Health inspection·March 14, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on record review and interview the facility failed to assess a new resident before transfering resident appropriately for one resident (R27) of 8 residents reviewed for accidents in a total sample of 28. This failure caused R27 to have a near fall that resulted in a broken toe. Findings Include: R27's admission nurse's notes dated 1/10/25 at 2:10 PM document resident is currently a (mechanical lift) for all transfers. On 3/11/25 at 9:00 AM R27 stated they (staff) got me up on a commode with two people and I did fine on the way to the commode but on the way back to the bed my legs did not work, and I stumbled. They used 5 people to get back to the commode and then used a (mechanical lift) to get me back in bed. When I stumbled my right foot got dragged across the floor. It started hurting the next day and then it started to bruise so we got an x-ray. I had a broken toe and had to wear a boot for a while. R27's Nurse's note dated 1/13/25 at 1:155 PM documents this nurse (V8/Registered Nurse) was called to resident's room to assist with a near fall during stand pivot turn transfer from commode to bedside. Upon entering (resident's room) resident was positioned on the edge of her commode with one CNA holding each leg, one CNA standing behind resident holding gait belt and one CNA attempting to hold resident in place near her abdomen. The resident was fearful of falling and with the assist of 5 she was moved back on commode, she leaned forward with a second assist of 5 she was placed on to her commode. Resident was then (mechanically lifted) transferred to her bed. On 3/12/25 at 10:30 AM V8 (Registered Nurse) stated I did not know how (R27) transferred. (V2/Registered Nurse/Director of Nursing) is the one who instructed (staff) to transfer her as a stand pivot two-person transfer. On 3/13/25 at 10:15 AM V2 (RN/DON) confirmed that she instructed staff to transfer R27 via stand pivot and two persons assist. I thought I saw that somewhere. V2 confirmed that R27 did not have any doctor's order regarding her transfer assistance, nor did R27 have any physical therapy or nursing assessment to evaluate how R27 was able to transfer until 3/12/25 which indicated R27 should be transferred via mechanical lift. R27's Nurse's note dated 1/17/25 at 3:35 AM documents When helping resident get her bed moved closer to the door I (V9/Licensed Practical Nurse) noticed a deep purple/ blue discoloration to her right great toe, doctor notified. Page 1 of 12 145886 145886 03/14/2025 Arcadia Care Aledo 304 S.W. 12th Street Aledo, IL 61231

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R27's Nurse's noted dated 1/17/25 at 11:21 AM documents this nurse (V2/Registered Nurse/Director of Nursing) spoke to the resident about discoloration to right great toe and pad of foot. Resident stated that she believed the discoloration was a result of her requiring to be (mechanically) lifted from her commode on 1-13-25 after a near fall attempting to stand from commode. R27's X-Ray report dated 1/18/25 documents exam: right foot, complete 3 views and reason: pain and bruising post injury. R27's x-ray impression: curvilinear oblique sagittal linear lucency through the tibial margin of the base of the proximal phalanx of the great toe, suspicious for an acute nondisplaced fracture in the appropriate clinical setting. Clinical correlation is advised. R27's Nurse's note dated 1/18/25 at 7:57 PM authored by V10 (Registered RN) documents Pain scale 6 of 10 to (right foot) New onset of pain. Medication administered for pain. Deep purple bruising noted. Reddish-purple bruising noted to (right) foot. R27's Nurse's note dated 1/19/25 at 4:00 AM documents this DON (V2 Registered Nurse/Director of Nursing) notified of x-ray results which showed suspicious acute non-displaced fracture of phalanx of the great toe on the right foot. Intervention- new order for ortho shoe support. 145886 Page 2 of 12 145886 03/14/2025 Arcadia Care Aledo 304 S.W. 12th Street Aledo, IL 61231

F 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to assess and identify triggers for one resident (R6) with a Primary Diagnosis of PTSD (Post Traumatic Stress Disorder) of two residents reviewed for Mood and Behavior in the sample of 28. Residents Affected - Few Findings include: Facility Policy/Behavioral Health Services Program dated 2025 documents: Mental Health Rehabilitated Services and behavior management program for Mental Illness and Intellectual Disabilities and other related disorders such as Substance Abuse Disorder and residents with a history of trauma and/or Post Traumatic Stress Disorder. The facility will attempt to identify, to the extent possible, any previous history of mental illness, trauma, abuse, substance use, comorbidities, pattern of behaviors, preferences, interests, daily routines, medication use and effective behavior management interventions in developing an individualized plan of care. The care plan should reflect: Identified or suspected triggers specific to each resident (environmental, emotional, physical, etc.) that may initiate or exacerbate behavioral symptoms. Specific individualized interventions for responding to target behaviors/triggers and expressions of distress. In developing the plan of care, the interdisciplinary team, in collaboration with the resident or family/representative, reviews the results of the assessment and cause identification above in order to develop individualized, person-centered interventions. Current Physician order Summary Report indicates R6 was admitted to the facility on [DATE] and indicates PTSD as R6's Primary Diagnosis. Behavioral Practitioner Note (initial visit) dated 8/22/23 indicates R6 With Generalized Anxiety Disorder with Panic Attacks. Questionable if (R6) has a strong previous traumatic event in her life that may have led to her current psychosis. (R6) reported seeing her daughter raped in the parking lot of the facility and despite her daughter calling and reporting it did not happen, (R6) did not believe her and felt as though her daughter was just sparing her feelings. Note indicates R6 with Chronic Post Traumatic Stress Disorder (new) and Plan: Need to rule out, need to gain trust of (R6) to obtain background stories. Trauma Informed Care assessment dated [DATE] indicates R6 refused to answer the assessment questions on that date. On 3/112/25 at 1:15pm V5, SSD (Social Services Director) stated that there are/were no other PTSD 145886 Page 3 of 12 145886 03/14/2025 Arcadia Care Aledo 304 S.W. 12th Street Aledo, IL 61231

F 0699 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assessments for R6. V5 stated she thought R6's Primary Diagnosis was Dementia but acknowledged attempts should have been made to assess R6 for history of trauma and triggers. Current Care Plan indicates R6 has impaired cognitive function/Dementia or impaired thought processes as evidenced by dementia and requires specialized Dementia unit. Care Plan indicates R6 has social isolation, hallucinations, and delusions. Care Plan indicates R6 has diagnoses of Dementia, PTSD, Psychotic Disorder and (R6's) behaviors are triggered by environmental factors. Care Plan did not identify the 'environmental factors. 145886 Page 4 of 12 145886 03/14/2025 Arcadia Care Aledo 304 S.W. 12th Street Aledo, IL 61231

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide an appropriate indication for use for four residents (R2, R15, R29, R39) receiving psychotropic medications, failed to identify behaviors requiring the use of psychotropic medications and failed to attempt a Gradual Dose Reduction for (R2) of five residents reviewed for unnecessary medications in the sample of 28. Findings include: Facility Policy/Behavioral Health Services Program dated 2025 documents: Review behaviors and interventions implemented during daily or weekly clinical review meetings. Review Care Area triggers for mood, behavior and/or psychotropic medications. The care plan should reflect: Baseline and ongoing details (e.g., frequency, intensity, and duration) of common behavioral expressions (targeted behavioral symptoms) and expected response to interventions. Identified or suspected triggers specific to each resident (environmental, emotional, physical, etc.) that may exacerbate behavioral symptoms. Specific individualized interventions for responding to target behaviors/triggers and expressions of distress. For psychotropic medications include indication/rationale for use, specific target behaviors, monitoring for efficacy and/or adverse consequences and (when applicable) plans for gradual dose reduction if an antipsychotic medication is used. Facility Policy/Psychotropic Medication-Gradual Dosage Reduction dated 10/2024 documents: To ensure that residents are not given psychotropic drugs unless psychotropic drug therapy is necessary to treat a specific or suspected condition as per current standards of practice and are prescribed at the lowest therapeutic dose to treat such conditions. Residents who use psychotropic drugs shall receive gradual dose reductions and behavior interventions, unless clinically contraindicated, in an effort to discontinue or reduce medication. A gradual dose reduction shall be encouraged at least twice yearly unless previous attempts at reduction have been unsuccessful, or reduction is contraindicated. 1. Current Physician Order Summary Report indicates R15 was admitted to the facility on [DATE] and has diagnoses that include Dementia with Agitation and Major Depressive Disorder. Order Report indicates R15 receives Quetiapine (antipsychotic) 100mg (milligram) twice daily for Unspecified Dementia with Agitation (order date 11/8/24). 145886 Page 5 of 12 145886 03/14/2025 Arcadia Care Aledo 304 S.W. 12th Street Aledo, IL 61231

F 0758 Level of Harm - Minimal harm or potential for actual harm Consent for Psychotropic Medications dated 1/1/25 indicates consent was not signed for Quetiapine until 1/1/25. On 3/11/25 and 3/12/25 R15 was seen at various times of the day to be either sitting or walking in the common area of the Memory Care Unit. R15 was easily reassured and redirected. Residents Affected - Some R15's care plan indicates a behavior of wandering into other residents' rooms (dated 12/9/24), potential to be verbally and physically aggressive (dated 12/9/24) and is resistive to care (dated 12/24/24) into other resident rooms. Care plan also indicates R15 is receiving anti-psychotic medications related to Psychotic disorder and Unspecified Dementia with severe agitation (date initiated 3/12/25). Care Plan does not identify behaviors requiring the use of antipsychotic medication. R15's Behavior Monitoring and Interventions Report (3 months) indicates the following behaviors were documented as occurring between March 1 - March 13, 2025: Screaming-not at others x1 Entering other residents' rooms x3 Repetitive motions x1 Insomnia x2 Wandering x1 Screaming at others x1 Hoarding x1 February 2025: Entering other residents' rooms x5 Insomnia x2 Wandering x2 Screaming at others x2 Accusing others x2 Cursing at others x1 Expressing frustration/anger at others x3 Pacing x1 145886 Page 6 of 12 145886 03/14/2025 Arcadia Care Aledo 304 S.W. 12th Street Aledo, IL 61231

F 0758 Agitated x1 Level of Harm - Minimal harm or potential for actual harm Exit Seeking x1. Panic x1. Residents Affected - Some Pushing others x1 Physically aggressive toward others x1 Anxious, restless x2 Public Sexual Acts x1 January 2025: Entering other residents' rooms x6 Wandering x3 Screaming at others x2 Accusing others x4 Cursing at others x5 Expressing frustration/anger at others x4 Agitated x3 Exit Seeking x4. Panic x3. Physically aggressive toward others x1 Anxious, restless x5 Public Sexual Acts x Threatening others x3 Pacing x2 Disruptive sounds x2 2. Current Physician Order Summary Report indicates R29 was admitted to the facility on [DATE] and has diagnoses that include Dementia with Mood and Behavioral Disturbance and Senile Degeneration of the Brain. 145886 Page 7 of 12 145886 03/14/2025 Arcadia Care Aledo 304 S.W. 12th Street Aledo, IL 61231

F 0758 Level of Harm - Minimal harm or potential for actual harm Order Report indicates R29 receives Quetiapine (antipsychotic) 25mg (milligram) twice daily for Senile Degeneration of the Brain (order date 11/7/24). Consent for Psychotropic Medications dated 3/3/25 indicates consent was not signed for Quetiapine until 3/3/25. Residents Affected - Some Psychiatry Note dated 2/3/25 indicates R29 is [AGE] years old and has had no change in behavior and continues to be treated by Hospice. Note indicates R29 was calm and cooperative with interview but disengaged. No indication of audio/visual hallucinations or delusions. Note indicated no medication changes were recommended. On 3/11/25 and 3/12/25 R29 was seen at various times of the day in his bed in his room. Only once seen up in the dining room for lunch On 3/12/25 at 10:20am R29 engaged in a brief conversation stating he was ok but tired a lot. On 3/12/25 at 10:30am V11, CNA (Certified Nurse Assistant) stated sometimes R29 hollers out and sometimes may see things that aren't really there But (29) can really only see out of one of his eyes. V11 stated R29 spends most of his time in bed. Current care plan indicates R29 is/has the potential to be verbally aggressive (dated 2/21/25) and is resistive to care. Care plan also indicates R29 is receiving anti-psychotic medications related to Senile Degeneration of the Brain (dated 3/12/25). Care Plan does not identify behaviors requiring the use of antipsychotic medication. R29's Behavior Monitoring and Interventions Report (3 months) indicates the following behaviors were documented as occurring between March 1 - March 13, 2025: March 1-March 13, 2025: Experiencing something not there x1 Insomnia x2 Refusing care x2 Screaming, not at others x1 Sad, tearful x1 Hitting Kicking others x1 Cursing at others x2 Scratching self x1 145886 Page 8 of 12 145886 03/14/2025 Arcadia Care Aledo 304 S.W. 12th Street Aledo, IL 61231

F 0758 Expressing frustration, anger with others x1 Level of Harm - Minimal harm or potential for actual harm Throwing, smearing food x1 Withdrawn, isolating x1. Residents Affected - Some February 2025: Insomnia x1 Refusing care x1 Screaming at others x1 Disruptive sounds x1 Anxious, restless x1 January 2025: Insomnia x1 Anxious, restless x1 4. R2's Physician Order Sheet dated March 2025 documents R2 was admitted to the facility in 2005 with diagnosis to include but not limited to major depressive disorder, other specified mental disorders due to known physiological condition anxiety, vascular dementia, moderate with mood disorder, bipolar disorder current episode mixed and unspecified psychosis not due to a substance or known physiological condition. R2's Physician Order Sheet dated March 2025 documents that R2 takes the antipsychotic medication Venlafaxine HCl ER 150 mg (milligrams) every day and Aripipazole 10 mg every day for Bipolar disorder. R2's current care plan documents identified behaviors as verbal aggression and refusing cares at times. R2's Behavior Monitoring Task in her electronic medical record did not identify any harmful behaviors occurring for R2 in the past year. R2's Psychiatry Progress Note dated 2/18/25 documents Gradual Dose Reduction (GDR) is clinically contraindicated at this juncture due to attempted dose reduction likely impairing resident's function and causing psychiatric instability by exacerbating an underlying psychiatric disorder. On 3/13/25 at 9:45 AM V2 (Registered Nurse/Director of Nursing) confirmed that there was no documentation of any GDR ever being done on R2 in the past year. V2 stated that R2 does not usually have any behaviors and when she does it is usually refusing cares. She does things on her own schedule, which is fine. We just go back later and ask again. V2 confirmed that R2 had no identified harmful behaviors to monitor for the use of antipsychotics. 145886 Page 9 of 12 145886 03/14/2025 Arcadia Care Aledo 304 S.W. 12th Street Aledo, IL 61231

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure the tops of stationary kitchen equipment, next to food preparation areas, are free of dirt/debris. This failure has the potential to effect all 38 residents residing in the facility. FINDINGS INCLUDE: Centers for Medicare and Medicaid Services [CMS] Form 671 [Long-term Care Facility Application for Medicare and Medicaid], dated 3/12/2025, signed by V1/Administrator, document 38 residents reside in the facility. On 3/11/2025, at 10:25 a.m., during the initial kitchen tour, with V4/Dietary Manager, the tops of the upright refrigerator and upright freezer were covered with dirt and debris. These two pieces, of equipment, are sitting next to the food preparation tables. On 3/11/2025, at 10:25 a.m., V4 confirmed, due to ventilation/air movement, the tops of stationary equipment should have been cleaned. 145886 Page 10 of 12 145886 03/14/2025 Arcadia Care Aledo 304 S.W. 12th Street Aledo, IL 61231

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the lids of trash dumpsters, located outside, are closed/secure to prohibit pests/animals from gaining access to discarded food/trash. This failure has the potential to effect all 38 residents residing in the facility. Residents Affected - Many FINDINGS INCLUDE: Centers for Medicare and Medicaid Services [CMS] Form 671 [Long-term Care Facility Application for Medicare and Medicaid], dated 3/12/2025, signed by V1/Administrator, document 38 residents reside in the facility. On 3/11/2025, at 10:25 a.m., during the initial kitchen tour, with V4/Dietary Manager, the lids of the trash dumpster, located outside, were left open. The large, steel, trash dumpster, is not secured by any walls/access doors. On 3/11/2025, at 10:25 a.m., V4 confirmed, the trash dumpster lids should be kept closed in order to prohibit access by pests/animals. 145886 Page 11 of 12 145886 03/14/2025 Arcadia Care Aledo 304 S.W. 12th Street Aledo, IL 61231

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to use a set standard to determine the presence of an infection. This failure has the potential to affect all 38 residents who currently reside in the facility. Residents Affected - Many Findings Include: The Facility's Antibiotic/Antimicrobial Stewardship Program policy dated 10/24 documents This facility is dedicated to implementing an Antibiotic/Antimicrobial Stewardship program to reduce the unnecessary use of antibiotics. This program helps ensure that our residents get the right antibiotics at the right time for the right duration, and can improve individual patient outcomes, prevent deaths from resistant infections, slow antibiotic resistance, decrease Clostridium Difficile Infections, and reduce healthcare costs. The Facility's Antibiotic/Antimicrobial Stewardship Program policy documents The Medical Director will set standards for antibiotic prescribing practices for all physicians providing care in the facility , review antibiotic use data gathered by tracking and monitoring, and providing feedback and recommendation to ensure that best practices are followed in the medical care of residents in the facility. The Director of Nursing and/or in conjunction with the Infection Control Officer will be responsible for setting the standards for assessing, monitoring and communicating changes in a resident's condition by the nursing staff providing direct care. The Facility's Infection Control Logs for December 2024, January and February 2025 did not indicate any set standards for determine the presence of an infection. On 3/12/25 at 11:00 AM V3 (Licensed Practical Nurse/Infection Preventionist) stated We have not been using any standardized diagnosing tools like McGeers or Loebs. I just took this job and will be implementing that right away. The Facility's Application for Medicare and Medicaid dated 3/12/25 documents 38 residents currently residing in the facility. 145886 Page 12 of 12