Inspection·November 8, 2023

F 0550 2. R63's Face Sheet, undated, documents R63 was admitted to the facility on [DATE]. Level of Harm - Actual harm R63's Electronic Medical Record, documents R63's diagnosis include Neurocognitive disorder with Lewy Bodies,, Transient Cerebral Ischemic Attack (TIA),and Dementia. Residents Affected - Few R63's Care Plan, dated 8/15/23, documents R63 has an ADL (activities of daily living) self-care performance deficit r/t (related to) Dementia, Hemiplegia. Interventions: Bathing/Showering: The resident requires assist of (#) staff member with bathing/showering. Bed Mobility: The resident requires assist of (#) staff member with bed mobility. The resident uses side rails to maximize independence with turning and repositioning in bed, Dressing: The resident requires (#) assist for dressing, Personal Hygiene: The resident requires (#) assist with personal hygiene and oral care. Toilet Use: The resident requires (#) assist with toileting, Transfer: The resident requires (specify equipment: gait belt, sit to stand, full mechanical lift) and (#) assist to transfer between surfaces. R63's Minimum Data Set, dated [DATE], documents R63 has a moderate cognitive impairment and requires dependence on staff for shower/bathing, substantial/maximal assistance from staff for dressing, personal hygiene, sit to stand, chair/bed to chair transfer, toilet transfer, and tub/shower transfer. R63 MDS documents R63 requires supervision for toileting and is always continent of bowel and bladder. On 11/5/23 at 9:35 AM, R63, lying in bed, with V4, Licensed Practical Nurse (LPN), providing skin care to his legs. R63 stated that he had some loose stool and wanting to use restroom, so V4 told him she would be back after he was done and did not offer assistance to get R63 to the restroom. R63 was seen getting out of his bed to his wheelchair with some difficulty, and wheeled himself to the restroom, stood and pivoted, and then put himself on the toilet. R63 asked to have the restroom door closed, and the door was closed. There were feces seen in his incontinence brief, and his pants appeared wet. R63's bed linen had feces on the incontinence pad once R63 got up. V4 entered the restroom to assist R63 and left the restroom door open, which made R63 visible to two other residents in the room (R70, and R10). On 11/8/23 at 8:30 AM, R70, R63's Roommate, stated, via dry erase board, Don't like when someone leaves restroom door open. On 11/8/23 at 8:35 AM, R63 stated I would rather have the door to the restroom closed while I am in there. It's supposed to be closed. On 11/8/23 at 8:38 AM, V13, CNA, stated Of course I would close the restroom door when a resident is in there. I don't go with the restroom door open, so why should they. On 11/8/23 at 9:35 AM, R10, R63's roommate, stated No, I don't like it when the restroom door is open, and someone is in there using it. It should be closed so we don't see them. On 11/8/23 at 12:37 V2, Director of Nurses (DON), stated I would expect staff to maintain the resident's privacy at all times, especially while using the restroom and/or with resident care. The facility's Resident Rights Policy, dated 9/2023, documents To promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems, and cognition limits) in the exercise of these rights. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability. Notice of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145928 If continuation sheet Page 2 of 26 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 145928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Jacksonville 1021 North Church Street Jacksonville, IL 62650 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 0550 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete rights will be provided upon admission to the facility. These rights include the resident's right to: Exercise his or her rights, and Privacy and confidentiality. Exercising rights means that residents have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules, as long as those rules do not violate a regulatory requirement. Facility practices designed to support and encourage resident participation in meeting care planning goals as documented in the resident assessment and care plan are not interference or coercion. Event ID: Facility ID: 145928 If continuation sheet Page 3 of 26 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 145928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Jacksonville 1021 North Church Street Jacksonville, IL 62650 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Potential for minimal harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. 4. On 11/7/2023 at 12:04 PM V18 Certified Nursing Assistant (CNA) stated the breakfast trays are still in resident rooms. Residents Affected - Some On 11/07/2023 at 12:05 PM R38's breakfast tray remains in room untouched. The facility Illinois long term care ombudsman program Resident's Rights for people in long-term care facilities, undated, documents under rights to safety documents your facility must be safe, clean, comfortable, and homelike. Based on observation, interview, and record review, the facility failed to remove breakfast meals from the rooms timely for 4 of 4 residents (R17, R38, R68, R279) reviewed for room cleanliness and homelike environment in the sample of 46. Findings include: 1. On 11/7/23 at 12:04 PM, R279's room had the breakfast tray on his bedside table. 2. On 11/7/23 at 12:05 PM, R68's room had the breakfast tray on his bedside table. 3. On 11/7/23 at 12:05 PM, R17's room had the breakfast tray on his bedside table. The facility document mealtimes, dated 11/08/23, documents breakfast is served at 7:30 AM and lunch is served at 11:30 AM. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145928 If continuation sheet Page 4 of 26 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 145928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Jacksonville 1021 North Church Street Jacksonville, IL 62650 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent resident-to-resident physical abuse for 4 of 24 residents (R2, R26, R45, R179) reviewed for abuse in the sample of 46. Findings include: R2's admission Profile, print date of 11/7/23, documents R2 was admitted on [DATE] and has diagnoses of Major Depression and Dementia. R2's Minimum Data Set (MDS), dated [DATE], documents that R2 is severely cognitively impaired and is independent with ambulation. R2's Care Plan, dated 4/18/23, documents, The resident is / has potential to be physically aggressive r/t (related to) Dementia, History of harm to others. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 02/03/2022 Assess and address for contributing sensory deficits. Date Initiated: 02/03/2022. Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. Date Initiated: 02/03/2022. R2's Care Plan, dated 1/25/23, documents, Resident is at a high risk for abuse/neglect as noted from Abuse screening r/t dementia. Interventions: Evaluate resident's responses to interventions Date Initiated: 05/02/2022. Law-enforcement and legal support as needed Date Initiated: 05/02/2022 Medical/Nursing assessment quarterly and prn (as needed) Date Initiated: 05/02/2022 Provide safe and secure environment Date Initiated: 05/02/2022. 1. The facility Final Abuse Investigation Report, dated 8/16/23, documents that on 8/10/23 R2 and R26 were involved in a resident-to-resident physical altercation. Conclusion: Both residents who reported the instance witnesses (R2) make physical contact with R26 after R26 gave the middle finger to R2. There were no injuries noted. 2. The facility Final Abuse Investigation Report, dated 7/28/23, documents that on 7/22/23 R2 and R26 were involved in a resident-to-resident physical altercation. Conclusion: R2 made physical contact with R26 after R26 stuck his tongue out at R2. There were no injuries noted. R26's admission Profile, print date of 11/8/23, documents that R26 was admitted on [DATE] and has diagnosis of Anxiety and Hemiplegia affecting his left side. R26's MDS, dated [DATE], documents that R26 is severely cognitively impaired. 3. The facility Final Abuse Investigation Report, dated 3/13/23, documents that on 3/6/23 R2 and R179 were involved in a resident-to-resident physical altercation. Conclusion: Based on the comprehensive investigation, the facility has determined: R2 and R179 were in a shared room. Loud voices were heard from R2 and R179. No staff witnessed the interaction between R2 and R179. R179 voices R2 made physical contact with him. There were no injuries noted. R179's admission Record, print date of 11/18/2019, documents that R179 was admitted on [DATE] and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145928 If continuation sheet Page 5 of 26 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 145928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Jacksonville 1021 North Church Street Jacksonville, IL 62650 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 0600 has a diagnosis of delusional disorders. Level of Harm - Minimal harm or potential for actual harm R179's MDS, dated [DATE], documents that R179 is severely cognitively impaired. Residents Affected - Some 4. The facility Final Abuse Investigation Report, dated 1/25/23, documents that on 1/18/23 R2 and R45 were involved in a resident-to-resident physical altercation. Summary: V19 Certified Nurse's Aide (CNA), was interviewed, and voices she witnessed R2 put his hands on R45 as R45 was walking past him in the hallway. V19 reports she heard R2 mumbling about not getting enough sleep and saw him lunge at R45 making contact with him. R45's admission Record, print date of 11/8/23, documents that R45 was admitted on [DATE] and has a diagnosis of Dementia. R45's MDS, dated [DATE], documents that R45 is severely cognitively impaired. On 11/07/23 at 3:55 PM, V1, Administrator, stated, We have changed his (R2) room and his dining room assignment. We know who he does not get along with, so we try to keep them apart. I have tried to find him other placement, but no one will take him because of his abuse. The Abuse policy, dated 4/23, documents, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145928 If continuation sheet Page 6 of 26 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 145928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Jacksonville 1021 North Church Street Jacksonville, IL 62650 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 11/07/2023 at 12:05 PM R38's breakfast tray remains in room untouched. R38's tray had 1 pancake, bowl of super cereal, 1 slice bacon, unopened carton of milk. Residents Affected - Some On 11/7/2023 at 12:44 PM R38's tray was delivered to her room. The tray had 2 Swedish meatballs, broccoli, power potatoes, fruit cocktail with cool whip on top and a mighty shake. On 11/07/23 at 2:09 PM R38's tray was on back on the cart. R38 did not eat Swedish meatball, fruit cocktail, or broccoli and the mighty shake on tray has not been opened. On 11/7/23, during the lunch meal, staff did not cue or help R38 to eat. R38's MDS, dated [DATE], documents that R38 has impaired cognition with a Brief Interview of Mental Status (BIMS) of 10 and requires supervision and set up for eating. R38's care plan, dated 6/29/2023, documents that R38 has an ADL self-care performance deficit related to diagnosis of schizoaffective diagnosis. R38's care plan documents the intervention; R38 is able to feed self with supervision as needed. R38's care plan documents R38 has a self-care deficit as evidenced by resident displays difficulty with eating. R38 has had a 10 percent decrease in her weight. R38's care plan documents that R38 will feed self-100% of each meal with minimal spilling with supervision and cueing assist of 1 staff member. R38's care plan documents the following interventions: encourage resident to feed self during meals, provide assistance during meals as needed. R38's care plan documents that R38 is at increased nutritional risk related to significant weight loss. R38's Nutritional Assessment, dated 9/15/2023, documents Body Mass Index (BMI): 13.7 (underweight). On 11/8/2023 at 11:48 AM, V1, Administrator, stated the facility does not have a policy for assistance with eating. V1 did state she would expect the facility to follow best practice and provide residents assistance with eating. 4. On 11/5/23 at 12:48 PM, V27, Certified Nurse Aide, delivered R69's noon meal tray to her room. The meal was a pork chop topped with vegetables, green beans, and stuffing. V27 told R69 where each food was located on the plate. V27 did not cut up R69's pork chop or hand R69 her fork. While V27 was standing at the bedside opening R69's milk, R69 grabbed the pork chop with both hands and began to eat it. V27 did not offer to cut up the pork chop or encourage R69 to use a fork. R69 ate her meal by using her hands. R69's admission Profile, print date of 11/7/23, documents that R69 was admitted on [DATE] and has a diagnosis of being blind in both eyes. R69's MDS, dated [DATE], documents that R69 requires supervision or touching assistance while eating. R69's Care Plan, dated 11/6/23, documents that R69 requires supervision assistance with eating. On 11/7/23 at 4:00 PM, V2, Director of Nursing, stated that V27 should have offered to cut up her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145928 If continuation sheet Page 7 of 26 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 145928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Jacksonville 1021 North Church Street Jacksonville, IL 62650 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 0677 food or encourage her to use her fork. Level of Harm - Minimal harm or potential for actual harm 3. R64's Care Plan, dated 11/2/2023, documents R64 has an ADL self-care performance deficit. It continues PERSONAL HYGIENE: The resident requires supervision assist with personal hygiene and oral care. Residents Affected - Some On 11/5/2023 at 9:20 AM R64 was sitting in his room in wheelchair. R64 had a scruffy beard. On 11/5/2023 from 9:38 AM to 9:44 AM R64 was sitting in hallway with a hair brush brushing beard. On 11/5/2023 at 9:50 AM R64 stated that he wanted to be shaved. R64 stated that he is itching bad. R64 stated that he was not brushing his beard. R64 stated that he is using the brush to scratch his face. On 11/6/2023 at 9:15 AM R64 was sitting in doorway with brush. R64 stated that he has asked for help with shaving and have not received it yet. R64 stated that he is still itching and continues to use the brush to scratch his face. R64 stated that when his facial hair grows it itches his face. R64 stated it that it is an unrelenting itch. R64 stated that it won't stop until he gets shaved. On 11/6/2023 at 12:47 PM R64 continues to have facial hair. Based on observation, interview, and record review, the facility failed to assist residents with incontinent care, bathing, grooming, hygiene, change of clothing, and eating assistance for residents who require assistance for 4 of 23 residents (R38, R63, R64, R69) reviewed for assistance with Activities of Daily Living (ADL) care in the sample of 46. The findings include: 1. R63's Face Sheet, undated, documents R63 was admitted to the facility on [DATE]. R63's Electronic Medical Record, documents R63's diagnoses include Neurocognitive disorder with Lewy Bodies, Chronic Obstructive Pulmonary Disease (COPD), Transient Cerebral Ischemic Attack (TIA), Atherosclerosis heart disease (ASHD), Cellulitis, Dementia, and Heart Failure. R63's Care Plan, dated 8/15/23, documents R63 has an ADL self-care performance deficit r/t (related to) Dementia, Hemiplegia. Interventions: Bathing/Showering: The resident requires assist of (#) staff member with bathing/showering, Bed Mobility: The resident requires assist of (#) staff member with bed mobility, the resident uses side rails to maximize independence with turning and repositioning in bed, Dressing: The resident requires (#) assist for dressing, Personal Hygiene: The resident requires (#) assist with personal hygiene and oral care. Toilet Use: The resident requires (#) assist with toileting, Transfer: The resident requires (specify equipment: gait belt, sit to stand, full mechanical lift) and (#) assist to transfer between surfaces. R63's Minimum Data Set (MDS), dated [DATE], documents R63 has a moderate cognitive impairment and requires dependence on staff for shower/bathing, substantial/maximal assistance from staff for dressing, personal hygiene, sit to stand, chair/bed to chair transfer, toilet transfer, and tub/shower transfer. R63 requires supervision for toileting and is always continent of bowel and bladder. On 11/5/23 at 9:35 AM, R63 was lying in bed with his wheelchair sitting next to his bed. V4, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145928 If continuation sheet Page 8 of 26 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 145928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Jacksonville 1021 North Church Street Jacksonville, IL 62650 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Licensed Practical Nurse (LPN), entered to provide wound care to R63. R63 stated that he had some loose stool and wanting to use restroom, and V4 told him she would be back after he was done. V4 did not help R63. R63 got out of his bed to his wheelchair with some difficulty, wheeled himself to the restroom, stood up and pivoted, and put himself on toilet. There was feces seen in his incontinence brief, with his pants appearing to be wet, and his bed linen had feces on the pad. Once R63 stood up, V4 entered to assist R63 and left the restroom door open with two other residents (R10 and R70) in the room with R63 visible to them. V4 put a new brief on R63's legs, once cleaned up, pulled up same pants. R63 said his wheelchair cushion was dirty, so V4 wiped it off. R63 stated that V4 told him that his pants were not wet, however, upon standing, the wheelchair cushion had a wet spot in the center of the cushion. R63 felt his pants and stated yes, they were wet. On 11/5/23 at 10:56 AM, R63 was seen back in his bed and remains in same clothing, including his pants that were previously wet/soiled. On 11/6/23 at 8:45 AM, R63 was seen sitting in the south dining room in his wheelchair with the same soiled clothes on as he had on the day prior (11/5/23). When asked about his pants, R63 stated the nurse told him his pants was dry. R63 stated that he got himself out of bed this morning to his wheelchair and has been in the dining room since 8:00 AM this morning, waiting for breakfast. R63 stated that he has not changed his clothes yet, and that he slept in the same clothes he had on yesterday. On 11/6/23 at 11:50 AM, R63 was lying in bed with the same soiled clothing on that he had on the day prior (11/5/23). On 11/6/23 at 3:10 PM, R63 stated I would have liked to change my clothes, but I can't do it by myself. On 11/7/23 at 8:30 AM, R63 was seen sitting in his wheelchair in the dining room with the same soiled clothes he has had on since Sunday (11/5/23). R63's pants and shirt appeared soiled, with flakes of dry skin and food particles. R63 stated that he slept with them on again and got up this morning to his wheelchair, and there was no one to help him change his clothes before breakfast, and that he can't do it himself. On 11/8/23 at 12:35 PM, V 2, Director of Nursing (DON), stated I would expect staff to be performing ADL care to residents as needed and/or scheduled, including showering, shaving, and changing clothes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145928 If continuation sheet Page 9 of 26 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 145928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Jacksonville 1021 North Church Street Jacksonville, IL 62650 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. On 11/5/2023 at 9:35 AM V5 entered R17's room to provide incontinent care. V5 poured no rinse peri wash in one basin adds water and washcloths, fills second basin with water and puts washcloths in the water. V5 cleansed hand with hand sanitizer on the wall, donned gloves, and places clean plastic bags on the floor. R17 was on left side facing the wall, bed pan under resident, liquid brown stool on buttocks. V5 with gloved hands takes washcloth cleans buttocks with washcloths with no wash peri wash, continues the process until R17 is clean. V5 did not dry R17 and did not cleanse R17's posterior thighs. R17 then rolled onto back. V5 took clean washcloth from basin and cleansed right side of groin. V5, then cleansed left side of groin. V5 then cleansed penis and did pull back foreskin. V5 did not lift scrotum and cleanse scrotum or under scrotum. V5 did not dry R17. V5 did not cleans inner thighs. R17's Care Plan, dated 10/23/2023, documents that R17 has an Activity of Daily Living (ADL) self-care performance deficit related to decreased mobility. R17's care plan documents that R17 is incontinent of bowel and bladder. R17's care plan documents R17 requires extensive to dependent assist by 1-2 staff for toileting. R17's MDS, dated [DATE], documents R17 requires extensive assistance and one-person physical assistance for toileting. R17's MDS document that R17 is not on a toileting program and R17is frequently incontinent of stool. The facility policy Incontinence Care, dated last revised 04/2021, documents to assist resident to / lie on bank and expose perineal area, may drape legs with bath blanket or sheet to provide privacy. The policy documents in the male resident wash the penis first, turn the resident to the side, the wash perineal area. the policy documents soap one cloth at a time to wash genitalia using a clean part of the cloth for each swipe/. Rinse e. Cleanse /rinse inner/upper thigh areas to remove urine moisture, gently pat area dry with a towel from anterior to posterior. Wash and rinse peri-anal area and pat dry. change gloves and perform hand hygiene. On 11/7/2023 at 2:36PM V2, DON, stated she would expect staff to provide complete incontinent care which would include cleansing all areas including labia, and genitalia on females and scrotum on men. V2 stated residents are to be dried after incontinent care. 4. R18's admission Profile, dated 11/7/23, documents that R18 was admitted on [DATE] and has diagnoses of Multiple Sclerosis, Dysphasia, and Muscular Dystrophy. R18's MDS, dated [DATE], documents that R18 is severely cognitively impaired, dependent on staff for toileting and is always incontinent of bowel and bladder. On 11/6/23 at 9:42 AM, V20, CNA, stated, (R18) was up when I got here this morning. I changed her at 6:00 AM when I first got here. I haven't changed her since. On 11/6/23 at 10:18 AM, R18's room was entered. R18 is in her geriatric reclining chair. R18 was lying in the chair with her pants pulled down to her knees. V20, CNA, and V21, Activities/CNA, were putting on a new incontinent brief. V21 was holding the soiled incontinent brief. The incontinent brief was fully saturated with urine. V20 and V21 both stated that they had performed the incontinent care while R18 was in the geriatric reclining chair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145928 If continuation sheet Page 10 of 26 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 145928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Jacksonville 1021 North Church Street Jacksonville, IL 62650 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 11/7/23 at 11:15 AM, V2, Director of Nurses, (DON) stated that incontinent care should not be done while in the geriatric reclining chair. V2 stated, I would imagine there is not enough room to do it correctly. V2 stated that residents should be checked for incontinence every 2 hours and changed if needed. Based on observation, interview and record review the facility failed to provide complete and timely incontinent care for 5 of 5 residents (R4, R17, R18, R33, R63) reviewed for incontinent care in a sample of 46. Findings include: 1. R33's Care Plan, dated 10/22/23, documents that R33 has bladder and bowel incontinence related to (r/t) Cognitive Impairment. It continues, Toilet before and after meals, upon rising in the AM and before bed at night. R33's Minimum Data Set (MDS), dated [DATE], documents that R33 is cognitively impaired, always incontinent of bowel and bladder, and totally dependent on 2 staff for toileting. On 11/6/2023 at 9:14 AM V5, Certified Nurse Aide (CNA), and V11, CNA, performed incontinent care. V5 and V11 assisted R33 in the bed using a full body lift. V5 and V11 then removed R33's pants revealing a soiled incontinent brief. V5 and V11 opened R33's brief and rolled the incontinent brief between R33's legs. V5 then, using a wet towel, wiped R33's groin and inner labia. V5 and V11 rolled R33 onto her right side and cleansed soft stool from R33's anal area, left buttock and partial buttock. V11 placed a clean incontinent brief behind R33. V5 and V11 then rolled R33 onto her left side and pulled the clean brief under R33. V11 and V5 then rolled R33 on her back and fastened the incontinent brief. V5 and V11 did not cleanse R33's entire right buttock, inner thighs, pubic area, or outer labia. 2. R4's Care Plan, dated 10/24/23, documents R4 has bowel and bladder incontinence r/t Inability to communicate needs. Interventions: Apply barrier cream after each incontinent episode, clean peri-area with each incontinence episode, (5/3/18) CNA to have Nurse on duty to turn off and unhook feeding before HOB (Head of Bed) is lowered to perform peri-care. It continues R4 has a self-care deficits r/t impaired cognitive, decreased mobility, incontinence, and SOB (shortness of breath). R4 does not alert you of his needs. R4's MDS, dated [DATE], documents R4 has a severe cognitive impairment and is dependent on staff for all Activities of Daily Living (ADLs). R4 is always incontinent of both bowel and bladder. On 11/6/23 at 9:35 AM, R4 was lying in bed, with his sheet off, and his incontinence brief unfastened. V9, CNA, entered with a handful of washcloths, a plastic bag, and a new incontinence brief to clean R4. V8, CNA, entered to assist V9. V9 went into the restroom and wet the washcloths, donned gloves, then turned R4 to his side while V8 wiped once to R4's bilateral buttocks, bilateral groins, pubic area, and his penis all while using the same washcloth and did not dry R4. V8 then placed a clean incontinent brief on the front of R4 and tucked it between his legs. R4 was then rolled to his other side while V8 wiped once to R4's buttocks and anal area and did not dry R4. V8 and V9 then fastened the incontinence brief around R4. 3. R63's Electronic Medical Record, documents R63's diagnosis include Neurocognitive disorder with Lewy Bodies, Chronic Obstructive Pulmonary Disease (COPD), Type 2 Diabetes Mellitus (DM), Transient (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145928 If continuation sheet Page 11 of 26 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 145928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Jacksonville 1021 North Church Street Jacksonville, IL 62650 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Cerebral Ischemic Attack (TIA), Atherosclerosis heart disease (ASHD), Cellulitis, Dementia, and Heart Failure. R63's Care Plan, dated 8/15/23, documents R63 has an ADL self-care performance deficit r/t Dementia, Hemiplegia. Interventions: Bathing/Showering: The resident requires assist of (#) staff member with bathing/showering, Bed Mobility: The resident requires assist of (#) staff member with bed mobility. The resident uses side rails to maximize independence with turning and repositioning in bed, Dressing: The resident requires (#) assist for dressing, Personal Hygiene: The resident requires (#) assist with personal hygiene and oral care. Toilet Use: The resident requires (#) assist with toileting, Transfer: The resident requires (specify equipment: gait belt, sit to stand, full mechanical lift) and (#) assist to transfer between surfaces. R63's MDS, dated [DATE], documents R63 has a moderate cognitive impairment and requires dependence on staff for shower/bathing, substantial/maximal assistance from staff for dressing, personal hygiene, sit to stand, chair/bed to chair transfer, toilet transfer, and tub/shower transfer. R63 MDS documents R63 requires supervision for toileting and is always continent of bowel and bladder. On 11/5/23 at 9:35 AM, R63 was lying in bed, with V4, Licensed Practical Nurse (LPN), providing skin care to his legs. R63 stated that he had some loose stool and wanting to use restroom, so V4 told him she would be back after he was done and did not help get R63 to the restroom. R63 was seen getting out of his bed to his wheelchair with some difficulty, and wheeled himself to the restroom, stood and pivoted and then put himself on the toilet. R63 asked to have the restroom door closed and was closed. There were feces seen in his incontinence brief, and his pants appeared wet. R63's bed linen had feces on the incontinence pad once R63 got up. V4 entered the restroom to assist R63 and left the restroom door open, which made R63 visible to two other residents in the room. V4 cleansed up R63's buttocks/anal area and put a new brief on R63's legs and pulled up R63's same wet pants. R63 stated that his wheelchair cushion was soiled, so V4 wiped off the cushion, and with gloves on, checked R63's pants and stated they were not wet. After V4 left the room, R63 stood up to check his pants and his wheelchair cushion had wet spot in the center of the cushion, where his buttocks/anal area would be. R63 then felt his pants and stated yes, they are wet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145928 If continuation sheet Page 12 of 26 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 145928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Jacksonville 1021 North Church Street Jacksonville, IL 62650 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 11/6/2023 at 11:33 AM V8, CNA was in R22's room repositioning R22. R22's head of bed elevated was elevated but R22 is lying almost flat in bed after V8 repositioned R22. R22's tube feeding was infusing at 75 cc (cubic centimeters) /hr (hour) per pump. R22's current PO documents Jevity 1.5 at 75 cc/hr with 250 cc fluid flush q 4 hours. R22's Care Plan dated 10/18/2023 documents R22 is at nutritional risk related to hypertension, dysphagia, malnutrition, and underweight tube feeding related to history of Cerebral Vascular Accident (CVA). R2's care plan documents the following interventions: the resident needs the Head Of Bed elevated 30 degrees during and thirty minutes after tube feeding. The Facility's Gastrostomy Tube - Feeding and Care Policy, dated 11/2023, documents To provide nutrients, fluids, and medications, as per physician orders, to residents requiring feeding through an artificial opening into the stomach. Procedure: 1. Licensed nurse will review physician's order for type of formula, concentration, rate of flow, and method of administration. 2. Enteral formula should be at room temperature. Check expiration date on feeding container. 3. Label container with resident's name, flow rate, date, and time. 4. Perform hand hygiene and apply gloves. 5. Position resident on his/her back with head elevated to minimal 30 degrees and preferable 45 degrees. 6. Expose gastrostomy tube, placing basin under tubing and remove plug. If plug is not attached to g-tube, place plug on a paper towel. 7. Observe for tube placement before: a) starting feeding, b) water flushes and hydration, and c) medication administration. 8. Observe for tube placement when resident is observed with symptoms of nausea, vomiting, and/or abdominal distention. 3. On 11/6/23 at 920 AM, V15, RN entered R18's room. V15 uncapped R18's G-tube and inserted the bolus syringe into the G-tube and administered 30 ml of water, 5 separate medications diluted in 5 ml of water each followed by 10 ml of water after each medication and then 170 ml of Jevity 1.5 followed by a 60 ml water flush. V15 did not check for residual before administering medications through the G-tube. On 11/7/23 at 11:15 AM, V2, Director of Nurses, (DON), stated that nurses should check for residual before using the G-tube for medications or feeding. R18's admission Profile, dated 11/7/23, documents that R18 was admitted on [DATE] and has diagnoses of Multiple Sclerosis, Dysphasia, and Muscular Dystrophy. R18's November 2023 Physician Orders documents, every 4 hours BOLUS JEVITY 1.5 170 ML Q 4 HOURS. every 4 hours Flush enteral tube q 4 hours with 60mls before and after each feeding. Based on observation, interview, and record review, provide gastrostomy tube (g-tube) feedings according to the facility policy, including correct resident positioning, and checking for placement and/or residual prior to administering tube feedings to the resident for 4 of 4 residents (R4, R18, R22, R70) reviewed for gastrostomy tube feedings in the sample of 46. The findings include: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145928 If continuation sheet Page 13 of 26 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 145928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Jacksonville 1021 North Church Street Jacksonville, IL 62650 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 0693 1. R4's Face Sheet, undated, documents R4 was originally admitted to the facility on [DATE]. Level of Harm - Minimal harm or potential for actual harm R4's Electronic Medical Record, documents R4's diagnosis (Dx) include Encephalopathy, chronic respiratory failure, chronic obstructive pulmonary disease (COPD), Dementia, Benign neoplasm of the brain, Traumatic brain injury, Dysphagia, Major depressive disorder, Contractures, COVID-19, Generalized anxiety disorder, Hyperlipidemia, Post traumatic seizures, Hypothyroidism, Hypertrophic pyloric stenosis, Anemia, Fibromyalgia, and Gastrostomy-Gastric Tube (G-Tube). Residents Affected - Some R4's Care Plan, dated 10/24/23, documents R4 is on a NPO (nothing by mouth) diet. Receives nutrition through gastrostomy tube feeding. Interventions: Diet as ordered NPO, enteral feedings as ordered by MD (medical doctor) and hold for Dilantin administration. It continues R4 has hx (history) of placing self on floor, will pull out tube feeding. It continues R4 requires tube feeding via g-tube, is NPO and takes his feedings in his room. Interventions: Check for tube placement and gastric contents/residual volume per facility protocol and record, dependent with tube feeding and water flushes. See MD orders for current feeding orders, (R4) needs the HOB (Head of Bed) elevated 45 degrees during and thirty minutes after tube feed, provide local care to G-Tube site as ordered and monitor for s/sx (signs/symptoms) of infection, (5/3/18) CNA (Certified Nursing Assistant) to have Nurse on duty to turn off and unhook feeding before HOB (head of bed) is lowered to perform peri-care. R4's Minimum Data Set (MDS), dated [DATE], documents R4 has a severe cognitive impairment and is dependent on staff for all Activities of Daily Living (ADLs), including eating/feeding. On 11/6/23 at 8:30 AM, R4 was lying in bed with no clothes on and an incontinence brief on. R4's gastric tube was not secured, and the hub appears to be about two inches out from the hole, with no dressing seen on. V15, Registered Nurse (RN), attached the new tubing with Jevity tube feeding, primed the tube, and then attached the tubing to R4's gastric-tube V15 then turned the pump on at 70 ML (milliliter)/HR (hour) without checking for residual of the tube first. On 11/6/23 at 9:35 AM, R4 lying in bed, when V8, Certified Nurse Aide, (CNA), and V9, CNA, entered to perform peri-care on R4. During care, V9 had turned R4 on his right side while V8 was performing care. R4 was then turned to his left side to finish care. V8 lowered R4's HOB, then raised R4's feet to pull him up in bed, and as she was doing this, she noticed that the tube feeding pump was still on, so V8 reached over and touched the pump and stated that she had paused the pump when she first entered the room and was just turning it back on. V8 was seen walking into the room and at no time did she approach the pump. R4's tube feeding was continuously running at 70 ML/HR during care. On 11/6/23 at 9:56 AM, V10, Registered Nurse (RN) stated The Nurses are the only ones allowed to turn the tube feeding on or off or stop or pause it. The CNAs should not be doing that, they should get a nurse to do it. On 11/6/23 at 10:35 AM, V9 stated I didn't see (V8) turn the pump off or on. I was focused on (R4). I would not touch the pump because I am not licensed. I would go get a nurse. R4's Physician Order (PO), dated 4/16/23, documents Check residual, hold if over 100 ML (milliliters) and notify physician. Every shift for g-tube. R4's PO, dated 6/8/23, documents Cleanse G-tube insertion site and apply drain sponge daily. Every night shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145928 If continuation sheet Page 14 of 26 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 145928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Jacksonville 1021 North Church Street Jacksonville, IL 62650 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 0693 Level of Harm - Minimal harm or potential for actual harm R4's PO, dated 7/31/23, documents Enteral Feed. one time a day Jevity 1.5 at 70 X 20 HRS (hours) to TV (total volume) 1400 ML. R4's PO, dated 8/14/23, documents Enteral Feed. Every shift Flush enteral tube Q (every) 4 hours with 200 MLs water. Residents Affected - Some 2. R70's Electronic Medical Record, documents R70's diagnoses include: Cerebral infarction, aphasia, metabolic encephalopathy, hyperlipidemia, hypertension (HTN), major depressive disorder, COPD, history of falls, suicidal ideations, alcohol abuse, and gastrostomy/Gastric-Tube (g-tube). R70's Care Plan, dated 10/23/23, documents R70 is at increased nutritional risk r/t (related to) DX (diagnosis): Depressive, COPD, Hypertension, NPO with G-Tube, Refuses g-tube feedings at times. Interventions: Encourage R70 to accept tube feedings give time in between an retry when refuses, one on one assist for g-tube care, prepare & serve diet as ordered. NPO diet, NPO texture feeding tube. R70's MDS, dated [DATE], documents R70 is cognitively intact and requires total dependence of one staff member for eating and supervision for all other ADLs. On 11/5/23 at 11:02 AM, R70's G-Tube dressing is dated 11/5/23 and was saturated with drainage. V4, Licensed Practical Nurse (LPN), used a syringe to administer 90 ML of water flush into R70's G-Tube, then inserted 250 ML of Jevity tube feeding, and another 90 ML of water flush, into R70's G-Tube, and then plugged the g-tube and left the room. V4 did not check for placement and/or residual prior to administrating water bolus and tube feeding. R70's Physician Order, dated 9/22/23, documents Enteral Feed. Five times a day FWF (full water flush) 90 ML Before and After Bolus Feedings. R70's Physician Order, dated 9/22/23, documents Enteral Feed. Five times a day. Jevity 1.5 Cal 250 ML Boluses Five Times a Day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145928 If continuation sheet Page 15 of 26 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 145928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Jacksonville 1021 North Church Street Jacksonville, IL 62650 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure there were sufficient nursing staff in the facility to provide adequate care and assistance for residents including assistance with bathing. This failure has the potential to affect all 77 residents in the facility. Findings include: 1. On 11/5/23 at 8:50 AM (a Sunday), the facility was entered. The facility was running one CNA short because of a call off. 2. On 11/06/23 at 11:00 AM, Resident Council Meeting was held in the Activity Department with 13 residents in attendance (R8, R24, R2, R41, R11, R32, R10, R71, R5, R43, R53, R16, and R62). Meeting was over at 11:30 AM. Issues brought up at meetings: Number one complaint is the Facility Staffing. There were multiple residents speaking out with a consensus of the committee, that stated that there is not enough help at the facility to take care of their needs, including answering call lights and assisting them when needed. On 11/6/2023 at 11:00 AM R8, Resident Council President, stated he was told that corporate limited the number of people they can have working. R8 stated that evenings are worse than other shifts. R8 stated that today (11/6/23) for example, the facility had three staff members call off, so things are not getting done like they should. R8 stated that they all see staff all the time on their cell phones and/or ear buds, instead of answering call lights and staff tend to hang out at the ends of the halls on their phones. The Facility's Resident Council Meetings for 2023 document 4/28/23 - CNA (Certified Nurse Assistant) always on their phones, not answering lights on nights. Smoke break: on weekends are becoming hard to find people that have to do it. 5/30/23 - CNA still on the phones, they are leaving dirty clothes on resident after meals. 6/27/23 - CNAs still on phone & ear buds, residents have soiled clothes on from meals, customer service a problem, on breaks a lot espec. (especially) on weekends. 7/25/23 - CNAs not answering call lights efficiently, on their phones, smoking a lot. 8/31/23 - CNAs on smoke breaks, call lights not answered fast enough. 9/26/23 - CNA's ice not being passed, call lights not being answered, on phones. 10/25/23 - CNAs not answered lights timely, on phones & have earbuds in. 3. R37's Minimum Data Set (MDS), dated [DATE], documents that R37 is cognitively intact. On 11/5/2023 at 9:30 AM R37 stated that she does not get her showers. R37 stated that she is told they don't have staff and that they are busy because they don't have staff. R37's Electronic Health Record does not document that R37 has received a shower. On 11/8/2023 at V11, VNA, stated that the showers are documented in the computer. V11 stated that there is no other place that it would be documented. On 11/8/2023 at 11:49 AM V1, Administrator, stated that they have enough staff when they show up. V1 stated that they don't use agency. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145928 If continuation sheet Page 16 of 26 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 145928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Jacksonville 1021 North Church Street Jacksonville, IL 62650 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 0725 4. R25's MDS, dated [DATE], documents that R25 is cognitively intact. Level of Harm - Minimal harm or potential for actual harm On 11/5/2023 9:28 AM R25 stated that she does not always get her showers on the day she is supposed to. R25 stated that she will get them whenever they have enough people. R25 stated that it takes a long time to answer the call light because they don't have enough people. Residents Affected - Many On 11/8/23 at 12:28 PM, V29, CNA, stated If we are short staffed, I would go to my managers and ask for assistance. I prioritize whatever is needed right then and there. If it is not urgent, I will tell the resident I will get back to them. I definitely think we need more help here. There are times when resident care is either not getting done or is delayed because we are short and running like crazy. On 11/8/2023 at 12:36 PM V4, LPN, stated that the facility does not have a staffing policy. V4 stated that they follow the federal regulation. The Payroll-Based Journal (PBJ), based on the required staffing information submitted by the facility, 3rd quarter triggered low staffing on the weekends. The Long - Term Care Facility Application for Medicare and Medicaid, dated 11/5/23, documents that 77 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145928 If continuation sheet Page 17 of 26 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 145928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Jacksonville 1021 North Church Street Jacksonville, IL 62650 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to properly store medication and label insulin for 4 of 5 residents (R14, R25, R34, R72) reviewed for medication labeling and storage in a sample of 46. Findings include: On [DATE] at 8:50 AM 100-Hall medication cart was inspected. The medication cart contained the following: R34's opened Humalog KwikPen 100 UNIT/ML (milliliter) Solution pen-injector was in the cart. There was no label on the pen as to when it was opened. V10, Licensed Practical Nurse (LPN) verified that the medication was opened, in use and no opened date was on the pen. R72's Novolog Pen FlexPen 100 UNIT/ML Solution pen-injector was in the cart. There was no label as to when it was opened. V10 verified that the medication was opened, in use and no opened date was on the pen. R14's Levemir FlexPen 100 UNIT/ML Solution pen-injector was in the cart. There was no label as to when it was opened. V10 verified that the medication was opened, in use and no opened date was on pen. R25's Novolog 100 UNIT/ML Solution pen-injector was in the cart. There was no label as to when it was opened. On [DATE] at approximately 1:40 PM the 100-hall medication cart, located at the nurse's station, was unlocked. On [DATE] at 11:51 AM V10 stated that the medications in the cart are in use. V10 stated that the insulins are to have an opened date. V10 stated that the date should be in a place that doesn't get wiped off. V10 stated that the first time the pen is used an open date is to be put in place. V10 stated that due to the expiration changing from the manufacture once open the open date is need so that they know when the medication expires. V10 stated that the medication cannot be used after expiration date. On [DATE] at 2:33 PM V2, Director of Nurses, stated that the insulin's expiration date changes once open. V2 stated that the insulin pens and vials are to be labeled with open date. V2 stated that the open date is how they tell when the expiration date is. V2 stated that once open the vials and pens are good for 28 days and some 30. V2 stated that it's important to let the nurses know when the expiration date is and to assure that expired medication is destroyed. V2 stated that the medication cart should be locked at all times when the nurse is not next to the cart. The facility's Medication Storage policy, dated 8/2023, documents Purpose: To ensure proper storage, labeling, and expiration dates of medications, biologicals, syringes, and needles. Guidelines: 5. Once any medication or biological package is opened, Facility should follow manufacture/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145928 If continuation sheet Page 18 of 26 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 145928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Jacksonville 1021 North Church Street Jacksonville, IL 62650 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 0761 date opened on the medication container when the medication has a shortened expiration date once opened. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145928 If continuation sheet Page 19 of 26 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 145928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Jacksonville 1021 North Church Street Jacksonville, IL 62650 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Potential for minimal harm Based on observation, interview, and record review, the facility failed to provide a palatable meal served at palatable temperatures for 13 of 13 residents (R2, R5, R8, R10, R11, R16, R24, R32, R41, R43, R53, R62, R71) reviewed for palatable food in the sample of 46. Residents Affected - Some Findings include: On 11/7/23 at 11:40 AM the noon meal was on steam table. With a calibrated thermometer the temperatures of the meal were taken and were as follows: meatballs 161degrees (°) Fahrenheit (F), mechanical meatballs 173.8 °F, pureed meatballs 149 °F, broccoli 165 °F, pureed broccoli 160 °F, butter noodles 189 °F, pureed noodles 160 °F. At 11:45 AM, V25, Dietary Aide, began to serve the meal. At 12:02 PM the 300 Hall Cart was taken to the hall. At 12:07 PM the sample tray was served. The meatball was 90 degrees F and cold on the inside. The butter noodles tasted starchy, and some were very mushy, and some were still hard. The broccoli was 90 degrees F and mushy. At 1:21 PM, the 100 Hall sample tray was served. The noodles tasted very starchy, and they were thick. The broccoli was mushy. All of the food items tasted lukewarm. At 12:49 PM the 300-hall dining room sample tray was served. The noodles tasted very starchy, and they were thick. On 11/06/23 at 11:00 AM, Resident Council Meeting was held in the Activity Department with 13 residents in attendance (R8, R24, R2, R41, R11, R32, R10, R71, R5, R43, R53, R16, and R62). The general consensus from the committee was that if you eat in the main dining room, the food is warm because it comes right out of the kitchen, if you eat in the south dining room or in your room, the food is always cold. R8, Resident Council President, stated that the staff will sometimes bring the food trays to the south (300 Hall) dining room in a warming cart, but they don't plug it in because it takes a special plug that they don't have that kind of outlet in the dining room and corporate said it would cost too much to do. R8 stated the staff try to get most people to eat in the dining room because the food is typically warmer. The policy Monitoring Food Temperatures for Meal Service, dated 9/23, documents, Meals that are served on room trays may be periodically checked at the point of service for palatable food temperatures. Food temperatures of hot foods on room trays at the point of service are preferred to be at 120 F or higher to promote palatability for the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145928 If continuation sheet Page 20 of 26 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 145928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Jacksonville 1021 North Church Street Jacksonville, IL 62650 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 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 water temperature of the dish machine was hot enough to sanitize the dishes to prevent food borne illness. This failure has the potential to affect all 77 residents living in the facility. Findings include: On 11/5/23 at 10:30 AM, the dish machine was being used. The temperature gauge was reading 80 degrees (?) Fahrenheit (F). V23, Dietary Manager, stated that she is going to have V14, Maintenance Director, come and check the machine out to see what is going on. On 11/5/23 at 11:00 AM, V1, stated that the water temperature is not getting hot enough and he is trying to figure out what is going on with it. On 11/5/23 at 11:10 AM, V1, Administrator stated that all of the dishes that were washed this morning are being rewashed and sanitized in the three-compartment sink. V1 stated that the machine was checked this morning and it was running 120 degrees and they are trying to figure out what is going on. On 11/6/23 at 9:00 AM, V14 stated that they have figured out that the problem is the hot water heater, and they are looking at replacing it but for now all the kitchen staff have been educated that they need to monitor the temperature gauge and if the temperature falls below 112 degrees F to stop and let the water heater heat back up and then start it back up. On 11/7/23 at 12:40 PM, V22, Dietary Aide, was using the dish washer. At this time the temperature gauge was reading 100 degrees F. V23 was standing at the machine also and she looked at the gauge and told V22 to stop using the machine that she was going to go check the hot water heater. V23 left the area. V22 continues to run dishes through the machine. V23 returns to the area and again tells V22 to stop using the machine. V23 stated that everyone knows to check the temperature gauge because that is what they are doing to make sure the machine is working properly. On 11/08/23 at 08:10 AM, V14, Maintenance Director , stated, The dishwasher should run at a temperature of 112 degrees (F) minimum and a maximum of 120 degrees (F) according to the chemicals that we use in the machine. We have an electric water heater that is not large enough to handle the kitchen when the machine runs back-to-back. I in serviced all of the kitchen staff on 11/6/23 and told them all to watch the temperature gauge and if the temperature falls below 112 stop washing the dishes and let the heater catch up and then start washing dishes again. (V22, Dietary Aide) is the type of employee that is going to do what she wants to do. She was educated by me on watching the temperatures. I have made up a new log that the staff are going to fill out every time the machine is ran. On 11/08/23 at 8:55 AM, V1, Administrator, stated that they are looking into either getting a new hot water heater or changing to chemicals that can be used with low temperatures. The Dish machine detergent bucket documents, Ideal wash temperatures for this product range from 140 ° to 160 degrees F (Fahrenheit). Wash temperatures as low as 120 F will produce acceptable results, although slower drying times will occur. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145928 If continuation sheet Page 21 of 26 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 145928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Jacksonville 1021 North Church Street Jacksonville, IL 62650 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 0812 Level of Harm - Minimal harm or potential for actual harm The dish machine itself documents, Wash temp (temperature) Minimum 120 °F. Rinse temp Minimum 120 °F. Required chlorine 50 ppm (parts per million). The Long - Term Care Facility Application for Medicare and Medicaid, dated 11/5/23, documents that 77 residents reside in the facility. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145928 If continuation sheet Page 22 of 26 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 145928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Jacksonville 1021 North Church Street Jacksonville, IL 62650 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 4. On 11/5/2023 at 9:35 AM during incontinent care V5, CNA, sanitized hands and then donned gloves. V5 with gloved hands began cleaning R17 of incontinent stool with wash cloths. V5 with gloved hands took the washcloth makes swipe folds and drops in plastic bag, repeated the process, doffed gloves, and donned gloves without sanitizing hands. V5 applied barrier cream, removed gloves, and reapplied gloves without sanitizing hands. Residents Affected - Some 5. On 11/8/23 at 12:36 PM, V2, Director of Nursing (DON), stated I would expect all staff to perform hand hygiene before and after resident care and would expect staff to change their gloves whenever they are soiled and between residents. The policy Hand Hygiene / Handwashing, dated 3/23, documents that hand hygiene should be done before donning gloves and after removing gloves. 3. On 11/5/2023 at 9:21 AM R16 was lying in bed with heavily soiled heel boots. R16's right foot and leg was wrapped with heavily brown soiled stretch bandage. The stretch bandage on the left leg was partial off of leg revealing multiples wounds to leg. Multiple flies observed flying around and landing on R16's right heel, right leg, and wounds to R16's left leg. On 11/5/2023 at 9:39 AM V10, LPN, performed R16's wound treatments to R16's right leg and heel and left leg. V10's right foot, heel, was sitting on the sheet, no dressing. The heavily soiled dressing was on the bed between R16's foot. V10 applied gloves and cut dressing in 6 small areas and placed directly on overbed table. No barrier in place. V10 then placed them in saline. The dressing fell on floor. V10 then applied the wet dressing to R16's shin. V10 then lifted R16's leg from bed revealing drainage on the sheet. V10 then felt for wound on heel with fingers and applied wet dressing. V10 then placed the heel back on the bed in the old drainage. V10 then picked dressing off the floor and applied to heel. V10 then removed gloves and went to cart outside room and obtained 4 packs of wrapping dressings. V10 then placed dressings on the over bed table. The dressings again fell to floor. V10 then picked up the dressings and placed on overbed tabled causing multiple dressings to fall to floor. V10 applied dressings to R16's legs. V10 then wrapped R16's legs with heavily soiled ace wraps to both legs. On 11/5/2023 at 9:40 AM V10 stated that she had to put these, heavily soiled elastic wraps, on because the facility did not have any more. On 11/8/2023 at 12:35 PM V3, Assistant Director of Nurses (ADON), stated that she would expect the nurse to cleanse off the overbed table and apply a barrier before placing clean dressings on the overbed table. V3 stated that she would expect the nurse to put a barrier in place between the resident leg and bed when performing treatment. V3 stated that once the wound is clean, she would expect the nurse to make sure that the wound does not come in contact with drainage on the bed or the soiled linen. V3 stated that she would expect the staff to apply clean ace wraps to R16's legs. V3 stated that they have plenty of ace bandages and that the nurse should have obtained a clean pair. V3 stated that if a dressing falls on the floor the dressing cannot be used. V3 stated that she expects the nurse to get rid of the dressing and not apply to resident. The facility's Dressing Change policy, dated 8/2023, documents Guidelines 2. Prepare a clean, dry work area at bedside. 3. Bring supplies into resident's room. Individual resident supplies may be placed on the overbed table after it has been disinfected and/or a protective barrier placed on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145928 If continuation sheet Page 23 of 26 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 145928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Jacksonville 1021 North Church Street Jacksonville, IL 62650 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some table. 7. Prepare/open any necessary supplies and place on top of clean barrier. 10. Remove soiled dressing and place in plastic trash bag. Based on observation, interview, and record review, the facility failed to perform appropriate hand hygiene, glove changes when soiled, and to ensure the wound care supplies were kept clean to prevent contamination and potential infection for 4 of 23 residents (R4, R16, R17, R63) reviewed for infection control in a sample of 46. Findings include: 1. On 11/6/23 at 9:35 AM, R4 was lying in bed with his sheet off, and his incontinence brief unfastened. V9, Certified Nurse Aide (CNA), entered with a handful of washcloths, a plastic bag, and new a new incontinence brief to clean R4. V8, CNA, entered to assist V9. V9 went into the restroom and wet the washcloths, donned gloves, then turned R4 to his side while V8 wiped once to R4's bilateral buttocks, bilateral groins, pubic area, and his penis all while using the same washcloth and did not dry R4. V8 then placed a clean depends on the front of R4 and tucked it between his legs. R4 was then rolled to his other side while V8 wiped once to R4's buttocks and anal area and did not dry R4. V8 and V9 then fastened the incontinence brief around R4. V8 did not change her gloves or perform hand hygiene before, during glove changes, or after care was given. 2. On 11/5/23 at 9:35 AM, R63 was lying in bed, with V4, Licensed Practical Nurse (LPN), providing skin care to his legs. R63 stated that he had some loose stool and wanting to use restroom, so V4 told him she would be back after he was done and did not offer assistance to get R63 to the restroom. R63 was seen getting out of his bed to his wheelchair with some difficulty, and wheeled himself to the restroom, stood and pivoted, and then put himself on the toilet. R63 asked to have the restroom door closed and the door was closed. There was feces seen in his incontinence brief, and his pants appeared wet. R63's bed linen had feces on the incontinence pad which was noticed once R63 got up. V4 entered the restroom to assist R63 and left the restroom door open, which made R63 visible to two other residents in the room. V4 cleansed up R63's buttocks/anal area and put a new brief on R63's legs and pulled up R63's same wet pants. R63 stated that his wheelchair cushion was soiled, so V4 wiped off the cushion, and with gloves on, checked R63's pants and stated they were not wet. After V4 left the room, R63 stood up to check his pants and his wheelchair cushion had wet spot in the center of the cushion, where his buttocks/anal area would be. R63 then felt his pants and stated yes, they are wet. V4 did not perform hand hygiene before, during glove changes, or after care done. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145928 If continuation sheet Page 24 of 26 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 145928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Jacksonville 1021 North Church Street Jacksonville, IL 62650 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. 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 prevent a fly infestation through effective pest control. This has the potential to affect all 77 residents who reside in the building. Residents Affected - Many 1. R16's Minimum Data Set (MDS), dated [DATE], documents that R16 is cognitively intact. On 11/5/2023 at 9:21 AM there were multiple flies on R16's heavily soiled dressing on right foot. A fly was on top of urine filled urinal and 1 fly floating in urine. 1 fly was on R16's arm. On 11/5/2023 at 9:39 AM R16 stated that the flies are bad. R16 stated that he doesn't have anything to kill them with. R16 stated that he does not like it and would rather not have them at all. On 11/6/2023 at 10:22 AM, R16 was lying in bed with 2 flies on R16 and flying around R16's feet and 1 fly on R16's arm. On 11/7/2023 at 12:42 PM R16 was lying in bed with flies on the bed and on R16's body. 2. R25's MDS, dated [DATE], documents that R25 is cognitively intact. On 11/5/2023 at 9:28 AM there was a fly on R25's arms and covers. R25 was observed swatting at the flies. The flies would fly away and return. On 11/7/2023 at 12:47 PM R25 was lying in bed, with eyes closed and noon meal tray in front of R25 uncovered. There were 3 flies on the plate and 1 fly on the meatballs. On 11/5/2023 at 9:28 AM R25 stated that the flies are horrible. R25 stated that she can't get rid of them and that the flies land on her food. R25 stated that she eats the food because she doesn't have a choice. 3. R37's MDS, dated [DATE], documents that R37 is cognitively intact. On 11/5/2023 at 9:30 AM there was a fly on R37's arm. R37 was observed swatting at fly and the fly would fly away and then return. On 11/5/2023 at 9:30 AM R37 stated that the flies are horrible. R37 stated that she tries to hit them, but she can't. R37 stated that she was given a fly swatter and the staff move it out of her reach and she can't use it. 4. On 11/5/23 at 12:50 PM, residents were seen sitting in the main dining room eating and / or getting fed. There were several flies that were seen flying around the resident tables and/or food trays. Multiple staff were in the dining room. There were no attempts by staff to remove flies. 5. On 11/5/2023 at 10:47 AM there were many flies on the 100-hall. The facility's Pest Control, dated 9/2023, documents that the purpose is to prevent or control insects and rodents from spreading disease. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145928 If continuation sheet Page 25 of 26 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 145928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Jacksonville 1021 North Church Street Jacksonville, IL 62650 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 0925 The Long-Term Care Facility Application for Medicare and Medicaid, dated 11/5/23, documents the total resident census as 77. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145928 If continuation sheet Page 26 of 26