Inspection·March 4, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete at the facility. I have been in therapy a couple times since I have been at the facility and therapy never did an assessment with me for my motorized wheelchair. I am very upset that I am unable to get around on my own now and have to rely on staff. On 2/27/24 at 10:42 AM V1 (Administrator in Training) stated, We (The Facility) took away (R2's) motorized wheelchair because (R2) has been outside multiple times and bumped her arms and ankles due to motorized wheelchair. V1 verified that the SS Motorized W/C Screens were conducted and R2 could be trained for safe operation of a motorized wheelchair. V1 also verified that no training was offered to R2 by a professional or therapy prior to taking away R2's motorized wheelchair. Event ID: Facility ID: 145968 If continuation sheet Page 2 of 18 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 145968 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Kewanee 144 Junior Avenue Kewanee, IL 61443 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 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Let each resident or the resident's legal representative access or purchase copies of all the resident's records. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide a resident's power of attorney health and medical records upon request for one of three residents (R3) reviewed for resident rights in the sample of 12. Findings Include: The Illinois Long-Term Care Ombudsman Program Resident's Rights for People in Long-term Care Facilities Resident Rights Handbook dated 11/2018 documents Your facility must allow you to see your records within 24 hours of your request (excluding weekends and holidays). You may purchase a copy of part or all of your records at a reasonable copy fee within two working days of your request. On 2/21/22 at 12:10 PM, V13 (R3's Power of Attorney) stated that R3 was hospitalized on [DATE] after suffering a stroke. V13 stated I have been talking to the facility about getting (R3's) records. They have not been helpful at getting me this information. We have asked for referrals to be sent so she can be transferred to another facility and (the facility) hasn't sent them the needed paperwork. They are not being helpful at getting me this information. (R3) has suffered a stroke and is having difficulty speaking. I am her Power of Attorney, her family member and her voice right now. R3's current electronic medical record Face Sheet documents, V13 is listed as R3's Power of Attorney for health. On 2/29/24 at 10:45 AM, V3 (Care Plan Coordinator) confirmed she also does some business office work if needed. V3 stated I have received requests from (V13) about (R3's) records. He emailed me. I have not provided any records to (V13) at this time because he has not signed a release of information. I do have emails from (V13) that documents the requests for (R3's) records to be sent. I have not sent him any records. The first request was on 2/19/24. He also emailed to request the records on 2/23/24 and 2/26/24. On 2/29/24 at 11:15 AM, V1 (Administrator in Training) stated We require family to sign a release for records. I don't have the policy on hand. I can't find it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145968 If continuation sheet Page 3 of 18 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 145968 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Kewanee 144 Junior Avenue Kewanee, IL 61443 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 0580 Level of Harm - Minimal harm or potential for actual harm Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on Interview and Record Review, the facility failed to notify a resident's physician of a new laboratory result for one of three residents (R3) reviewed for Physician Notification in the sampled of 12. Residents Affected - Few Findings include: The facility's Notification of Change in Resident Condition or Status policy, dated 10/12/05, documents The facility and/or facility staff shall promptly notify appropriate individuals (i.e., Administrator, Director of Nursing, Physician, Guardian, Health Care Power of Attorney, etcetera) of changes in the resident's medical/mental condition and or status. The nurse supervisor/charge nurse will notify the resident's attending physician or on call physician when there has been; A need to alter the resident's medical treatment significantly, Abnormal lab findings. R3's Physician Order Sheet, dated 11/1/23-2/29/24, documents R3 has a laboratory order for PT (Prothrombin)/INR (International Standardized Ratio for clotting in the blood) one time only related to Personal History of Pulmonary Embolism, Personal History of other Venous Thrombosis and Embolism, until 1/25/24. This order has a start date of 1/25/24. R3's Laboratory report, dated 1/26/24, documents R3's INR result was 1.3. This report also documents an INR range for Standard Anticoagulant is 2.0-3.0 and Aggressive Anticoagulant is 2.5-3.5. R3's Nursing Progress notes, dated 1/11/24-2/9/24 do not document that V8 (R3's Primary Physician) was ever notified of R3's PT and INR results that were completed on 1/26/24. On 2/21/24 at 1:40 PM, V1 (Administrator in Training) stated I don't know if (V8, R3's Primary Physician) was notified of the 1/26/24 laboratory result for (R3's) PT/INR. If he was notified it should be in the progress note or a new updated order would be in place. On 2/21/24 at 2:00 PM V9 (V8's Medical Office Licensed Practical Nurse) stated I do not see where we (doctor office) were ever notified of the PT/INR results for (R3) on or after 1/26/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145968 If continuation sheet Page 4 of 18 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 145968 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Kewanee 144 Junior Avenue Kewanee, IL 61443 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on interview and record review, the facility failed to ensure the interdisciplinary team and the residents' representatives were invited and attended care plan conferences for two of three residents (R1 and R2) reviewed for care planning in the sample of 12. Findings include: The facility's Comprehensive Care Planning policy dated 11-1-17 documents, The Care Plan Conference (meeting) shall be held as necessary to communicate major revisions to the Comprehensive Care plan and minimally with every Comprehensive MDS (Minimum Data Set) completed. The facility shall make effort that the conference: a. Be attended by a representative from each discipline involved in the resident's care as possible. b. Be attended by the resident. c. Be attended by a representative of the resident's choice if that person so chooses to attend. 1. R1's BIMS (Brief Interview Mental Status) dated 11/23/2023 documents R1 is Cognitively Intact. R1's Medical Record dated 2-23-23 through 2-23-24 does not include documentation of R1's Power of Attorney/POA (V6) being invited to R1's care plan meetings. On 2-21-24 at 10:00 AM R1 stated she does not remember every attending a care plan meeting or her family ever attending a care plan meeting. R1 stated she would like for her family to attend her care plan meetings. On 2-21-24 at 10:20 AM V4 (Prior Care Plan Coordinator) stated she had never invited R1's Power of Attorney (V6) to R1's care plan meetings. V4 stated, I just thought that since (V6) visits daily that would be good enough. There was never an interdisciplinary team available to be able to hold the meetings anyway. On 2-23-24 at 5:00 PM V6 stated, I have not been invited to (R1's) care plan meetings in over two years. I would like to attend the care plan meetings to address concerns with all departments, so we are all on the same page with mom's cares. On 2-27-24 at 1:00 PM V3 (Care Plan Coordinator) stated she has not invited V6 to R1's care plan meetings. 2. R2's BIMS (Brief Interview Mental Status) dated 12/05/2023 documents R2 is Cognitively Intact. R2's Care Plan Summary and Attendance Record dated 12/08/2023 documents a nursing representative and R2 were the only two people that were in attendance for the care plan meeting. On 2/21/24 at 10:37 AM V12 (R2's Health Care Power of Attorney) stated, I have not been invited to a care plan meeting for (R2) since last September 2023. I am involved with (R2's) care plan meetings and I would like to be invited to them and (R2) would like me to attend as well. On 2/21/24 at 12:27 PM R2 stated, I would like (V12) my Health Care Power of Attorney to attend my care plan meetings. The last care plan meeting (the facility) had for me was in December 2023 and it was only me and a nurse. They did not include or invite (V12), and I would like (V12) to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145968 If continuation sheet Page 5 of 18 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 145968 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Kewanee 144 Junior Avenue Kewanee, IL 61443 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 0657 involved with my care plan meetings. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145968 If continuation sheet Page 6 of 18 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 145968 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Kewanee 144 Junior Avenue Kewanee, IL 61443 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide an adequate amount of sit-to-stand mechanical lifts to transfer and toilet residents timely for nine of nine residents (R3-R11) reviewed for accommodation of needs in the sample of 12. These failures resulted in R3 soiling her brief and sitting in urine and feces for over an hour at a time on multiple occasions, causing R3 visible emotional distress, embarrassment, and anxiety, and resulted in R4 experiencing unwanted urinary incontinence and embarrassment. Residents Affected - Few Findings include: The facility's Limited Resident Lift Program (undated) documents 1. Equipment: Must have enough lift, slings, etc. to effectively transfer all heavy residents in a timely manner. Goals: 4. Maximize safe, functional independence without compromising the resident's dignity and rights. Compliance: D. Mechanical lifting devices and other equipment /aids: b. Mechanical lifting devices and other equipment/aids will be maintained regularly and kept in proper working order. The Facility Assessment Tool dated 2-21-24 documents, Part 2: Services and Care We Offer Based on our Residents' Needs. Resident support/care needs- Bowel/bladder: Bowel/bladder toileting programs, incontinence prevention and care, intermittent or indwelling or other urinary catheter, ostomy, responding to requests for assistance to the bathroom/toilet promptly in order to maintain continence and promote resident dignity. On 2-21-24 at 11:00 AM V1 (Administrator-In-Training) provided a list of current residents (R4-R11) requiring the use of a sit-to-stand mechanical lift machine for transfers and toileting. On 2-27-24 from 10:00 AM through 10:15 AM a tour of the building was done. During this tour the facility had one sit-to-stand mechanical lift machine within the building, to use for four hallways that occupied residents. 1. R3's BIMS (Brief Interview of Mental Status) dated 12-13-23 documents R3 is cognitively intact. R3's Care Plan dated 2-8-24 documents R3 requires staff assistance for transfers and toileting. R3's Progress Notes document R3 was hospitalized on [DATE] and still remains hospitalized . R3's Grievance/Complaint Report Form dated 2-8-24 and signed by V1 (Administrator-In-Training) documents, (R3) complaints of not being able to go to the bathroom as quick as she need to due to second stand-up lift broke down. (R3) states she has urgency when she needs to go. Method of correction or disposition of complaint: Staff in-serviced to take resident to the bathroom first or as quick as they can does have past history of chronic urinary symptoms and urgency. (R3) also educated that we could use bed pain if she desires as another means to toilet. On 2-21-23 at 12:10 PM, V13 (R3's Family Member) stated (R3) reported to me that they (the facility) only have one sit to stand so they have to wait a long time to go to the bathroom. She is not getting the help she needs. (R3) will not be going back there (the facility) because she is embarrassed. (R3) was visibly crying to me and my mother that the facility did not have a machine to get her up and toilet her. (R3) told us she had to sit in poop and pee for hours a lot of different days. (R3) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145968 If continuation sheet Page 7 of 18 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 145968 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Kewanee 144 Junior Avenue Kewanee, IL 61443 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 voiced the concerns to (V1 Administrator-In-Training) and (V1) told (R3) she would have to use the bed pan. (R3) does not like having to use a bed pan and should not have to. Level of Harm - Actual harm Residents Affected - Few 2. R4's current Care Plan dated 2-21-24 documents R4 requires full assistance of staff and a sit-to-stand as needed for transfers and toileting. On 2-27-24 at 10:40 AM R4 was sitting in her recliner. R4 stated she sometimes wets her pants waiting on someone to transfer her. R4 stated she tries to hold it but it just comes out after waiting so long for the machine (sit-to-stand). I do not like sitting in wet pants. It is embarrassing. 3. R5's current Care Plan dated 2-21-24 documents R5 requires full assistance of staff and a sit-to-stand for transfers and toileting. On 2/28/24 at 1:15 PM R5 was lying in bed in her room. R5 confirmed she needs assistance to get out of bed with a lift device. R5 stated I have to wait a long time. Sometimes an hour and it's usually when I hit my call light because they only have so many machines and other people use them too. It is a long time to wait when I have to go to the bathroom. 4. R6's current Care Plan dated 2-21-24 documents R6 requires full assistance of staff and a sit-to-stand for transfers and toileting. 5. R7's current Care Plan dated 2-21-24 documents R7 requires full assistance of staff and a sit-to-stand for transfers and toileting. 6. R8's current Care Plan dated 2-21-24 documents R8 requires full assistance of staff and a sit-to-stand lift as needed for transfers and toileting. 7. R9's current Care Plan dated 2-21-24 documents R9 requires full assistance of staff with a sit-to-stand lift for transfers and toileting. 8. R10's BIMS Evaluation dated 11-27-24 documents R10 is cognitively intact. R10's current Care Plan dated 2-21-24 documents R10 is unable to transfer independently due to the diagnoses of weakness and uses a sit-to-stand lift with staff assistance. On 2-28-24 at 1:25 PM R10 was sitting in his wheelchair in his room. R10 stated, There is only one lift (sit-to-stand) here and it is usually on the other side of the building. I try to put my call light on earlier than I think I will need it, so I don't pee myself. Sometimes it takes half an hour to over an hour for the staff to get me to the toilet once I use my call light. I wear an (adult brief) so I wet myself in it when I need to. I don't like wetting myself. What am I supposed to do? 9. R11's current Care Plan dated 2-21-24 documents R11 requires full assistance of staff and a sit-to-stand as needed for transfers and toileting. On 2-26-24 at 12:35 PM R11 stated, I just get myself up to the bathroom if staff do not help me in time. I do not wait for the lift. On 2-27-24 at 10:20 AM V20 (CNA/Certified Nursing Assistant) stated, There is not enough sit-to-stand lift to toilet the residents timely. We only have one lift for all four hallways. (R11) gets (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145968 If continuation sheet Page 8 of 18 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 145968 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Kewanee 144 Junior Avenue Kewanee, IL 61443 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 upset, yells, and screams and sometimes soils herself. Residents are also late getting up for meals at times. Level of Harm - Actual harm Residents Affected - Few On 2-27-24 at 10:50 AM V21 (CNA) stated, The residents have to wait a long time sometimes to get up to the toilet because we only have one sit-to-stand lift. Residents will soil themselves at times before we can get to them. On 2-27-24 at 1:00 PM V1 (Administrator-In-Training) stated, The second sit-to-stand lift has been broken for about a month now and we are awaiting parts. There is one machine in the building. On 2-27-24 at 2:13 PM V25 (CNA) stated, Residents were having to wait longer periods of time due to only having one sit to stand lift. R3 would always get upset having to wait longer periods of time because she would have to use the restroom. R5 also got upset multiple times when it was time for her to lay down and she had to wait because we only had the one sit to stand. On 2-27-24 at 2:19 PM V24 (CNA) stated, I work second shift mostly. It is very difficult to get people up timely when we only have one sit-to-stand in the building. (R3) has requested to go to the bathroom before and had to wait for an hour and a half, because the sit-to-stand was being used on other residents. (R3) was very upset and very anxious about this and I don't blame her. Sometimes residents because they need a sit-to-stand lift must wait until its done being used on other residents. (R11) is a high fall risk and will get up on her own if we cannot get to her call light timely. There have been multiple times (R11) has transferred herself to the toilet and should not have had to. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145968 If continuation sheet Page 9 of 18 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 145968 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Kewanee 144 Junior Avenue Kewanee, IL 61443 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess resident surroundings for a safe environment and failed to develop and implement interventions to promote a safe environment for one of three residents (R2) reviewed for accidents in a sample of 12. These failures resulted in R2 sustaining a right shin wound from hitting her right shin on an exposed sharp bolt located on R2's bedframe on two separate occasions 27 days apart. The first occurrence resulted in R2's right shin wound becoming infected, and the second occurrence resulted in R2 requiring an emergency room visit to obtain three staples to close a right shin laceration. Findings include: The facility's Quality Care Reporting policy dated 12-12-23 documents, Policy: (The Facility) works to continuously improve residents care, safety and operations within the facility. A Quality Care Reporting Form will be completed to assist in the Quality Assurance process. Purposes: To help identify problems or potential problems. To act as a record, when analyzed, will prevent similar mishaps or injuries. To improve quality of resident care and overall safety in the facility. Procedure: Charge Nurse will: 1. Complete a Quality Care Reporting Form for happenings out of the ordinary which results in a potential for injury, or actual injury or damage to: resident, visitor, employee or property. Administrator and/or DON (Director of Nursing) will: 1. Review the Quality Care Reporting form for completeness. 2. Investigate all reports upon receipt. 3. Obtain additional information from resident, staff, family, etc. (et cetera) as needed. The following list contains examples of action to be taken: h. Repair or replace equipment. R2's BIMS (Brief Interview Mental Status) dated 12-05-2023 documents R2 is Cognitively Intact. R2's A.I.M (Acute Illness Management) For Wellness Change in Status Record dated 6-22-23 documents R2 had a change in skin integrity/wound appearance. Right lower leg 7.5 cm (centimeter) by 3.5cm unstageable wound. This same form documents R2's comments/response to event was, I ran into my bed with the w/c (wheelchair) a week ago. I thought you knew. The third shift nurse knew. R2's A.I.M (Acute Illness Management) For Wellness Change in Status Record dated 6-22-23 documents R2 had a change in skin integrity/wound appearance. New or worsening pus at wound, skin, or soft tissue noted. R2 may need a prescription for an antibiotic. Event first noted on 6-12-23. Right lower leg 7.5 cm (centimeter) by 3.5cm unstageable wound. This same form documents R2's comments/response to event was, I ran into my bed with the w/c (wheelchair) a week ago. I thought you knew. The third shift nurse knew. R2's Electronic Medical Record did not include any documentation on R2's right shin area from 6-12-23 to 6-22-23. R2's MAR (Medication Administration Record) documents an order dated 6-23-23 for Keflex (antibiotic) 500mg three times a day until 7-7-23 for right leg. R2's Progress Note dated 6-24-23 and signed by V17 (Licensed Practical Nurse/LPN) documents Keflex continues for area on right leg with NAR (No Adverse Reactions) noted. Area remains red and swollen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145968 If continuation sheet Page 10 of 18 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 145968 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Kewanee 144 Junior Avenue Kewanee, IL 61443 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 0689 R2's Progress Note dated 6-24-23 documents Antibiotic continues for cellulitis (infection) to right leg. Area remains red and warm to touch. Level of Harm - Actual harm Residents Affected - Few R2's Physical Therapy and Rehab Specialist Initial Evaluation dated 6-27-23 documents, R2 states she recently ran her wheelchair into the bed and her big toe into the doorframe which has left a hematoma on her right shin and cut on her right big toe. R2's Care Plan 6-22-23 (date of injury) through 7-19-23 does not include an intervention to protect R2 from sustaining further injury from R2's exposed bed frame bolts. R2's Progress Note dated 7-19-23 and signed by V17 (LPN) documents, (R2) was going into her room and hit the edge of her bed causing a 1.5 cm (centimeter) laceration to her RLE (Right Lower Extremity). Resident sent out to local ED (Emergency Department). R2's Local ED Noted dated 7-19-23 documents (R2) to the ED today via EMS (Emergency Medical System) from (the facility) with c/o (complaints of) laceration to right lower leg on shin. Three staples applied by V18 (Local ED Physician). R2's Progress Note dated 7-19-23 and signed by V17 documents, (R2) returned to facility per facility van. Three sutures noted to RLE. Keep wound clean and dry. Put a thin layer of antibiotic ointment. Put ice pack on site if swelling occurs for 20 minutes. (R2) denies any pain or discomfort at this time. On 2-21-24 at 12:27 PM R2 was sitting in her room in her manual wheelchair beside her bed. R2's bed frame had a pool noodles (foam noodles) taped to her bedframe. Foam noodles were loose and sagging leaving R2's bed frame bolts exposed. On 2-26-24 at 10:00 AM R2 was sitting in her room in her manual wheelchair. R2 sitting in between her bed and an empty bed. The empty bed was noted to have two sharp bolts sticking out approximately two inches from the bed frame in close proximity to R2's right leg. On 2-26-24 at 10:05 AM R2 stated, The facility tries to blame everything on my electric wheelchair. I had two injuries because of the bolts located on my bed frame. I told (V1) (AIT/Administrator in Training) the first time about the bolts and they did nothing to fix the issue, just that I need to learn how to drive my electric wheelchair better. The second injury I had to my right shin was because of the same bolts sticking out. (The facility) had maintenance come to my room and pad my bed frame to cover the bolts, but they still won't pad this other bed frame. My room is tiny and it's hard to maneuver between two beds with my wheelchair and bolts sticking out of the frame. R2's right shin had two quarter size deep indentations where her previous injuries had occurred from the R2's bed frame. On 2-26-24 at 12:00 PM V14 (Former Maintenance Director) stated, A few months ago (V1) came and got me and asked me if we had pool noodles to cover up the bolts that were sticking out on (R2's) bed frame. (V1) said (R2) had hit her leg on the bolts before and had just hit her leg [NAME] on the bolts that were sticking out of (R2's) bedframe. (R2) busted her leg open and had to get stitches the second time. The beds at the facility are so old and there are four bolts that stick out approximately two inches from the bed frames. Those bolts were used to attach full side rails back in the day. Full side rails are not used anymore so the bolts just stick out. The facility did not provide me with any tools to cut the bolts off to make the bolts smooth. There are still beds there with exposed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145968 If continuation sheet Page 11 of 18 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 145968 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Kewanee 144 Junior Avenue Kewanee, IL 61443 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 0689 bolts. Level of Harm - Actual harm On 2-27-24 at 11:08 AM V17 stated, On 7-19-23 (R2) reported to me that she had hit her right shin on her bedframe. I was in the room but didn't inspect (R2's) bed frame fully. (R2) is alert and is able to tell you exactly what she hit her right shin on. Residents Affected - Few On 2-27-24 at 11:15 AM V1 (AIT) stated there were no interventions developed or implemented to address R2's bed frame after R2 hit her shin on her bed and becoming infected on 6-22-23. R2 hit her shin again on the bed frame on 7-19-23 sustaining a laceration that required sutures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145968 If continuation sheet Page 12 of 18 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 145968 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Kewanee 144 Junior Avenue Kewanee, IL 61443 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. Based on interview and record review, the facility failed to provide a sufficient amount of direct care staff to provide timely care to dependent residents. This failure has the potential to affect all 54 residents currently residing at the facility. Findings include: The Resident Room Roster dated 2-21-24 indicates that 54 residents are currently residing in the facility. The facility's Nurse Staffing policy (undated) documents the following: It is the policy of (facility) to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental and psychosocial wellbeing of each resident. Nursing staff shall be based upon resident evaluation by the Administrator and Director of Nursing as specified by the (State Agency). Each skilled care resident shall receive at least 3.8 hours of nursing and personal care each day, and 2.5 hours of nursing and personal care each day for a resident needing intermediate care. A minimum of 25% of nursing and personal care time shall be provided by licensed nurses, with at least 10% of nursing and personal care time by Registered Nurses. Registered Nurses and Licensed Practical Nurses employed by a facility in excess of these requirements may be used to satisfy the remaining 75% of the nursing and personal care time requirements. The division of nursing needs by shift will be calculated based on resident census and needs. The Facility Assessment Tool dated 2-21-24 documents, Part 2: Services and Care We Offer Based on our Residents' Needs. Resident support/care needs- Bowel/bladder: Bowel/bladder toileting programs, incontinence prevention and care, intermittent or indwelling or other urinary catheter, ostomy, responding to requests for assistance to the bathroom/toilet promptly in order to maintain continence and promote resident dignity. Staffing Plan: Evaluation of overall number of facility staff needed to ensure a sufficient number of qualified staff are available to meet each residents' needs. Individual staff assignment: Staff assignments and continuity of care is determined on current census and resident acuity of care needed. On 2-21-24, V1 (Administrator in Training) provided copies of the facility's Daily Staffing Assignment sheets (dated 1-1-24 through 2-21-24) which indicate the length of time and location of the staff members working for each day. V1 (Administrator in Training) stated the facility determines their minimum requirements based on facility's assessment and the minimum daily staffing calculator. The Daily Staffing Assignment Sheets and Minimum Daily Staffing Calculations dated 1-7-24 and 1-12-24 both document staffing was below (the facility) minimum requirements based off the staffing calculator utilized to determine staff needs. The facility's Resident Council Meeting Minutes for November (2023) document, The residents are having issues with their beds sometimes not being made. The facility's Resident Council Meeting Minutes for December (2023) document, The residents are having issues with their beds sometimes not being made. R12's Grievance Complaint Report dated 1-22-24 documents, (R12) complained of CNA (Certified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145968 If continuation sheet Page 13 of 18 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 145968 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Kewanee 144 Junior Avenue Kewanee, IL 61443 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 Nursing Assistant) coming in to answer her call light, turning it off, but then forgetting to come back. Level of Harm - Minimal harm or potential for actual harm The facility's Resident Council Meeting Minutes for January (2024) document, The residents voiced that there are times the CNAs shut their call lights off without meeting their needs. A CNA will shut the call light off and tell the resident that they will be right back, but then the CNA forgets to come back. The residents are reporting that there are times when their beds are not being made in a timely manner, or sometimes not being made at all. Residents Affected - Many R1's BIMS (Brief Interview of Mental Status) dated 11-23-23 documents R1 is cognitively intact. R1's current Plan of Care documents R1 is incontinent of bowel and bladder and is dependent on staff for toileting and hygiene. On 2-21-24 at 11:40 AM R1 stated, There are not enough staff here throughout the night. I have laid in poop for hours before. R2's BIMS dated 12-05-2023 documents R2 is Cognitively Intact. R2's current Plan of Care dated 2-12-24 documents R2 requires two staff assist with a mechanical lift to transfer and toileting. On 2-21-24 at 12:30 PM R2 stated, I have had to wait multiple times on evening and night shift to use the bathroom because the staff state they are short. They have also made me use the bed pan so they don't have to get me up with the (mechanical lift) since they are short staffed. I do not like that. With staff being short on evening and night shift this has caused me to have to sit in my urine for over an hour. It's embarrassing having to ask for help and to sit in urine for that long when I am able to let them know when I need to use the bathroom. On nights one CNA (V23) comes in and shuts off my call light when I need changed and never returns. It's just really upsetting. On 2-26-24 at 10:15 AM V1 AIT (Administrator in Training) confirmed the daily staffing sheets were accurate for 1-7-24 and 1-12-24 and staffing was below their minimum requirements based off the staffing calculator utilized to determine staff needs. On 2-27-24 at 10:20 AM V20 (CNA) stated, There is not enough staff a lot of times on third shift which delays the residents from getting up for breakfast in time or toileted timely. On 2-27-24 at 10:50 AM V21 (CNA) stated, The residents have to wait a long time sometimes to get up in the morning and are late for breakfast at times. There needs to be more CNAs to assist the residents. On 2-27-24 at 2:19 PM V24 (CNA) stated, I work second shift mostly. It is very difficult to get people up timely when we only have one sit-to-stand in the building. (R3) has requested to go to the bathroom before and had to wait for an hour and a half, because the sit-to-stand was being used on other residents. (R3) was very upset about this and I don't blame her. Sometimes residents do soil themselves because we are either short staffed and have a hard to get to everyone timely, or because they need a sit-to-stand lift and must wait until its done being used on other residents. (R11) is a high fall risk and will get up on her own if we cannot get to her call light timely. There have been multiple times (R11) has transferred herself to the toilet and should not have had to. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145968 If continuation sheet Page 14 of 18 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 145968 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Kewanee 144 Junior Avenue Kewanee, IL 61443 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 R10's BIMS Evaluation dated 11-27-24 documents R10 is cognitively intact. Level of Harm - Minimal harm or potential for actual harm R10's current Care Plan dated 2-21-24 documents R10 is unable to transfer independently due to the diagnoses of weakness and uses a sit-to-stand lift with staff assistance. Residents Affected - Many On 2-28-24 at 1:25 PM R10 was sitting in his wheelchair in his room. R10 stated, It seems like there is not enough staff on the night shift. The staff try hard, there just is not enough. I have to wait to go to bed and get out of the dining room. At night is takes longer to answer my call light to use the restroom. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145968 If continuation sheet Page 15 of 18 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 145968 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Kewanee 144 Junior Avenue Kewanee, IL 61443 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to adequately manage a resident's Coumadin (anticoagulant medication) dosage to ensure the medication was reaching therapeutic levels, develop a policy on anticoagulant medication management, and obtain treatment adjustment from the physician for a non-therapeutic INR (International Standardized Ratio for clotting in the blood) lab result for a resident with a history of a high risk blood clotting disorder for one of three residents (R3) reviewed for High Risk Medications. This failure resulted in R3 requiring emergency medical services followed by a medical transfer and admission to a tertiary critical care (higher level/specialized) hospital for treatment of Acute Ischemic Stroke Left MCA (Middle Cerebral Artery) territory with right facial droop and weakness, Lactic Acidosis (lactic acid in the bloodstream) and Subtherapeutic INR, resulting in R3 experiencing aphasia, dysphagia, right sided weakness, mental anguish, and hospitalization for 17 days. Residents Affected - Few These failures resulted in an Immediate Jeopardy. Findings include: The Immediate Jeopardy started on 1/26/24 when the facility received R3's Laboratory result of a subtherapeutic INR and failed to inform the resident's primary Physician of the result and need to alter the current anticoagulant medication dosage, and did not record the INR result on the Protime flowsheet, resulting in R3 suffering a change in cognition and being transferred to the emergency room then subsequently transferred the a tertiary critical care hospital for treatment of Acute Ischemic Stroke Left MCA territory with right facial droop and weakness, Lactic Acidosis and Subtherapeutic INR. V1 (Administrator in Training) was notified of the Immediate Jeopardy on 2/27/24 at 1:07 PM. While the immediacy was removed on 2/27/24, the facility remains out of compliance at a severity Level II as the facility continues to have members of the IDT (Inter-Disciplinary Team) including a nurse review all admissions for anticoagulant medication and ensure proper lab orders during Quality Assurance meetings, review all current admitted residents with anticoagulant medication for lab orders during Quality Assurance meeting weekly, and audit all other residents with high-risk medications for adequate lab monitoring. R3's Physician Order Sheet, dated 11/1/23-2/29/24, documents R3 has diagnoses including but not limited to Hypertension, History of Pulmonary Embolism, History of other Venous Thrombosis and Embolism, Antiphospholipid Syndrome and Heart Failure. This order sheet documents R3 has a laboratory order for PT (Prothrombin)/INR one time only related to Personal History of Pulmonary Embolism, Personal History of other Venous Thrombosis and Embolism, until 1/25/24. This order has a start date of 1/25/24. This order sheet also documents a medication order for Warfarin Sodium (Coumadin) two and a half milligrams to give 1 tablet by mouth one time a day every Monday, Wednesday, and Friday for blood thinner, start date 1/12/24. This order sheet also documents a medication order for Warfarin Sodium five milligrams to give 1 tablet by mouth one time a day every Tuesday, Thursday, Saturday, and Sunday for blood thinner, start date 1/11/24. No other Warfarin orders were started after 1/12/24 for R3. R3's Laboratory report, dated 1/26/24, documents R3's INR result was 1.3. This report also documents an INR range for Standard Anticoagulant is 2.0-3.0 and Aggressive Anticoagulant is 2.5-3.5. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145968 If continuation sheet Page 16 of 18 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 145968 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Kewanee 144 Junior Avenue Kewanee, IL 61443 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 0757 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On 2/21/24 at 12:10 PM, V13 (R3's Family Member) stated I am going off what the neurologist doctor said to me. When we were in the emergency room, I don't know his name but after she was taken there, I asked specifically what caused her stroke and he said likely medication management. Her level was too low for the Coumadin to be considered therapeutic. (R3) is still having left side weakness, aphasia (difficulty formulating thoughts into words and speaking) and dysphagia (difficulty swallowing). She has to eat soft foods only which she cries about. She was able to eat regular food before this. (R3) also has suffered memory loss with her stroke. On 2/21/24 at 1:40 PM, V1 (Administrator in Training) stated I don't know if (V8 R3's Primary Physician) was notified of the 1/26/24 laboratory result for (R3's) PT/INR. If he was notified it should be in the progress note or a new updated order would be in place. On 2/21/24 at 2:00 PM V9 (V8's Medical Office Licensed Practical Nurse) stated I do not see where we (doctor office) were ever notified of the PT/INR results for (R3) on or after 1/26/24. R3's Physician visit history, provided by V1 on 2/21/24, documents that the last visit from V8 was on 12/12/23. R3's Nursing Progress notes, dated 1/11/24-2/9/24 do not document that V8 was ever notified of R3's PT and INR results that were completed on 1/26/24. R3's Nursing Progress note, dated 2/10/24 at 8:15 AM, documents R3 was transferred to a local hospital after appearing to have experienced a change in Cognitive Ability. R3's Nursing Progress note, dated 2/10/24 at 1:27 PM, documents Informed by emergency room nurse That (R3) had Stroke with Left sided weakness and sepsis. Resident will be re-transferred to (tertiary critical care hospital). R3's emergency room provider notes, dated 2/10/24 at 9:22 AM, documents This [AGE] year-old woman sent from (the facility) because mental status change concerning for possible stroke. The (facility) said that the right sided face is drooping compared to normal, and (R3) is not speaking as she normally does. R3's emergency room hospital record, dated 2/10/24 at 12:15 PM, documents R3 is being transferred to a tertiary hospital for Acute ischemic stroke left MCA (Middle Cerebral Artery) territory with right facial droop and weakness, Lactic acidosis rule out sepsis and Subtherapeutic INR. This record also documents Brief Summary: Work up in emergency room shows INR subtherapeutic at 1.3. Patient had a CTA (Computed Tomography Angiography) of the head which showed acute ischemic infarct in the left MCA territory in the left temporal lobe region, no hemorrhage. On 2/26/24 at 11:20 AM V19 (Pharmacist) stated, (R3's) INR of 1.3 is not within therapeutic range. A physician should have been notified to possibly adjust (R3's) Warfarin dose. On 2/26/24 at 12:45 PM V15 (R3's Primary Hospital Physician) stated, (R3) is currently in the hospital being treated for the effects of her stroke. (R3's) sub-therapeutic INR levels contributed to (R3's) stroke. (R3) had a history of developing blood clots. On 2/26/24 at 12:55 PM V16 (R3's Neurologist) stated, (R3) had a history of a disorder called Anti-Phospholipid Syndrome which is a disorder that puts (R3) at a high risk for developing blood clots. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145968 If continuation sheet Page 17 of 18 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 145968 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Kewanee 144 Junior Avenue Kewanee, IL 61443 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 0757 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few (R3) also has a history of a Pulmonary Embolism and Venous Thrombosis. (R3's) INR levels should have been watched closely and as soon as the facility knew (R3's) INR levels were 1.3 (sub-therapeutic) on 1/26/24 the facility should have notified the physician to get (R3's) Warfarin (anti-coagulant) dose adjusted to ensure (R3's) INR levels were therapeutic to prevent blood clots. Sub-therapeutic INR levels would have caused a clot to throw and caused (R3's) stroke. On 2/27/24 at 10:15 AM, V1 (Administrator in Training) stated We do not have a Coumadin specific policy or one for anticoagulant monitoring. We use the Protime (PT) Flowsheet for residents on Coumadin and that is where nurses will document INR results and then dose changes and when the Physician was notified of them. V1 confirmed R3's Protime flowsheet has not been documented on since December of 2023. The facility's Notification of Change in Resident Condition or Status policy, dated 10/12/05, documents The facility and/or facility staff shall promptly notify appropriate individuals (i.e., Administrator, Director of Nursing, Physician, Guardian, Health Care Power of Attorney, etcetera) of changes in the resident's medical/mental condition and or status. The nurse supervisor/charge nurse will notify the resident's attending physician or on call physician when there has been; A need to alter the resident's medical treatment significantly, Abnormal lab findings. The facility's Laboratory Tests policy, dated 9/27/17, documents Appropriate laboratory monitoring of disease processes and medication requires consideration of many factors including concomitant disease(s) and medication(s), wishes of the resident and family and current standards of practice. On 2/29/24 the surveyor confirmed through interview, and record review that the facility took the following actions to remove the immediacy: 1. All nursing staff including agency nurses in-serviced on proper monitoring of anticoagulant use and ensuring high risk medication labs are reported and adjusted to ensure the resident reaches therapeutic levels by V1 on 2/27/24. 2. Staff In-service on the policy to monitor and complete the PT/INR flow sheet by V1 on 2/27/24. 3. All nursing staff including agency educated on notification to physician immediately with lab results by V1 on 2/27/24. 4. R3 no longer lives at facility, all other charts reviewed for any residents receiving anticoagulant therapy by V3 (Care Plan/MDS Coordinator) on 2/27/24. 5. MD reviewed policy for lab monitoring and signed off on policy on 2/27/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145968 If continuation sheet Page 18 of 18