well as the safety of other residents and employees of the facility. In addition, the facility shall take all steps necessary to ensure the safety of residents including, but not limited to, the separation of the residents. Accused individuals not employed by the facility will be denied unsupervised access to their residence during the course of the investigation. Internal Investigation: All incidents will be documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of resident property occurred, was alleged or suspected. Any incident or allegation involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property will result in an investigation. Investigation Procedure: the appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interview table. Any written statements that have been submitted will be reviewed, along with any medical records or other documents. The administrator or person designated to act as administrator in the administrator's absence will review the report. The administrator or designee is then responsible for forwarding a final written report of the results of the investigation and of any corrective action taken to the Department of Public Health within five working days of the reported incident.R2's admission Record documents R2 is an [AGE] year-old that was admitted to the facility on [DATE] with the diagnoses of Obsessive Compulsive Disorder Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145774 If continuation sheet Page 15 of 19 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 08/11/2025 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few and Generalized Anxiety Disorder.R2's current Care Plan documents R2 and R2's responsible party are in favor of long-term placement and have expressed a desire to remain at (the facility) for permanent placement, No discharge/transfer potential at this time. This same Care Plan documents R2 displays signs and symptoms of depression and anxiety.R2's Past Due [NAME] Dated 1-29-25 and signed by V6 (Prior Business Office Manager) documents, This letter is to inform you (R2) that you have an outstanding balance at (the facility) in the amount of 3,755.00 dollars. Statement is enclosed. All payments are due by the fifth of the month. If you should have questions, please feel free to call me at [PHONE NUMBER]. Note: Please note if payment is not received in full within 30 days (the facility) may take further action, including but not limited to issuing a Notice of Involuntary Transfer or Discharge.R2's Past Due Statement Dated 8/1/25 and sent to R2 and V11 (R2's Guardian) documents, Amount Due: 15,297.00 dollars. The balance is due upon receipt. If the balance is not paid in 30 days, an Involuntary Transfer and Discharge Notice may be issued.R2's Banking Statement dated 1/1/25 through 1/31/25 documents R2's primary checking account has V11 listed as Guardian of the account. This statements document 2,167.00 dollars were deposited during this timeframe into R2's account ending in (5990) and 1,800.00 dollars were debited during this timeframe and transferred to another bank account, (ending in 2428) that is not associated with R2. The first date noted that a transfer was made to the account not associated with R2 (ending in 2428) was on 1/6/25 in the amount of 155.00 dollars.R2's Bank Statements dated 2/1/25 through 6/30/25 document R2's social security deposits into R2's personal checking account ending in 5990 continued to be electronically transferred into another bank account ending in 2428, that was not associated with R2.R2's Facility Financial Statement dated 2/1/25 through 8/1/25 document V11 has not made a payment to the facility for R2's room and board during this timeframe. R2's Final Abuse Investigation Report dated 8/1/25 documents, Original Allegation: Exploitation of funds. On 7/30/25 V1 (Administrator) was notified by the Business Office Manager (V3) and Regional Financial Coordinator (V5) were gathering financial information for (R2's) Medicaid application. During review of financial documents, concerns were noticed that (R2's) social security income was being deposited into (R2's) personal bank account, but then immediately transferred to a different/unknown bank account that (R2) claims to have no access to. Conclusion and Action Taken: Based on the results of the investigation the facility found the following: a. (V3/Business Office Manager) and (V5/Regional Financial Coordinator) noted discrepancies on (R2's) banking documents. B. Facility abuse coordinator contacted local authorities with concerns related to potential financial exploitation. 3. Facility is working with legal and State Office of Guardianship to address change of guardian due to concerns of not being able to contact them and concerns about monetary misappropriation.R2's Local Police Department Report dated 7/30/25 and signed by V16 (Local Police Officer) documents, I (V16) received a call from (V1/Administrator). (V1) advises some of her employees notice that (R2's) bank accounts appear to have fraudulent activity. (V1) advised (R2's) Medicaid checks are coming in, but it appears the money is then moved to another account.On 8/6/25 at 11:02 AM V6 (Prior Business Office Manager) stated, While I was working at the facility I suspected (R2's Guardian/V11) was stealing (R2's) money because (V11) wasn't paying (R2's) bill starting sometime around January 2025. Sometime in March 2025 I (R2) reported to me that she felt like (V11) was stealing (R2's) money and using the money. I did not report this to (V4/Prior Administrator) or V1 (Administrator). I was so busy with everything I did not get time to report.On 8/6/25 at 1:55 PM R2 was sitting in the dining room. R2 stated, I told (V6/Prior Business Office Manager) around March (2025) that I needed a new pair of shoes and asked my sister (V11) to get me some shoes and (V11/R2's Guardian) told me I didn't have any money to get shoes. I told (V6) that I thought (V11) might be stealing my money (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145774 If continuation sheet Page 16 of 19 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 08/11/2025 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few since (V11) is on my bank accounts and I couldn't even get a pair of shoes. (V6) told me she thought (V11) might be stealing my money too because my stay at the nursing home was not being paid for by (V11). No one has gotten back to me until about two weeks ago when (V3/Business Office Manager) asked me if it was okay for the facility to get a copy of my bank statements and said they suspect (V11) might be taking my funds. I gave them the okay to get my bank statements because I am scared I will not get to live here, and this is the only place I have ever lived. I do not want to leave here due to (V11) not paying my bills.On 8/7/25 at 10:20 AM V4 (Prior Administrator) stated, I know we (the facility) thought (V11) was spending (R2's) social security and the facility was not getting paid. When I was at the facility the financials were a hot mess. (R2) would say that (V11) was not turning over (R2's) money. V4 verified she never investigated the allegation of V11 exploiting R2's funds and never protected R2 from further exploitation.On 8/7/25 at 11:30 AM V1 (Administrator) verified an investigation had not been done and no one protected R2 from further exploitation of funds until 7/30/25 (six months after V5/Prior Business Office Manager) was made aware. 2. R3's admission Record documents R3 is a [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Hemiplegia and Hemiparesis following a Cerebral Infarction, Bipolar Disorder, Vascular Dementia, Aphasia, Schizoaffective Disorder, and Depression. This same admission Record documents V8 is R3's Guardian and Responsible Party.R3's MDS assessment dated [DATE] documents R3 is cognitively impaired.R3's current Care Plan documents R3 has an appointed Legal Representative/Guardian as evidenced by a court order and R3's Guardian (V8) will advocate and discuss best interest of R3 when in question of decision maker. This same Care Plan documents R3 has expressed a desire to remain at (the facility) for permanent placement and R3 has episodes of depression as evidenced by mood triggers.R3's Statement dated 1-1-25 documents, Amount Due: 4,238.00 dollars. The balance is due upon receipt. If the balance is not paid in 30 days, an Involuntary Transfer and Discharge Notice may be issued.R3's Past Due [NAME] Dated 4-29-25 and signed by V6 (Prior Business Office Manager) documents, This letter is to inform you (R3) that you have an outstanding balance at (the facility) in the amount of 1,993.00 dollars. Statement is enclosed. All payments are due by the fifth of the month. If you should have questions, please feel free to call me at [PHONE NUMBER]. Note: Please note if payment is not received in full within 30 days (the facility) may take further action, including but not limited to issuing a Notice of Involuntary Transfer or Discharge.R3's Past Due [NAME] Dated 7-29-25 and signed by V5 (Regional Financial Coordinator) documents, This letter is to inform you (R3) that you have an outstanding balance at (the facility) in the amount of 14,277.00 dollars. Statement is enclosed. All payments are due by the fifth of the month. If you should have questions, please feel free to call me at [PHONE NUMBER]. Note: Please note if payment is not received in full within 30 days (the facility) may take further action, including but not limited to issuing a Notice of Involuntary Transfer or Discharge.R3's Banking Statements dated 12/5/24 through 6/3/25 document R3 as the primary bank account holder of the account number ending in 7125, and V8 was listed on the account as R3's Guardian. These same Bank Account Statements document 1,354.00 dollars were being deposited monthly into R3's account number ending in 7125 from R3's long-term disability, and 2,191.00 dollars were being deposited monthly into R3's account number ending in 7125 from the Social Security Administration. These Banking Statements document none of R3's 1,354.00 dollars deposited by R3's long term disability have been surrendered to (the facility) and also document multiple charges have been taken out of R3's account for purchases to grocery stores, gas stations, department stores, fast food restaurants, cannabis dispensary's, car dealerships, online retailers, and car dealerships, and multiple payments to credit card accounts were made during this time.R3's Final Abuse Investigation dated 7/7/25 documents, Original (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145774 If continuation sheet Page 17 of 19 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 08/11/2025 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Allegation: Exploitation of funds. On 7/2/25 (V1/Administrator) was notified by (V3/Business Office Manager) and (V5/Regional Financial Coordinator). (V3) and (V5) were gathering financial information for (R3's) Medicaid application. During review of (R3's) financial documents, concerns were noticed that (V8/R3's Guardian) was spending (R3's) private income on personal use items and this was brought to the attention of the facility's Abuse Coordinator (V1). Based on the facts of the investigation the facility has found the following: (V3) and (V5) noted discrepancies on (R3's) banking documents. (V1) contacted local authorities with concern related to potential financial exploitation.R3's Local Police Department Report dated 7/2/25 and signed by V16 (Local Police Officer) documents, On 7/2/25, (V16) was on duty for the (local) police department. I was contacted by (V1/Administrator). (V1) advises that they have a resident (R3) that they believe has fraudulent activity to their bank account. (V1) advised that the resident is (R3). (V1) advises (R3's) brother (V8) is (R3's) stated approved Guardian. (V1) stated that she observed transactions from (R3's) account for oil changes, groceries, and the cannabis dispensary that were made by (V8). (V1) advised (R3's) income comes from SSI (Supplemental Security Income) and Disability and believed the case with be Social Security/Medicaid Fraud.On 8/6/25 at 11:02 AM V6 (Prior Business Office Manager) stated, While I was working at the facility, (V8/R3's Guardian) stopped paying the entire amount for (R3's) bill to the facility. (V8) was the representative payee for (R3's) social security check. I was supposed to do (R3's) Medicaid recertification sometime around March 2025 and noticed (R3) was also getting a disability check from prior employment. (V8) had never been turning the disability check money over. I recall (R3's) disability check being over 1,000.00 dollars per month. I stuck the information in (R3's) file and never got time to deal with (V8) not paying the facility. I figured (V8) was spending (R3's) money. I do not think an investigation was ever done about this.On 8/6/25 at 1:38 PM V8 (R3's Guardian) stated, (R3) has been getting a check from long-term disability for years. The facility has always been aware. In fact, back in March (V6/Prior Business Office Manager) told me to keep it and not worry about it, and the facility would never find out about it. I have been using the check to come and see (R3) and take (R3) out to dinner. V8 also confirmed he has been using R3's long-term care disability checks to buy V8 and his family personal items, to pay taxes, and to pay personal credit card accounts.On 8/7/25 at 10:20 AM V4 (Prior Administrator) stated, I am not aware of an investigation ever being done regarding (V8) exploiting (R3's) funds.On 8/7/25 at 11:30 AM V1 (Administrator) verified an investigation was not done and R3's funds were not protected from V8 until 7/2/25 (approximately four months after V5 was made aware).The Immediate Jeopardy started on 1/29/25 when V5 (Prior Business Office Manager) first suspected V11 (R2's guardian) was exploiting R2's funds and failed to report this to the Administrator, therefore R2 was never protected from further exploitation of funds and in investigation was not done immediately.V1 (Administrator) and V15 (Regional Director of Operations/RDO) were notified of the Immediate Jeopardy on 8/8/25 at 8:10 AM. On 8/9/25 this surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1.On 8/8/25 V3 (Business Office Manager) and V5 (Regional Financial Coordinator) completed a 100 percent audit of all resident trust funds to ensure all residents' accounts were paid up to date and all discrepancies were immediately investigated.2.On 8/8/25 V15 (RDO) educated V1 on the facility's abuse policy regarding protection of the residents from abuse and initiating an investigation immediately.3.On 8/8/25 V1 (Administrator) and V17 (MDS Coordinator) in-serviced all staff regarding the facility's abuse policy and procedures.4. On 8/8/25 V1 held a QA (Quality Assurance) meeting with the Inter-Disciplinary Team to ensure compliance with reporting Abuse and Misappropriation of resident funds.5.On 7/31/25 V1 notified the Social Security Administration and R2's social (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145774 If continuation sheet Page 18 of 19 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 08/11/2025 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 0610 Level of Harm - Immediate jeopardy to resident health or safety security funds were suspended.6.On 8/8/25 V1 notified the Social Security Administration and R3's social security funds were suspended.7. On 8/8/25 V1 contacted The Guardian Life Insurance Company of America to ask for R3's long term disability check to be sent directly to R3 in care of (the facility) due to exploitation of finances by (V8/R3's Guardian).8. On 8/8/25 V3 (Business Office Manager) sent all residents and residents' representative current financial statements by certified mail.9. On 8/8/25 V1 provided all families with a copy of the facility's Abuse Policy by certified mail.Completion Date: 8/8/25. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145774 If continuation sheet Page 19 of 19