Health inspection·December 13, 2024

F 0567 having access to it. 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: 145968 If continuation sheet Page 2 of 4 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 12/13/2024 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 Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to notify the health care power of attorney of a change in condition for 2 residents (R5 and R19) of three reviewed for discharge in the sample of three. Findings Include: The Facility's Physician-Family Notification-Change in Condition policy dated 11/2018 documents the purpose of the policy to ensure that medical care problems are communicated to the attending physician or authorized designee and family/responsible party in a timely, efficient, and effective manner. The facility will inform the resident; consult with the resident's physician or authorized designee such as Nurse Practitioner, and if known, notify the resident's legal representative or an interested family member when there is B. A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). D. A decision to transfer or discharge the resident from the facility. 1.R5's Medical Records document that she was admitted on [DATE] with diagnosis of CHF (Congestive Heart Failure). R5's Nurse's notes indicate that on 12/02/24 at 9:01 AM R5 had shortness of breath, altered mental status and tachycardia with a history of uncontrolled atrial fibrillation. R5 was sent to the emergency room for evaluation and returned with orders for a hospice evaluation related to CHF. R5's Health Care Power of Attorney dated 11/15/23 and signed by R5 lists V12 as her Health Care Power of Attorney. R5's Medical Record did not contain any documentation of notification of change of condition/transfer to emergency room and hospice evaluation to V12. On 12/12/24 at 10:00 AM V7 (Social Service Director) stated that she has worked at the facility since 09/02/2024 and has never been able to get ahold of V12 (R5's Health Care Power of Attorney) for any reasons. V7 stated to her knowledge no one has been able to get ahold of him. V7 confirmed that there is no documentation of any attempts to reach V12 and states that the phone number listed for him is not in use. V7 stated that she did not know what the next step would be to attempt to reach a health care power of attorney or what she should do in the instance of a health care power of attorney being habitually unreachable. On 12/12/24 at 9:30 AM V2 (Director of Nursing) confirmed there was no documentation of notification of V12 (R5's Health Care Power of Attorney) of her change in condition. 2. R19's medical record documents that she was admitted on [DATE] after a fall at home with a hip fracture and surgery. R19 also had pneumonia and exacerbation of CHF (Congestive Heart Failure). R19's Health Care Power of Attorney dated 11/12/24 and signed by R19 lists V11 as her Health Care Power of Attorney. R19's Health Care Power of Attorney form also listed V11's phone number. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145968 If continuation sheet Page 3 of 4 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 12/13/2024 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 Residents Affected - Few R19's Nurse's notes document that on 11/26/24 at 2:20 PM R19 was found unresponsive and sent to the emergency room. R19's note documents that R19 was readmitted to the hospital for pneumonia and exacerbation of CHF (Congestive Heart Failure). R19's Transfer/Discharge form dated 11/26/24 documented that V11 (R19's Health Care Power of Attorney) could not be called because the facility did not have a phone number for her. On 12/12/24 at 9:30 AM V2 (Director of Nursing) confirmed that V11 (R19's Health Care Power of Attorney) was not notified of R19's transfer to the hospital due to the facility not having her phone number. V2 reviewed and confirmed that V11's phone number was in R19's Medical Record on her Health Care Power of Attorney form dated 11/12/24. We didn't think we had (V11)'s phone number. I don't know why the number was not listed on the face sheet like it normally should have been. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145968 If continuation sheet Page 4 of 4