Health inspection·March 2, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free of physical abuse by another resident for two of five residents (R3, R4) reviewed for abuse in the sample list of nine. Findings include: R3's Facility Census documents R3 was admitted to the facility on [DATE] and has the following medical diagnoses, Dementia, Major Depressive Disorder and Alcohol Abuse. R3's Minimum Data Set (MDS) dated [DATE] documents R3's Brief Interview for Mental Status (BIMS) score no score due to R3 having severe cognitive impairment and not being able to participate in the interview. R3's Incident Note dated 2/21/25 at 12:05pm documents Staff alleged a physical altercation occurred between R3 and R4. Medical Doctor, R3 and R4's Power of Attorneys, and Ombudsman were notified. R4's Facility Census documents R4 was admitted to the facility on [DATE] and has the following medical diagnoses, Wernicke's Encephalopathy, Major Depressive Disorder and Anxiety Disorder. R4's Minimum Data Set (MDS) dated [DATE] documents R4's Brief Interview for Mental Status (BIMS) score no score due to R4 having severe cognitive impairment and not being able to participate in the interview. R4's Incident Note dated 2/21/25 at 12:05pm documents Staff alleged a physical altercation occurred between R3 and R4. Medical Doctor, R3 and R4's Power of Attorneys, and Ombudsman were notified. On 3/1/25 at 10:39am V7 Certified Nursing Assistant stated that on 2/10/25 V7 was working the 2:00pm 10:00pm shift on the 300 hall. V7 stated that at 8:00pm, R4 was walking towards R3 who was sitting in R3's wheelchair in front of R3's room. V7 stated as R4 approached R3, R4 attempted to grab R3's hat that was on R3's head. V7 stated that R3 then got up from R3's wheelchair and punched R4 with a closed left fist and struck R4 in the right side of R4's head by R4's eye. On 3/1/25 at 10:56am V1 Administrator stated on 2/10/25 at 8:00pm an incident had occurred between R3 and R4. V1 stated, as soon as V1 was informed of the incident V1 reported it to Illinois Department of Public health and informed R3 and R4's Power of Attorney's, Medical Doctor, Police and Ombudsman. V1 stated V1 investigated the incident and interviewed V7 who was the only staff that witnessed the incident. V1 stated that V7 informed V1 that on 2/10/25 V7 was working the 300 hall and at Page 1 of 3 145371 145371 03/02/2025 Arcadia Care Bloomington 1509 North Calhoun Street Bloomington, IL 61701

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 8:00pm, R4 tried to grab R3's hat and R3 got up from R3's wheelchair and hit R4 in R4's right side of R4's head near R4's eye. The Facility's Abuse Prevention Policy dated 9/24 documents: Guidelines: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. 145371 Page 2 of 3 145371 03/02/2025 Arcadia Care Bloomington 1509 North Calhoun Street Bloomington, IL 61701

F 0609 Level of Harm - Minimal harm or potential for actual harm Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review the facility failed to immediately report an allegation of abuse to the State Agency for two of three residents (R3, R4) reviewed for Abuse in the sample of eight. Residents Affected - Few Findings include: R3's Incident Note dated 2/21/25 at 12:05pm documents Staff alleged a physical altercation occurred between R3 and R4. Medical Doctor, R3 and R4's Power of Attorneys, and Ombudsman were notified. R4's Incident Note dated 2/21/25 at 12:05pm documents Staff alleged a physical altercation occurred between R3 and R4. Medical Doctor, R3 and R4's Power of Attorneys, and Ombudsman were notified. The facility's Abuse Investigations and R3 and R4's Electronic Medical Record dated 2-10-25 through 2-20-25 were reviewed and do not include evidence of R4's abuse allegation, that was reported to V8 Previous Administrator on 2/10/25, being reported to the State Agency. The Facility's Abuse Prevention Program policy dated September 2024 documents, Internal Investigation: Any allegation of abuse or any incident that results in serious bodily injury will be reported to the Illinois Department of Public Health immediately, but not more than two hours of the allegation of abuse. On 3/1/25 at 10:39am V7 Certified Nursing Assistant stated that on 2/10/25 V7 was working the 2:00pm 10:00pm shift on the 300 hall. V7 stated that at 8:00pm, R4 was walking towards R3 who was sitting in R3's wheelchair in front of R3's room. V7 stated as R4 approached R3, R4 attempted to grab R3's hat that was on R3's head. V7 stated that R3 then got up from R3's wheelchair and punched R4 with a closed left fist and struck R4 in the right side of R4's head by R4's eye. V7 stated, V7 did notify V8 Previous Administrator and later learned that V8 never reported the incident. On 3/1/25 at 10:56am V1 Administrator stated on 2/21/25 V1 started working back at the facility as the Administrator. V1 stated staff brought it to V1's attention that on 2/10/25 at 8:00pm an incident occurred between R3 and R4. V1 stated, V7 Certified Nursing Assistant did report the incident on that day to V8 Previous Administrator who did not report the incident to Illinois Department of Public Health. V1 stated V1 investigated and interviewed V7 who was the only staff that witnessed the incident. V1 stated that V7 informed V1 that on 2/10/25 V7 was working the 300 hall and at 8:00pm, R4 tried to grab R3's hat and R3 got up from R3's wheelchair and hit R4 in R4's right side of R4's head near R4's eye. V1 stated that V7 notified V8 Previous Administrator who did not report the incident to Illinois Department of Public Health as required. 145371 Page 3 of 3