Health inspection·May 9, 2025

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few pulled indwelling foley out. Noted with massive bleeding from his penis area, with blood clots. Progress Note dated 03/07/25 at 7:53 AM Wife and MD (Medical Doctor) notified with orders to send to (Hospital) ED (Emergency Department). R21's EMR contained no documentation of written notice for reason of transfer to the hospital provided to R21 and/or the representative. The facility was unable to provide documentation for written notification of the reason for transfers to the hospital. On 05/07/25 at 3:38 PM, V1 (Administrator) stated written notification of the reason for transfer to the hospital was not given to the residents and/or their representatives. V1 stated they were not aware that written notification should have been given. The ombudsman was not notified of the residents' transfers to the hospital for February 2025. The facility's Clinical Protocol: Transfer or Discharge Notice, last approved 06/2022 showed Policy Statement: Our community shall provide a resident and/or the resident's representative (sponsor) with a thirty (30) day written notice of an impending transfer or discharge. Exceptions to the 30-day requirement apply when the transfer or discharge is affected because of the following, in these cases, the notice is provided as soon as practicable and the notice to the ombudsman is sent when practicable. 1. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the community. 6. An immediate transfer or discharge is required by the resident's urgent medical needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146056 If continuation sheet Page 2 of 11 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 05/09/2025 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to implement dietician-recommended interventions for resident with significant weight loss. This applies to 1 resident (R13) reviewed for weight loss in a sample of 14 residents. Residents Affected - Few The findings include: On 5/6/25 at 10:57 AM, R13 was asleep in bed with his mouth hanging open and his cheeks sunken in, appearing thin. R13's MDS (Minimum Data Set) dated 3/20/25 shows his cognition is severely impaired and he requires supervision with eating. R13's Nutrition note written on 5/6/25 by V12 (Dietician) states R13 has had a 14.5% weight loss in the last 6 months. V12 wrote R13 gets large portions, fortified pudding at lunch, and fortified ice cream with lunch and dinner. V12 noted that R13 has a pressure ulcer to his sacrum. V12 wrote that R13 is meeting majority of his nutrition needs with supplements and the rest of his nutrition is provided with meals. V12 wrote that R13's weight loss continues, despite multiple interventions. R13's weights documented in EHR (Electronic Health Record) as the following: 5/1/25- 141 pounds, down from 11/2/24- 165 pounds (14.55% in the last 6 months). On 5/8/25 at 12:34 PM, R13 was observed eating lunch in the facility dining room, sitting next to V11 (R13's wife). R13's lunch did not include a large portion, fortified pudding, or fortified ice cream. V11 said last she knew, R13 weighed right around 175 pounds. V11 said R13 did not get pudding or a fortified ice cream and R13's appetite fluctuates. R13 ate a slice of pie, about 25% of his sweet potatoes, 80% of his pea salad, and 20% of his BBQ pork. R13 did not eat any of his cornbread and he received regular sized portions of lunch items. Throughout lunch service, no staff were seen checking on R13 to see how much he had eaten, how his appetite was, or to encourage him to eat. At 12:57 PM, V11 unlocked R13's wheelchair and removed him from the dining room. Lunch had ended and R13 never received fortified pudding, a fortified ice cream, or a large portion. On 5/8/25 at 2:25 PM, V2 (Director of Nursing) said, if ordered, fortified pudding and fortified ice cream should be given by dietary staff. V2 said if dietician recommendations are not followed, there is a risk the resident will continue to lose weight. V2 said this is a concern because weight maintenance is important for preventing disease and illnesses and promoting wound healing. V2 said she knows R13 is supposed to be receiving double portions at mealtimes. On 5/8/25 at 2:42 PM, V6 (Food Service Director) said V12 (Dietician) emails V2 and V6 to let them know when she orders supplements for a resident. V6 said V12 (Dietician) will then put the recommendations directly into the menu system so the supplements/recommendations will print out on the resident's meal ticket for each meal. V6 said she then highlights on the meal ticket if it says double portion or fortified pudding. V6 said the kitchen staff just had a meeting about supplements in which she told the staff if any items are highlighted on the meal ticket, the resident must get those items. V6 said the server is responsible for giving the resident fortified pudding and fortified ice cream and the [NAME] is responsible for making sure the resident gets double, or large portions. V6 then provided surveyor with R13's meal ticket, which showed large portions with all meals and fortified pudding at lunch. V6 said residents with large portions ordered should get double scoops. V6 said V12 (Dietician) did not add fortified ice cream onto R13's meal ticket. V6 then spoke with V12 to verify and V12 told V6 that R13 is also supposed to be on fortified ice cream. When V6 was told R13 did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146056 If continuation sheet Page 3 of 11 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 05/09/2025 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not get fortified pudding, fortified ice cream, or large portion with lunch, V6 said she did not know what happened, but it is a concern that R13 didn't get the recommended supplements because he could lose more weight. V6 said weight maintenance is important for the resident's immune system, strength, and overall health. R13's Care Plan initiated on 10/6/22 states resident has a compromised nutritional status related to the diagnosis of weight loss, and interventions include provide supplements as ordered, monitor and document food intake at each meal, report any intake decline to physician, and provide diet as ordered. The facility's policy titled, Significant Weight Gain or Loss Policy last revised 2/24 states, Purpose: To ensure that insidious/significant weight gain or loss will be identified so that nutritional needs can be evaluated, and appropriate intervention provided. Responsibility: Licensed Nursing Personnel/Dietician/Dietary Manager. Guidelines: .2. Dietician/Nursing will determine significant weight changes: .c. gain or loss of 10% in the last six months. 3. Dietician will review these clients and document the change. 4. If recommendations are indicated, will be communicated to nursing to notify the provider of the significant weight changes and recommendation . The facility's policy titled, Weight Monitoring last revised 01/2023 states, Policy Statement: It is the policy . that appropriate nutritional care shall be provided to residents who have a significant weight change. A significant weight change is identified as a weight loss or gain of 5% in 30 days, 7.5% in 90 days, or 10% in 180 days. Policy Interpretation and Implementation: . E. The RD should make recommendations for nutritional interventions . RD recommendations should be reviewed and initiated by nursing associates . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146056 If continuation sheet Page 4 of 11 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 05/09/2025 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. 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 follow the physician order to administer intravenous (IV) antibiotics. This applies to 1 of 1 resident reviewed (R225) for IV antibiotics in a sample of 14. Residents Affected - Few The Findings include: R225 is an [AGE] year-old male admitted on [DATE] with an admitting diagnosis including infection and inflammatory reaction due to an indwelling urethral catheter. Record review on R225's Physician Order Sheet (POS) dated 5/6/25 indicates: Meropenem-Sodium Chloride intravenous solution reconstituted 1 gram in 50 milliliters (1gm/50ml). Use 1 gm IV every 8 hours for bacterial infection until 5/11/25 23:00. On 5/6/25 at 10:31 AM, R225 was observed in his bed with a 100 ml 0.9 NS reconstituted with 1-gram Meropenem infusing at 50 ml/hr. The infusion pump was programmed for Meropenem infusing at 50 ml/hr with only 50 ml as the volume to be infused. On 5/6/25 at 11:58 AM, V2 (Director of Nursing) stated, I am supposed to mix Meropenem 1 gram with 50 ml of 0.9 NS, but I didn't have 50 ml bag and that's why I mixed with a 100 ml bag After reconstituting 1 gm of Meropenem with 100 ml 0.9 NS, the resident is going to get only half the dose if I run it at 50 cc/hr for an hour. On 5/6/2025 at 11:58 AM, there was no documentation in R225's medical record that showed R225's Physician was notified that 50ml IV bags were not available and that 100ml would need to be infused for the full Meropenem dose, or if the 100ml with the full dose would require more time for the infusion, or if infusing 100ml over one hour was acceptable. The facility presented a policy on Administering Medications through Secondary IV tubing document (last approved 1/2024): Review physician order and confirm the 5 rights of medication (right resident, medication name, dose, route, rate). If no rate is ordered, calculate the rate according to dose, volume, and time ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146056 If continuation sheet Page 5 of 11 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 05/09/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm 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 maintain the kitchen facility in a manner to prevent foodborne illness. This applies to 22 residents in the facility receiving dietary services. Residents Affected - Many Findings include: On 05/06/25 at 10:30 AM, V6 (Dietary Manager) confirmed 22 residents in the facility receive food services from the kitchen. 1.) On 05/06/25 at 11:29 AM, V6 tested red sanitization bucket #3 at 500ppm (Parts Per Million). On 05/08/25 at 11:13 AM, V6 stated the red disinfecting bucket should be 200 to 400ppm. If the sanitizer level is too high could cause a chemical reaction to the skin. If it comes in contact with food, it may contaminate the food and cause illness. The facility policy Sanitizing Food Contact Surfaces dated 1/25 states the sanitizer solution must be at 200 ppm to 400 ppm. 2.) On 05/06/25 at 11:00 AM, the walk-in cooler contained a one-gallon bottle of barbeque sauce with no opened-on or use-by dates. A one-gallon bottle of barbeque sauce good thru 3/29/25. Hot dogs in a zippered bag good thru 4/23/25. A lump of grayish white meat in a silver facility metal pan, identified by V6 as turkey, had no contents label, opened on, or use by date. An opened one-gallon bottle of Balsamic vinaigrette without an opened on or use by date. A dented 6lb 6oz can of diced pears with a greenish gray furry substance growing on the can. A 6lb 12oz can of tapioca pudding with a greenish gray furry substance and white glaze-like substance on the can. Two factory sealed containers of rice pudding with a good-thru date of 4/8/25. Parmesan cheese in a zippered bag good-thru 4/24/25. Processed cheese block factory packaging half ripped off, with product open to air and did not have an opened on or use by date. American cheese in a zippered bag with a use by date of 5/1/25. Three 5lb bags of mozzarella good thru 3/17/25. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146056 If continuation sheet Page 6 of 11 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 05/09/2025 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 0812 A 1lb 14oz tub of basil pesto good thru 4/14/25. Level of Harm - Minimal harm or potential for actual harm 3.) On 05/06/25 at 10:30 AM, the dry storage contained a zippered bag of white flakes identified by V6 as coconut flakes did not have a contents label opened on or use by date. Residents Affected - Many Cherry pie filling 20 lbs. (pounds) no opened on or use by date. Quinoa 8lbs no opened on or use by dates. Two dented 6 lbs. 9oz. (ounce) cans of ground tomatoes. A dented 6lb. 10oz can of mandarin oranges. A dented 6lb 15oz can of kidney beans. A dented 6.6lb can of diced pears. A facility bin of penne pasta good thru date of 5/5/25 Egg noodles good thru 5/5/25. A 5lb bag of pepitas open to air. A box of gelatin agent 1lb ¼ oz open to air. Sliced strawberry topping 7lb 6oz that had been accessed. Manufacturer's label read to refrigerate after opening. Maraschino Cherries 4.5lbs did not have an opened-on or use-by date. The manufactures label read to refrigerate after opening. A 5lb bag of graham cracker crumbs that were accessed, did not have an opened-on or use-by date. A 25lb bag of panko Japanese breadcrumbs was open to air and had a good thru date of 1/10/25. Shelving with emergency food contained a 6.56lb can of pear halves good thru 4/1/23. A dented 3lb 2 oz can of chicken noodle soup good thru 4/1/25. Two 3lb 2oz cans of chicken noodle soup good thru 4/1/25. On 05/08/25 11:13 AM, V6 (Dietary Manager) stated, dented cans that arrive at the facility dented are rejected because we can't verify if it was packaged incorrectly or not properly sealed- they may have botulism. If we dent it the cans, we are ok to use them because we know we dropped it and there is nothing wrong with it. If the edges are dented even if we dropped the can, we would not use the can of food. Food should be labeled with an opened on and use by date, so we know when to pull it off the shelf. There is a safety risk using food that is outdated it could be spoiled and cause illness. Food items should be labeled with the contents in case someone has an allergy we don't want to serve it to them. Food items that should be refrigerated should not be stored in the dry storage area (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146056 If continuation sheet Page 7 of 11 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 05/09/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many because it could start to grow bacteria. Food items should be securely sealed so no contaminates get inside- contaminates could cause illness. Outdated food items could be spoiled and cause residents to become sick. V6 stated I don't know how those cans got in the refrigerator- the stuff growing on top looked like mold. We wouldn't want it growing in the refrigerator because it could cause illness. The Facility policy Receiving (dated 1/25) showed to refuse dented cans. The facility did not provide a policy for dented cans stored in the facility. The facility policy Food Supply and Storage (dated 1/25) showed all food, non- food items, and supplies that will be used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Foods past the use-by, sell by, best-by, or enjoy by date should be discarded. Cover, label, and date unused portions and open packages. Discard food past the use-by or expiration date. The facility Refrigerated Storage Life of Foods chart (dated January 2024) shows fruit purees, fillings and sauces are good for one month after opening and must be refrigerated. 4.) On 05/06/25 at 11:24 AM, the walk-in freezer was observed with V8 (Server). Meat patties in a clear plastic bag had no contents label, opened-on, or use-by date. Corned beef labeled good thru 3/21/25. Food in a clear bag identified by V8 as cut-up sausage was without a label to identify contents or use-by date. Food identified by V8 as potato wedges was in a clear bag without a label to identify contents or use-by date. 5.) On 05/06/25 at 11:35 AM, the reach in coolers were observed with V8. Reach in cooler #1 contained an unlabeled plastic bag with creamy white substance in a facility container identified by V8 as a multi-use container of yogurt. The container had no label to identify contents or any dates. 6.) On 05/06/25 at 11:40 AM, The kitchen shelving was observed with V6 (Dietary Manager.) A zippered bag of white powder identified by V6 as pureed bread had no label to identify contents, opened-on or use-by dates. A 4.5lb bag of pureed bread had no opened-on or use-by dates. On 05/07/25 at 12:10 PM, V9 (Cook) tested the food holding temperatures. Between temperature testing the dressing and ground turkey. V9 used the same small probe wipe. V9 then tested the gravy then the sliced turkey without wiping the probe in between. On 05/08/25 at 11:13 AM, V6 stated usually we use a new wipe for testing each food item. Not using a fresh wipe to temperature each food item could cause a cross contamination and negatively affect persons with food allergies. The facility policy Meal Quality and Temperature (dated 1/25) showed thermometers are cleaned and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146056 If continuation sheet Page 8 of 11 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 05/09/2025 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 0812 sanitized before use, between food items, and after use with approved sanitizer wipes or solutions. 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: 146056 If continuation sheet Page 9 of 11 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 05/09/2025 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 0880 Provide and implement an infection prevention and control program. 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 follow Enhanced Barrier Precautions (EBP) during high contact resident care activities and failed to perform hand hygiene during incontinent care. This applies to 3 of 3 residents (R6, R13, and R225) in a sample of 14. Residents Affected - Few The findings include: 1. R6 is a [AGE] year-old female admitted on [DATE] with diagnoses including urinary tract infection and neuromuscular bladder dysfunction. On 5/6/25 at 10:39 AM, R6 was in her bed with an EBP sign on the entry door, requiring gloves and a gown to provide high-touch resident care activities. R5 was observed with an indwelling catheter bag on the floor with full of urine. On 5/6/25 at 10:40 AM, V5 (Certified Nursing Assistant/CNA) stated that she is not aware of the last time the bag was emptied, and it was supposed to be emptied every shift. V5 emptied 1600 milliliters (ml) of urine without wearing a gown and stated that the bag shouldn't be on the floor. 2. R225 is an [AGE] year-old male admitted on [DATE] with diagnoses including infection and inflammatory reaction due to an indwelling urethral catheter. On 05/06/25 10:35 AM, R225 was in his bed with an EBP sign at the entry door, requiring gloves and a gown when providing high-touch resident care activities. On 05/06/25 at 10:36 AM, observed V4 (Licensed Practical Nurse/LPN) touching the resident's linen and indwelling catheter tubing without wearing a gown. 05/08/25 10:38 PM V2 (Director of Nursing/DON) stated all of our staff are supposed to wear a gown and gloves when providing high touch resident care activities, including indwelling catheter care, for residents on EBP, and the indwelling catheter bag shouldn't be on the floor. The facility provided the Enhanced Barrier Precaution Guidelines dated 05/2024 document: 1. Enhanced Barrier Precautions (EBP) is an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high-contact resident care activities when contact precautions do not otherwise apply. 3. On 5/8/25 V14 (Wound Care Family Nurse Practitioner) and V13 (Registered Nurse) were observed providing incontinence care for R13 prior to performing wound care. V13 and V14 rolled R13 onto his right side. Then with gloved hands, V13 used a wipe to remove stool from R13's buttocks. After wiping away R13's stool, V13 did not change her gloves. V13 and V14 then switched sides of the resident so V14 could measure R13's sacral wound. When V13 arrived at the right side of R13's bed, she placed her left hand with the soiled glove on R13's left buttock and her soiled right gloved hand on R13's posterior thigh to hold R13 in place while V14 measured his wound. On 5/8/25 at 2:25 PM, V2 (DON) said after providing incontinence care and wiping away stool from a resident, the first thing the staff member should do is remove their gloves, wash their hands, and put on new gloves. V2 said the staff member should remove soiled gloves before touching a clean area (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146056 If continuation sheet Page 10 of 11 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 (X3) DATE SURVEY COMPLETED A. Building 05/09/2025 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 0880 of the resident for infection control purposes, to prevent cross contamination. Level of Harm - Minimal harm or potential for actual harm The facility's policy titled, Hand Hygiene/Handwashing last revised 03/2023 states, Definition: Hand Hygiene means cleaning your hands by using either handwashing (washing hands with soap and water), antiseptic hand wash, or antiseptic hand rub .Guidelines: .Examples of When to Perform Hand Hygiene: . If hands will be moving from a contaminated body site to a clean body site during patient care . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146056 If continuation sheet Page 11 of 11