Health inspection·September 16, 2024

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to protect residents from misappropriation of resident property for nine residents (R7, R8, R9, R10, R11, R12, R13, R14 and R15) of nine residents reviewed for missing medications, in a sample of 15. Residents Affected - Some FINDINGS INCLUDE: The facility policy, Abuse Prevention and Reporting, dated (reviewed) 08/2023 directs staff, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Misappropriation of resident property means the deliberate misplacement, exploitation or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. The facility Preliminary 24-Hour Abuse Investigation Report dated 8/30/24 documents, We (facility) have received all allegation (of) Theft. On 8/29/24 (the facility) made aware of alleged misappropriation of resident property. Investigation initiated. Staff member identified (V6/RN) and suspended pending investigation. Follow up report will be sent. The (facility) Count of Missing Medication form, provided by V9/Regional Director of Operations documents, R11 (Pharmacy) dispensed 60 Norco 5/325 MG tablets on 8/26/24- missing: R14 (Pharmacy) dispensed 60 Norco 5/325 MG tablets on 8/19/24- missing and R14 (Pharmacy) dispensed 60 Norco 5/325 MG tablets on 8/1/24- missing and R14 (Pharmacy) dispensed 30 Norco 5/325 MG tablets on 7/18/24- missing; R15 (Pharmacy) dispensed 60 Norco 5/325 MG tablets on 7/30/24- missing and R15 (Pharmacy) dispensed 60 Norco 5/325 MG tablets on 8/9/24- missing; R13 (Pharmacy) dispensed 60 Norco 5/325 MG tablets on 7/6/24- missing and R13 (Pharmacy) dispensed 60 Norco 5/325 MG tablets- missing; R12 (Pharmacy) dispensed 60 Norco 5/325 MG tablets on 7/22/24- missing and (Pharmacy) dispensed 58 Norco 5/325 MG tablets on 8/26/24- missing; R10 (Pharmacy) dispensed 120 Norco 5/325 MG tablets- missing; R9 (Pharmacy) dispensed 90 Oxycontin 5/325 MG tablets on 8/15/24- missing; R7 (Pharmacy) dispensed 60 Tramadol 50 MG tablets on 7/22/24- missing; R8 (Pharmacy) dispensed 120 Norco 5/325 MG tablets on 8/13/24- missing. The facility Final Abuse Investigation Report, Original Allegation: Misappropriation of Property, dated Initial Report: 8/30/24, Final Report: 9/5/24 documents, Facts Determined: On 8/29/24 at approximately 12 (12:00) P.M., (facility) made aware of alleged misappropriation of medication occurring by alleged perpetrator (V6/Former Employee Registered Nurse) at facilities (V6) had been contracted at as agency staff. Resident's (R7, R8, R9, R10, R11, R12, R13, R14 and R15) Medical Doctor, local police department and Ombudsman were notified of the allegation. Alleged perpetrator (V6) identified and suspended pending investigation. All residents with pain medication assessed, no change in pain status noted. Both residents and staff interviews were initiated. Conclusion and Action Taken: IDT (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 145319 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 145319 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at El Paso 555 East Clay El Paso, IL 61738 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)