Inspection·September 30, 2024

F 0568 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed provide quarterly statements for Resident Trust Funds for five (R1, R2, R3, R5, R6) of five residents reviewed for Trust Funds in the sample list of six. Findings include: The facility's undated Resident Funds Policy and Procedure documents The facility will institute security measures to insure that resident funds managed by the facility are safeguarded from theft or mismanagement and shall include: signed vouchers for all resident transactions, computerized tracking of account activity, monthly oversight by the facility Administrator, and signed quarterly statements. On 9/30/24 V1 Administrator in Training provided the facility's Resident Trust Fund binder which contained monthly logs that document transactions, withdrawals, and balances for residents. The binder included R1's, R2's, R3's, R5's, and R6's Resident Trust Fund Transaction Logs dated July-September 2024. These logs were not signed by the residents and there were no signed quarterly statements in the binder. The facility's Fax (Electronic Facsimile) Worksheet IDPH (Illinois Department of Public Health) Notification Form dated 9/13/24 documents on 9/13/24 at 11:00 PM V1 was notified of an allegation of misappropriation of R1's property involving V3 Business Office Manager and V4 Activity Aide. The facility's Final Report to IDPH for this incident documents the anonymous caller alleged V3 and V4 took $600 from R1's Trust Fund Account which was given to V5 (V3's and V4's Family Member) for car repairs. R1's Minimum Data Set (MDS) dated dated 9/9/24 documents R1 has a Brief Interview for Mental Status score of 12, the higher end of moderate cognitive impairment. On 9/30/24 at 8:43 AM R1 stated the other day V1 talked to R1 about R1's Resident Trust Fund. R1 stated R1 never receives receipts for transactions or quarterly statements, so R1 did not notice any prior unauthorized transactions. R3's MDS dated [DATE] documents R3 as cognitively intact. On 9/30/24 at 9:09 AM R3 stated R3 has a Resident Trust Fund account managed by the facility. R3 stated R3 never receives quarterly statements for R3's Trust Fund. On 9/30/24 at 9:36 AM V3 Business Office Manager stated the residents are suppose to receive quarterly statements for Trust Funds, but V3 was not trained on that so therefor the residents have not been getting the statements. (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 6 Event ID: 145389 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 145389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Watseka 715 East Raymond Road Watseka, IL 60970 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)