Health inspection·February 5, 2025

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to ensure a thorough investigation was conducted following a report of potential mistreatment of a resident (R4) for three residents reviewed for abuse in a sample of four. Residents Affected - Few Findings include: Abuse Prevention and Reporting - Illinois dated 11/28/16 documents, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Abuse is defined as, the willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. If further documents, It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. This policy continues, 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. This policy further documents, Upon learning of the report, the administrator or a designee shall initiate an incident investigation. Investigation Procedures within this policy document, 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 interviewable. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or other documents. Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked, will be interviewed to determine whether any one has witnessed any prior abuse, neglect, exploitation, mistreatment or misappropriation of resident property by the accused individual. A handwritten letter dated 01/26/25 and signed by V8 (Licensed Practical Nurse/LPN) documents, I was standing in the hall by the room tray cart and heard (R4) ask for hot water from (V9 Housekeeping/Laundry) and she stated she made some, (R4) asked why she didn't bring him any and she stated she wasn't going to bring any to him. (R4) then said, 'You f****** b****'. V9 then ran down the hall and said, 'who are you calling a f****** b****. On 02/04/25 at 10:35 V8 reiterated what her handwritten report stated and said that V9 and R4 were yelling back and forth. V8 stated that V9's demeanor toward R4 was sassy. V8 further stated V9 did not threaten R4 but her actions and yelling were inappropriate. V8 confirmed per facility policy, V9 was sent home from work pending report and investigation. On 02/04/25 at 3:16 PM V9 stated she had transferred from being a dietary aide to working in laundry and housekeeping just prior to this incident with R4. On 02/04/25 at 2:36 PM V1 (Administrator) confirmed there was no additional interviews conducted and she just thought V9 was having a bad day. V1's investigation did not include interviews with any dietary staff, laundry or housekeeping staff, other witnesses, or other residents which V9 interacts with. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145811 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 145811 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Peoria Heights 1629 East Gardner Lane Peoria Heights, IL 61616 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure competent nursing care was provided for one of one resident who sustained a fall with a head injury (R1) in a sample of four. Findings include: V3 (Medical Director's) fax dated 02/23/24 documents standing orders for all residents under V3's care which are to be implemented immediately. Residents taking any form of anticoagulant that experience witnessed or unwitnessed trauma to the head requires transport to the emergency room for evaluation. These orders were signed by V2 (Director of Nursing/DON) who was in the role of Assistant Director of Nurses at the time of signing on 02/26/24. R1's January 2025 Physician Order Summary Report documents R1 has diagnoses which include, abnormalities of gait and mobility, lack of coordination, muscle wasting and atrophy and unsteadiness on feet. R1 is prescribed Eliquis 2.5 milligrams twice daily and Aspirin 81 milligrams daily. Section GG of R1's Minimum Data Sheet documents R1 utilizes a walker for ambulation. R1's mobility assessment documents he requires supervision or touching assistance to transfer or walk 10 feet. R1's Brief Interview for Mental Status dated January 3, 2025, documents R1 scored 13, indicating he is cognitively intact. R1's weekly skin checks documented on treatment administration records/TAR for 01/25/25 and 02/01/25 are both marked i indicating intact according to the legend on the TAR. R1's progress note signed by V7 (Licensed Practical Nurse/LPN) dated 01/23/25 at 6:44 AM documents R1 sustained a fall on 01/23/25 while in the dining room. This progress note documents R1 is alert and oriented to time, person, place, and situation and has no new skin concerns or change in condition. R1's progress note signed by V7 (LPN) dated 01/23/25 at 6:57 AM documents R1 had no new injuries noted on assessment and no bruising. R1's progress note for 72-hour charting follow up signed by V7 and dated 01/24/25 at 7:33 AM documents no skin issues. R1's progress note for 72-hour charting follow up signed by V19 (Registered Nurse/RN) and dated 01/24/25 at 7:02 PM documents R1 had no skin issues and no bruising. R1's progress note for 72-hour charting follow up signed by V20 (RN) and dated 01/25/25 at 7:00 AM documents R1 had no skin issues and no bruising. R1's progress note for 72-hour charting follow up signed by V21 (LPN) and dated 01/26/25 at 3:08 AM documents R1 had no new injuries on assessment, no skin issues, and no bruising. R1's progress note for 72-hour charting follow up dated 01/26/25 at 4:12 PM documents R1 had no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145811 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 145811 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Peoria Heights 1629 East Gardner Lane Peoria Heights, IL 61616 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 0726 injuries and no bruising. Level of Harm - Minimal harm or potential for actual harm R1's progress note for 72-hour charting follow up signed by V22 (RN) dated 01/27/25 at 3:42 AM documents R1 had no skin issues and no bruising. Residents Affected - Few R1's progress note signed by V5 (LPN) and dated 01/31/25 at 10:00 AM documents R1 sustained a fall in his bedroom and R1 was alert and oriented to time, person, place, and situation. A follow up assessment post fall dated 01/31/25 at 10:00 AM documents R1 had no skin issues or bruising. R1's 72-hour Occurrence Follow up Charting dated 01/31/25 at 10:00 AM documents R1 has no skin issues and no bruising. This document was signed by V5 (LPN). A Comprehensive Incident Fall assessment dated [DATE] and signed by V7 (LPN) documents R1 fell on [DATE], in the dining room and documented R1 was alert and oriented. V7 also documented R1's fall was witnessed, R1 did not strike head and neurological checks were not indicated. On 01/31/25 at 3:05 PM R1 was sitting on a love seat with a walker in front of him. R1 reported he had recently fallen. R1 stated he fell on this date (01/31/25) in his room but didn't get injured. R1 further stated he fell in the dining room about a week ago before breakfast and hit his head on a chair. R1 then pointed to his left ear and said, This is what I got. (from the fall). R1's left ear appeared bruised with a dark purple bruise covering about 2/3 of his ear starting at the top and extending downward. The front and back of R1's ear had bruising. R1 stated he also had injuries to his left arm from this fall. The top of R1's left forearm had an area which appeared to be an untreated scabbed skin tear which was approximately 3-4 inches long and light brown and yellow faded bruises on the underside of his forearm extending from the wrist to just below the elbow. R1 stated that he became dizzy before falling and that staff helped him up. R1 stated he was not seen by a physician or sent to the emergency department. On 01/31/25 at 3:30 PM V5 (LPN) confirmed R1 had fallen in his room on this date around 10:00 AM. V5 stated she did not document R1's bruised left ear or injuries to R1's left arm because they were not new and happened from a previous fall about a week ago. R1 confirmed she was not able to locate any documentation of these injuries in the computerized charting system between 01/23/25 and the present time. On 02/04/25 at 9:40 AM V7 (LPN) stated that R1 fell in the dining room on 01/23/25 at about 5:45 AM after he lost his balance. V7 stated she was called to the dining room by V6 (Certified Nursing Assistant/CNA). V7 stated R1 did not hit his head per V6 and that R1 was weak on that day. On 02/04/25 at 9:53 AM V4 (R1's Power of Attorney/POA) stated he visited R1 on 01/22/25 and the R1 had no injuries. V4 stated he was notified of R1's 01/23/25 fall at about 4:00 PM on the day of the fall. When V4 visited R1 on 1/25/25 he had a big goose egg on his skull behind his left ear and extensive bruising including his left ear and left and right arms. V4 stated R1 told him these injuries occurred when he fell in the dining room on 01/23/25. On 02/4/25 at 2:12 PM V2 (Director of Nursing/DON) stated R1 did not have neurological checks completed after his 01/23/25 fall because it was documented that he did not hit his head which was inaccurate. V2 stated neurological checks should have been completed and documented. V2 also confirmed R1's bruises to his left ear and left arm as well as the skin tear to his left arm were not documented between 01/23/25 and 01/31/25 until brought to her attention on 01/31/25 at which time a skin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145811 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 145811 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Peoria Heights 1629 East Gardner Lane Peoria Heights, IL 61616 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 0726 assessment was completed and orders for treatment were obtained. Level of Harm - Minimal harm or potential for actual harm On 02/04/25 at 3:20 PM V6 (CNA) stated she was coming back from break before breakfast. V6 stated as she was walking down the hall, she heard a thud and turned around. V6 stated she yelled down the hallway for V7 to help, assisted R1 up, asked if he was okay and left him in the care of V7. V6 again stated she did not see R1 fall, she heard it. V6 stated she didn't know if R1 hit his head or not. Residents Affected - Few On 02/05/25 at 11:16 AM V3 (Medical Director) stated it would be his expectation that the facility would have any resident who is on any anticoagulant sent to the emergency department for evaluation if they had any type of head injury rather it was immediately. V3 confirmed he does consider Eliquis to be an anticoagulant. V3 stated he would consider a bruise on R1's ear resulted from a head injury, especially given R1's recent fall. V3 stated R1 should have had neurological checks performed and documented. A facility investigation titled Final Abuse Investigation Report dated 02/10/25 involving R1 documents, Conclusion and action taken: 1. Based on the results of the investigation the facility has found the following: a. It is believed (R1) hit head/left ear during a fall noted to have occurred on 1/23/25 in the dining room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145811 If continuation sheet Page 5 of 5