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 (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 3 Event ID: 145371 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 145371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Bloomington 1509 North Calhoun Street Bloomington, IL 61701 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)