Inspection·January 7, 2025

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 01/07/25 at 10:30 AM a State Agency Serious Injury Incident and Communicable Disease Report (Follow-up Reportable) was reviewed. The Investigation Summary dated 12/17/24 documented the following: The grievance was given immediate, full attention to the bleeding wound and the DON (Director of Nursing) investigated. The same report documented it was determined that the new blood thinners caused spontaneous bleeding from the wound. The following written statements were attached to the report. V2 (DON) wrote I recall the grievance only from re-reading it. I do not recall when it was presented to me. I was off on May 21, 2024. The SSD (Social Services Director) signed it on 05/28/24 so I am assuming that is when I wrote in my part about the wound that was bleeding. I did not respond to the complaint of a CNA being rough. My concerns were focused on the wound. A written statement dated 12/11/24 documented Admin spoke with [former CNA V10] to receive a statement regarding the grievance of rough care back on 05/20/24. [V10] does not recall the incident. The initial and final reportables showed that the facility initiated the rough handling allegation investigation on 12/11/24, seven months after the incident. On 01/02/25 at 9:37 AM V7 (Former Administrator) stated She was on PTO (Paid Time Off) on 05/20/24 when the incident of alleged rough handling had taken place. V7 stated she did not report the incident to State Agency because she was not made aware of the incident until December 2024 when the consultant came to the facility to audit. V7 stated the allegation was not investigated in May. On 01/02/25 at 2:25 PM V2 (DON) stated on 05/20/24 she was not aware of R1 being rough handled. Stated she was only notified by the floor nurse that R1 was having bleeding from her wound, and she was being sent out to the hospital for evaluation. V2 stated she did not speak with R1's daughter that day (05/20/24). V2 stated R1's bleeding was being caused by the wound debridement on its own. The resident was taking Eliquis. After the resident was sent out for evaluation, she was admitted to the hospital but did not return to the facility. I only zoned into the bleeding wound; I did not address the rough handling. V2 stated on 05/28/24 she signed off on the grievance regarding the bleeding wound. I am not sure if the issue of rough handling was told to the abuse coordinator. The abuse coordinator was the administrator. The social services department handles the grievances. When there is an issue, it is their responsibility to notify the proper department manager. That is the normal process. All issues are handled from there. V2 stated V10 was not terminated, she left voluntarily for a position with better pay and closer to home. V2 stated V10 was not sent home pending investigation. I am not aware of an investigation regarding the rough handling. On 01/02/25 at 3:30 PM V1 (Administrator) stated he does not have any knowledge of the alleged rough handling because he was not working at the facility at the time. V1 stated he started as the administrator on 12/18/24. When I started, the investigation was completed. From what I read and heard; I see no evidence of any rough handling occurred. If I got a report of a resident being rough handled, I will follow the company and state guidelines. V1 stated he is the abuse coordinator for the facility. The facility's Abuse Investigation and Reporting Policy last approved 12/2024 showed: Policy statement: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, electronic mail, social media, videotaping, photographing, and other imaging of resident, and/or injuries of unknown source ('abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by community management. Conclusions of investigations will also be reported, as defined by the (Facility) Abuse Prevention policy. Policy Interpretation and Implementation: Role of the Administrator or designee: D. The administrator or designee will suspend immediately any employee who has been accused of resident abuse, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146056 If continuation sheet Page 2 of 3 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 146056 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at Kankakee 901 North Entrance Avenue Kankakee, IL 60901 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete pending the outcome of the investigation. E. The administrator or designee will monitor for any further potential abuse, neglect, exploitation, or mistreatment is prevented while the investigation is in progress. Reporting: A. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported to the Administrator or designee and to the following other officials or agencies: 1. The State licensing/certification agency responsible for surveying/licensing the community. E. The Administrator or his/her designee will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident . Event ID: Facility ID: 146056 If continuation sheet Page 3 of 3